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Volume 33(1); June 2018
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Original articles
Diagnostic value of BRAFV600E mutation analysis in fine needle aspiration for evaluation of thyroid nodules
Hae Won Lee, So Young Ock, Bu Kyoung Kim, Su Kyoung Kwon, Young Sik Choi, Jeong Hoon Kim, Sang Bong Jung
Kosin Med J. 2018;33(1):1-11.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.1
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

Ultrasound-guided fine-needle aspiration (FNA) is routinely used in the evaluation of thyroid nodules. However, it has several pitfalls, as has been noted in nondiagnostic and indeterminate cases. This study aims to investigate the value of BRAFV600E mutation co-testing in FNA cytology.

Method

A total of 310 patients underwent BRAFV600E mutation co-testing in FNA cytology on thyroid nodules between June 2013 and June 2014. Of the 310 patients, 69 patients who had undergone a surgery for thyroid nodules were included in this study. The presence of the BRAFV600E mutation was determined by allele-specific polymerase chain reaction amplification of exon 15 of the BRAF gene.

Results

Of 69 cases, 33 (47.8%) were BRAFV600E mutation positive. The BRAFV600E mutation was not significantly associated with high-risk features such as tumor size, lymph node metastasis, and pathological stage. The respective diagnostic performance of FNA (P = 0.02), BRAFV600E mutation (P = 0.03), and ultrasonographic (P = 0.00) findings was statistically significant. The sensitivity, specificity and positive predictive value of FNA was 64.9%, 83.3%, and 94.8%. The sensitivity, specificity and positive predictive value of BRAFV600E mutation was 56.1%, 91.7%, and 96.9% and the US features was 91.2%, 91.7%, and 98.1% respectively. However, sensitivity of FNA with BRAFV600E mutation (77.2%) was lower than FNA with US (92.9%) and combination all together (92.9%).

Conclusion

In this study, we found that US features were the most useful in preoperative differential diagnosis of thyroid nodules. BRAFV600E mutation co-testing in FNA cytology was also useful for diagnosis of thyroid tumors.

Antibiotic resistance of Staphylococcus aureus colonized in children with staphylococcal scalded skin syndrome
Seom Gim Kong
Kosin Med J. 2018;33(1):12-19.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.12
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

Systemic antibiotic therapy with semisynthetic penicillinase-resistant penicillin or vancomycin and clindamycin are recommended for the treatment of staphylococcal scalded skin syndrome (SSSS). This study assessed the rate of antibiotic resistance of Staphylococcus aureus isolated from the anterior nares or skin of children diagnosed with SSSS.

Methods

A retrospective review of the medical records of 25 patients with SSSS between July 2010 and October 2014 was conducted. The clinical characteristics of patients were collected and the antibiotic susceptibility of S. aureus were analyzed using automated systems.

Results

The median age of the patients was 22 months (range: 2-95). Ninety-two percent of patients were less than 5 years of age. Nasal swab samples of all patients and skin swab samples of 17 patients were cultured to isolate S. aureus. Twenty-one (84%) of 25 patients were colonized with methicillin-resistant S. aureus (MRSA). The results of swab samples of the other four patients were no growth or isolation of bacteria other than S. aureus. Among 20 strains isolated from the anterior nares, 1 strain (5%) was methicillin-susceptible S. aureus. All 15 strains isolated from the skin were MRSA. All 21 strains isolated from anterior nares or skin were found to be resistant to clindamycin upon evaluation using automated systems.

Conclusions

The rates of methicillin and clindamycin resistance in S. aureus colonized in children with SSSS were very high. Further studies evaluating proper antibiotic regimens and the effectiveness of systemic antibiotic therapy are needed.

Clinical significance of serum neutrophil gelatinase-associated lipocalin in the early diagnosis of renal function deterioration after radical nephrectomy
Taek Sang Kim, Su Hwan Kang, Pil Moon Kang, Hongkoo Ha, Su Dong Kim, Jangho Yoon, Hyunyong Hwang
Kosin Med J. 2018;33(1):20-28.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.20
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

The standard metrics used to monitor the progression of acute kidney injury (AKI) include markers such as serum creatinine, blood urea nitrogen, and estimated glomerular filtration rate (eGFR). Moreover, neutrophil gelatinase-associated lipocalin (NGAL) expression has been reported to modulate oxidative stress.

Methods

We aimed to evaluate the usefulness of serum NGAL levels for monitoring renal function after radical nephrectomy (RN). We prospectively collected data from 30 patients who underwent RN. We analyzed serum NGAL and creatinine at 6 time points: preoperative day 1, right after surgery, 6 hours after surgery, postoperative day (POD) 1, POD 3, and POD 5. We compared these measurements according to the eGFR values (classified as chronic kidney disease stage III; CKD III or not) using data obtained 3 months after surgery.

Results

The mean age was 65.5 years (range, 45–77 years), and the male-to-female ratio was 2:1. At the last follow-up examination, there were 12 patients (40%) with CKD III. Using receiver operating characteristic analysis, we found that serum creatinine on POD 5 (area under the curve [AUC], 0.887; P = 0.000) and NGAL at 6 hours after LRN (AUC, 0.743, P = 0.026) were significant predictors of CKD III. The development of CKD III after LRN was associated with the serum creatinine level on POD 5 and the NGAL at 6 hours after surgery.

Conclusions

Compared to serum creatinine, serum NGAL enabled earlier prediction of postoperative CKD III. Therefore, serum NGAL measured 6 hours after surgery could be a useful marker for managing patients after RN.

Changes in Antimicrobial Susceptibility Pattern of Blood Isolates at a University Hospital in the Kyungnam area during 2005-2014
Dahae Yang, Woonhyoung Lee
Kosin Med J. 2018;33(1):29-40.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.29
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

Blood culture is a one of the most important procedure for diagnosis and treatment of infectious disease, but distribution of pathogenic species and the antimicrobial susceptibility can be vary from pathogen, individual trait, regional or environmental features. In this study, we investigated the changes in frequency of occurrence and antimicrobial susceptibility pattern of blood isolates from 2005 to 2014.

Methods

Data of blood isolates from Kosin Gospel Hospital during 2005 to 2014 were analyzed retrospectively. Blood isolates were cultured for 5 days using BACTEC Plus Aerobic/F and BACTEC lytic/10 Anaerobic/F. Identification and antimicrobial susceptibility test was performed using VITEK 1 system, VITEK 2 XL, PHOENIX 100 and conventional method.

Results

9,847 isolates were identified during 10 years. Among the isolates aerobic or falcutative anaerobic bacteria were isolated in 99.5% specimens, anaerobic were 0.1%, and fugi were 0.4%. Most commonly isolated bacteria were coagulase-negative Staphylococcus (CoNS) followed by Escherichia coli, Staphylococcus aureus and Klebsiella pneumoniae. Candida parapsilosis were most frequently isolated among fungi. The proportion of S. aureus, A. baumannii and E. faecium were increased, while Pseudomonas aeruginosa and Streptococcus pneumoniae decreased over decennium. Imipenem resistant K. pneumoniae were identified. Vancomycin resistant E. faecium and imipenem resistant A. baumannii were increased (7.1% in 2005 to 12.3% in 2014, 0% in 2005 to 55.6% in 2014, respectively).

Conclusions

Over the last 10 year, CoNS were the most frequently isolated pathogen. Imipenem resistant K. pneumoniae was emerged. Vancomycin resistant E. faecium and imipenem resistant A. baumannii increased during this period.

Are there differences in hepatitis-B immunization status between diabetes and non-diabetes subjects in Korea?
Ji Young Park, Su Kyoung Kwon
Kosin Med J. 2018;33(1):41-50.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.41
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

The American Diabetes Association (ADA) recommends hepatitis-B virusVIruS vaccination for unvaccinated adults with diabetes. However, the Korean Diabetes Association (KDA) did not recommend hepatitis-B vaccination for unvaccinated adults with diabetes. This study was performed to assess the differences in hepatitis-B virus antigen and antibody status between Korean patients with diabetes and those without by using national survey data.

Methods

We analyzed hepatitis-B virus antigen and antibody status in 9,771 South Korean people from the general population based on the Korean National Health and Nutrition Examination Survey. Diabetes patients were defined as those with a measured fasting plasma glucose over 126 mg/dL or those who had been previously diagnosed with diabetes by other health care centers.

Results

Subjects with diabetes accounted for 812 (8.3%) among the 9771 study subjects. The prevalence ofhepatitis-B (HBsAg) seropositive subjects was not significantly different (3.9% vs. 4.6%, P = 0.09) between subjects with diabetes and those without. The prevalence of hepatitis-B antibody (HBsAb) positive subjects and unimmunized subjects was not significantly different (55.2% vs. 58.2%, P = 0.09, 40.9% vs. 37.2%, P = 0.09) between the two groups. The prevalence of unimmunized subjects decreased by age (< 20 years 33.3 % vs. 33.0%, 20~29 years 49.1% vs. 41.2%, 30~39 years 41.9% vs. 37.7%, 40~49 years 35.1% vs. 33.5%, 50~59 years 39.0% vs. 38.0%, 60~69 years 41.2% vs. 39.8%, > 70 years 48.5% vs. 42.8%) but was not significantly different between the 2 groups.

Conclusions

From this study, we conclude that there are not sufficient grounds to recommend routine hepatitis-B virus vaccination for unvaccinated Korean subjects with diabetes at this point in time in Korea. Further prospective studies will be needed.

Effect of Computerized Neuropsychologic Test in Subacute Post-Stroke Patient With Cognitive Impairment
Chang Hwa Lee, Won Sik Moon, Yong Hyun Han, Po Sung Jun, Gi Hun Hwang, Ho Joong Jung
Kosin Med J. 2018;33(1):51-63.   Published online June 30, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.51
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

To investigate the effects of Computerized Neuropsychologic Test (CNT) on cognitive function and daily life performance in subacute post-stroke patients with cognitive impairment.

Methods

Korean Mini-Mentals State Examination (K-MMSE), Korean version of Modified Barthel Index (K-MBI) were investigated in 125 subacute post-stroke patients with cognitive impairment. We analyzed K-MMSE and K-MBI which were conducted 63 patients who had received CNT and 62 patient who had not received CNT from baseline to 8 weeks follow-up. In the experimental group, initial K-MMSE and K-MBI were conducted 13.3 ± 6.8 weeks after the onset of stroke and their age was 63.4 ± 13.3. In the control group, initial K-MMSE and K-MBI were conducted 13.2 ± 7.7 weeks after the onset of stroke and their age was 65.1 ± 11.6.

Results

The 8 weeks follow-up total K-MMSE score and total K-MBI score of experimental group were significantly higher than control group (P < 0.05). In K-MMSE subsection, orientation, judgement, recall, language & visual reconstruction were significantly higher in experimental group than control group (P < 0.05). In K-MBI subsection, personal hygiene, bathing self, toilet, dressing, ambulation, chair/bed transfer were significantly higher in experimental group than control group (P < 0.05). The change of total K-MMSE score of experimental group was significantly correlated with change of total K-MBI score (P < 0.05), but control group was not (P > 0.05). In K-MMSE subsection, change of orientation, registration, language and visual reconstruction were correlated with total K-MBI s core after CNT. Especially, the experimental group, total K-MBI score of the left hemisphere damage group was significantly higher than the right hemisphere damage group (P < 0.05).

Conclusions

This study shows that CNT is effective on subacute post-stroke patients with cognitive impairment. Improvement of cognitive function can expect a positive outcome on daily life performance, in particular, it can be expected to improve the prognosis of patients with stroke, the left hemisphere lesions.

Iodine nutritional status and awareness of iodine deficiency among adults, including pregnant women, in Tuguegarao, Philippines
Young Sik Choi, Kwang-Hyuk Seok, Jong Jin Lee, Gina Jieun Hong, Pablo M. Afidchao, Bu Kyung Kim, Jee-Yeong Jeong
Kosin Med J. 2018;33(1):64-74.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.64
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

Iodine deficiency causes multiple health problems. Previously we reported that 96% of high school students in Tuguegarao, Philippines had adequate iodine levels. However, iodine deficiency-associated problems remain among adults in the Philippines. Therefore, we evaluated iodine nutritional status and goiter prevalence among adults, including pregnant women, in Tuguegarao, Philippines.

Methods

A total of 245 adults, including 31 pregnant women, provided samples for urinary iodine analysis, and all pregnant women completed a questionnaire about iodine deficiency.

Results

The median urinary iodine level was 164.0 ± 138.4 g/L; 38.4% of the participants were iodine deficient, according to the International Council for Control of Iodine Deficiency Disorders (ICCIDD) criteria. No severe iodine deficiency was observed. Among the 31 pregnant women, 24 (77.5%) fell into the iodine deficient category defined by a stricter World Health Organization (WHO) guideline, in which iodine deficiency is considered when urinary iodine levels are below 150 g/L. Almost half (42%) of the pregnant women were unaware of the harmful effects of iodine deficiency on the human body and their fetus.

Conclusions

Although iodine nutritional status in the Philippines has improved, iodine deficiency still exists among adults, especially among pregnant women. Therefore, our study strongly suggests that a better strategy should be established to monitor iodine nutritional status among adults continually, and to focus on populations susceptible to iodine deficiency, including pregnant women and women of reproductive age, to achieve the total elimination of iodine deficiency.

Expression of vascular endothelial growth factor is a clinically useful predictor for aggressive basal cell carcinoma
Jong Soon Choi, Dong Chan Lee, Hee Kyung Chang
Kosin Med J. 2018;33(1):75-84.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.75
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM
Objectives

Basal cell carcinoma (BCC) tumors are locally invasive but rarely metastatic. However, aggressive metastatic variants are being increasingly reported in elderly people. Here we investigated the clinical utility of vascular endothelial growth factor (VEGF) as a predictive biomarker for aggressive BCC variants.

Methods

Thirty-five pathologically confirmed cases of BCC that underwent surgical removal in the Plastic Surgery Department between January 1, 2011 and December 31, 2012 were studied. VEGF expression was analyzed in formalin-fixed paraffin-embedded tumor tissue by immunohistochemical staining. Positive staining was defined as more than 10% of the tumor cells showing immunoreactivity. The associations of VEGF expression with various clinicopathologic parameters were analyzed.

Results

The face was the most prevalent site (28/35), with 15 cases from the nose, 6 cases from the eyelid, and 5 cases from the cheek. The patients were aged between 41 and 86 years, with a mean age of 69.26 ± 173.903 years. The mean BCC size was 1.34 ± 3.853 cm, with a range of 0.3 cm to 12.0 cm. The mean tumor invasion depth from the basement epidermal membrane was 0.17 ± 0.035 cm, with a range of 0.03 cm to 1.10 cm. A mean of 5.66 ± 20.938 intraoperative frozen section slides were examined. VEGF was not expressed in 14 of the 35 patients (40.0%), whereas 42.9% of the patients had low expression and 17.1% of the patients had high expression. VEGF expression was significantly associated with age (P = 0.022), size (P = 0.030), site (P = 0.013), tumor invasion depth (P = 0.019), and number of intraoperatively frozen sections (P = 0.003).

Conclusions

These results suggest that VEGF expression as assessed by immunohistochemistry can predict aggressive or poor prognosis in BCC.

Case reports
IgA nephropathy in a patient with ankylosing spondylitis well controlled with etanercept
Do-Hyeong Lee, Geun-Tae Kim, Na-Kyoung Hwang, Eun-Heui Kim
Kosin Med J. 2018;33(1):85-90.   Published online June 30, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.85
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM

Ankylosing spondylitis (AS) can involve the eye, gastrointestinal system, cardiopulmonary system, skin, kidneys, and spinal and peripheral joints. It is rarely accompanied by immunoglobulin A (IgA) nephropathy. Although IgA is involved in both AS and IgA nephropathy, the relationship between these diseases remains unclear. We detected hematuria and proteinuria in a 32-year-old male patient with ankylosing spondylitis that remained stable for 4 years through treatment with etanercept, a tumor necrosis factor-α (TNF-α) inhibitor, and diagnosed IgA nephropathy through a renal biopsy. IgA nephropathy seems to be less commonly associated with AS disease activity or specific treatment such as TNF-α inhibitor use.

Unilateral Horner's Syndrome following supraclavicular brachial plexus block
Dawoon Oh
Kosin Med J. 2018;33(1):91-95.   Published online June 30, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.91
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM

Supraclavicular brachial plexus block, due to its wide range of indications, is the most widely practiced procedure in anesthesiology. We experienced the case of a 45-year-old female patient who developed unilateral Horner's Syndrome after the use of supraclavicular brachial plexus block. The patient recovered spontaneously from the Horner's syndrome after 2 hours. If Horner's syndrome should occur, its etiology will need to be assessed. It is also important to assure the patient they will recover from the complication within a year.

Fatal neurological complication after liver transplantation in acute hepatic failure patient with hepatic encephalopathy
Joo-Yun Kim, Hyun-Su Ri, Ji-Uk Yoon, Eun-Ji Choi, Hye-Jin Kim, Ju-Yeon Park
Kosin Med J. 2018;33(1):96-104.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.96
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM

Liver transplantation is a current definitive treatment for those with end-stage liver disease. Hepatic encephalopathy is a common complication of hepatic failure, which can be improved and aggravated by various causes. It is important to differentiate hepatic encephalopathy from other diseases causing brain dysfunction such as cerebral hemorrhage, which is also related to high mortality after liver transplant surgery. A 37-year-old patient was presented with acute liver failure and high ammonia levels and seizure-like symptoms. Computed tomography (CT) of his brain showed mild brain atrophy, regarded as a symptom of hepatic encephalopathy, and treated to decrease blood ammonia level. Deceased donor liver transplantation was performed and liver function and ammonia level normalized after surgery, but the patient showed symptoms of involuntary muscle contraction and showed loss of pupil reflex and fixation without recovery of consciousness. Brain CT showed brain edema and bilateral cerebral infarction, and the patient died after a few days. The purpose of this case report is to emphasize the importance of preoperative neurological evaluation, careful transplantation decision, and proper perioperative management of liver transplantation in patients with acute hepatic encephalopathy.

Increased arterial stiffness causing resistant hypertension in an adolescent with Neurofibromatosis type 1
Min Jung Cho
Kosin Med J. 2018;33(1):105-109.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.105
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM

Neurofibromatosis type 1 is an autosomal dominant genetic disorder characterized by the presence of café au lait spots, axillary and inguinal freckling, Lisch nodules, and neurofibromas. Hypertension is a relatively frequent complication, usually caused by renal artery stenosis or pheochromocytomas. We describe the case of a 15-year-old boy with neurofibromatosis type 1 who was also diagnosed with resistant hypertension. Despite an extensive evaluation, the etiology of his hypertension remained indeterminate. Estimation of the brachial-ankle pulse wave velocity and ambulatory arterial stiffness index could validate the existence of arterial stiffness. Further, a combination of carvedilol and angiotension receptor blockers was administered, which successfully controlled his resistant hypertension. We propose that the estimation of the brachial-ankle pulse wave velocity measure and ambulatory arterial stiffness index is a noninvasive method, and these two parameters are relatively simple tools that can be used for the detection of arterial stiffness due to neurofibromatosis type 1-related vasculopathy.

An atypical case of Lemierre syndrome following oropharyngeal infection
Seo Yeon Yang, Hae Yeul Park, Kyoung Hwa Lee, You Jin Chun, Hyo Eun Kim, Seong Han Kim, Su Jin Jeong
Kosin Med J. 2018;33(1):110-116.   Published online January 21, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.110
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM

Lemierre syndrome is characterized by anaerobic bacterial infection in the head and neck and clinical or radiological evidence of internal jugular vein thrombophlebitis. The most common pathogens are Fusobacterium species, particularly Fusobacterium necrophorum. Septic emboli resulting from infected thrombophlebitis of the internal jugular vein leads to metastatic infections involving lung, liver, kidney, bone and central nervous system. The accurate diagnosis and treatment is important because it may be associated with a high mortality rate if untreated. We present a case of 28-year-old man with an atypical history for the diagnosis of Lemierre syndrome, which showed no definite evidence of internal jugular thrombophlebitis.

Pontine Hypoplasia and Cri-du-chat Syndrome in a Preterm Infant
Yu Jin Jung
Kosin Med J. 2018;33(1):117-121.   Published online June 30, 2018
DOI: https://doi.org/10.7180/kmj.2018.33.1.117
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Abstract PDFPubReader   CrossRef-TDMCrossref - TDM

A premature infant with gestational age 36+4 weeks was admitted with respiratory distress syndrome. Surfactant and ventilation were firstly done to improve his respiration. After extubation, weak, high-pitched cry and asymmetric face with micrognathia and hypertelorism were detected. Therefore, cytogenetic analysis was performed, and his karyotype was 46, XY, del(5) (p14p15.33). Pontine hypoplasia was detected on cranial magnetic resonance imaging (MRI). Therefore, karyotyping and cranial MRI should be performed in case of preterm infants with suspicion of Cri-du-chat syndrome (CdCS).


KMJ : Kosin Medical Journal