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Volume 34(1); June 2019
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Original articles
Association between Ischemic Electrocardiographic Changes during Acetylcholine Provocation Test and Long-Term Clinical Outcomes in Patients with Vasospastic Angina
Sung Il Im, Seung-Woon Rha, Byoung Geol Choi, Jin Oh Na, Cheol Ung Choi, Hong Euy Lim, Jin Won Kim, Eung Ju Kim, Chang Gyu Park, Hong Seog Seo
Kosin Med J. 2019;34(1):1-14.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.1
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

Intracoronary injection of acetylcholine (Ach) has been shown to induce significant coronary artery spasm (CAS) in patients with vasospastic angina. Clinical significance and angiographic characteristics of patients with ischemic electrocardiogram (ECG) changes during the Ach provocation test are not clarified yet.

Methods

A total 4,418 consecutive patients underwent coronary angiography with Ach provocation tests from 2004 to 2012 were enrolled. Ischemic ECG changes were defined as transient ST-segment depression or elevation ( > 1 mm) and T inversion with/without chest pain. Finally, a total 2,293 patients (28.5% of total subjects) proven CAS were enrolled for this study.

Results

A total 119 patients (5.2%) showed ECG changes during Ach provocation tests. The baseline clinical and procedural characteristics are well balanced between the two groups. Ischemic ECG change group showed more frequent chest pain, higher incidence of baseline spasm, severe vasospasm, multi-vessel involvement, and more diffuse spasm ( > 30 mm) than those without ischemic ECG changes. At 5 years, the incidences of death, major adverse cardiac events (MACE) and major adverse cardiac and cerebral events (MACCE) were higher in the ischemic ECG change group despite of optimal medical therapy.

Conclusions

The patients with ischemic ECG changes during Ach provocation tests were associated with more frequent chest pain, baseline spasm, diffuse, severe and multi-vessel spasm than patients without ischemic ECG changes. At 5-years, the incidences of death, MACE and MACCE were higher in the ischemic ECG change group, suggesting more intensive medical therapy with close clinical follow up will be required.

Prognostic Value of Procalcitonin in Pneumonia among Patients Admitted to Intensive Care Unit.
Deok Hee Kim, Hae Won Jung, Hyung Koo Kang
Kosin Med J. 2019;34(1):15-23.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.15
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

Pneumonia is one of the leading causes of death in the intensive care unit (ICU). Many biomarkers for predicted prognosis have been suggested; among these, procalcitonin (PCT) is known to increase in cases of bacterial infection. However, there have been many debates regarding whether PCT is an appropriate prognostic marker for pneumonia. Therefore, we investigated whether PCT can serve as a biomarker for pneumonia, and compared it with CURB-65, which is a known tool for predicting the prognosis of pneumonia.

Methods

Levels of PCT and CURB-65 scores were compared between 30-day non-survival (n = 30) and survival (n = 101) patients. Relationships between PCT and CURB-65 were determined by using linear regression analysis, as well as by using receiver operating characteristic (ROC) curve analysis and calculation of the area under the curve (AUC). High and low PCT groups were compared.

Results

High PCT and high CURB-65 score were positively associated with 30-day mortality. For the prediction of 30-day mortality, initial PCT and CURB-65 exhibited AUCs of 0.63 and 0.66; these were not significantly different (P = 0.132). We found that the high PCT group had a higher rate of initial treatment failure (91%, P = 0.004).

Conclusions

Initial PCT can be a prognostic biomarker for mortality in severe pneumonia, similar to the CURB-65 score. Initial high PCT was positively associated with initial treatment failure.

The Effectiveness of Dexmedetomidine in Vacuum-Assisted Breast Biopsy Under Monitored Anesthesia Care
Kyung Woo Kim, Jun Ha Park, Seunghwan Kim, Eun Jin Ahn, Hyo Jin Kim, Hey Ran Choi, Yeo Goo Chang, Si Ra Bang
Kosin Med J. 2019;34(1):24-29.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.24
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

Vacuum-assisted breast biopsy (VABB) is a widely used technique for the diagnosis of breast lesions. It is carried out with local anesthesia, but procedural pain and stress are still problematic. Dexmedetomidine is a α-2 receptor agonist that can sedate without significant respiratory depression. The study aimed to report the effectiveness of sedation with monitored anesthesia care (MAC) using dexmedetomidine in VABB.

Methods

This was a retrospective chart review of patients who received VABB under MAC with dexmedetomidine. Forty-seven patients during the period of February 2015 to July 2016 were included. We collected data on patient characteristics, infusion drug and dose, induction to incision time, anesthetic, operation, and recovery time and other complications and vital signs.

Results

The mean operating time was 50.1 ± 24.9 minutes, and the anesthetic time was 71.2 ± 28.3 minutes. The mean time from induction to incision was 17.0 ± 5.2 minutes, and the recovery time was 20.1 ± 10.3 minutes. None of the patients needed an advanced airway management. Further, none of them showed hemodynamic instability.

Conclusions

VABB was successfully performed with MAC using dexmedetomidine, and there was no respiratory depression or hemodynamic instability.

Gamma Knife Radiosurgery in Recurrent Trigeminal Neuralgia after Other Procedures
Jae Meen Lee, Beong Ik Hur, Chang Hwa Choi
Kosin Med J. 2019;34(1):30-37.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.30
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

Trigeminal neuralgia (TN) is undurable paroxysmal pain in the distribution of the fifth cranial nerve. Invasive treatment modalities for TN include microvascular decompression (MVD) and percutaneous procedures, such as, radiofrequency rhizotomy (RFR). Gamma Knife radiosurgery (GKRS) is a considerable option for patients with pain recurrence after an initial procedure. This study was undertaken to analyze the effects of gamma knife radiosurgery in recurrent TN after other procedures.

Methods

Eleven recurrent TN patients after other procedures underwent GKRS in our hospital from September 2004 to August 2016. Seven patients had previously undergone MVD alone, two underwent MVD with partial sensory rhizotomy (PSR), and two underwent RFR. Mean patient age was 60.5 years. We retrospectively analyzed patient's characteristics, clinical results, sites, and divisions of pain. Outcomes were evaluated using the Visual Analog Scales (VAS) score.

Results

Right sides were more prevalent than left sides (7:4). The most common distribution of pain was V1 + V2 division (n = 5) following V2 + V3 (n = 3), V2 (n = 2), and V1 + V2 + V3 (n = 1) division. Median GKRS dose was 80 Gy and the mean interval between the prior treatment and GKRS was 74.45 months. The final outcomes of subsequent GKRS were satisfactory in most cases, and at 12 months postoperatively ten patients (90.0%) had a VAS score of ≤ 3.

Conclusions

In this study, the clinical result of GKRS was satisfactory. Invasive procedures, such as, MVD, RFR are initially effective in TN patients, but GKRS provides a safe and satisfactory treatment modality for those who recurred after prior invasive treatments.

Comparative Study of Dynamic Susceptibility Contrast Perfusion MR Images between Warthin's Tumor and Malignant Parotid Tumors
Shin Young Park, Hak Jin Kim, Wonjae Cha
Kosin Med J. 2019;34(1):38-46.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.38
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM
Objectives

To identify diagnostically meaningful differences between Warthin's tumor and malignant masses in the parotid gland by dynamic susceptibility contrast (DSC) MR imaging.

Methods

Eleven malignant parotid tumors and 9 Warthin's tumors were included. MR imaging was performed on all patients. Signal intensity time curves of tumors were obtained by DSC MR imaging and dynamic susceptibility contrast percentages (DSC%) were calculated.

Results

No significant difference was observed between malignant tumors and Warthin's tumors (P = 0.437), although DSC% values tended to be higher for Warthin's tumors.

Conclusions

Warthin's tumor tended to have higher DSC% values than malignant parotid tumors, but this difference was not significantly different.

Case reports
Lethal Cardiac Complications in a Long-Term Survivor of Spinal Muscular Atrophy Type 1
Min-Jung Cho
Kosin Med J. 2019;34(1):47-51.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.47
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Spinal muscular atrophy (SMA) is a rare neuromuscular disease characterized by degeneration of the anterior horn cells of the spinal cord and motor nuclei in the lower brainstem, resulting in hypotonia, progressive proximal muscle weakness, paralysis, and progressive respiratory insufficiency. We report the case of a 6-year-old girl diagnosed with spinal muscular atrophy type 1 (Werdnig-Hoffman disease) who has been treated at home with non-invasive ventilation (assist-control mode with a back-up respiratory rate of 26 per minute). She presented with an atrioventricular block and atrial fibrillation, as well as paroxysmal fluctuation of blood pressure and heart rate indicating autonomic dysfunction. Although it is known that patients with spinal muscular atrophy type 1 do not generally demonstrate cardiac problems, it can be concluded based on findings in our case that long-term survivors with spinal muscular atrophy type 1 may develop cardiac rhythm disturbances. We therefore recommend that the possibility of cardiac complications and autonomic dysfunction should be borne in mind in the management of such patients.

Advantages of Using Ultrasound in Regional Anesthesia for a Super-Super Obese Patient
Woo Jae Yim, Kyoung Sub Yoon, Jeong In Hong, Sang Yoong Park, So Ron Choi, Jong Hwan Lee
Kosin Med J. 2019;34(1):52-56.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.52
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

In this case report, we describe the use of ultrasound in the administration regional anesthesia for a super-super obese patient. A 23-year-old female patient (height 167.2 cm, weight 191.5 kg, body mass index 68.6 kg/m2) was admitted to the hospital for surgical repair of an anterior talofibular ligament rupture. We used ultrasound to help facilitate the administration of regional anesthesia. In the sagittal view of the lumbar spine, (with the patient in a sitting position) we were able to identify the border between the sacrum and the lumbar vertebral; in the transverse view, we were able to identify the transverse process, posterior dura, vertebral body, and the distance from the skin to the posterior dura. After skin marking, regional anesthesia was successfully performed. Based on this case study, we suggest that ultrasound can be very useful in regional anesthesia for severely obese patients.

Mycoplasma Pneumoniae-Associated Necrotizing Pneumonia in Children: a case-report
Chan ho Lee, So Yoon Jo, Keon Woo Na, Sung Won Kim, Yoon Ha Hwang
Kosin Med J. 2019;34(1):57-64.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.57
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Mycoplasma pneumoniae is the most common bacterial strain causing atypical pneumonia in children and adolencents. Although it is known to cause mild symptoms, it can also cause severe pulmonary or extrapulmonary complications in rare cases. Necrotizing pneumonia (NP) is often reported as a complication of Streptococcus pneumoniae and is very rarely caused by M. pneumoniae. We report a case in which a 5-year-old boy was diagnosed with lobar pneumonia with symptoms that aggravated even with macrolide antibiotic treatment. Anti-mycoplasma pneumoniae Ig-M test yielded high values, and direct polymerase chain reaction results were also positive. NP caused by M. pneumoniae was confirmed on computed tomography. After treatment involving tosufloxacin and systemic steroid, the lesion decreased in size and improved gradually when followed-up for more than 1 year. The patient did not have any predisposing or risk factors for NP.

Persistent Complete Atrioventricular Block after Induction of General Anesthesia in a Healthy Patient
Gyeong-Jo Byeon, Hye-Jin Kim, Hyun-Su Ri, Su Sung Lee, Hee Young Kim
Kosin Med J. 2019;34(1):65-71.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.65
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

A 38-year-old female patient had bradycardia in the preoperative electrocardiogram (ECG), and she showed severe bradycardia, with the heart rate (HR) under 40 beats per minute (bpm) even after arrival in the operating room. Immediately after endotracheal intubation, ventricular tachycardia with HR over 200 bpm occurred, but it disappeared voluntarily. The surgery was postponed for additional cardiac evaluation because of the persistent severe bradycardia. On postanesthesia day 2, complete atrioventricular (AV) block appeared. We expected spontaneous recovery over 2 weeks, but the complete AV block persisted. A permanent pacemaker was eventually inserted, and the patient was discharged without other complications on day 4 after insertion of the pacemaker. We report this case because complete AV block has commonly occurred in patients with risk factors such as first AV block, secondary AV block, or bundle branch block, but complete AV block has occurred despite the absence of arrhythmia in this patient.

A Case of an Infant Diagnosed with Cow's Milk Allergy and Concurrent Meat Allergy via ImmunoCAP ISAC®
So Yoon Jo, Chan Ho Lee, Sung Won Kim, Yoon Ha Hwang
Kosin Med J. 2019;34(1):72-77.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.72
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

Approximately 13–20% of infants with milk allergies concurrently exhibit beef allergies. Here, we report a 24-month-old infant who exhibited both pork and beef allergies, concurrently with a milk allergy. The infant's laboratory test results were: 3.73 ISU-E (ISAC standardized unit for IgE) for cow milk β-lactoglobulin, 23.8 ISU-E for casein, 12.8 ISU-E for cow milk Bos d 6 of serum albumin, and 4.85 ISU-E for cat Fel d 2. This case report summarizes an infant patient diagnosed with a meat allergy that was associated with cow's milk allergy, using ImmunoCAP ISAC®. Not only ImmunoCAP ISAC® but also immunocap can be used to diagnose milk allergy and meat allergy at the same time, immunocap testing for component antigen is rare. ImmunoCAP ISAC® is used to diagnose these allergies in our case study, as it has advantage that only 1ml of blood is needed to run various component antigen tests.

A Case of Malignant Lymphoma Misdiagnosed as Acute Tonsillitis with Subsequent Lymphadenitis
Young Chul Kim, Minsu Kwon, Jin Pyeong Kim, Jung Je Park
Kosin Med J. 2019;34(1):78-82.   Published online June 30, 2019
DOI: https://doi.org/10.7180/kmj.2019.34.1.78
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Abstract PDFPubReader   ePub   CrossRef-TDMCrossref - TDM

A 56-year-old female presented with clinical features of acute tonsillitis with subsequent cervical lymphadenitis. After taking empirical antibiotics for 1 week, the acute infection symptoms and signs were resolved. However, an asymmetric enlargement of the left palatine tonsil with ipsilateral neck swelling remained. Subsequent tonsillectomy and lymph node excisional biopsy were performed due to the possibility of malignancy. The patient was eventually diagnosed as malignant lymphoma according to pathological confirmation. We demonstrate the diagnostic challenges in such a rare case and emphasize the importance of differentiating malignant lymphoma from an atypically presenting acute infectious disease.


KMJ : Kosin Medical Journal