Jong-Joon Ahn

Corticosteroid treatment in critically ill patients with pandemic influenza A/H1N1 2009 infection: analytic strategy using propensity scores.

RATIONALE Administration of adjuvant corticosteroids to patients with pandemic influenza A/H1N1 2009 (pH1N1) may reduce inflammation and improve outcomes. OBJECTIVES To assess the effect of adjuvant corticosteroid treatment on the outcome of critically ill patients with pH1N1 infection. METHODS All adult patients with confirmed pH1N1 admitted to the intensive care unit of 28 hospitals in South Korea from September 2009 to February 2010 were enrolled. Patients with and without adjuvant corticosteroid treatment were retrospectively compared by two risk stratification models: (1) a retrospective cohort study that used propensity score analysis to adjust for confounding by treatment assignment and (2) a propensity-matched case-control study. MEASUREMENTS AND MAIN RESULTS A total of 245 patients were enrolled in the cohort study, 107 of whom (44%) received adjuvant steroid treatment. In the cohort study, the 90-day mortality rate of patients given steroids (58%, 62 of 107) was significantly higher than that of those not given steroids (27%, 37 of 138) (P < 0.001). The steroid group was more likely to have superinfection such as secondary bacterial pneumonia or invasive fungal infection, and had more prolonged intensive care unit stays than the no-steroid group. Multivariate analysis indicated that steroid treatment was associated with increased 90-day mortality when independent predictors for 90-day mortality and propensity score were considered (adjusted odds ratio, 2.20; 95% confidence interval, 1.03-4.71). In the case-control study, the 90-day mortality rate in the steroid group was 54% (35 of 65) and 31% (20 of 65) in the no-steroid group (McNemar test, P = 0.004). CONCLUSIONS Adjuvant corticosteroids were significantly associated with higher mortality in critically ill patients with pH1N1 infection.

Nutritional status and disease severity in patients with chronic obstructive pulmonary disease (COPD)

The purpose of this study was to identify the relationship between nutritional status and the severity of the disease in patients with COPD in South Korea. This study used pretest data from a larger intervention study. Data were collected from March to October 2010, and 251 patients diagnosed with COPD from five hospitals in South Korea were included in the analysis. All participants were interviewed face-to-face. Actual dietary intake was measured by a 24-h dietary recall, and the body mass index (BMI), obstruction of the airway (FEV1% predicted), degree of dyspnea (modified Medical Research Council: MMRC), and exercise capacity (6min walking distance: 6MWD) (BODE) index was calculated to estimate the severity of the condition. Lower BODE index scores indicate lower risk of mortality. The data were analyzed by descriptive statistics, a χ(2) test, t-tests, analysis of variance (ANOVA), Pearson correlation, and hierarchical multiple regression using SPSS 18.0. The mean age of the participants was 66.83 years and 92.4% of the participants were men. The mean total energy intake was 1431.65kcal, and the mean BODE index score was 2.89. Total energy intake significantly explained additional variance in BODE, BMI, the severity of the perceived dyspnea, and the length of 6min walk after controlling for age, duration after diagnosed with COPD, and physical activities. The findings of this study emphasized the importance of calorie intake in the disease severity among COPD patients. Further research on the effects of nutritional intervention on the health outcomes of patients with COPD is warranted.

A Case of Atypical Skull Base Osteomyelitis with Septic Pulmonary Embolism

Skull base osteomyelitis (SBO) is difficult to diagnose when a patient presents with multiple cranial nerve palsies but no obvious infectious focus. There is no report about SBO with septic pulmonary embolism. A 51-yr-old man presented to our hospital with headache, hoarseness, dysphagia, frequent choking, fever, cough, and sputum production. He was diagnosed of having masked mastoiditis complicated by SBO with multiple cranial nerve palsies, sigmoid sinus thrombosis, and septic pulmonary embolism. We successfully treated him with antibiotics and anticoagulants alone, with no surgical intervention. His neurologic deficits were completely recovered. Decrease of pulmonary nodules and thrombus in the sinus was evident on the follow-up imaging one month later. In selected cases of intracranial complications of SBO and septic pulmonary embolism, secondary to mastoiditis with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld.

Orthostatic hypacusis in a patient with CSF hypovolaemia

The syndrome of CSF hypovolaemia has been a recognized cause of orthostatic headache (a headache in the upright position relieved by recumbancy) (1– 3). Among other clinical manifestations, a change in hearing has also been described in this syndrome (1, 2, 4, 5). However, the pathogenesis of hearing changes in CSF hypovolaemia is unclear. We report a patient with CSF hypovolaemia who had orthostatic hypacusis (hearing impairment in the upright position relieved by recumbancy) that was clearly demonstrated by pure tone audiometry. The anatomical and physiological relationship between CSF space and inner ear structure may explain the pathogenesis of orthostatic hypacusis in CSF hypovolaemia.

Predictors of low levels of self-efficacy among patients with chronic obstructive pulmonary disease in South Korea

The aim of this study was to identify related factors of low levels of self-efficacy in patients with Chronic Obstructive Pulmonary Disease (COPD). A cross-sectional research design used descriptive statistics, χ(2) test, t-test, and binary logistic regression. Two hundred and forty-five patients with COPD were recruited from five hospitals in South Korea. The COPD Self-Efficacy Scale, the Bristol COPD Knowledge Questionnaire, Personal Resource Questionnaire 2000, BODE index, and the International Physical Activity Questionnaire short version were utilized to assess self-efficacy, disease-related knowledge, social support, disease severity, and physical activity, respectively. The BODE index, affect-oriented coping, and duration since diagnosis of COPD were included as significant predictors of self-efficacy. These findings suggest possible screening methods to identify patients with low levels of self-efficacy and future intervention targeting for these patients would strengthen the efficiency of an intervention.

Hemothorax caused by spontaneous rupture of a metastatic mediastinal lymph node in hepatocellular carcinoma: a case report.

To the Editor, The frequency of massive hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma (HCC) has been reported to be 10% to 18% because of the extensive vascular structure and relatively small amount of fibrous tissue in these tumors [1]. Hemothorax caused by rupture of a lung or pleural metastasis of HCC occurs less frequently. Although one case of cardiac tamponade caused by spontaneous rupture of a metastatic mediastinal lymph node (MLN) has been described [2], to our knowledge, no case of hemothorax due to spontaneous rupture of a metastatic MLN of HCC has been reported in the Korean- or English-language literature. We describe here a case of massive hemothorax due to spontaneous rupture of a metastatic MLN in HCC. A 60-year-old male Korean farmer was brought to the Department of Emergency, Ulsan University Hospital with dyspnea and left pleuritic chest pain within 6 hours after symptom onset. Six years earlier, he was diagnosed with chronic hepatitis B-related cirrhosis and 4 years earlier he had been diagnosed with HCC (Fig. 1A) and underwent a right hepatic lobectomy. Multiple metastatic pulmonary nodules were detected 3 months after the surgery and the patient received six cycles of a cisplatin-based chemotherapy regimen over 6 months. Contrast-enhanced computed tomography (CT) scanning showed complete disappearance of the multiple metastatic lung nodules after chemotherapy. At 8 months after finishing the chemotherapy, however, he was readmitted to our hospital due to a single metastatic nodule in the left lower lobe of the lung and underwent metastasectomy with video-assisted thoracoscopic surgery (VATS). Pathological examination of the lung nodule removed showed results consistent with metastatic HCC. Figure 1 Chest computed tomography scans showing (A) a 10-cm sized intrahepatic peripheral capsular enhanced mass, (B) a single enlarged lymph node (white arrow) in the left inferior pulmonary ligament, and (C) a 73 × 84-mm ruptured low-attenuated central ... At 1 year before admission, CT images of the chest showed a single enlarged lymph node (LN) in the left inferior pulmonary ligament, regarded as a metastatic MLN of HCC (Fig. 1B). Two weeks before this admission, follow-up CT images showed enlargement of the metastatic MLN, and the patient was scheduled for additional chemotherapy. On the day of admission, the patient experienced an abrupt onset of dyspnea and left pleuritic chest pain. Physical examination on admission revealed an acutely ill-looking man with body temperature of 36.5℃, pulse rate of 130 beats per minute, blood pressure of 100/70 mmHg, and a respiration rate of 32 breaths per minute. Laboratory test results included hemoglobin 12.3 g/dL, hematocrit 33.4%, white blood cell count 4.37 × 103/µL, platelet count 9.9 × 104/µL, aspartate aminotransferase 47 IU/L, alanine aminotransferase 60 IU/L, total bilirubin 2.0 mg/dL, albumin 3.2 mg/dL, and α-fetoprotein 819.2 ng/mL. Chest X-rays showed a massive left-sided pleural effusion, with the trachea deviated to the right side. Massive hemothorax was diagnosed by thoracentesis. CT images of the chest revealed a 73 × 84 mm-sized ruptured low-attenuated central necrotic mass with massive left side hemothorax (Fig. 1C). A chest tube was inserted and approximately 1,200 mL of bloody fluid was drained. Arteriography of the bronchial arteries revealed a massive ruptured LN in the left inferior pulmonary ligament, to which blood was supplied by an accessory bronchial artery originating 10 cm beneath the left bronchial artery. These findings indicated that the massive hemothorax was caused by a spontaneous rupture of a metastatic MLN of HCC into the intrapleural space. Transcatheter arterial embolization (TAE) of the left bronchial artery was performed successfully, injecting 13 mL of lipiodol ultraf luide (Guerbet, Aulnay-sous-Bois, France) and 30 mg of adriamycin (doxorubicin hydrochloride) with polyvinyl alcohol particles (contour emboli, Interventional Therapeutics Corp., Fremont, CA, USA) (Fig. 1D). No complication was observed and the pleural effusion gradually disappeared thereafter. The patients dyspnea improved, as did his physical condition. Following removal of the chest tube, he was discharged after 15 days in the hospital and was followed monthly as an outpatient at the department of oncology for 3 months. Serial chest X-rays revealed a decrease in the size of the MLN with lipiodol embolization. Four months later, however, the patient died at home. Due to its vascular structure and relatively small amount of fibrous tissue, spontaneous rupture of HCC is not uncommon [1]. Rupture of HCC is considered a medical emergency and is associated with high mortality. HCC frequently metastasizes, most often to the lungs, LNs, bones, and adrenal glands. Moreover, HCC metastases, like the primary tumors, may rupture spontaneously. Sohara et al. [3] reviewed 10 cases with HCC complicated by hemothorax, including four case reports in Japanese, describing patients with metastasis to the chest wall and rib, lung, pleura, diaphragm, and MLN [4]. Those reports included the first case of hemothorax from spontaneous rupture of a mediastinal metastasis [4]. Common clinical presentations are chest pain and dyspnea initially [3]. Other signs are palpitations and hypotension, consistent with hypovolemic shock. Reported rare signs included massive hemoptysis and respiratory failure. Our patient also developed hemothorax with sudden-onset chest pain, dyspnea, and tachycardia. Ruptured HCC can be treated surgically or by TAE, with the latter now used widely for HCC ruptured into the peritoneal cavity. Masumoto et al. [5] first reported hemothorax due to HCC rupture successfully controlled by TAE and our case was also successfully controlled using TAE. On the other hand, surgically treated and untreated failures have been reported and drainage-only cases do allow complete control [3]. Our patient had been diagnosed with HCC 4 years earlier and had undergone various treatments, including right hepatic lobectomy, six cycles of chemotherapy for multiple lung metastases, VATS metastasectomy for a single metastasis in the lung, and TAE for rupture of metastatic MLN causing massive hemothorax. TAE was effective, in that bleeding was successfully controlled and pleural effusion did not recur. Our findings suggest that patients with HCC should be closely monitored and suitably managed to improve survival. In conclusion, this is the first report of hemothorax secondary to spontaneous rupture of metastatic MLN of HCC in the Korean- or English-language literature. The hemothorax was successfully treated with TAE. The various manifestations observed in patients with HCC suggest the need for careful monitoring and suitable management.

A Case of Alveolar Soft Part Sarcoma of the Pleura

Alveolar soft part sarcoma (ASPS) is a rare malignant soft-tissue neoplasm of unknown histogenesis. The two main sites of occurrence are the lower extremities in adults and the head and neck in children. We report the first case of pleural ASPS occurring in a 58-yr-old man who presented with progressive dyspnea. A computed tomographic scan of the thorax revealed a large enhancing pleural mass with pleural effusion in the left hemithorax. Wide excision of the pleural mass was performed. Histologically, the tumor consisted of organoid nests of large polygonal cells, the cytoplasm of which had eosinophilic and D-PAS positive granules. Immunohistochemical staining showed that the tumor cell nuclei were positive for transcription factor 3 (TFE3). The pleural ASPS with multiple bone metastases recurred 1 yr after surgery and the patient died of acute pulmonary embolism 1.5 yr after diagnosis.

Prospective phase II trial of a combination of gemcitabine and UFT as first-line treatment in elderly patients with advanced non-small cell lung cancer.

BACKGROUND The standard regimen in elderly patients with non-small-cell lung cancer (NSCLC) is still uncertain. Gemcitabine is one of the most widely used drugs for the treatment of NSCLC, and several phase II trials specifically designed for elderly patients with advanced NSCLC have confirmed the role of gemcitabine in this setting. In addition, oral uracil-tegafur (UFT) was associated with a survival advantage in the adjuvant setting. Therefore, we performed a phase II study using the combination of gemcitabine and UFT as first-line therapy in elderly patients with advanced NSCLC. METHODS Chemotherapy-naïve, elderly (≥ 70 years) patients who had histologically or cytologically confirmed with stage IIIB or IV NSCLC with a performance status of 1-2 were enrolled. Patients received gemcitabine (1250 mg/m(2) on days 1 and 8, respectively) and UFT (400mg/day on days 1-14) every 3 weeks for up to four cycles. Patients who had not progressed after four cycles continued UFT monotherapy until progression. Primary endpoint was overall response rate and secondary endpoints were overall survival, time to progression and safety profiles. RESULTS Between March 2008 and November 2010, 48 patients were enrolled. The median age was 74.5 years (range: 70-84 years), and there were 29 males. The performance status was 1 in 41 and 2 in 7 patients. Thirty-one (64.6%) patients were stage IV and seventeen (35.4%) patients were stage IIIB. Thirty patients (62.5%) completed four cycles of chemotherapy. Response was evaluated in 44 patients. Partial response was achieved in twelve (25.0%) patients and stable disease in 23 (47.9%) patients. Disease control rate was 72.9%. The median survival time was 6.1 months (95% confidence interval [CI]; 5.1-7.0 months), the 1-year survival rate was 29.1% and the median time to progression was 4.6 months (95% CI; 3.7-5.5 months). Toxicities were mild and mostly hematological adverse events. Grade 3/4 neutropenia occurred in 8.3% of patients and one patients experienced febrile neutropenia. Grade 3/4 anemia and thrombocytopenia occurred in 2.1% and 2.1% of patients, respectively. Non-hematological toxicities were tolerable. CONCLUSIONS The combination of gemcitabine and UFT was effective in disease control and well tolerated first-line regimen in elderly patients with advanced NSCLC.

Mediastinal Bronchogenic Cysts : Demonstration of Fluid-Fluid Level in Bronchoscopic US Imaging.

We report the findings for 2 patients with a fluid-fluid level seen on endobronchial ultrasound (EBUS) images of bronchogenic cysts. The EBUS images demonstrated a well-circumscribed cyst with a fluid-fluid level showing an anechoic upper part and a relatively hyperechoic lower part. A fluid-fluid level on EBUS imaging of a bronchogenic cyst, which can help confirm the cystic nature of the lesion, has not been previously reported. EBUS-based confirmation of these cysts using fluid-fluid levels may help avoid unnecessary aspiration of the lesions.

Non-infected and Infected Bronchogenic Cyst: The Correlation of Image Findings with Cyst Content.

We hereby report a case on bronchogenic cyst which is initially non-infected, then becomes infected after bronchoscopic ultrasound (US)-guided transesophageal fine-needle aspiration (FNA). The non-infected bronchogenic cyst appears to be filled with relatively echogenic materials on US, and the aspirate is a whitish jelly-like fluid. Upon contrast-enhanced MRI of the infected bronchogenic cyst, a T1-weighted image shows low signal intensity and a T2-weighted image shows high signal intensity, with no enhancements of the cyst contents, but enhancements of the thickened cystic wall. The patient then undergo video-assisted thoracic surgery 14 days after the FNA. The cystic mass is known to be completely removed, and the aspirate is yellowish and purulent. To understand the image findings that pertain to the gross appearance of the cyst contents will help to diagnose bronchogenic cysts in the future.