Sorafenib is an emerging therapeutic option for radioactive iodine (RAI)-refractory differentiated thyroid carcinoma. However, the effects of sorafenib as an adjuvant treatment following surgery or radiation on brain metastases from poorly differentiated thyroid carcinoma (PDTC) have never been reported. A 52-year-old patient underwent total thyroidectomy for follicular thyroid carcinoma. Despite high-dose RAI therapy, a neck mass and lung metastases were developed. PDTC was diagnosed by neck mass removal. During adjuvant external beam radiation therapy (EBRT) to the neck, brain metastases developed. After palliative EBRT for brain metastases, the brain tumor size decreased but lung metastases markedly progressed. Off-label sorafenib was used to treat progressive multiple metastatic lesions. Over five months of sorafenib treatment, the sum of the longest diameters for target lesions was decreased by 45% in brain and 13% in lung. Sorafenib can be considered a new adjuvant therapeutic option for metastatic brain lesions from PDTC after EBRT.
Adenocarcinoma, Follicular ; Brain Neoplasms ; Brain* ; Humans ; Iodine ; Lung ; Middle Aged ; Neck ; Neoplasm Metastasis* ; Radiotherapy* ; Thyroid Gland* ; Thyroid Neoplasms* ; Thyroidectomy

The three major forms of treatment for Graves thyrotoxicosis are antithyroid drugs, radioactive iodine therapy and thyroidectomy. Surgery is the definitive treatment for Graves thyrotoxicosis that is generally recommended when other treatments have failed or are contraindicated. Generally, thyrotoxic patients should be euthyroid before surgery to minimize potential complications which usually requires preoperative management with thionamides or inorganic iodine. But several cases of refractory Graves' disease have shown resistance to conventional treatment. Here we report a 40-year-old female patient with Graves' disease who complained of thyrotoxic symptoms for 7 months. Her thyroid function test and thyroid autoantibody profiles were consistent with Graves' disease. One kind of thionamides and beta-blocker were started to control her disease. However, she was resistant to nearly all conventional medical therapies, including beta-blockers, inorganic iodine, and two thionamides. She experienced hepatotoxicity from the thionamides. What was worse is her past history of serious allergic reaction to corticosteroids, which are often used to help control symptoms. A 2-week regimen of high-dose cholestyramine improved her uncontrolled thyrotoxicosis and subsequent thyroidectomy was successfully performed. In conclusion, cholestyramine could be administered as an effective and safe adjunctive agent for preoperative preparation in patients with severe hyperthyroid Graves's disease that is resistant to conventional therapies.
Adrenal Cortex Hormones ; Adult ; Antithyroid Agents ; Cholestyramine Resin* ; Drug Resistance ; Female ; Glycogen Storage Disease Type VI ; Graves Disease* ; Humans ; Hypersensitivity ; Iodine ; Thyroid Function Tests ; Thyroid Gland ; Thyroidectomy* ; Thyrotoxicosis

A hospitalist-run acute medical unit (AMU) opened at a tertiary care hospital on August 2015 for the first time in Korea. Patients visiting the emergency department (ED) with acute medical problems are admitted to the AMU. They stay in that unit for less than 72 hours and are discharged or transferred to specialty wards if longer treatment is necessary. We reviewed 19,450 medical admissions through the ED from January 2014 to September 2016. The median length of stay (LOS) significantly decreased from 10.0 days (interquartile range [IQR], 5.5–16.7) to 9.1 days (IQR, 5.1–15.0) (P < 0.001) after the establishment of the AMU. The median waiting time in the ED significantly shortened by 40% (P < 0.001). Future studies on the impact of AMU on in-patient morbidity, mortality, re-admission rate, and patient or staff satisfaction are necessary.
Emergencies* ; Emergency Service, Hospital* ; Hospital Medicine ; Hospitalists ; Humans ; Korea ; Length of Stay* ; Mortality ; Tertiary Healthcare*

Bevacizumab (Avastin(R)) is a monoclonal antibody against the vascular endothelial growth factor (VEGF) receptor that increases the overall survival rate when added to standard chemotherapy regimens in patients with metastatic colorectal cancer. The known toxicities of bevacizumab are hypertension, proteinuria, wound healing complications, arterial thrombosis, bleeding, and gastrointestinal complications. Especially ischemic colitis can rapidly develop into bowel perforation, so an emergency operation often is needed. Recently, a 65-year-old male patient developed ischemic pancolitis after FOLFOX (85 mg/m2 Oxaliplatin, d1;200 mg/m2 Leucovorin, d1;400 mg/m2 5-FU iv bolus, d1-2;and 600 mg/m2 5-FU, d1-2, every two wk) and Bevacizumab combination chemotherapy was administered. However, he recovered after early conservative care without surgery. We report this case with a review of literature.
Aged ; Antibodies, Monoclonal, Humanized/administration & dosage/*adverse effects ; Antineoplastic Combined Chemotherapy Protocols/therapeutic use ; Colitis, Ischemic/*chemically induced/radiography ; Colorectal Neoplasms/drug therapy/pathology ; Drug Administration Schedule ; Fluorouracil/administration & dosage ; Humans ; Intubation, Gastrointestinal ; Leucovorin/administration & dosage ; Male ; Organoplatinum Compounds/administration & dosage ; Tomography, X-Ray Computed

Background: Romosozumab has shown significant improvement in bone mineral density (BMD) in previously reported trials. However, BMD reflects only bone strength and does not offer insight into the bone microarchitecture. The trabecular bone score (TBS) is a non-invasive tool used to assess bone microarchitecture. Several previous studies have evaluated the efficacy of anti-osteoporotic agents using the TBS. However, data regarding the potency of romosozumab based on the TBS is lacking. This retrospective observational cohort study demonstrated the impact of romosozumab use on the TBS. Methods: The primary outcome was the percentage change in the TBS from baseline to post-treatment. Postmenopausal osteoporosis patients were followed up for 6 and 12 months after romosozumab (210 mg monthly, N =10) and denosumab (60 mg every 6 months, N=21) or ibandronate (150 mg monthly, N=24) treatments, respectively. Patients who had previously used osteoporosis medications were included, if any the washout period was sufficient. Results: The percentage change in TBS from baseline to post-treatment was 2.53±2.98% (6 months, N=10; P=0.04), 0.59%±3.26% (12 months, N=21; P=0.48), and -0.45±3.66% (12 months, N=24; P=0.51) in the romosozumab, denosumab, and ibandronate groups, respectively. Romosozumab demonstrated a noticeable increase in TBS, although it did not reach the least significant change (5.8%) in TBS. Conclusions Romosozumab improved the TBS in postmenopausal women with osteoporosis. TBS may be potentially useful for monitoring romosozumab treatment.

Background: The effects of elevated follicle-stimulating hormone (FSH) levels on physiological changes in the bone remain unclear. This study aimed to clarify the association between FSH concentrations and bone mineral density (BMD) and bone turnover markers (BTM) in late postmenopausal women. Methods: A total of 169 Korean women were enrolled. The participants’ ages ranged from 60 to 84 years (mean age, 69.0±5.1) and reported a mean duration of 19.4±6.6 years since menopause (YSM). The participants showed an average body mass index (BMI) of 24.4±2.8 kg/m2. Age, YSM, estradiol, testosterone, and BMI were confounders in the Pearson's partial correlation. A test for trends across the quartiles of FSH levels was performed for each variable. Results: The mean FSH and estradiol concentrations were 61.5 IU/L and 2.9 pg/mL, respectively. Serum FSH concentration was not significantly associated with BMD (lumbar, r=0.09, P=0.30; total hip, r=0.00, P=0.96; and femoral neck, r=0.05, P=0.62). BTM across the FSH quartiles did not show any trend association (bone-specific alkaline phosphate, P=0.31; crosslinked C-terminal telopeptide of type I collagen, P=0.90). Instead, FSH levels were negatively correlated with BMI (r=-0.34, P=0.00). In the multivariate regression model adjusted for age, testosterone, and estradiol, only BMI showed a negative value across the FSH quartiles (β coefficient -0.11, P=0.00). Conclusions This study identified that high FSH concentrations were not associated with bone loss or high bone turnover in women in the late postmenopausal period.

Background/Aims: Despite the prominence of denosumab as the number one prescribed anti-osteoporosis drug in Korea, the effects of denosumab in male osteoporosis patients were not researched sufficiently. Moreover, concerns on rebound vertebral fractures associated with poor denosumab adherence exist. Methods: We retrospectively evaluated 147 Korean male osteoporosis patients treated with denosumab. After 12 months of treatment, 60 patients were lost during follow-up, and eight were excluded due to missing data. Out of the initial 147 patients, 79 were considered eligible for the analysis of the efficacy of denosumab. 54 patients were initially drug-naïve, and 25 had previously received bisphosphonate therapy. Results: In 54 drug-naïve patients, significant increases in bone mineral density (BMD) were observed in all measurement sites: 5.2% ± 3.7% in the lumbar spine, 2.3% ± 2.8% in the femoral neck, and 1.9% ± 2.8% in the total hip (p < 0.01, respectively). Trabecular bone score showed an increase of 0.5% ± 5.8% in drug-naïve patients. Likewise, in 25 patients with previous bisphosphonate treatment, increase in BMD were observed as well: 4.8% ± 3.5% in the lumbar spine, 1.4% ± 3.6% in the femoral neck, and 0.8% ± 2.1% in the total hip (p < 0.01, p = 0.06, p = 0.06, respectively). Significant declines of –55.1% ± 31.8% in C-terminal telopeptide of type 1 collagen (CTX), and –62.9% ± 21.3% in total procollagen 1 N-terminal propeptide (P1NP), in drug-naïve patients; and –37.7% ± 41.5%, in CTX and –55.4% ± 30.1%, in P1NP in patients with previous bisphosphonate treatment were exhibited after 12 months of treatment. The adherence rates of the second and third dosing schedules were 79.9% and 56.8%, respectively. Conclusions Our study indicates that denosumab is effective in increasing BMD in Korean osteoporosis males regardless of prior bisphosphonate treatment.

BACKGROUND/AIMS: Lymphocytic thyroiditis as cytology diagnosis from fine needle aspiration (FNA) is frequently detected in patients with thyroid nodules. However, the clinical outcome for upcoming hypothyroid events has been rarely clarified in euthyroid patients. METHODS: We retrospectively reviewed the data of patient who had lymphocytic thyroitidis on FNA cytology of thyroid nodule from January 2005 to December 2010 at a tertiary referral hospital. In total, 109 patients with follow-up thyroid function tests (TFT) were enrolled. Final outcomes included overt and subclinical hypothyroidism with thyroid stimulating hormone (TSH) levels ≥ 10 mIU/L. Potential parameters predicting clinical hypothyroidism were analyzed by multivariate analysis. RESULTS: Over the mean follow-up duration of 51.6 months, 14 out of 109 patients (12.8%) developed clinical hypothyroidism that required thyroid hormone replacement. The median onset time to hypothyroidism was 16 months (range, 3 to 88) and ≥ 60% of patients experienced clinical hypothyroidism within 1 year. By multivariate analysis, background thyroiditis (relative risk [RR], 9.78; p = 0.004), thyroid peroxidase antibody positivity (RR, 9.90; p = 0.003), nodule size (RR, 1.24; p < 0.001), and initial TSH (RR, 1.47; p = 0.009) were the independent risk factors for predicting hypothyroidism in euthyroid patients. CONCLUSIONS Hypothyroidism frequently occurs during the follow-up in euthyroid patients with thyroid nodules which show lymphocytic thyroiditis on FNA cytology. Close surveillance and regular TFT are needed in high-risk patients for upcoming clinical hypothyroidism.

Background: Persistence with denosumab in male patients has not been adequately investigated, although poor denosumab persistence is associated with a significant risk of rebound vertebral fractures. Methods: We retrospectively evaluated 294 Korean male osteoporosis patients treated with denosumab at three medical centers and examined their persistence with four doses of denosumab injection over 24 months of treatment. Persistence was defined as the extent to which a patient adhered to denosumab treatment in terms of the prescribed interval and dose, with a permissible gap of 8 weeks. For patients who missed their scheduled treatment appointment(s) during the follow-up period (i.e., no-shows), Cox proportional regression analysis was conducted to explore the factors associated with poor adherence. Several factors were considered, such as age, prior anti-osteoporotic drug use, the treatment provider’s medical specialty, the proximity to the medical center, and financial burdens of treatment. Results: Out of 294 male patients, 77 (26.2%) completed all four sequential rounds of the denosumab treatment. Out of 217 patients who did not complete the denosumab treatment, 138 (63.6%) missed the scheduled treatment(s). Missing treatment was significantly associated with age (odds ratio [OR], 1.03), prior bisphosphonate use (OR, 0.76), and prescription by non-endocrinologists (OR, 2.24). Denosumab was stopped in 44 (20.3%) patients due to medical errors, in 24 (11.1%) patients due to a T-score improvement over –2.5, and in five (2.3%) patients due to expected dental procedures. Conclusion Our study showed that only one-fourth of Korean male osteoporosis patients were fully adherent to 24 months of denosumab treatment.