BACKGROUND: Total obstruction of the left main coronary artery is a common cause of sudden death but is rarely seen in patients who survive to undergo diagnostic evaluation or treatment. METHODS: During twenty six-year period, we encountered 5 patients with chronic total obstruction of the left main coronary artery out of about 4,000 patients who underwent coronary angiography. RESULTS: All patients have undergone coronary bypass surgery. These patients present with increasingly severe angina. A right dominat coronary anatomy is always found, usually with well-developed right-to-left collaterals. Left ventricular function was severely impaired in two patients out of five patients. CONCLUSIONS: The results of surgical revascularization in our patients and others described in the literature can support the safety and efficacy of this approach.
Coronary Angiography ; Coronary Vessels* ; Death, Sudden ; Humans ; Ventricular Function, Left

BACKGROUND: Glucocorticoid-induced osteoporosis is characterized by decreased osteoblastic activity and replacement of bone marrow with adipocytes. Since osteoblast and adipocytes are derived from the same mesenchymal stem cell, one might speculate that there is an interaction between these two cells types. In fact, leptin that is secreted from adipocytes is known to stimulate differentiation of osteoblasts, while it inhibits the differentiation of adipocytes. Furthermore, it has been demonstrated that PPAR is present in osteoblasts and it is increased by leptin in adipocytes. However, the role of PPAR and leptin remains unknown in glucocorticoid-induced osteoporosis. The aims of this study are to investigate the effect of glucocorticoid on bone mineral density and gene expression in osteoblasts and adipocytes, and to study the role of PPAR and leptin in the mechanism of glucocorticoid-induced osteoporosis. METHODS: Methylprednisolone, 1 mg/200 g-weight, was injected into five rats (steroid group) and saline was given to five rats (control group) for eight weeks. The bone mineral density was determined by dual energy X-ray absoptiometry. Gene expression of osteocalcin, alkaline phosphatase, lipoptrotein lipase, and PPAR -2 was assessed by RT-PCR. Serum leptin level was measured using a commercial radioimmunoassay kit. RESULTS: 1) The body weight of the steroid group was significantly lower than that of the control group (451.4+/-12.9 g vs. 247.6+/-19.8 g, p<0.05). The bone mineral density of the steroid group tended to be lower than that of the control group (0.27+/-0.01 g/cm2 vs. 0.26+/-0.01 g/cm2, p>0.05). 2) In the steroid group, the gene expressions of osteocalcin (1.00+/-0.08 vs. 0.23+/-0.16, p<0.05) and alkaline phosphatase (0.47+/-0.07 vs. 0.33+/-0.18, p<0.05) were decreased significantly compared to those in controls. 3) In the steroid group, the gene expression of lipoprotein lipase (0.23+/-0.06 vs. 0.39+/-0.12, p>0.05) and+/-PAR 2 (0.17+/-0.08 vs. 0.22+/-0.12, p>0.05) tended to be increased compared to that in the contol group. 4) The serum leptin level of the steroid group tended to be lower than that of the control group (0.20+/-0.12 g/L vs. 0.10+/-0.09 g/L, p>0.05). CONCLUSION: These data suggest that long-term administration of a large dose of glucocorticoid suppresses differentiation of osteoblasts and enhances the differentiation of adipocytes, which may be mediated by increased expression of PPAR and decreased synthesis of leptin.
Adipocytes ; Alkaline Phosphatase ; Animals ; Body Weight ; Bone Density ; Bone Marrow* ; Gene Expression ; Leptin ; Lipase ; Lipoprotein Lipase ; Mesenchymal Stromal Cells* ; Methylprednisolone ; Osteoblasts ; Osteocalcin ; Osteoporosis ; Peroxisome Proliferator-Activated Receptors ; Radioimmunoassay ; Rats

PURPOSE: Warthin-like papillary carcinomawas named owing to its close histologic resemblance to a tumor encountered in salivary gland, and this tumor is a variant of papillary thyroid carcinoma. Among the variants of papillary thyroid carcinoma, the tall cell variant and diffuse sclerosing variant have more aggressive behavior than the classic papillary carcinoma. But Warthin-like papillary carcinoma arises in a background of thyroiditis and it behaves in an indolent fashion. Since then, a few case have reported in Korea. We report here on the clinicopathologic features of five cases of warthin-like papillary carcinoma. METHODS: From Jan. 1996 to Feb. 2008, five patients who were diagnosed with Warthin-like papillary thyroid carcinoma at YUMC were retrospectively reviewed. RESULTS: All 5 patients whose pathologic features were warthin- likepapillary thyroid carcinoma were women (age range: 34~60 years). The tumor size ranged from 0.6 to 2.4 cm. 3 tumors were confined to the thyroid, but 2 tumors had invaded the strap muscles. 3 of the 5 tumors arose in a background of lymphocytic thyroditis. Central nodal metastases were identified in 2 cases. But no lateral nodal or distant metastasis had occurred. The mean duration of follow- up was 16.5 months (range: 5~50 months). 1 patient died because of lung cancer, and there was no recurrence for the other 4 cases during the follow-up period. CONCLUSION: Although the long-term follow-up data on patients with Warthin-like papillary carcinoma is not available, the clinicopathologic data does not show that Warthin-like papillary carcinoma is any more aggressive than the usual papillary carcinoma.

A 50-year-old male visited the outpatient clinic and complained of fever, poor oral intake, and weight loss. A chest X-ray demonstrated streaky and fibrotic lesions in both lungs, and chest CT revealed multifocal peribronchial patchy ground-glass opacities with septated cystic lesions in both lungs. Cell counts in the bronchoalveolar lavage fluid revealed lymphocyte-dominant leukocytosis, and further analysis of lymphocyte subsets showed a predominance of cytotoxic T cells and few T helper cells. Video-assisted wedge resection of the left upper lobe was performed, and the histologic examination was indicative of a Pneumocystis jirovecii infection. Trimethoprim-sulfamethoxazole (TMP-SMX) was orally administered for 3 weeks; however, the patient complained of cough, and the pneumonia was aggravated in the follow-up chest X-ray and chest CT. Molecular studies demonstrated mutations at codons 55 and 57 of the dihydropteroate synthase (DHPS) gene, which is associated with the resistance to TMP-SMX. Clindamycin-primaquine was subsequently administered for 3 weeks replacing the TMP-SMX. A follow-up chest X-ray showed that the pneumonia was resolving, and the cough was also alleviated. A positive result of HIV immunoassay and elevated titer of HCV RNA indicated HIV infection as an underlying condition. This case highlights the importance of careful monitoring of patients with P. jirovecii pneumonia (PCP) during the course of treatment, and the molecular study of DHPS mutations. Additionally, altering the anti-PCP drug utilized as treatment must be considered when infection with drug-resistant P. jirovecii is suspected. To the best of our knowledge, this is the first case of TMP-SMX-resistant PCP described in Korea.
Anti-Bacterial Agents/*administration & dosage ; Drug Resistance, Bacterial ; Humans ; Lung/microbiology/radiography ; Male ; Middle Aged ; Pneumocystis jirovecii/*drug effects/genetics/isolation & purification/physiology ; Pneumonia/*drug therapy/immunology/microbiology/radiography ; Sulfamethoxazole/*administration & dosage ; Trimethoprim/*administration & dosage

PURPOSE: In a retrospective study for the pediatric patients who underwent liver transplantation in the past 6 years at Samsung Medical Center, the clinical features of 5 patients with posttransplant lymphoproliferative disorder (PTLD) were analyzed. METHODS: Between June 1996 and June 2002, 41 pediatric patients underwent liver transplantation. Seven of them died in the postoperative period. Thirty-five including one patient who died of PTLD were finally reviewed. Patients were divided into two groups: high risk group, EBV naive recipients of EBV-positive grafts; low risk group, the patients other than those in high risk group. The authors reviewed age at operation, immunosuppressive agent, postoperative duration until diagnosis, postoperative duration until EBV seroconversion, presence of treatment against rejection, and presenting symptoms of PTLD. RESULTS: Five of 41 patients (12.2%) developed PTLD. All of them belonged to high risk group, and the incidence of PTLD in high risk group was 31.3% (5/16). The mean age at operation was 10.8 months old and the mean duration between operation and diagnosis for PTLD was 9.8 months. Primary EBV infection developed after a median of 6 months after transplantation. One patient was diagnosed as laryngeal and gastrointestinal PTLD and the other four, gastrointestinal PTLD. The following symptoms and signs were seen in the patients: anemia (100%), hypoalbuminemia (100%), fever (80%), diarrhea (80%), gastrointestinal bleeding (80%), and anorexia (60%). CONCLUSION: PTLD is one of the major complications after pediatric liver transplantation, especially in the group of high-risk recipients. Anemia, hypoalbuminemia, fever, diarrhea and gastrointestinal bleeding were features that are characteristic of PTLD. The common features of PTLD development were: (i) EBV-positive donors placed into EBV naive recipients, (ii) primary EBV infection about 6 months after transplantation, (iii) young age, about 1 year old at operation, and (iv) the requirement for intensive posttransplant immunosuppression.
Anemia ; Anorexia ; Diagnosis ; Diarrhea ; Epstein-Barr Virus Infections ; Fever ; Hemorrhage ; Herpesvirus 4, Human ; Humans ; Hypoalbuminemia ; Immunosuppression ; Incidence ; Liver Transplantation* ; Liver* ; Lymphoproliferative Disorders* ; Postoperative Period ; Retrospective Studies ; Tissue Donors ; Transplants

PURPOSE: Hepatic allografts from donors with hepatitis B core antibody have been demonstrated to transmit hepatitis B virus (HBV) infection to recipients after liver transplantation (LT). The efficacy of hepatitis B immune globulin (HBIg) to prevent de novo hepatitis B was investigated by comparing active immunization in the early phase to HBIg monotherapy in the late phase of pediatric liver transplants at Samsung Medical Center. METHODS: Among pediatric liver transplants, from May, 1996 to June, 2002, 15 recipients who were hepatitis B surface antigen (HBsAg) (-) received an allograft from a donor with hepatitis B core antibody (HBcAb) (+). Except two who died from unrelated causes, eleven of 13 recipients were HBsAb (+), and 2 were naive (HBsAb(-), HBcAb(-)). All patients were vaccinated for HBV before LT. In the early phase (January, 1997~November, 1997, 3 patients), HBsAb (+) recipients received booster vaccination after LT. In the late phase (December, 1997~, 10 patients), all recipients were given booster vaccination and received HBIg therapy in order to maintain HBsAb titer greater than 200 IU/L. Lamivudine was given in one case because of severe side effect of HBIg. We retrospectively analyzed the effect of the preventive therapy for de novo hepatitis B through medical records. RESULTS: De novo hepatitis B developed in three of 13 recipients (23.1%). All of 3 patients who received active immunization in the early phase became HBsAg (+) at 7~19 months after transplantation. One of them was naive before LT and the other two were HBsAb (+). All of 10 recipients who were given HBIg in the late phase remained HBsAg (-) at 7~55 months' follow-up. CONCLUSION: Passive immunization with HBIg was effective for prevention of de novo hepatitis B in HBsAg (-) recipients of hepatic allografts from HBcAb (+) donors.
Allografts ; Follow-Up Studies ; Hepatitis B Surface Antigens ; Hepatitis B virus ; Hepatitis B* ; Hepatitis* ; Humans ; Immunization, Passive ; Lamivudine ; Liver Transplantation* ; Liver* ; Medical Records ; Retrospective Studies ; Tissue Donors ; Vaccination

Endobronchial hemorrhage is common complication of bronchoscopic biopsy. There are several hemostatic methods including cold saline irrigation, topical vasoactive substance instillation, tranexamic acid treatment, and balloon tamponade. Insertion of balloon catheter into bronchoscopic working channel is relatively simple and useful method for the selective hemostasis. Here, we report a case of 75-year-old female patient who had hemorrhage during endobronchial biopsy with flexible bronchoscopy. Since primary treatments such as cold saline irrigation and epinephrine instillation had been failed to stop hemorrhage, balloon catheter was immediately inserted into the bleeding site for temporal hemostasis. And then, bronchial artery embolization was followed for the additional treatment of hemorrhage. We suggest to use balloon catheter as a bridge therapy before bronchial artery embolization.
Aged ; Balloon Occlusion* ; Biopsy ; Bronchial Arteries* ; Bronchoscopy ; Catheters ; Epinephrine ; Female ; Hemorrhage* ; Hemostasis ; Humans ; Tranexamic Acid

There are three compartments of regional lymph node to which metastases from thyroid cancers can occur: central, lateral, and mediastinal compartment. The mediastinal metastases from thyroid cancers are extremely rare, comparing the relatively common forms of metastases to central or lateral compartments. The importance of complete surgical lymph node dissection of central or lateral compartment for thyroid cancer has been well described, but mediastinal lymph node dissection has been sporadically reported. For mediastinal compartment metastases, operation techniques consist of sternal split, thoracoscopic surgery, or VATS (Video-assisted thoracoscopic surgery). Robotic surgery system was introduced recently with the objective of enhancing the dexterity and view during procedure that uses a videoscope. Many institutions report the experience with minimally invasive resection of mediastinal mass using robotic surgery system. We report that one case of robot-assisted mediastinal lymph node dissection for metastatic papillary thyroid cancer.
Carcinoma, Papillary ; Lymph Node Excision* ; Lymph Nodes* ; Neoplasm Metastasis ; Thoracic Surgery, Video-Assisted ; Thoracoscopy ; Thyroid Gland* ; Thyroid Neoplasms*

PURPOSE: Controversy still exists concerning the extent of neck nodedissection in thyroid carcinoma patients. A modified neck dissection is usually performed for the treatment of thyroid carcinoma patients with positive lateral neck nodes. When performing a neck dissection, removal of the nodes superior to the spinal accessory nerve (level IIB) is difficult and time consuming. This study was performed to determine whether level IIB node dissection is always necessary in therapeutic neck dissection for metastatic papillary thyroid carcinoma. METHODS: A total of 200 neck dissections were performed in 175 papillary thyroid carcinoma patients with positive lateral neck nodes between September 2005 and June 2007. The patterns of lateral neck metastasis were analyzed with respect to neck level, but the level IIB nodes were studied as separate specimens. Potential factors predicting level IIB node metastasis were also evaluated. RESULTS: The most common site of metastasis was level III, showing 95.0% (190/200), followed by level IV 66.0% (132/200), level IIA 54.0% (108/200), and level V 15.5% (31/200). Level IIB metastases were seen in 12 necks (6.0%) and seen only in the necks with positive level IIA nodes. In 11 of the 12 necks, the primary tumors were located in the upper pole of the thyroid. CONCLUSION: Level IIB node dissection is not necessary when there is no level IIA metastasis. Even when there is level IIA metastasis, level IIB node dissection is not always necessary, unlessthe primary tumors are located in the upper pole of the thyroid.
Accessory Nerve ; Humans ; Lymph Node Excision* ; Lymph Nodes* ; Neck Dissection ; Neck* ; Neoplasm Metastasis* ; Thyroid Gland* ; Thyroid Neoplasms*

Anaplastic thyroid carcinoma (ATC) is a rare disease that shows very aggressive behavior. Most ATCs arise from pre-existing thyroid carcinomas. However, anaplastic transformation occurring in metastatic cervical nodes is extremely rare. We report herein on 3 cases of anaplastic transformation of metastatic lateral cervical lymph nodes from primary papillary thyroid carcinoma (PTC), which happened long after the initial surgical treatment. All the patients died of disease within 4 months in spite of aggressive treatment for the lesions. Our experience supports that appropriate lymph node dissection is mandatory at the time of initial surgery even for differentiated thyroid carcinomas.
Humans ; Lymph Node Excision ; Lymph Nodes* ; Rare Diseases ; Thyroid Carcinoma, Anaplastic ; Thyroid Gland* ; Thyroid Neoplasms*