Gallstone is a common disease with a prevalence of about 10%, but biliary ileus is a rare entity with a frequency of about 1% for all the symptomatic patients. We are reporting on a case of perforated terminal ileum that was due to gallstone, and this was without any associated intestinal obstruction or bilioenteric fistula. A 76 year old man presented with a history of jaundice and dark colored urine for a 3-month duration with no clinical features of intestinal obstruction. There was no past history of biliary tract disease. The abdominal radiograph demonstrated no biliary stones or classical findings of gallstone ileus, but there was a suspicion of cholangiocarcinoma. Laparotomy was performed. A perforation of terminal ileum was identified in the mesenteric border of the terminal ileum and adjacent to ileocecal valve, and it was wrapped by omentum. A small 1.5 cm sized stone was impacted in the mesentery at the site of the perforation. The perforation site was closed. Cholecystectomy and proximal common bile duct resection with Roux-en-Y choledochojejunostomy was then performed.
Aged ; Biliary Tract Diseases ; Cholangiocarcinoma ; Cholecystectomy ; Choledochostomy ; Common Bile Duct ; Fistula ; Gallstones* ; Humans ; Ileocecal Valve ; Ileum* ; Ileus ; Intestinal Obstruction ; Jaundice ; Laparotomy ; Mesentery ; Omentum ; Prevalence

PURPOSE: Recently, laparoscopic appendectomy (LA) has been widely performed in developed countries. In addition, minimally invasive surgery such as LA is a challenge to surgical residents. The aim of this study is to evaluate learning curve of residents in comparison to that of experienced surgeons. METHODS: Fifty cases of LA that were performed by experienced surgeons (group A) and forty-seven cases of LA that were performed by 8 residents (group B) were reviewed retrospectively. RESULTS: Operative time was longer in group B (50.8+/-12 vs. 82.8+/-40 min. P<0.001). Hospital days of group B was shorter (4.8+/-2.4 vs. 3.7+/-2.1 days P=0.021). No other parameters were statistically significant. In group A, wound infection developed in 1 case. In group B, wound infection developed in 4 cases, intraabdominal abscess in 1, subcutaneous emphysema in 1. CONCLUSION: Inexperienced surgeons can perform laparoscopic appendectomy easily in the early days of individual laparoscopic training course.
Abscess ; Appendectomy ; Developed Countries ; Learning Curve ; Operative Time ; Retrospective Studies ; Subcutaneous Emphysema ; Wound Infection

PURPOSE: Despite the reduced incidence and mortality of gastric cancer, this illness still remains the second leading cause of cancer death in Korea. Various adjuvant chemotherapies have been proposed for patients with advanced gastric cancer. Randomized trials comparing chemotherapies with best supportive care have consistently shown that cytotoxic treatment is of some benefit. Nevertheless, there has been no major improvement in the overall prognosis of advanced gastric cancer. METHODS: We have examined the chemotherapy sensitivity of advanced gastric cancer specimens by using an ex vivo ATP based chemosensitivity assay (ATP-TCA). A variety of chemotherapeutic agents were tested. The one hundred and forty specimens we tested were from resection specimens. RESULTS: The histological tumor classification, lymphatic invasion, neural invasion and venous invasion affected the chemosensitivity of some drugs. 5-FU was a more potent drug than cisplatin, doxorubicin, iriontecan and methotrexate. The chemosensitivity of differentiated cancer was different compared to that of undifferentiated cancer. Doxorubicin and iriontecan were more effective in poorly differentiated, signet ring cell and diffuse type cancers. The manner of tumor invasion affected the chemosensitivity to some drugs. CONCLUSISON: Further study is necessary to assess the effectiveness of some chemotherapy drugs on advanced gastric cancer, including their effect on tumor recurrence and patient survival.
Adenosine Triphosphate ; Cisplatin ; Doxorubicin ; Fluorouracil ; Humans ; Incidence ; Korea ; Methotrexate ; Prognosis ; Recurrence ; Stomach Neoplasms

Vocal cord dysfunction (VCD), a condition that frequently mimics or confounds asthma, is characterized by a paradoxical adduction of the vocal cords on inspiration. The apposition of the vocal cords produces airflow obstruction sufficient to cause wheezing, chest tightness, shortness of breath, and cough. Misdiagnosis as asthma has led to inappropriate treatment, most notably with high-dose corticosteroids. Herein we report two cases of VCD who presented with chronic cough and episodic breathlessness, respectively. Flow-volume loops on spirometry were abnormal, with evidence of variable extrathoracic airway obstruction, manifested as flat or truncated inspiratory loops. Laryngoscopy or bronchoscopy demonstrated paradoxical adduction with posterior "chinking" of the vocal cords on inspiration. One case also had asthma and depressive illness. After the diagnosis of VCD, the clinical manifestations resolved with speech therapy and/or psychotherapy. VCD should be suspected in patients with asthma-like symptoms. An early diagnosis avoids unnecessary aggressive management.
Adrenal Cortex Hormones ; Airway Obstruction ; Asthma ; Bronchoscopy ; Cough ; Diagnosis ; Diagnostic Errors ; Dyspnea ; Early Diagnosis ; Humans ; Laryngoscopy ; Psychotherapy ; Respiratory Sounds ; Speech Therapy ; Spirometry ; Thorax ; Vocal Cord Dysfunction* ; Vocal Cords*

BACKGROUND: Several investigators have demonstrated a considerable disagreement between FEV1 and PEFR to assess the severity of airflow obstruction. The purpose of this study was to examine whether the discrepancy between the two measurements affects the assessment in the severity of acute asthma. METHODS: Thirty-five consecutive asthma patients measured both FEV1 and PEFR at 0, 1hr, 1, 3, 5, 7 days of an emergency room admission using a spirometer and a Ferraris PEFR meter. The degree of discrepancy between FEV1 and PEFR expressed as % predicted values was determined. RESULTS: When predictive equations that recommended by the instrument manufacturers were used, PEFR measured with the PEFR meter (f-PEFR) was significantly higher than FEV1 at all time points, with 16.1% mean difference and unacceptable wide limits of agreement (-20.0~52.3%). The classification in severity was significantly different between FEV1 and f-PEFR (p < 0.001). The discrepancy was inter-instrumental in large part because f-PEFR was 10.1% higher than spirometric PEFR. Different predictive equations altered the degree of the differences but could not completely correct it. CONCLUSION: These results indicate that f-PEFR values underestimate the severity of airflow obstruction in acute asthma despite using recommended predictive equations. Therefore, these confounding factors should be considered when the severity of airflow obstruction is assessed with PEFR.
Acute Disease ; Adult ; Aged ; Airway Obstruction/diagnosis/*physiopathology ; Asthma/*physiopathology ; Comparative Study ; Female ; Forced Expiratory Volume/physiology ; Human ; Male ; Middle Age ; Peak Expiratory Flow Rate/*physiology ; Predictive Value of Tests

Background: Clonal hematopoiesis of indeterminate potential (CHIP) has been reported to be associated with increased cardiovascular disease, aging and insulin resistance. Despite the debate of causal contribution of CHIP on metabolic diseases, we want to explore whether CHIP is related to diabetic peripheral neuropathy (DPN). Methods: This study analyzed the prevalence of CHIP in patients with type 2 diabetes classified according to DPN status. Logistic regression analysis was used to evaluate the association between CHIP and DPN. Results: CHIP was more prevalent in subjects without DPN than those with DPN (19.9% vs. 8.8%, respectively; P=0.013). Individuals having any CHIP, or DNA methyltransferase 3A (DNMT3A) CHIP were less likely to have any abnormality shown in DPN test; the adjusted odds ratio were 0.85 (95% confidence interval [CI], 0.73 to 1.00) and 0.70 (95% CI, 0.56 to 0.89), respectively. Interestingly, DNMT3A CHIP showed the negative association, but Tet methylcytosine dioxygenase 2 (TET2) CHIP showed the positive association with abnormal feet electrochemical skin conductance level. Conclusion On the contrary to expectations, CHIP was negatively associated with DPN. Functional linking between the mutation in hematopoietic cells and DPN, and the opposite role of DNMT3A and TET2 should be investigated.

BACKGROUND: Wheezing is one of the characteristics of asthma, Intensity of wheezing is correlated with the severity of airway obstruction. However, some asthmatic patients may show wheezing despite normal ventilatory function. OBJECTIVE: To determine the cause of wheezing in asthmatic patients with normal ventilatory function. METHODS: Thirty-eight consecutive asthmatic patients with wheezing despite FEV1> or =80% of predicted value were retrospectively examined for clinical data. RESULTS: Twenty-seven patients (71.1%) were women. Sixteen patients (42.1%) showed airway obstruction based on the Intermountain Thoracic Society criteria. Patients with airway obstruction had significantly lower FEF50% than did those without it (P<.001). When the patients with no wheezing were re-examined by the pulmonary function test. 14 patients (48.3%) showed a significant bronchodilation. In patients without airway obstruction, FEF50/FIF50 was significantly higher than in those with it (P<.01), and FEF50/FIF50 >1 suggesting upper airway obstruction was observed in 7 of 16 (43.8%) patients. Associated diseases were rhinitis in 21 (55.3%) patients, sinusitis in 18 (47.4%), and postnasal drip syndrome in 3 (7.9%). CONCLUSIONS: Wheezing despite normal ventilatory function in asthma occurs more often in women. It may be related to reversible airway obstruction in nearly half patients and to upper airway obstruction such as rhinitis. in considerable numbers of the remaining patients.
Airway Obstruction ; Asthma* ; Female ; Humans ; Respiratory Function Tests ; Respiratory Sounds* ; Retrospective Studies ; Rhinitis ; Sinusitis

Catastrophic antiphospholipid syndrome (APS) is defined as a rare, life-threatening autoimmune disorder leading to multiorgan failure. Probable APS, with clinical manifestations similar to APS without antiphospholipid antibodies, was suggested to be seronegative catastrophic APS. The triggering factors of catastrophic APS are various, including infection, trauma, malignancy, and surgery. In approximately 40% of patients, catastrophic APS develops from an unknown cause. We report a case of seronegative catastrophic APS due to an unknown origin. A 20-year-old man presented with cough, abdominal pain, skin lesions, tunnel vision, and watery diarrhea without fever. His symptoms and laboratory test suggested disseminated intravascular coagulation. Considering seronegative catastrophic APS, we treated with intravenous steroid and intravenous immunoglobulin, but the effects were limited. After weekly treatment with rituximab, an immune-modulating agent, his laboratory findings including thrombocytopenia and coagulation tests, returned to normal. We conclude that rituximab can be an effective treatment for seronegative catastrophic APS.
Abdominal Pain ; Antibodies, Antiphospholipid* ; Antiphospholipid Syndrome ; Autoimmune Diseases ; Cough ; Diarrhea ; Disseminated Intravascular Coagulation* ; Fever ; Humans ; Immunoglobulins ; Skin ; Thrombocytopenia ; Young Adult ; Rituximab

Bacillus Calmette-Guerin (BCG) is reported to suppress Th2 response and asthmatic reaction. Dendritic cells (DCs), the major antigen-presenting cells, infections with BCG are known to result in inducing various cytokines. Thus, DCs are likely to play a role in the effects of BCG on asthma. This study aims at investigating that cytokine milieu secreted by BCG-treated DCs directly enhances allergen-specific Th1 response and/or suppresses Th2 response in allergic asthma. DCs and CD3+ T cells were generated from Dermatophagoides farinae-sensitive asthmatics. DCs were cultured with and without BCG and subjected to flow cytometric analysis. IL-12 and IL-10 were determined from the culture supernatants. Some DCs were cocultured with T cells in the presence of D. farinae extracts after adding the culture supernatants from BCG-treated DCs, and IL-5 and IFN-gamma were determined. BCG-treated DCs enhanced significantly the expressions of CD80, CD86, and CD40, and the productions of IL-12 and IL-10. Addition of culture supernatants from BCG-treated DCs up-regulated production of IFN-gamma by T cells stimulated by DCs and D. farinae extracts (p<0.05), but did not down-regulate production of IL-5 (p>0.05). The cytokine milieu secreted by BCG-treated DCs directly enhanced allergen-specific Th1 response, although did not suppress Th2 response.
Antigens, Dermatophagoides/*immunology ; Asthma/*immunology ; Cells, Cultured ; Coculture Techniques ; Culture Media ; Cytokines/*immunology/secretion ; Dendritic Cells/cytology/*immunology/secretion ; Humans ; Hypersensitivity/immunology ; Interferon Type II/immunology/secretion ; Interleukin-10/immunology/secretion ; Interleukin-12/immunology/secretion ; Interleukin-5/immunology/secretion ; Lymphocyte Activation/immunology ; Mycobacterium bovis/*immunology ; Research Support, Non-U.S. Gov't ; Th2 Cells/cytology/immunology/secretion ; Up-Regulation/immunology

The objective of this study is to investigate whether BCG infection before, during or after sensitization suppresses allergen-induced airway hyperresponsiveness and eosinophilic inflammation in allergic asthma rats, and to determine the required dose of BCG to induce such an inhibition. Eighty-seven Sprague-Dawley (SD) rats were sensitized and provoked with ovalbumin (OA). A pretreatment of 6 x 10(4) or 6 x 10(5) colony forming units (CFUs) of BCG or saline was done at four different times: 3 days before sensitization, at sensitization, 3 days before provocation, or at provocation. The assessment of tracheal smooth muscle (TSM) responsiveness to electrical field stimulation or acetylcholine (ACh) and bronchoalveolar lavage (BAL) were performed 1 day after OA provocation. Doses of 6 x 10(4) CFUs inhibited TSM sensitivity of rats infected 3 days before sensitization or at sensitization, but not 3 days before provocation or at provocation. However, doses of 6 x 10(5) CFUs significantly inhibited not only the airway eosinophilia of rats infected 3 days before sensitization or at sensitization, but also the TSM sensitivity of rats infected 3 days before provocation or at provocation. In conclusion, BCG infection suppresses the development of sensitivity of airway smooth muscle and airway eosinophilic inflammation in allergic asthma rats. Furthermore, a relatively high dose of BCG infection inhibits airway sensitivity, even after allergen sensitization.
Animal ; Asthma/immunology* ; BCG Vaccine/immunology* ; Disease Models, Animal ; Disease Models, Animal ; Eosinophils/immunology ; Leukocyte Count ; Lung/immunology* ; Male ; Muscle, Smooth, Vascular/immunology ; Rats ; Rats, Sprague-Dawley ; Time Factors ; Vaccination