Background: Although rhythm control could be the best for symptomatic atrial fibrillation (AF), some patients fail to achieve sinus rhythm (SR). This study aimed to identify clinical risk factors of failed electrical cardioversion (ECV). Methods: A total of 248 patients who received ECV for persistent AF or atrial flutter (AFL) were retrospectivelyreviewed. Patients were divided into three groups: Group 1 maintained SR for > 1 year, group 2 maintained SR ≤ 1 yearafter ECV, and group 3 failed ECV. SR maintenance was assessed using regular electrocardiography or Holter monitoring. Results: Patients were divided into group 1 (73, 29%), group 2 (146, 59%), and group 3 (29, 12%). The mean ageof patients was 60 ± 10 years, and 197 (79%) were male. Age, sex, and baseline characteristics were similar amonggroups. However, increased cardiac size, digoxin use, heart failure (HF), and decreased left ventricular ejection frac‑ tion (LVEF) were more common in group 3. Univariate analysis of clinical risk factors for failed ECV was increasedcardiac size [hazard ratio (HR) 2.14 (95% confidence interval [CI], 1.06–4.34, p = 0.030)], digoxin use [HR 2.66 (95% CI, 1.15–6.14), p = 0.027], HF [HR 2.60 (95% CI, 1.32–5.09), p = 0.005], LVEF < 40% [HR 3.45 (95% CI, 1.00–11.85), p = 0.038], and decreased LVEF [HR 2.49 (95% CI, 1.18–5.25), p = 0.012]. Among them, HF showed clinical significance only by multivariate analysis [HR 3.01 (95% CI, 1.13–7.99), p = 0.027]. Conclusions Increased cardiac size, digoxin use, HF, LVEF < 40%, and decreased LVEF were related to failed ECV for persistent AF or AFL. Among these, HF was the most important risk factor. Further multi-center studies including greater number of participants are planned.

Hypertrophic cardiomyopathy (HCM) is associated with an increased incidence of Wolff–Parkinson–White (WPW) syndrome and atrial fibrillation. However, a delta-like wide QRS can be observed in the hypertrophied myocardium. When considering the rarity of the paraseptal bypass tract (BT), the normal QRS axis suggests a higher possibility of HCM origin. Otherwise, there is no known electrocardiographic clue indicating a wide QRS differentiation between HCM and WPW syndrome. Moreover, the atriofascicular, nodofascicular/ventricular or fasciculoventricular BT should be differentiated. In this case, atrioventricular conduction system incidental injury revealed a wide QRS origin from the HCM, but this method should be avoided except in some selected cases.

Hypertrophic cardiomyopathy (HCM) is associated with an increased incidence of Wolff–Parkinson–White (WPW) syndrome and atrial fibrillation. However, a delta-like wide QRS can be observed in the hypertrophied myocardium. When considering the rarity of the paraseptal bypass tract (BT), the normal QRS axis suggests a higher possibility of HCM origin. Otherwise, there is no known electrocardiographic clue indicating a wide QRS differentiation between HCM and WPW syndrome. Moreover, the atriofascicular, nodofascicular/ventricular or fasciculoventricular BT should be differentiated. In this case, atrioventricular conduction system incidental injury revealed a wide QRS origin from the HCM, but this method should be avoided except in some selected cases.

OBJECTIVES: When a patient who attempts suicide visits the emergency room, it is important that the departments of emergency medicine, internal medicine, and psychiatry communicate with each other and prioritize treatment. This study was conducted to verify the effectiveness of the multidisciplinary emergency consultation system (ECS) for drug intoxicated patients. METHODS: We retrospectively analyzed the data from medical records prior to the ECS, from July 2017 to May 2018, and after the ECS, from July 2018 to May 2019, to verify the effectiveness of the system. RESULTS: After the ECS, admission to open wards was significantly higher than to the intensive care units (χ²=8.567, p=0.014). In addition, the proportion of consultations to the department of psychiatry among patients admitted to other departments tended to increase (χ²=4.202, p=0.053), and the time required for consultation response decreased (Z=−2.031, p=0.042). As a result of the consultation, the proportion of the patients who had been transferred to the department of psychiatry was increased (χ²=4.692, p=0.043), and the time spent to transfer tended to decrease (Z=−1.941, p=0.052). CONCLUSIONS After implementing the ECS for drug intoxicated patients, unnecessary intensive care unit admissions, consultation response time, and the time spent to transfer were reduced, and the rate of consultation referrals and transfer rates increased. This means that the multidisciplinary consultation system rapidly provided essential medical services to patients at lower medical costs.

PURPOSE: Acute hepatitis A (AHA) and acute hepatitis B (AHB) are caused by an acute infection of the hepatitis A virus and the hepatitis B virus, respectively. In both AHA and AHB, liver injury is known to be mediated by immune cells and cytokines. In this study, we measured serum levels of various cytokines and T-cell cytotoxic proteins in patients with AHA or AHB to identify liver injury-associated cytokines. MATERIALS AND METHODS: Forty-six patients with AHA, 16 patients with AHB, and 14 healthy adults were enrolled in the study. Serum levels of 17 cytokines and T-cell cytotoxic proteins were measured by enzyme-linked immunosorbent assays or cytometric bead arrays and analyzed for correlation with serum alanine aminotransferase (ALT) levels. RESULTS: Interleukin (IL)-18, IL-8, CXCL9, and CXCL10 were significantly elevated in both AHA and AHB. IL-6, IL-22, granzyme B, and soluble Fas ligand (sFasL) were elevated in AHA but not in AHB. In both AHA and AHB, the serum level of CXCL10 significantly correlated with the peak ALT level. Additionally, the serum level of granzyme B in AHA and the serum level of sFasL in AHB correlated with the peak ALT level. CONCLUSION: We identified cytokines and T-cell cytotoxic proteins associated with liver injury in AHA and AHB. These findings deepen the existing understanding of immunological mechanisms responsible for liver injury in acute viral hepatitis.
Acute Disease ; Adult ; Alanine Transaminase/blood ; Biomarkers/blood ; Cytokines/*blood ; Enzyme-Linked Immunosorbent Assay ; Fas Ligand Protein/blood ; Female ; Hepatitis A/blood/virology ; Hepatitis A virus/*genetics/immunology ; Hepatitis B/blood/virology ; Hepatitis B virus/*genetics/immunology ; Humans ; Interleukin-6/blood ; Interleukin-8/blood ; Interleukins/blood ; Liver Failure/immunology/metabolism/*pathology ; Male ; Middle Aged ; T-Lymphocytes, Cytotoxic/immunology/*metabolism

PURPOSE: T cell-mediated immune responses, and particularly activation of polyfunctional T cells that simultaneously produce multiple cytokines, are necessary for the control of Mycobacterium tuberculosis. In the present study, we examined if DNA immunization of Mycobacterium tuberculosis resuscitation-promoting factor B (RpfB) elicits polyfunctional T cell responses in mice. MATERIALS AND METHODS: C57BL/6 mice were immunized intramuscularly three times, at 3-week intervals, with RpfB-expressing plasmid DNA. For comparison, protein immunization was performed with recombinant RpfB in control mice. After immunization, RpfB-specific T cell responses were assessed by interferon-gamma (IFN-gamma) enzyme-linked immunosorbent spot assay and intracellular cytokine staining (ICS), and T cell polyfunctionality was assessed from the ICS data. RESULTS: RpfB DNA immunization induced not only humoral immune responses, but also CD8+ and CD4+ T cell responses. Immunodominant T-cell epitopes were identified within RpfB by assays with overlapping peptides. RpfB DNA immunization elicited a polyfunctional CD8+ T cell response that was dominated by a functional phenotype of IFN-gamma+/TNF-alpha+/IL-2-/CD107a+. CONCLUSION: RpfB DNA immunization elicits polyfunctional CD8+ T cell responses, suggesting that RpfB DNA immunization might induce protective immunity against tuberculosis.
Animals ; Complement Factor B* ; Cytokines ; DNA* ; Epitopes, T-Lymphocyte ; Immunity, Humoral ; Immunization* ; Interferon-gamma ; Mice ; Mycobacterium tuberculosis* ; Peptides ; Phenotype ; Plasmids ; T-Lymphocytes ; Tuberculosis ; Vaccines, DNA

Ectopic breast tissue can occur anywhere along the incompletely regressed mammary ridge. Among the various types of breast choristoma, ectopic breast tissue, which has only glandular tissue without a nipple or areola, is most commonly detected in axillary areas. However, ectopic breast cancer is often not detected until significant clinical symptoms have been revealed, or diagnosis is delayed. Furthermore, an examination of ectopic breast tissue tends to be omitted from a screening mammography. Especially, the microcalcifications of ectopic breast tissue are difficult to delineate on mammography. Herein, the authors report a case of ectopic breast carcinoma that showed clustered microcalcifications on screening mammography, and discuss the interpretation and implications of microcalcification in ectopic breast tissue.
Breast Neoplasms ; Breast* ; Carcinoma, Ductal* ; Choristoma ; Diagnosis ; Mammography* ; Mass Screening* ; Nipples

PURPOSE: Papillary thyroid carcinoma (PTC) is the most common malignant tumor of the thyroid and BRAFV600E mutation is the most frequent genetic alteration in PTC. BRAFV600E mutation has been demonstrated as a prognostic biomarker for prediction of poor clinicopathological outcomes, such as increased incidence of extrathyroidal extension, lymph node metastasis, and advanced stage. However, there is conflicting literature regarding the association of BRAFV600E mutation and aggressive clinicopathological features. In this study, we investigated the prevalence of BRAFV600E mutation in PTC and determined the association of BRAF mutation with indicators of poor prognosis for PTC. METHODS: We reviewed 1009 patients with PTC, who underwent thyroid surgery at Kyungpook National University Hospital between January 2013 and March 2014. BRAFV600E mutation analysis was performed using real-time polymerase chain reaction based amplification of DNA extracted from paraffin-embedded tumor specimens. RESULTS: BRAFV600E mutation was detected in 863 (85.5%) patients. In univariate analysis, histologic subtype, extrathyroidal extension, and advanced stage showed significant association with BRAFV600E mutation. In addition, concurrent Hashimoto's thyroiditis showed an association with low prevalence of BRAFV600E mutation. However, no statistically significant association was observed for age, gender, multifocal or bilateral tumor, and lymph node metastasis. Multivariate analysis showed an independent association of extrathyroidal extension with BRAFV600E mutation. CONCLUSION: In this study, extrathyroidal extension of PTC is an independent prognostic factor associated with BRAFV600E mutation status. However, conduct of further large scale studies with long term follow up is required before the BRAF mutation can be conclusively recommended as a prognostic biomarker.
DNA ; Gyeongsangbuk-do ; Humans ; Incidence ; Lymph Nodes ; Multivariate Analysis ; Neoplasm Metastasis ; Prevalence ; Prognosis ; Real-Time Polymerase Chain Reaction ; Thyroid Gland ; Thyroid Neoplasms* ; Thyroiditis

PURPOSE: The Rectus abdominis muscle free flap is utilized in various reconstruction surgeries due to easiness in harvesting, consistency of vascular pedicle and reduced donor site morbidity. But rarely, femoral nerve injury during rectus abdominis harvesting can be resulted. We report a case of femoral nerve injury after rectus muscle harvesting and discuss the injury mechanism with the follow-up process of this injury. METHODS: To reconstruct the defect of middle cranial base after wide excision of cystic adenocarcinoma of the external ear, rectus muscle free flap was havested in usual manner. To achieve a long vessel, inferior epigastric artery was dissected to the dividing portion of femoral artery and cut. RESULTS: One week after the surgery, the patient noted sensory decrease in the lower leg, weakness in muscle strength, and disabilities in extension of the knee joint resulting in immobilization. EMG and NCV results showed no response on stimulation of the femoral nerve of the left leg, due to the defects in femoral nerve superior to the inguinal ligament. With routine neurologic evaluations and physical therapy, on the 75th day after the operation, the patient showed improvement in pain, sensation and muscle strength, and was able to move with walking frame. In 6 months after the operation, recovery of the muscle strength of the knee joint was observed with normal flexion and extension movements. CONCLUSION: Rarely, during dissection of the inferior epigastric artery, injuries to the femoral nerve can be resulted, probably due to excessive traction or pressure from the blade of the traction device. Therefore, femoral nerve injury can be prevented by avoiding excessive traction during surgery.
Adenocarcinoma ; Ear, External ; Epigastric Arteries ; Femoral Artery ; Femoral Nerve* ; Follow-Up Studies ; Free Tissue Flaps ; Humans ; Immobilization ; Knee Joint ; Leg ; Ligaments ; Muscle Strength ; Rectus Abdominis* ; Sensation ; Skull Base ; Tissue Donors ; Traction ; Walking

PURPOSE: Grave's disease is an autoimmune disease with chronic and systemic features. It affects the orbital fat and muscle bringing about defect in extrinsic eye motility, diplopia, optic nerve defect and lid retraction. In patients with lagopthalmos and resulting facial deformity, treatment can be done by rectus muscle recession or filling with various material. Autogenous auricular cartilage graft is often used and synthetic material such as synthetic acellular dermis, polyethylene meshs are also used for filling of the depressed area. Nevertheless, autogenous auricular cartilage grafts are difficult to utilize and synthetic materials sometimes result in protrusion or infection. Therefore, hard palate mucosa was considered as an alternative. We report two cases of patients with lower eyelid retraction corrected with autogenous hard palate mucosa. METHODS: We performed this operation in two patients of Graves' ophthalmopathy. The capsulopalpebral fascia was incised and elevated through an incision on the conjunctiva. Then, the harvested hard palate mucosa was sutured to the inferior border of the tarsus and covered with the conjunctiva. RESULTS: The lower eyelid retraction was corrected successfully. No hypertrophy or deformation of the transplanted hard palate mucosa was noted 6 months after the surgery. CONCLUSIONS: From the results above, we may conclude that the hard palate mucosa serves as an ideal spacer for the curvature and the inner lining in lower lid retraction. Hard palate mucosa is as sturdy as the autogenous cartilage but is much easier to utilize. It can be also used for lid retraction after lower lid aesthetic surgeries or traumas.
Acellular Dermis ; Ankle ; Autoimmune Diseases ; Cartilage ; Congenital Abnormalities ; Conjunctiva ; Diplopia ; Ear Cartilage ; Eyelids* ; Fascia ; Humans ; Hyperthyroidism ; Hypertrophy ; Mucous Membrane* ; Optic Nerve ; Orbit ; Palate, Hard* ; Polyethylene ; Transplants