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Purpose: Acute myocardial infarction (AMI) and stroke are leading global causes of death and can be used to assess acute care quality. We examined the 30-day mortality trends after emergency department admission for AMI and stroke in Korea from 2008 to 2019, focusing on regional and income disparities., Materials and Methods: The AMI and stroke patients admitted to hospitals in Korea were collected from the claims data. We analyzed age and sex-standardized 30-day mortality for AMI, as well as hemorrhagic and ischemic strokes. Disparities in mortality were analyzed using absolute differences and relative ratios between the Organization for Economic Cooperation Development (OECD) and Korea, and among income levels and regions in Korea. A 12-year joinpoint regression was used to determine the annual percent change and the average annual percent change., Results: The trends in the 30-day AMI mortality of Korea were not significantly changed from 2008 to 2019; the gap remained at 1.2 between the OECD and Korea. Korea maintained lower mortality rates for hemorrhagic and ischemic stroke than the mean of OECD. In Korea, the 30-day hemorrhagic stroke mortality showed a constant decreasing trend for the higher-income group living in urban areas; it led to a widened gap based on income levels in urban areas. The 30-day mortality for ischemic stroke tended to decrease in the higher-income group and urban areas., Conclusion: National-level intervention is needed to manage regional and income-based disparities in AMI and stroke 30-day mortality. It is important to understand the variance in mortality rate by different geographical regions and income levels to establish an appropriate public health strategy., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2024.)

Purpose: The increase in thyroid cancer incidence has inevitably led to an increase in thyroid cancer surgeries. This meta-regression analysis aimed to determine if the rate of post-thyroidectomy complications changes by year., Materials and Methods: PubMed and Embase databases were used to perform a systematic literature search of studies published from January 1, 2005, using the keywords "thyroidectomy" and "complication." A meta-regression was performed for post-thyroidectomy hypocalcemia and bleeding., Results: This meta-analysis included 25 studies involving 927751 individuals. Through the years of publications in this study, there was no significant difference in the proportion of post-thyroidectomy hypocalcemia and bleeding ( p =0.9978, 0.6393)., Conclusion: Although the number of thyroid surgeries has recently increased, the incidence of post-thyroidectomy hypocalcemia and bleeding did not significantly increase., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2024.)

Purpose: The present study aimed to identify microorganisms in follicular fluids and to investigate their association with in vitro fertilization (IVF) outcomes., Materials and Methods: This study was conducted as a prospective study of 49 infertile females undergoing IVF/intracytoplasmic sperm injection cycles between 2013 and 2016. Paired follicular fluid and vaginal secretions were collected on the day of ovum pick up and were cultured to detect microorganisms., Results: Fifteen women (30.6%) had no microorganisms in follicular fluid or vaginal swabs, 23 (46.9%) had microorganisms on vaginal swab alone, 3 (6.1%) had microorganisms in follicular fluid alone, and 8 (16.3%) had microorganisms in both follicular fluid and vaginal swabs. The same microorganisms were detected in both the follicular fluid and vaginal swabs of three women, while different microorganisms were detected between follicular fluid and vaginal swabs in five women. Follicular fluid microorganisms were not associated with embryo quality or clinical pregnancy rates during IVF cycles. However, significantly decreased implantation rates (9.1% vs. 29.4%, p =0.031) and clinical pregnancy rates on embryo transfer day 5 (0% vs. 83.3%, p =0.048) were observed in the group that was positive for vaginal pathogens., Conclusion: Follicular fluid contains microorganisms that can differ from those in the vagina of the same women; however, they do not appear to be associated with embryo quality or clinical pregnancy rates in IVF cycles. In contrast, vaginal pathogens were found to be associated with worse implantation rates and clinical pregnancy rates in IVF cycles., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2022.)

Purpose: In the recent antiretroviral therapy (ART) era, a large proportion of Korean patients with human immunodeficiency virus (HIV) infection were shown to have low CD4 cell counts at diagnosis and during ART initiation. We investigated the survival trends in patients living with HIV/acquired immunodeficiency syndrome (AIDS) in Korea who started ART in the 2000s, and evaluated the risk factors for mortality to elucidate the association between survival and low CD4 cell counts at ART initiation., Materials and Methods: Patients with HIV infection who were aged >18 years and had started ART between 2001 and 2015 in the Korean HIV/AIDS cohort study were enrolled. We compared the clinical characteristics, mortality, and causes of death among the enrolled subjects based on the time of ART initiation. Cox regression analysis was used to estimate the adjusted hazard ratios of mortality based on the time of ART initiation., Results: Among the 2474 patients enrolled, 105 (4.24%) died during the follow-up period of 9568 patient-years. Although CD4 cell counts at the time of ART initiation significantly increased from 161 [interquartile range (IQR), 73.5-303] in 2001-2003 to 273 (IQR, 108-399) in 2013-2015 ( p <0.001), they remained low during the study period. The incidence of all-cause mortality was 10.97 per 1000 patient-years during the study period. There was no decreasing trend in mortality between 2001 and 2015. Age >40 years [adjusted hazard ratio, 3.71; 95% confidence interval (CI), 2.35-5.84] and low CD4 counts (<100 cells/mm³: adjusted hazard ratio, 2.99; 95% CI, 1.44-6.23) were significant risk factors for mortality., Conclusion: Despite excellent HIV care available in the recent ART era, the survival of patients with HIV/AIDS undergoing ART did not improve between 2001 and 2015 in Korea., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2020.)

Purpose: To determine the relationship between uterine leiomyoma and female sexual dysfunction (FSD) among premenopausal and postmenopausal women., Materials and Methods: The study population consisted of consecutive women who underwent gynecologic screening tests, including transvaginal ultrasound, and completed the questionnaires on FSD. A total of 841 women were included from January 2010 to December 2011. FSD was defined as Female Sexual Function Index (FSFI) ≤26.55. The relationship between uterine leiomyoma and FSD were compared according to menopausal status., Results: In premenopausal group (n=564), there were no differences in the frequency of FSD (55.0% vs. 58.8%, p =0.387) and total FSFI score. However, in postmenopausal group (n=277), women with uterine leiomyoma had a lower frequency of FSD than those without uterine leiomyoma (71.3% vs. 86.4%, p =0.003). This relationship between uterine leiomyoma and lower frequency of FSD in postmenopausal women remained significant after adjusting for confounding variables., Conclusion: The relationship between uterine leiomyoma and FSD is different depending on the menopausal status., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2019.)

Purpose: Although laparoscopic adjustable gastric bands are considered a standard treatment for severe obesity, their use remains controversial. We evaluated rates of band explantation and the incidences of complications leading to and following band explantation., Materials and Methods: This retrospective review was performed on patients that underwent adjustable gastric band explantation. For each of the three groups of patients that underwent explantation, we compared demographic and anthropometric data, band duration in situ, operative approach, and morbidities., Results: Between January 2009 and October 2018, a total of 267 patients underwent primary laparoscopic adjustable gastric band surgery. Of these 267 patients, 99 (37.1%) underwent band explantation. Numbers (%) of patients in the slippage (SL), band erosion (BE), and intolerance (IT) groups were 13 (13.1%), 39 (39.4), and 47 (47.5%), respectively. Mean %EBMIL values at explantation in these groups were 74.6±45.5, 79.7±40.3, and 36.1±46.0, respectively ( p <0.001), and mean times for maintaining bands in situ were 45.1±28.0, 39.4±24.3, and 51.2±22.7 months, respectively. Isolated band removal was performed for slippage (SLi, n=12), band erosion (BEi, n=39), and intolerance (ITi, n=31). The numbers (%) of patients in the SLi, BEi, and ITi groups that experienced a surgical complication (Clavien-Dindo class ≥1) were 0 (0.0%), 24 (61.5%), and 3 (9.7%), respectively ( p <0.001). In the BEi group, four patients (4/39, 10.3%) underwent reoperation after AGB removal., Conclusion: During our 10 years of experience, 37.1% of adjustable gastric band had to be removed. Intra-abdominal abscess and intragastric bleeding were rare but serious complications after explantation. Potential candidates for adjustable gastric band should be informed of the high long-term risk of band explantation and its associated morbidities., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2019.)

Purpose: Myasthenia gravis (MG) is a lifelong autoimmune disorder that affects neuromuscular transmission. The long-term treatment plan should include immunotherapy. We investigated the long-term safety and efficacy of tacrolimus for the treatment of MG in real-world clinical practice., Materials and Methods: We retrospectively reviewed 160 MG patients treated with tacrolimus from 2005 to 2015. Myasthenia Gravis Foundation of America (MGFA) clinical classification, MGFA post-intervention status, myasthenic functional score, and dose of oral prednisolone were investigated., Results: Adverse events occurred in 68 patients (42.5%), most of which were minor and well-managed. Clinical severity scales improved after administration of tacrolimus, compared to the baseline. Compared to 6 months before administration of tacrolimus, prednisolone dose significantly decreased at 12 months after treatment (2.85±0.92 mg/day, p =0.002), 18 months after treatment (3.36±0.99 mg/day, p =0.001), and 24 months after treatment (3.71±0.93 mg/day, p <0.001)., Conclusion: Tacrolimus may be effective in reducing the severity of MG and may permit a reduction in the steroid dose prescribed to the patients. Adverse events due to tacrolimus treatment were not serious., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2019.)

Purpose: To investigate the associations between sperm DNA fragmentation (SDF) and embryo formation rate in normal responder women to in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI)., Materials and Methods: Fifty-three consecutive, fresh IVF/ICSI cycles performed from 2014 to 2017 were selected. All women were normal responders (4 to 14 mature oocytes were retrieved) and at least one normally fertilized oocyte with two pronuclei was obtained in all cycles. Semen was collected on the day of oocyte retrieval, and SDF levels were measured by sperm chromatin dispersion test (Halosperm assay). At day 3 after insemination, embryo quality was evaluated by morphologic criteria and categorized as A/B/C/D. Top quality embryo were defined as grade A embryos with seven cells or more., Results: SDF levels showed a positive linear correlation with the male's age (r=0.307, p =0.025) and a negative linear correlation with sperm motility (r=-0.491, p <0.0001). To achieve top-quality or a grade A embryo formation rate >70%, the cut-off value SDF was <30.7% for each. Among individuals with SDF <30.7%, the median top-quality or grade A embryo formation rate was significantly higher than that among individuals with SDF ≥30.7% (38.1% vs. 20.0%, p =0.038; 50% vs. 25.0%, p =0.017)., Conclusion: In normal responder women, high SDF level resulted in low day 3 embryo formation rates. Our results suggest a paternal effect on embryo quality in IVF/ICSI cycles., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2019.)

Purpose: Gastric cancer shows a male predominance that might be explained by protective effects from estrogens in females. Two Lauren classification histological subtypes, intestinal and diffuse, have distinct carcinogeneses. The purpose of this study was to estimate the effects of sex hormone on female gastric cancer according to Lauren classification., Materials and Methods: We reviewed medical records for and administered questionnaires, surveying reproductive and hormonal factors, to 758 patients who underwent gastrectomy for gastric cancer at Samsung Medical Center from May 2012 to November 2014. Clinicopathological characteristics were compared between females and males. The incidence of intestinal-type gastric cancer was compared between females subgroups, consist of premenopausal women and three groups of postmenopausal women (five-year intervals after menopause), and males. The association between reproductive factors and intestinal-type gastric cancer was analyzed by multivariate models for the female group., Results: In total, 227 females (29.9%) and 531 males (70.9%) were included in the analysis. Undifferentiated adenocarcinoma and diffuse-type histology were more frequent in female patients than male patients. While 221 (41.6%) male patients had intestinal-type gastric cancer, no premenopausal female patient had this type of gastric cancer. The incidence of intestinal-type gastric cancer increased with time after menopause, and was similar to males after 10 years from menopause. Parity was associated with an increased risk of intestinal-type gastric cancer in menopausal women., Conclusion: These findings support that female sex hormones might be protective against intestinal-type gastric cancer., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2018)

Purpose: The aim of this study was the compare the midterm outcomes of laparoscopic greater curvature plication (LGCP) and laparoscopic sleeve gastrectomy (LSG) in obese patients with a body mass index (BMI) of 30 to 35 kg/m²., Materials and Methods: This single center, retrospective review of prospectively collected data was conducted for obese patients that underwent LGCP or LSG from March 2013 to February 2016. These two patient groups were compared in terms of demographics, perioperative outcomes, weight loss [percent excess weight loss (%EWL)], comorbidity resolution, and immediate and long-term complications., Results: A total of 149 patients were eligible for the study. Seventy-five patients underwent LGCP (group A) and 74 LSG (group B). These two groups were matched for age, gender, and baseline BMI. Three patients in each group were readmitted for complications within 30 days postoperatively. %EWL in groups A and B were 51.1±16.9 and 47.8±20.8 at 3 months (p=0.084), 71.1±20.2 and 74.5±21.8 at 6 months (p=0.165), 77.1±18.4 and 87.8±25.1 at 12 months (p=0.002), 70.5±18.5 and 83.4±28.7 at 24 months (p=0.005), and 67.3±15.3 and 78.6±31.7 at 36 months (p=0.054), respectively. Intergroup differences in resolution rates of metabolic comorbidities between the two groups were not significant., Conclusion: Although mean weight loss after LGCP was inferior to that after LSG, especially after six months postoperatively, it was acceptable, and LGCP had an excellent metabolic comorbidity resolution rate in patients with BMIs, ranging from 30 to 35 kg/m²., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2017)

Purpose: Myotonic dystrophy type 1 (DM1) is characterized by progressive muscular weakness with symptoms caused by involvement of the brain. The aim of this study was to delineate global changes in cortical thickness and white matter integrity in patients with DM1, compared to age-matched healthy controls, and in brain areas highly correlated with CTG repeat size., Materials and Methods: Cortical thickness and white matter integrity were compared in nine adult DM1 patients and age matched healthy controls using T1-weighted and diffusion tensor imaging. The patients' intelligence quotient (IQ) and CTG repeat size were measured in each individual., Results: Cortical thickness was significantly reduced in the frontal, temporal, and occipital cortices, while tract-based spatial statistics showed decreased diffusion metrics in widespread areas, including the bilateral orbitofrontal, anterior frontal, insular, external capsule, and occipital cortices in DM1 patients, compared to controls. Additionally, thickness was negatively correlated with the number of CTG repeats in those areas. White matter integrity was negatively correlated with CTG repeats in the left entorhinal, anterior corona radiata, orbitofrontal, and lateral occipital areas. No statistically significant correlation was found between IQ scores and the size of CTG repeats., Conclusion: Our results suggest that DM1 is associated with wide distributions of network changes in both gray and white matter. Some of areas related to cognition showed significant correlations with CTG repeats., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2017)

Purpose: To assess the ability of a mechanical in-exsufflator (MI-E), either alone or in combination with manual thrust, to augment cough in patients with neuromuscular disease (NMD) and respiratory muscle dysfunction., Materials and Methods: For this randomized crossover single-center controlled trial, patients with noninvasive ventilator-dependent NMD were recruited. The primary outcome was peak cough flow (PCF), which was measured in each patient after a cough that was unassisted, manually assisted following a maximum insufflation capacity (MIC) maneuver, assisted by MI-E, or assisted by manual thrust plus MI-E. The cough augmentation techniques were provided in random order. PCF was measured using a new device, the Cough Aid., Results: All 40 enrolled participants (37 males, three females; average age, 20.9±7.2 years) completed the study. The mean (standard deviation) PCFs in the unassisted, manually assisted following an MIC maneuver, MI-E-assisted, and manual thrust plus MI-E-assisted conditions were 95.7 (40.5), 155.9 (53.1), 177.2 (33.9), and 202.4 (46.6) L/min, respectively. All three interventions significantly improved PCF. However, manual assistance following an MIC maneuver was significantly less effective than MI-E alone. Manual thrust plus MI-E was significantly more effective than both of these interventions., Conclusion: In patients with NMD and respiratory muscle dysfunction, MI-E alone was more effective than manual assistance following an MIC maneuver. However, MI-E used in conjunction with manual thrust improved PCF even further., Competing Interests: The authors have no financial conflicts of interest.

Purpose: Bariatric surgery is relatively new in Korea, and studies comparing different bariatric procedures in Koreans are lacking. This study aimed to compare the clinical outcomes of laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) for treating morbidly obese Korean adults., Materials and Methods: In this multicenter retrospective cohort study, we reviewed the medical records of 261 obese patients who underwent different bariatric procedures. Clinical outcomes were measured in terms of weight loss and resolution of comorbidities, such as diabetes, hypertension, and dyslipidemia. Safety profiles for the procedures were also evaluated., Results: In terms of weight loss, the three procedures showed similar results at 18 months (weight loss in 52.1% for SG, 61.0% for LAGB, and 69.2% for RYGB). Remission of diabetes, hypertension, and dyslipidemia was more frequent in patients who underwent RYGB (65.9%, 63.6%, and 100% of patients, respectively). Safety profiles were similar among groups. Early complications occurred in 26 patients (9.9%) and late complications in 32 (12.3%). In the LAGB group, five bands (6.9%) were removed. Among all patients, one death (1/261=0.38%) occurred in the RYGB group due to aspiration pneumonia., Conclusion: The three bariatric procedures were comparable in regards to weight-loss outcomes; nevertheless, RYGB showed a higher rate of comorbidity resolution. Bariatric surgery is effective and relatively safe; however, due to complications, some bands had to be removed in the LAGB group and a relatively high rate of reoperations was observed in the RYGB group.

Purpose: An epidemiological study of myasthenia gravis (MG) has not been performed in Korea. The purpose of this study was to estimate the prevalence and incidence of MG in Korea., Materials and Methods: Health Insurance Review and Assessment (HIRA) data from 2010 to 2014 were searched for MG codes as defined by the International Classification of Diseases, 10th revision. After identifying MG cases, we estimated the prevalence and annual incidence of MG based on the HIRA database and Korean population data., Results: During the study period, 10138 MG cases were identified. The prevalence of MG was 10.42 cases per 100000 people in 2010 and this increased every year to 12.99 cases per 100000 people in 2014. The average incidence of MG between 2011 and 2014 was 0.69 cases per 100000 person-years. The prevalence and incidence were higher in the older (≥ 50 years) age group than in the younger (<50 years) age group [prevalence: 9.26 vs. 19.24 per 100000, relative risk 2.077, 95% confidence interval (CI) 1.976-2.183, p<0.001; incidence: 0.47 vs. 1.18 per 100000, relative risk 2.490, 95% CI 2.006-3.091, p<0.001]., Conclusion: This study was the first nationwide population-based epidemiological study of MG in Korea. The prevalence and incidence of MG were consistent with those of previous studies. We found an increase in the prevalence of MG and a predominance of elderly MG patients.

Purpose: The aim of this study was to compare short-term outcomes [food tolerance scores (FTS) and quality of life] after three types of restrictive bariatric surgery: laparoscopic adjustable gastric banding (LAGB), laparoscopic greater curvature plication (LGCP), and laparoscopic sleeve gastrectomy (LSG)., Materials and Methods: From January 2012 to December 2013, all patients that underwent primary surgery were included in one of the LAGB, LGCP, or LSG groups. These three groups were then compared with respect to FTS, gastrointestinal quality of life indices (GIQLI), and the Medical Outcomes Study Short-Form 36 (SF-36) questionnaire. Questionnaires were sent to all patients both pre- and post-operatively., Results: A total of 85 patients (LAGB=45, LGCP=22, and LSG=18) returned the questionnaires in full, and these patients constituted the study cohort. The cohort was predominately female (n=73, 85.9%). Mean percentage excess weight loss (%EWL) values after LAGB, LGCP, and LSG were 65.4 ± 27.0%, 65.6 ± 25.2%, and 82.7 ± 21.7%, respectively (p=0.044). Mean postoperative FTSs and improvements in total GIQLIs after LAGB, LGCP, and LSG were 15.96, 20.95, and 21.33 and -3.40, 6.68, and 18.78, respectively (p<0.05). All procedures produced improvements in the three SF-36 domain scores. Subgroup analysis revealed significant differences between the three procedures in terms of improvements in general health and emotional well-being., Conclusion: LGCP is safe and effective at achieving significant weight loss. In terms of food tolerance and GI quality of life, LGCP was found to be comparable to gastric banding and sleeve gastrectomy.

Purpose: The present study aimed to investigate the role of hepatic venous pressure gradient (HVPG) for prediction of long-term mortality in patients with decompensated cirrhosis., Materials and Methods: Clinical data from 97 non-critically-ill cirrhotic patients with HVPG measurements were retrospectively and consecutively collected between 2009 and 2012. Patients were classified according to clinical stages and presence of ascites. The prognostic accuracy of HVPG for death, survival curves, and hazard ratios were analyzed., Results: During a median follow-up of 24 (interquartile range, 13-36) months, 22 patients (22.7%) died. The area under the receiver operating characteristics curves of HVPG for predicting 1-year, 2-year, and overall mortality were 0.801, 0.737, and 0.687, respectively (all p<0.01). The best cut-off value of HVPG for predicting long-term overall mortality in all patients was 17 mm Hg. The mortality rates at 1 and 2 years were 8.9% and 19.2%, respectively: 1.9% and 11.9% with HVPG ≤17 mm Hg and 16.2% and 29.4% with HVPG >17 mm Hg, respectively (p=0.015). In the ascites group, the mortality rates at 1 and 2 years were 3.9% and 17.6% with HVPG ≤17 mm Hg and 17.5% and 35.2% with HVPG >17 mm Hg, respectively (p=0.044). Regarding the risk factors for mortality, both HVPG and model for end-stage liver disease were positively related with long-term mortality in all patients. Particularly, for the patients with ascites, both prothrombin time and HVPG were independent risk factors for predicting poor outcomes., Conclusion: HVPG is useful for predicting the long-term mortality in patients with decompensated cirrhosis, especially in the presence of ascites.

Purpose: This study was designed to investigate the characteristics of Korean patients with calpainopathy., Materials and Methods: Thirteen patients from ten unrelated families were diagnosed with calpainopathy via direct or targeted sequencing of the CAPN3 gene. Clinical, mutational, and pathological spectra were then analyzed., Results: Nine different mutations, including four novel mutations (NM&#95;000070: c.1524+1G>T, c.1789&#95;1790inA, c.2184+1G>T, and c.2384C>T) were identified. The median age at symptom onset was 22 (interquartile range: 15-28). Common clinical findings were joint contracture in nine patients, winged scapula in four, and lordosis in one. However, we also found highly variable clinical features including early onset joint contractures, asymptomatic hyperCKemia, and heterogeneous clinical severity in three members of the same family. Four of nine muscle specimens revealed lobulated fibers, but three showed normal skeletal muscle histology., Conclusion: We identified four novel CAPN3 mutations and demonstrated clinical and pathological heterogeneity in Korean patients with calpainopathy.

Purpose: Although guidelines indicate that routine dissection of the central lymph nodes in patients with thyroid carcinoma should include the right para-oesophageal lymph nodes (RPELNs), located between the right recurrent laryngeal nerve and the cervical oesophagus and posterior to the former, RPELN dissection is often omitted due to high risk of injuries to the recurrent laryngeal nerve and the right inferior parathyroid gland., Materials and Methods: We retrospectively identified all patients diagnosed with papillary thyroid carcinoma who underwent total thyroidectomy with central lymph node dissection, including the RPELNs, between January 1, 2009 and December 31, 2013 at the Thyroid Cancer Center of Yonsei University College of Medicine, Seoul, Korea., Results: Of 5556 patients, 148 were positive for RPELN metastasis; of the latter, 91 had primary tumours greater than 1 cm (p<0.001). Extrathyroidal extension by the primary tumour (81.8%; p<0.001), bilaterality, and multifocality were more common in patients with than without RPELN metastasis; however, there were no significant differences in age and sex between groups. A total of 95.9% of patients with RPELN metastasis had central node (except right para-oesophageal lymph node) metastasis, and the incidence of lateral neck node metastasis was significantly higher in patients with than without RPELN metastasis (63.5% vs. 14.3%, p<0.001). Forty-one patients underwent mediastinal dissection, with 11 patients confirmed as having mediastinal lymph node metastasis with RPELN metastasis on pathological examination., Conclusion: RPELN metastasis is significantly associated with lateral neck and mediastinal lymph node metastasis.

Purpose: Despite technical simplicity and the low cost of brachial-ankle pulse wave velocity (BA-PWV), its use has been hampered by a lack of data supporting its usefulness and reliability. The aim of this study was to evaluate the usefulness of BA-PWV to measure aortic stiffness in comparison to using cardiovascular magnetic resonance (CMR)., Materials and Methods: A total of 124 participants without cardiovascular risk factors volunteered for this study. BA-PWV was measured using a vascular testing device. On the same day, using CMR, cross-sectional areas for distensibility and average blood flow were measured at four aortic levels: the ascending, upper thoracic descending, lower thoracic descending, and abdominal aorta., Results: Compared to PWV measured by CMR, BA-PWV values were significantly higher and the differences therein were similar in all age groups (all p<0.001). There was a significant correlation between BA-PWV and PWV by CMR (r=0.697, p<0.001). Both BA-PWV and PWV by CMR were significantly and positively associated with age (r=0.652 and 0.724, p<0.001). The reciprocal of aortic distensibility also demonstrated a statistically significant positive correlation with BA-PWV (r=0.583 to 0.673, all p<0.001)., Conclusion: BA-PWV was well correlated with central aortic PWV and distensibility, as measured by CMR, regardless of age and sex.

Purpose: This retrospective study was done to investigate the mean platelet volume (MPV) level in patients with psoriasis vulgaris and its relationship with disease severity., Materials and Methods: We undertook a cross-sectional study on 176 patients and 101 healthy controls to examine the association between MPV and psoriasis. Various clinical and laboratory parameters were analyzed and compared., Results: Platelet distribution width and MPV were significantly higher in patients with psoriasis than controls. In addition, there was positive correlation between Psoriasis Area Severity Index (PASI) and MPV. When psoriasis patients were grouped into mild psoriasis (PASI<10) and moderate to severe psoriasis (PASI≥10), the MPV of the latter group was significantly elevated. Nevertheless, patients with higher MPV level (MPV≥10.4 fL) did not show higher PASI than lower MPV level (MPV<10.4 fL). MPV levels significantly decreased after improvements of psoriasis with various treatments. The variations of MPV and PASI also showed significant correlation., Conclusion: We have shown that MPV is increased in psoriasis patients and correlates with disease severity. Therefore, MPV levels may be considered as a marker of disease severity of psoriasis.

Purpose: The purpose of this study was to investigate the correlation between rotational axes of femur and tibia with the use of Linker., Materials and Methods: This study was carried out from August 2009 to February 2010 on 54 patients (106 knees), who were diagnosed with simultaneous bilateral total knee arthroplasty. With the use of postoperative computed tomography scans, it was investigated how much the rotational angle of femoral and tibial components matched., Results: The tibial component was internally rotated for the femoral component at an angle of 0.8°. The femoral component was externally rotated for the surgical transepicondylar axis (TEA) at an angle of 1.6 (range: from 4.8° of internal rotation to 7.9° of external rotation, SD=2.2°), and the tibial component was externally rotated for the surgical TEA at an average angle of 0.9 (range: from 5.1° of internal rotation to 8.3° of external rotation, SD=3.1°)., Conclusion: The femoro-tibial synchronizer helped to improve the orientation and positioning of both femoral component and tibial component, and also increase the correlation of the rotational axes of the two components.

Purpose: Ultrasound (US) and US-guided fine needle aspiration biopsies (FNAB) are considered the modalities of choice for assessing lymph nodes suspected of containing metastases, but the sensitivity of FNAB varies and is specific to the operator. We analyzed the risk of FNAB providing false negative results of lateral neck node metastasis, and evaluated diagnostic accuracy of FNAB, in patients with papillary thyroid cancer., Materials and Methods: FNAB was performed in 242 patients suspected of having lateral neck node metastasis on preoperative imaging. Thyroglobulin in the fine-needle aspirate washout (FNA wash-out Tg) and computed tomography enhancement (Hounsfield units) were measured. Patients with negative results on FNAB were examined by intraoperative frozen section. The false negative and true negative groups were compared., Results: Of the 242 patients, 130 were confirmed as having lateral neck node metastases. In 74 patients, the metastasis was identified by FNAB. False positive results were observed in 2 patients (0.8%) and false negatives in 58 (44.6%). Risk analysis showed that patient age <45 years (p=0.006), tumor size >1 cm (p=0.008) and elevated FNA wash-out Tg (p=0.004) were significantly associated with false negative results on FNAB. The accuracy of FNAB increased significantly when combined with FNA wash-out Tg (p=0.003)., Conclusion: To reduce the false negative rate of FNAB, patient age (<45 years), tumor size (>1 cm) and FNA wash-out Tg (>34.8 ng/mL) should be considered in preoperative planning. Accuracy may be improved by combining the results of FNAB and FNA wash-out Tg.

Purpose: The underlying cause of myasthenia gravis (MG) is unknown, although it likely involves a genetic component. However, no common genetic variants have been unequivocally linked to autoimmune MG. We sought to identify the genetic variants associated with an increased or decreased risk of developing MG in samples from a Korean Multicenter MG Cohort., Materials and Methods: To determine new genetic targets related to autoimmune MG, a whole genome-based single nucleotide polymorphisms (SNP) analysis was conducted using an Axiom™ Genome-Wide ASI 1 Array, comprising 598375 SNPs and samples from 109 MG patients and 150 neurologically normal controls., Results: In total, 641 SNPs from five case-control associations showed p-values of less than 10⁻⁵. From regional analysis, we selected seven candidate genes (RYR3, CACNA1S, SLAMF1, SOX5, FHOD3, GABRB1, and SACS) for further analysis., Conclusion: The present study suggests that a few genetic polymorphisms, such as in RYR3, CACNA1S, and SLAMF1, might be related to autoimmune MG. Our findings also encourage further studies, particularly confirmatory studies with larger samples, to validate and analyze the association between these SNPs and autoimmune MG.

Purpose: This study was designed to investigate the characteristics of Korean adrenomyeloneuropathy (AMN) patients., Materials and Methods: We retrospectively selected 12 Korean AMN patients diagnosed by clinical analysis and increased plasma content of very long chain fatty acids., Results: All 12 patients were men. Patient ages at symptom onset ranged from 18 to 55 years. Family history was positive in two patients. The phenotype distributions consisted of AMN without cerebral involvement in seven patients, AMN with cerebral involvement in two patients, and the spinocerebellar phenotype in three patients. Nerve conduction studies revealed abnormalities in four patients and visual evoked tests revealed abnormalities in three patients. Somatosensory evoked potential tests revealed central conduction defects in all of the tested patients. Spinal MRI showed diffuse cord atrophy or subtle signal changes in all 12 patients. Brain MRI findings were abnormal in six of the nine tested patients. These brain abnormalities reflected the clinical phenotypes. Mutational analysis identified nine different ABCD1 mutations in 10 of 11 tested patients. Among them, nine have been previously reported and shown to be associated with various phenotypes; one was a novel mutation., Conclusion: In conclusion, the present study is the first to report on the clinical and mutational spectrum of Korean AMN patients, and confirms various clinical presentations and the usefulness of brain MRI scan.

Purpose: We previously reported that insulin resistance, low high-density lipoprotein (HDL) cholesterol, and glycaemic exposure Index are independently associated with peripheral neuropathy in Korean patients with type 2 diabetes mellitus. We followed the patients who participated in that study in 2006 for another 6 years to determine the relationship between insulin resistance and neuropathy., Materials and Methods: This study involved 48 of the original 86 Korean patients with type 2 diabetes mellitus who were referred to the Neurology clinic for the assessment of diabetic neuropathy from January 2006 to December 2006. These 48 patients received management for glycaemic control and prevention of diabetic complications in the outpatient clinic up to 2012. We reviewed blood test results and the nerve conduction study findings of these patients, taken over a 6-year period., Results: Low HDL cholesterol and high triglycerides significantly influenced the development of diabetic neuropathy. Kitt value (1/insulin resistance) in the previous study affected the occurrence of neuropathy, despite adequate glycaemic control with HbA1c <7%. Insulin resistance affected the development of diabetic neuropathy after 6 years: insulin resistance in 2006 showed a positive correlation with a change in sural sensory nerve action potential in 2012., Conclusion: Diabetic neuropathy can be affected by previous insulin resistance despite regular glycaemic control. Dyslipidaemia should be controlled in patients who show high insulin resistance because HDL cholesterol and triglycerides are strongly correlated with later development of diabetic neuropathy.

Purpose: Pouch dilatation and band slippage are the most common long-term complications after laparoscopic adjustable gastric banding (LAGB). The aim of the study is to present our experience of diagnosis and management of these complications., Materials and Methods: The pars flaccida technique with anterior fixation of the fundus was routinely used. All band adjustments were performed under fluoroscopy. We analyzed the incidence, clinico-radiologic features, management, and revisional surgeries for treatment of these complications. We further presented the outcome of gastric plication techniques as a measure for prevention of these complications., Results: From March 2009 to March 2012, we performed LAGB on 126 morbidly obese patients. Among them, 14 patients (11.1%) were diagnosed as having these complications. Four patients (3.2%) had concentric pouch dilatations, which were corrected by band adjustment. Ten (7.9%) had eccentric pouch with band slippage. Among the ten patients, there were three cases of posterior slippage, which were corrected by reoperation, and seven cases of eccentric pouch dilatation with anterior slippage. Three were early anterior slippage, which was managed conservatively. Two were acute anterior slippage, one of whom underwent a revision. There were two cases of chronic anterior slippage, one of whom underwent a revision. The 27 patients who underwent gastric plication did not present with eccentric pouch with band slippage during the follow-up period., Conclusion: The incidence of pouch dilatation with/without band slippage was 11.1%. Management should be individualized according to clinico-radiologic patterns. Gastric plication below the band might prevent these complications.

Purpose: We devised an intraoperatively identifiable mechanical axis (IIMA) as a reference of alignment in total knee arthroplasty (TKA)., Materials and Methods: Between February 2010 and January 2011, primary TKAs were consecutively performed on 672 patients (1007 knees) using an IIMA as a reference in the coronal plane., Results: The alignment of the lower extremity improved from a mean of 11.4±6.7° (-10.3-34.4°) of varus preop. to 0.7±3.5° (-5.2-8.6°) immediately after surgery. Mean alignment of the femoral component in the coronal plane was 89.3±2.3° (83.4-97.2°) postop. and mean alignment of the tibial component was 90.4±2.2° (85.1-94.2°) postop., Conclusion: This study showed that IIMA could be of considerable value as a new guider of alignment that is easily accessible and highly effective during total knee arthroplasty.

Purpose: This study was designed to determine the relationship of cigarette smoking to the frequency and qualitative differences among KRAS mutations in lung adenocarcinomas from Korean patients., Materials and Methods: Detailed smoking histories were obtained from 200 consecutively enrolled patients with lung adenocarcinoma according to a standard protocol. EGFR (exons 18 to 21) and KRAS (codons 12/13) mutations were determined via direct-sequencing., Results: The incidence of KRAS mutations was 8% (16 of 200) in patients with lung adenocarcinoma. KRAS mutations were found in 5.8% (7 of 120) of tumors from never-smokers, 15% (6 of 40) from former-smokers, and 7.5% (3 of 40) from current-smokers. The frequency of KRAS mutations did not differ significantly according to smoking history (p=0.435). Never-smokers were significantly more likely than former or current smokers to have a transition mutation (G→A or C→T) rather than a transversion mutation (G→T or G→C) that is known to be smoking-related (p=0.011). In a Cox regression model, the adjusted hazard ratios for the risk of progression with epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) were 0.24 (95% CI, 0.14-0.42; p<0.001) for the EGFR mutation and 1.27 (95% CI, 0.58-2.79; p=0.537) for the KRAS mutation., Conclusion: Cigarette smoking did not influence the frequency of KRAS mutations in lung adenocarcinomas in Korean patients, but influenced qualitative differences in the KRAS mutations.

Purpose: Glucosamine (UDP-N-acetyl)-2-epimerase/N-acetylmannosamine kinase (GNE) myopathy is an autosomal recessive neuromuscular disorder characterized by early adult-onset weakness of the distal muscles of the lower limbs. The clinical spectrum of GNE myopathy varies, and it is not clear how the same GNE gene mutations can result in different phenotypes. Here, we present clinical, pathological and genetic characteristics of twenty-one Korean patients with GNE myopathy., Materials and Methods: Twenty-one GNE myopathy patients were included in this study, conducted from 2004 to 2011. Based on medical records, patients' gender, onset age, family history, clinical history, serum creatine kinase (CK) level, neurologic examination, findings of muscle biopsy, muscle imaging findings and electrophysiologic features were extensively reviewed. Mutation of the GNE gene (9p13.3) was confirmed by DNA direct sequencing analysis in all patients., Results: The mean onset age was 23.8±8.8 years (mean±SD). Patient serum CK levels were slightly to moderately elevated, ranging from 41 to 2610 IU. Among the patients, twelve patients were female and nine patients were male. Except for eight patients, all of the patients presented initially with only distal muscle weakness in the lower extremities. The most common mutation was V572L, followed by C13S., Conclusion: The clinical manifestations of our patients with GNE mutations varied. Among twenty-one patients, thirteen patients showed the typical GNE myopathy phenotype. There was no relationship between clinical features and site of mutation. Therefore, we suggest that neither homozygous nor compound heterozygous models are correlated with disease phenotype or disease severity.

Epidermoid tumor of the cavernous sinus is rare. The aim of this case report is to discuss the role of neuroendoscopes in the removal of such lesions. A 21-year-old man presented with 6-year history of progressive headache, diplopia, and visual disturbance. Work-up revealed an epidermoid tumor located in the right cavernous sinus. An extradural transcavernous approach was utilized via a traditional frontotemporal craniotomy with endoscopic assistance. The postoperative course was uneventful with immediate improvement of the patient's headache. Postoperative magnetic resonance imaging demonstrated complete removal of the tumor. There were no signs of recurrence during a 2-year follow-up period. The endoscope is a useful tool for removing epidermoid tumors from the cavernous sinus and enhances visualization of areas that would otherwise be difficult to visualize with microscopes alone. Endoscopes also help minimize the retraction of neurovascular structures.

Purpose: Subacute combined degeneration (SCD) involves progressive degeneration of the spinal cord, optic nerve, and peripheral nerves. Vitamin B12 (VB12) is a co-factor in myelin synthesis. Because each cell that constitutes the myelin component in the central nervous system and peripheral nervous system is different, it is improbable that these cells undergo simultaneous degeneration. However, the sequence of degeneration in SCD has not been established., Materials and Methods: In this study, we analysed medical records and electrophysiological data of patients who showed neurological symptoms and whose serum VB12 levels were lower than 200 pg/mL., Results: We enrolled 49 patients in this study. Their mean VB12 level was 68.3 pg/mL. Somatosensory evoked potential (SEP) study showed abnormal findings in 38 patients. Of the 40 patients who underwent visual evoked potential (VEP) study, 14 showed abnormal responses. Eighteen patients showed abnormal findings on a nerve conduction study (NCS). In this study, abnormal posterior tibial nerve SEPs only were seen in 16 patients, median nerve SEPs only were seen in 3 patients, abnormal VEPs only in two, and abnormal NCS responses in one patient. No patient complained of cognitive symptoms., Conclusion: In SCD, degeneration appears to progress in the following order: lower spinal cord, cervical spinal cord, peripheral nerve/optic nerve, and finally, the brain.

Acute sensorimotor polyneuropathy that resembles Guillain-Barré syndrome (GBS) is rarely accompanied with nephrotic syndrome, and its underlying immunological mechanisms are unclear. A 56-year-old man presented with simultaneous acute progressive symmetric sensorimotor polyneuropathy and proteinuria. A kidney biopsy revealed focal segmental glomerulosclerosis. Serial electrophysiologic studies showed only a transient proximal conduction block in the median nerve, stimulated somatosensory evoked potential and prolonged terminal latencies of the median and peroneal nerves. The patient's neurologic deficits and kidney dysfunction recovered with corticosteroid treatment. Our case showed that somatosensory evoked potential study can be an important objective tool in the diagnosis of acute polyneuropathy with normal distal nerve conduction and that corticosteroids should be considered in the initial treatment of GBS-resembling polyneuropathy associated with nephrotic syndrome.

Purpose: Low grade inflammation is a well-known characteristic in obese subjects. We investigated body weight changes and inflammatory markers after 12-week intervention trial., Materials and Methods: Twenty-six obese subjects were enrolled and 19 (13 men and 6 women) completed the study. Sibutramine is an FDA-approved drug for body weight control; therefore, we chose this drug as the standard treatment medication in this study. Patients were randomly allocated to receive an anti-inflammatory agent (Diacerein treatment group; n = 12) or placebo (n = 7) for 12 weeks. Anthropometry, body proportion by dual-energy X-ray absorptiometry, and metabolic parameters at the beginning and end of study were measured and compared., Results: The treatment group had a tendency towards more reduction in anthropometry as compared to the placebo group, in body weight reduction (-7.0 kg vs. -4.6 kg), body mass index (-2.51 kg/m² vs. -1.59 kg/m²), and waist circumference (-7.3 cm vs. -4.4 cm). These reductions were not statistically significant. Changes in levels of high-sensitivity C-reactive protein and adiponectin in the treatment group were more favorable than in the placebo group., Conclusion: This small pilot study showed no statistical difference for changes in anthropometry, and inflammatory markers between the two groups. Therefore, we could not find any additional effects of Diacerein on weight loss and inflammatory variables in this study.

Purpose: We investigated whether infantile vulvar abscesses are predictable features of rectovestibular fistula with a normal anus., Materials and Methods: A retrospective analysis of five infants with vulvar abscesses and rectovestibular fistulae with normal anuses was performed., Results: Four cases had a left vulvar abscess, and in one case the vulvar abscess was on the right side. All caregivers reported passage of stool from the vagina. The fistulae were almost uniformly located from the vestibule to the rectum above the anal dentate line, observable by visual inspection and probing under anesthesia. The first two cases were treated with division and closure of the fistulae after a diverting loop colostomy, and the remaining three cases with fistulotomy and curettage. There was no recurrence during the median follow-up period of 38 months., Conclusion: This unique rectovestibular fistula should be suspected in female infants with vulvar abscesses, especially when parents report passage of stool from the vagina. Fistulotomy and curettage may be an initial treatment and effective as a temporary diverting colostomy and delayed repair of the fistula.

Purpose: The purpose of this paper is to test the hypothesis that combination therapy of serial cast and botulinum toxin type A (BTX-A) injection can further enhance the effects of a BTX-A injection in ambulant children with cerebral palsy (CP) who have an equinus foot., Materials and Methods: Children in group A (30 legs of 21 children) received a serial casting application after an injection of BTX-A, and children in group B (25 legs of 17 children) received only a BTX-A injection. Assessments were performed before the intervention and 1 month after the intervention., Results: After the intervention, there were significant improvements in tone, dynamic spasticity, and passive range of motion (ROM) in both groups. However, the changes were greater in group A than in group B. Dimension D (standing) in Gross Motor Function Measure (GMFM)-66 was significantly improved in group A but not in group B. On the other hand, there were no significant changes in dimension E (walking, running, jumping) in GMFM-66 in either group., Conclusion: The results of our study suggest that a serial casting application after BTX-A injection can enhance the benefits of BTX-A injection in children with cerebral palsy.

Purpose: Nemaline myopathy (NM) is a clinical heterogeneous congenital myopathy characterized by the presence of subsarcolemmal or cytoplasmic rod-like structures that call nemaline bodies in the muscle fibers. The purpose of this study was to investigate the clinical diversity and pathological features of Korean patients with NM., Materials and Methods: Eight patients underwent analyses of clinical manifestations by a structured protocol. Diagnoses were established by a muscle biopsy., Results: Two patients had the typical congenital type, which exhibited neonatal hypotonia and delayed motor milestone, and five patients had the childhood onset type, which exhibited mild gait disturbance as a first symptom. One patient had the adult onset type, which showed acute respiratory failure. Limb weakness was proximal-dominant occurred in six patients. Hyporeflexia was observed in most patients. Elongated faces and high arched palates and feet were also observed. On light microscopy, the nemaline bodies were observed in type 1 and 2 fibers. All patients showed type 1 predominance and atrophy. In the two cases in which ultrastructural studies were performed, typical nemaline rods and disorganized myofibrillar apparatus were detected., Conclusion: In conclusion, the eight Korean patients in this study with NM shared common clinical expressions such as proximal limb weakness, reduced deep tendon reflex, and dysmorphic features. This study, however, showed that clinical heterogeneity ranged from typical congenital, mildly affected childhood to the adult onset form with acute respiratory failure. The pathological findings in this study were in accordance with those of other previous reports.

The aim of this study is to determine whether the posterior cervical fusion methods with the plate-screw system applied to the lateral mass of cervical spine are radiologically safe to patients. The lateral cervical X-rays and CT scans were done on 40 normal adults without cervical problem. Based on Roy-Camille and Magerl's method, the theological trajectory of screw was shown on films and the parameters were measured. The study based on Roy-Camille's method showed less than one percent chance of injury on the facet joint and the mean depth of the screw to be 10.5 +/- 1.4 mm. On the other hand, Magerl's method showed the mean depth of screw to be 11.9 +/- 1.5 mm which is slightly larger than that of Roy-Camille's method and no chance of facet injury occurred. A reduced lateral angle of screw (19.6 +/- 3.5 degrees C) performed with the concept based on Magerl's method resulted a longer depth of screw (13.5 +/- 2.1 mm). Both Roy-Camille and Magerl's methods seemed to be radiologically safe to normal persons. However, the authors recommend the reduced lateral angle (19.6 +/- 3.5 degrees C) of screw based on the Magerl's method more than an original Magerl's methods.

A randomized prospective study was performed on the anesthetic induction, maintenance, and recovery characteristics of sevoflurane-nitrous oxide, compared to that of target- controlled propofol and fentanyl anesthesia, for forty day-case hysteroscopic surgery. The patients in the sevoflurane group (n = 20) received sevoflurane-nitrous oxide for both induction (8%) and maintenance (1 - 2%) of anesthesia, while the patients in the propofol group (n = 20) received target-controlled propofol (4 micro g/ml, 3-6 micro g/ml as occasion demanded) with fentanyl (1 micro g/kg). In both groups, the airway was maintained by a facemask with the patient breathing spontaneously during the surgery. The mean times to unconsciousness and readiness for surgery were similar in both groups, with those for the sevoflurane group, compared to the propofol group being 80.4 +/- 18.9 vs. 83.6 +/- 38.8 sec, and 220.1 +/- 76.9 vs. 231.0 +/- 95.4 sec, respectively. Propofol was associated with significantly higher incidences of involuntary movement (30% vs. 5%) and apnea (35% vs. 0%) during the induction period than with sevoflurane. Hemodynamic variables were similar with the exception of significantly lower blood pressures during the first 5 minutes of induction with propofol. Emergence times to eye opening, hand squeezing and orientation for sevoflurane compared to propofol were: 316.6 +/- 79.3 vs. 507.4 +/- 218.8 sec, 390.0 +/- 69.3 vs. 653.1 +/- 201.6 sec and 380.6 +/- 80.8 vs. 666.3 +/- 208.7 sec, respectively, all of these being significantly faster for sevoflurane than propofol. The postanesthetic Aldrete's recovery scores of the patients immediately after surgery were higher in the sevoflurane group. Propofol was associated with more drowsiness, with sevoflurane being associated with more nausea, in the recovery period; however, neither delayed the time to discharge (103.7 +/- 28.1 vs. 99.0 +/- 36.2 min). In conclusion, sevoflurane-nitrous oxide appears to be superior for day-case hysteroscopic surgery, than target-controlled propofol with fentanyl, with regards to the speed of recovery from anesthesia and the return to hemodynamic stability.

Progressive narrowing of distal carotid arteries and the development of compensatory fine networks are the characteristic findings of moyamoya disease. Cerebral infarction in moyamoya disease is due to a decreased blood flow and shows an uneven distribution in the distal bed of the anterior and middle cerebral arteries. The progression of disease in the posterior circulation follows that in the anterior circulation. Posterior circulation symptoms due to cerebral infarction usually occur in the advanced stage of the disease and follow the anterior circulation symptoms. We encountered an unusual case of moyamoya disease which initially presented with a transient visual field defect. One month later our patient developed blindness and her cerebral angiography showed advanced moyamoya disease.

Segmental vitiligo usually has an onset early in life and spreads rapidly within the affected area. Among 1,300 patients with vitiligo, 191 patients with segmental vitiligo involving the face were evaluated. In this study, the distribution of segmental vitiligo on the face could be classified into 5 patterns which have distinctive features. This classification of facial segmental vitiligo can provide some indication of the future distribution of early lesions if they have begun to spread.

Carotid artery stenting has been accepted as a potential alternative to carotid endarterectomy in patients with significant carotid artery stenosis. The objective of this study was to evaluate the feasibility, safety and long-term outcome of percutaneous stenting of carotid artery stenosis in patients with coexisting symptomatic coronary disease. Between May 1996 and May 1999, we performed carotid artery stenting at 48 lesions in 36 patients with carotid stenosis of 60% and symptomatic coronary artery stenosis. Twenty-one patients (58%) had neurologic symptoms. Carotid stenting was performed in 43 internal, 2 external and 3 common carotid lesions. We used Wallstent in 46 lesions, Palmaz stent in 2 lesions and Microstent II in 1 lesion. Staged or combined coronary intervention was performed in 18 patients (50%) and staged coronary artery bypass surgery was performed in 6 patients (17%). In the other 12 patients (33%), medical treatments were performed. Carotid stenting was successful in all lesions. Simultaneous bilateral carotid stenting was performed in 11 patients (31%). One major and 1 minor stroke developed during the procedure. There were no deaths during the procedures and within 30 days post-procedure. During the follow-up of 14 +/- 7 (3 to 40) months, there were no deaths or neurological events. On follow-up (6 +/- 1 months) angiography and/or duplex sonography of 44 eligible lesions in 32 patients, there were 2 cases of asymptomatic restenosis (4.5%) which developed in Palmaz stents implanted at the external carotid artery and the common carotid artery, respectively. In conclusion, carotid artery stenting in patients with coexistent carotid and coronary artery disease is feasible, safe and shows favorable follow-up outcomes.

The Lambert-Eaton myasthenic syndrome (LEMS) heralds the occurrence of malignancy, especially small-cell lung cancer (SCLC), but it can also occur in the absence of cancer. Twelve patients were diagnosed as LEMS by clinical features and the classical electrophysiological triad, which includes a low amplitude of compound muscle action potentials (CMAP), decremental responses on low-rate stimulation, and incremental responses on high-rate stimulation on the repetitive nerve stimulation (RNS) test. There were 6 male and 6 female patients, ranging in age from 49 to 66 years. Malignancy(all were SCLC) was found in 7 patients. Males predominantly expressed the paraneoplastic form; whereas the primary autoimmune form was found only in women, who showed a good response to corticosteroid treatment. The neurological features were similar in both groups: proximal lower limb weakness, depressed muscle stretch reflexes, and dryness of mouth in nearly all patients. Bulbar dysfunction and limb paresthesia were a little more frequent in the paraneoplastic form. In RNS tests, the characteristic electrophysiological abnormalities were found in all patients and were more profound in the paraneoplastic form. We concluded that LEMS is commonly associated with malignancy, especially SCLC, but it should also be stressed that there are many female LEMS patients who do not harbor any malignancy at all, and that other treatment strategies such as immunotherapy should be considered for these patients.

The association of vitiligo and pernicious anemia has been previously documented. The low levels of folic acid and vitamin B12 were thought to be related to vitiligo. To date, there have been very few reports about the serum levels of folic acid and vitamin B12 in patients with vitiligo. Using radioimmunoassay, we measured the serum levels of folic acid and vitamin B12 in 100 Korean patients with vitiligo. The mean serum levels of folic acid and vitamin B12 were 6.31 +/- 2.82 ng/ml and 630.25 +/- 230.94 pg/ml, respectively, in patients with vitiligo. These levels showed no significant difference compared to the normal control group, suggesting that folic acid and vitamin B12 do not appear to play a role in the pathogenesis of vitiligo.

Carotid cavernous dural arteriovenous fistula (DAVF) usually presents with conjunctival injection, proptosis, loss of visual acuity and ophthalmoplegia. There have been some carotid cavernous DAVF case reports presenting with isolated oculomotor, abducens and trochlear nerve palsy. We experienced a patient presenting with bilateral abducens nerve palsy and no other ocular signs who was diagnosed as carotid cavernous DAVF after conventional angiography. According to this case, carotid cavernous DAVF should be considered in the differential diagnosis of isolated bilateral abducens nerve palsy, in which case conventional angiography may be helpful in diagnosis.