Does Sedation Affect Examination of Esophagogastric Junction during Upper Endoscopy?

PURPOSE: During sedated esophagogastroduodenoscopy (EGD), patients may not be able to perform inspiration, which is necessary to examine the esophagogastric junction. Therefore sedation may affect diagnosis of gastroesophageal reflux-related findings. The aim of our study was to investigate the effect of sedation on diagnosis of gastroesophageal reflux-related findings during EGD. MATERIALS AND METHODS: This retrospective study evaluated 28914 patients older than 20 years who underwent EGD at our institution between January 2011 and December 2011. Ultimately, 1546 patients indicated for EGD for health check-up and symptom evaluation were included. RESULTS: There were 18546 patients who had diagnostic EGD: 10471 patients (56%) by non-sedated EGD and 8075 patients (43%) by sedated EGD. After statistical adjustment for age, sex, and body mass index, minimal change esophagitis, and hiatal hernia were significantly less frequently observed in the sedated EGD group [odds ratio (OR), 0.651; 95% confidence interval (CI), 0.586 to 0.722 and OR, 0.699; 95% CI, 0.564 to 0.866]. Nevertheless, there was no significant difference in other findings at the gastroesophageal junction, such as reflux esophagitis with Los Angeles classification A, B, C, and D or Barrett's esophagus, between the two groups. Similarly, there were no differences in early gastric cancer, advanced gastric cancer, and gastric ulcer occurrence. CONCLUSION: Sedation can impede the detection of minimal change esophagitis and hiatal hernia, but does not influence detection of reflux esophagitis of definite severity and Barrett's esophagus.ope

Overlooked Management and Risk Factors for Anemia in Patients with Intestinal Behçet's Disease in Actual Clinical Practice

BACKGROUND/AIMS: Anemia in patients with inflammatory bowel disease significantly affects the quality of life. The aim of this study was to investigate the frequency of and risk factors for anemia and to describe the management of anemia in patients with intestinal Behçet's disease (BD) in actual clinical practice. METHODS: We included 64 patients with intestinal BD who visited the outpatient clinic of a tertiary referral center in June 2011 and had available laboratory data for the subsequent 6 months. RESULTS: Anemia was detected in 26 patients (40.6%). After 6 months, anemia was still present in 14 of these patients (53.8%). The cause of anemia was investigated in eight patients (30.8%), and oral iron supplementation was prescribed to four patients (15.4%). Of these four patients, two (50%) recovered completely within 6 months. Anemia was associated with a high Disease Activity Index for Intestinal Behçet's Disease (DAIBD, p=0.024), erythrocyte sedimentation rate (p=0.003), and C-reactive protein (p=0.049) in univariate analysis. In multivariate analysis, the factor predictive for anemia in patients with intestinal BD was a higher DAIBD (≥40; odds ratio, 4.08; 95% confidence interval, 1.21 to 13.71; p=0.023). CONCLUSIONS: Although anemia is common in intestinal BD patients, its clinical importance is overlooked in daily practice. Moderate to severe disease activity is predictive of anemia.ope

Physical activity and quality of life of patients with inflammatory bowel disease

This study examined the association between physical activity (PA) and quality of life (QOL) in Korean patients with inflammatory bowel disease (IBD).We enrolled 158 patients with IBD (81 men and 47 women). PA levels were assessed using the International PA questionnaire. Using self-reported frequency (day) and duration (h) of physical activities, the patients were categorized into 3 groups based on their total metabolic equivalent (MET-h/wk) values: least, moderate, and most active. The QOL of patients with IBD was assessed using the inflammatory bowel disease questionnaire (IBDQ), the Medical Outcomes Study 36-Item Short Form Version 2 (SF36v2), the EuroQOL five dimensions questionnaire (EQ5D), and the EuroQOL visual analog scale (EQ-VAS).Of 158 patients, 62, 73, and 23 patients with Crohn disease, ulcerative colitis, and intestinal Behçet disease, respectively, were included. The mean age was 45.96 ± 17.58 years, and 97 (61.4%) patients were men. Higher PA levels correlated with higher EQ5D and EQ-VAS scores (P < .001 and P = .004 respectively). In addition, depending on the type of PA, the amount of leisure activity was associated with higher IBDQ (κ = 0.212, P = .018), physical function of SF36v2 (κ = 0.197, P = .026), EQ5D (κ = 0.255, P = .002), and EQ-VAS (κ = 0.276, P = .001) scores. The frequency of sweat-inducing exercise showed an inverse correlation with IBDQ (κ = -0.228, P = .011), physical function of SF36v2 (κ = -0.245, P = .006), EQ5D (κ = -0.225, P = .007), and EQ-VAS (κ = -0.246, P = .004) scores.Increased PA levels were associated with improved QOL in patients with IBD. More leisure activity and non-sweat-inducing exercise were associated with improved QOL in patients with IBD.ope

The effect of prediagnostic aspirin use on the prognosis of stage III colorectal cancer

BACKGROUND: Many studies have suggested that the regular use of non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, has a protective effect and survival benefit on colorectal cancer (CRC). However, recent data suggest that CRCs have different responses to NSAIDs depending on the timing of NSAID initiation, duration of NSAID use, and molecular characteristics of the tumor. The aim of this study was to evaluate the effect of long-term prediagnostic aspirin use on the prognosis of stage III CRC. METHODS: From 2007 to 2009, patients who were diagnosed with stage III CRC were recruited, and their medical records were retrospectively analyzed. Patients were divided into prediagnostic aspirin users (who used aspirin for more than three months continuously before CRC diagnosis) and non-users (who did not use of aspirin and NSAIDs). The two groups were compared in terms of recurrence, cancer-specific mortality, disease-free survival (DFS), and cancer-specific survival. In an experimental study, three CRC cell lines (Caco2, SW480, and DLD-1) were pretreated with aspirin (1 mM) for four days or 28 days to make aspirin-resistant cells, treated with 5-fluorouracil (5-FU; 2 µM), and apoptosis was measured with flow cytometry using Annexin-V and propidium iodide double staining. RESULTS: Compared with the aspirin non-users (N=565), the prediagnostic aspirin users (N=121) were not different in terms of baseline characteristics including tumor characteristics, except for comorbidities and diabetes medication and statin use, which were higher in the prediagnostic aspirin users. Recurrence and cancer-specific mortality in stage III CRC were significantly higher in prediagnostic aspirin users than non-users (46.7% vs. 32.3%, P=0.003 and 32.2% vs. 19.8%, P=0.003, respectively). Survival analysis using Cox proportional hazards modeling demonstrated that DFS was significantly worse in prediagnostic aspirin users than non-users (HR, 1.525 (1.018-2.286); P=0.041). In cell line experiments, long-term aspirin pretreatment induced an increase in 5-FU-induced apoptosis in SW480 cells compared with control treatment without aspirin pretreatment. However, Caco2 cells showed a significant decrease of apoptosis in the same experiments and no change in DLD1 cells. CONCLUSION: Prediagnostic long-term aspirin use in stage III CRC could be a negative prognostic factor depending on the characteristics of the CRC.ope

The Effect of Metformin on Responses to Chemotherapy and Survival in Stage IV Colorectal Cancer with Diabetes

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Conventional endoscopic features are not sufficient to differentiate small, early colorectal cancer

AIM: To evaluate the depth of invasion of small, early colorectal cancers (ECCs) using conventional endoscopic features. METHODS: From January 2005 to September 2011, colonoscopy cohort showed that a total of 72 patients with small colorectal cancers with the size less than 20 mm underwent colonoscopy at the Yonsei University College of Medicine, Seoul, South Korea. Among them, 8 patients were excluded due to incomplete medical records. Finally, a total of 64 ECCs with submucosa (SM) invasion and size less than 20 mm were included. One hundred fifty-two adenomas with size less than 20 mm were included as controls. Nine endoscopic features, including seven morphological findings (i.e., loss of lobulation, excavation, demarcated and depressed areas, stalk swelling, fullness, fold convergence, and bleeding ulcers), pit patterns, and non-lifting signs, were evaluated retrospectively. All endoscopic features were evaluated by two experienced endoscopists who have each performed over 1000 colonoscopies annually for more than five years without knowledge of the histology. RESULTS: Among the morphological findings, the size of deep submucosal cancers was bigger than that of superficial lesions (16.9 mm vs 12.3 mm, P < 0.001). Also, demarcated depressed areas, stalk swelling, and fullness were more common in deep SM cancers than in superficial tumors (demarcated depressed areas: 52.0% vs 15.7%, P < 0.001; stalk swelling: 100% vs 4.2%, P < 0.001; fullness: 25.0% vs 0%, P = 0.001). Among deep SM cancers, 96% of polyps showed invasive pit patterns, whereas 19.4% of superficial tumors showed invasive pit patterns (P < 0.001). A positive non-lifting sign was more common in deep SM cancers (85.0% vs 28.6%, P < 0.001). Diagnostic accuracy of invasive morphology, invasive pit patterns, and non-lifting signs for deep SM cancers were 71%, 82%, and 75%, respectively. CONCLUSION: Conventional endoscopic findings were insufficient to discriminate small, deep SM cancers from superficial SM cancers by white light, standard colonoscopy.ope

Clinical meaning of BRAF mutation in Korean patients with advanced colorectal cancer

AIM: To evaluate the clinicopathological features of colorectal cancer (CRC) with a v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) mutation and its molecular interaction with microsatellite instability (MSI) and v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (KRAS) in patients with advanced CRCs. METHODS: From October 2009 to December 2011, 141 patients with stage III (n = 51) or IV (n = 90) CRCs who were tested for the BRAF mutation at Severance Hospital were included. Among 141 patients, five were excluded due to follow-up loss. Therefore, 136 patients were included in the study. The clinicopathological data, MSI status, and KRAS/BRAF mutation status were reviewed retrospectively. In addition, to evaluating the value of BRAF mutation status, progression-free survival and overall survival in all patients were collected and compared between the BRAF wild-type group and BRAF mutation group. RESULTS: Of 136 patients, 80 (58.8%) were male and the mean age was 59 years. BRAF and KRAS mutations were detected in 9.6% and 35.3% of patients, respectively. Only 4.3% of patients had MSI-high tumors and there were no MSI-high in tumors with a BRAF mutation. BRAF mutations tended to be more frequent in stage IV than in stage III (11.76% vs 5.88%, P = 0.370). Patients with a BRAF mutation had a lower incidence of KRAS mutation than those without (7.69% vs 38.21%, P = 0.033). Overall survival was significantly shorter in the BRAF mutation group than in the BRAF wild-type group both by univariate analysis (P = 0.041) and multivariate analysis (HR = 2.195; 95%CI: 1.039-4.640; P = 0.039), while progression-free survival was not different according to BRAF mutation status. CONCLUSION: CRCs with a BRAF mutation have distinct molecular features and resulted in a poor prognosis in Korean patients with advanced CRC.ope

The Rebleeding Risk and Prognostic Factors of Acute Hemorrhagic Rectal Ulcer

Background/Aims: Acute hemorrhagic rectal ulcer (AHRU) is an important etiology of lower gastrointestinal bleeding in intensive care unit patients and hospital inpatients. Moreover, with increasing elderly populations, and improved survival in critically ill patients, the incidence of AHRU has increased. The aim of this study is to determine rebleeding risk and prognostic factors of AHRU patients. Methods: We retrospectively reviewed 32 patients with AHRU in Severance Hospital from February 2006 to October 2010, collected clinical data, and analyzed their association with the recurrence of bleeding and mortality of patients. Results: The mean age of patients was 65.5 years, and 27 patients (84.4%) showed Eastern Cooperative Oncology Group performance status 3-4. Nineteen patients (59.4%) had recurrent bleeding. Hypoalbuminemia (≤2.5 g/dL) was a risk factor of rebleeding in univariate and multivariate analysis. For patients with chronic liver disease, hypoalbuminemia (≤2.5 g/dL), renal dysfunction (>2 mg/dL) and thrombocytopenia (40 seconds) increased mortality (P=0.028, P=0.008 and P=0.027, respectively) and the patients with rebleeding showed a tendency toward higher mortality, compared to those without (57.9% vs. 23.1%, P=0.051). Conclusions: In AHRU patients, hypoalbuminemia was a risk factor of rebleeding, and chronic liver disease, hypoalbuminemia, renal dysfunction, thrombocytopenia and no endoscopic treatment at the first bleeding event was correlated with relatively earlier rebleeding.ope

전기(傳記)에 나타난 Samuel Johnson이 문학관

Samuel Johnson(1709~1784)은 Life of Cowley에서 천재를 a mind of large general powers, accidentally determined to some particular direction으로 정의했다. 자신의 경험적 사실과 연관되는 경우 흔히 그렇듯이 이 정의도 단순한 일반론으로서 보다는 자신에 대한 해명으로 새겨 들을 때 그 의미가 한결 돋보일 뿐 아니라 나아가 Johnson과 그의 문학을 이해하는 데 종요로운 길잡이가 될 수 있다고 생각된다. Johnson의 문학활동 연보를 살펴보면 천재에 대한 위의 정의가 그 자신에게 고스란히 들어맞음을 확인할 수 있다. 그의 활동영역은 문학의 모든 분야를 섭렵했다고 할 정도로 광범위했다. 詩, 비평, 사전편찬, 정기간행 에세이, 전기 등의 분야에서 각기 그 방면의 우뚝한 봉우리가 될 성취를 이루었을 뿐 아니라 극작에도 손을 댄 적이 있고 Rasseläs와 같은 소설에 가까운 작품을 쓰기도 했다. 확실히 그의 재능은 이처럼 다방면에 걸쳐 발휘된 크고 일반적인 것이었는데, 그것이 우연히 어느 특정한 방면, 방향에로 집중, 결집되는(determined) 곳은 바로 전기였다고 판단된다

4기 대장암 환자에서 NSAIDs 복용 여부에 따른 항암약물요법 반응 및 질병의 예후

Dept. of Medicine/석사Background: Colorectal cancer (CRC) is the third most frequent cancer in Korea, and it is continuously increasing in prevalence. Despite improved survival rates, the five-year survival in stage IV CRC is less than 10%. There have been many studies which have suggested that there is a protective and adjuvant therapeutic effect on CRC from the regular use of non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin. However, recently accumulating data suggest that CRCs have different responses to NSAIDs, depending on the timing of initiation, duration of therapy or target groups. In particular, the data about the effect of NSAIDs on stage IV CRC patients have been limited. The aim of this study was to evaluate the effect of NSAIDs on tumor response and prognosis of stage IV CRC.Methods: From January 2005 to December 2010, patients who were diagnosed with stage IV CRC and received chemotherapy at Severance Hospital and who had underlying hypertension (HTN), coronary artery disease (CAD), angina or rheumatoid arthritis (RA) (diseases associated with NSAID use) were recruited, and their medical records were retrospectively analyzed. The NSAIDs non-user group was defined as never having used NSAIDs or patients who took NSAIDs for less than one month, and the prediagnostic NSAID-user group was defined as patients who took NSAIDs over the 12 consecutive months before diagnosis with stage IV CRC. The two groups were compared in terms of baseline characteristics, tumor response, overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS) and disease-free survival (DFS).Results: Compared with the NSAID non-user group (N=137), the prediagnostic NSAID-user group (N=29) was not different in terms of baseline characteristics, except for CAD prevalence, which was higher in the prediagnostic NSAID-user group (p=0.004). There was no significant difference in tumor response between the NSAID non-user group and the prediagnostic NSAID-user group based on use of NSAIDs during chemotherapy (p=0.304). The OS, PFS and DFS were significantly different in univariate analysis between the NSAID non-user group and the prediagnostic NSAID-user group (OS: 20.48 months vs. 27.03 months, p=0.035, PFS: 8.55 months vs. 13.26 months, p=0.048, DFS: 11.20 months vs. 25.60 months, p=0.031). In multivariate analysis, the OS and CSS of the NSAID non-user group were better than those of the prediagnostic NSAID-user group (overall mortality: HR, 0.478; 95% CI 0.234-0.974; p=0.042, cancer-specific mortality: HR, 0.386; 95% CI 0.163-0.910; p=0.030). Conclusion: Long-term NSAID use before diagnosis with stage IV CRC could be a negative prognostic factor.ope