WCIM 2014 SEOUL KOREA 209
Poster Session
The Korean Journal of Internal Medicine Vol. 29, No. 5 (Suppl. 1)
PS 0623 Others
Ovarian Serous Cystadenoma in a 29-Year Old Post-Tahbso Female with Mayer-Rokitansky-Kus- ter-Hauser Syndrome, Heterotaxy Syndrome with Polysplenia and Hypothyroidism: A Case Report
Renato Jr ONG1, Tomasito SY1, Patricio PALMES1 West Visayas State University Medical Center, Philippines1
Background: The incidence of MRKH is 1 in every 4,500 female live births, while Het- erotaxy syndrome occurs in 4 in every 1M live births. There was one reported case of MRKH with Hypothyroidism and one case with Hypoplastic R lung. The incidence of MRKH plus Heterotaxy syndrome with polysplenia is still unknown. MKRH with ovar- ian tumors revealed 5 reported cases but none of these was consistent with ovarian serous cystadenocarcinoma. There is no documented association of Heterotaxy syn- drome with polysplenia and ovarian serous cystadenocarcinoma.
Clinical Presentation: A 29-year old female was admitted for an appendectomy with incidental note of an unresectable retroperitoneal mass. Biopsy showed suppurative appendix and an abscess with granuloma formation. She underwent pelvic laparotomy with bilateral salpingooophorectomy at age 16 for primary amenorrhea and an absent vaginal orifi ce.
Diagnostic Work Up: CBC showed anemia and persistent leukocytosis with absolute neutrophilia. There were low Na+ and K+ levels and remittent azotemia with hypoal- buminemia. TSH was high but T3 was low. Karyotyping bared normal 46,XX karyotype.
Chest X-ray revealed narrowed right intercostal spaces; hyperlucent left lung with widened intercostal spaces; shifting of the trachea and mediastinum to the right; and elevated right hemidiaphragm. Chest and abdominal CT scan demonstrated structural alterations consistent with Heterotaxy syndrome; a lobulated, solid mass with areas of hypodensities and punctuate calcifi cations within the pelvic cavity. 2D-Echocardiogra- phy showed a dextro-positioned heart.Hormone panel was consistent with menopau- sal levels. Immunohistochemistry studies showed infl ammatory myofi broblastic tumor.
Autopsy revealed ovarian serous cystadenocarcinoma.
Treatment Outcome: Anemia was corrected, and intravenous antibiotics were start- ed. Patient was discharged improved, however, eventually succumbed after 5 months.
PS 0624 Others
The Mindset of Indian Internal Medicine Residents - A Questionnaire Based Study
Arjun KHANNA1, Virendra ATAM2
VMMC and Safdarjang Hospital, India1, King George’s Medical University, India2
Background: The branch of Internal Medicine (IM) is all encompassing and ever grow- ing. The residents of IM undergo 3 years of rigorous training in our country. This is a questionnaire based study to gauge their attitude towards IM as a branch, its various aspects and towards the concept of “super-specialization” which is slowly but steadily catching on even in the resource limited countries.
Method: 50 IM residents were given a questionnaire having questions framed by our faculty. The responses marked were evaluated.
Results: 88% residents (44/50) were happy with their decision of having chosen IM as a branch for specialization. All 6 who were unhappy, were fi rst year residents. only 4%
(2/50) did not want to pursue further super specialization after residency. The most important reason cited, 77% (37/48) was peer pressure to pursue a higher degree, even when the resident was not particularly interested in doing further fellowship.
The most sought after branch for fellowship was cardiology - 62.5%(30/48). Only 24% (12/50) were willing to take up a government job post residency. 44%(22/50) were confi dent of reaching a diagnosis when encountering a patient for the fi rst time, without asking for any laboratory investigations, but only 10% (5/50) accepted doing a complete physical examination of their patients in the OPD or wards. 86%(43/50) were confi dent in doing most ward procedures confi dently and independently. 100%
marked, that they were overworked.
Conclusions: IM residents from the developing world, like their western counterparts are more interested in pursuing super specialization rather than sticking to IM alone.
Despite ample clinical material, most prefer laboratory investigations for patient eval- uation. The need of the hour is to make IM training more comprehensive.
PS 0625 Others
A Tool Which Judges Effi ciently the Cost Effective- ness of Brand-Name Drugs in Chronic-Disease Medical Treatment Until Generic Drugs are Put on the Market
Koichi ONO1
Innoshima Medical Associated Hospital, Japan1
Background: I made a practical tool “Moneymedicine” to evaluate medicinal value, by combining medicinal offi cial prices and useful results from studies as Evidence-based medicine (EBM) or drug informations (DI). The purpose of this study is to evaluate its usefulness using this tool.
Methods: The formula is simple: a price is divided or multiplied with improvement rate from EBM or DI.
Results: (1) Average reductions in systolic blood pressure using angiotensin II receptor antagonists from DI were 10.4 mmHg for losartan 50 mg, 14.8 for candesartan 8 mg, 13.0 for valsartan 80 mg, 11.8 for telmisartan 40 mg, 15.7 for olmesartan 20 mg, 12.1 for irbesartan 100 mg, and 20.5 for azilsartan 20 mg. Each daily costs (yen) of these are 136.5, 135.6, 109.1, 125.0, 123.3, 123.4, and 140.6, respectively. The results are 13.1, 9.16, 8.39, 10.6, 7.85, 10.2, and 6.86, respectively, and indicate that azilsartan 20 mg od is the most advantageous medicine. (2) There are the direct thrombin inhibitor (dabigatran) and the factor Xa inhibitors (rivaroxaban, apixaban) as novel oral antico- agulants (NOACs). Each daily cost of usual dosage is ¥ 545.6. The relative risk over the warfarin of apoplexy and systemic embolism from the results of large, randomized tri- als; RE-LY, RE-LY ASIA, ROCKET-AF, J-ROCKET-AF, and ARISTOTLE (all and Asian Pacifi c region), were 0.66, 0.45, 0.88, 0.49, 0.80, and 0.52, respectively. It is judged that dab- igatran should be used fi rst. However, when results were adjusted by CHADS2 score, rivaroxaban should be used fi rst to prevent Asian patients from cerebral infarction.
Conclusions: This concept belongs to the cost-effectiveness analysis of Pharmacoeco- nomics. Using this useful tool “Moneymedicine”, we can choose and use the most profi table medicine in the category.
PS 0627 Others
How a Good News Changed to Bad News; A Rare Case of Metastatic Adenocarcinoma of the Pancreas Pre- sented with High Bhcg Levels and Bilateral Ankle Pain:
Faisal BUTT1
Tan Tock Seng Hospital, Singapore1
6 –year old female admitted on 17-08-2013 with complaints of right ankle and foot pain for the last 2 weeks. On examination, her right ankle was swollen and warm, with full range of movements. The right dorsum was erythematous. Her initial investiga- tions showed an increased WBC 22,200 (neutrophils 12,100) with an Hb of 11.8 and platelets 177 x 103. The xrays of ankles were unremarkable. Her urine pregnancy test interestingly came positive, as she denied any recent sexual intercourse, the last being 8 months ago. She underwent an ultrasound of abdomen and pelvis to look for the source of elevated HCG, which showed multiple solid hepatic nodules, likely neoplastic (metastatic v/s primary), the largest being ~6.8x6.2x4.9cm. The CT study showed a 4 cm hypodense mass in the tail of pancreas extending into the proximal part of the splenic vein. The liver showed numerous hypodense lesions in both lobes keeping with the metastases. In addition, there were fi lling defects noted in the segmental arteries in both lower lung lobes, keeping with pulmonary emboli. The following ultrasound Doppler study of the lower limbs had evidence of mid-distal superfi cial femoral and popliteal veins bilaterally. She underwent image guided liver biopsy and started on long-term low-molecular weight heparin for the PE. The histology showed an invasive adenocarcinoma, in keeping with metastasis from a ductal adenocarcinoma of the pancreas. Medical oncology team was consulted and advise for outpatient palliative chemotherapy. She was discharged stable and she followed up with Medical oncology and received fi rst cycle of Chemotherapy (oxaliplatin, fl uorouracil, irinotecan,leucov- orin) on 10th sept.2013 which she tolerated well.
