Many advances in the treatment of multiple myeloma have been made due to the use of transplantation and the introduction of novel agents including thalidomide, lenalidomide, and bortezomib. The first step is recognizing the symptoms and starting prompt treatment. Different strategies should be selected for young and elderly subjects. Young patients are commonly eligible for transplantation, which is now considered the standard approach for this setting, and various inductions therapies containing novel agents are available before transplantation. Elderly patients are usually not eligible for transplantation, and gentler approaches with new drugs combinations are used for their treatment.

The number of hemodialysis patients and dialysis facilities is increasing each year, but there are no surveillance programs validating that the services and equipment of each hemodialysis unit meet specified safety and quality standards. There is a concern that excessive competition and illegal activities committed by some dialysis facilities may violate patients' right to health. Contrastingly, developed countries often have their own survey program to provide initial certification and monitoring to ensure that these clinics continue to meet basic requirements. Because hemodialysis units provide renal replacement therapy to critical patients suffering from severe chronic renal failure, appropriate legal regulation is important for the provision of initial certification and maintenance of facility, equipment, and human resource quality. Therefore, several standards providing minimum requirements for the area of hemodialysis unit, equipment for emergency care, physician and nurse staffs, water purification and quality management are urgently needed.

Traditional biomarkers, including C-reactive protein, leukocytes, erythrocyte sedimentation rate, and clinical signs and symptoms, are not sufficiently sensitive or specific enough to guide treatment decisions in infectious febrile diseases. Procalcitonin (PCT) is synthesized by a large number of tissues and organs in response to invasion by pathogenic bacteria, fungi, and some parasites. A growing body of evidence supports the use of PCT as a marker to improve the diagnosis of bacterial infections and to guide antibiotic therapy. Clinically, PCT levels may help guide the need for empirical antibiotic therapy, source control for infections, and duration of antibiotic therapy. The aim of this review is to summarize the current evidence for PCT in different infections and clinical settings, and to discuss the reliability of this marker in order to provide physicians with an overview of the potential for PCT to guide antibiotic therapy.

Background/Aims: Several prognostic markers for heart failure (HF) have been determined but the importance of liver function tests (LFTs) remains unknown. The aim of this study was to determine the prognostic significance, if any, of abnormal LFTs in acute decompensated HF. Methods: All adult patients (> 18 years of age) who were admitted to a community hospital with a diagnosis of acute decompensated HF during the period January 2008 to December 2009 were identified. Exclusion criteria included acute coronary syndrome, active hepatobiliary disease, renal failure (serum creatinine ${\geq}$ 2 mg/dL), and malignancy. The primary end point was readmission secondary to acute exacerbation of HF. The Cox proportional hazard model was used for statistical analyses. Results: Univariate analysis showed that serum total bilirubin (TB, p < 0.01), serum B-type natriuretic peptide (p < 0.05), ejection fraction (EF, p < 0.05), and heart rate (p < 0.05) were significant predictors of hospital readmission secondary to acute decompensated HF. Multivariate analysis showed that high serum TB (> 1.3 mg/dL) on admission was an independent predictor (p < 0.05) of hospital readmission secondary to HF. The 'at-risk' group-patients with serum TB > 1.3 mg/dL and/or EF < 35% on admission-had a readmission rate that was $87%{\pm}20%$ (p < 0.05) higher than those with neither criterion. Conclusions: In patients with acute decompensated HF, elevated serum TB on admission with or without low EF (< 35%) predicts a worse prognosis and early future readmission, secondary to HF.

Background/Aims: The aim was to compare the insulin sensitivity and secretion index of pregnant Korean women with normal glucose tolerance (NGT), gestational impaired glucose tolerance (GIGT; only one abnormal value according to the Carpenter and Coustan criteria), and gestational diabetes mellitus (GDM). Methods: A cross-sectional study was performed with 1,163 pregnant women with positive (1-hour plasma glucose ${\geq}$ 7.2 mmol/L) in a 50-g oral glucose challenge test (OGCT). The 100-g oral glucose tolerance test (OGTT) was used to stratify the participants into three groups: NGT (n = 588), GIGT (n = 294), and GDM (n = 281). Results: The GDM group had higher homeostasis model assessment of insulin resistance and lower insulin sensitivity index ($IS_{OGTT}$), quantitative insulin sensitivity check index, homeostasis model assessment for estimation of index ${\beta}$-cell secretion (HOMA-B), first and second phase insulin secretion, and insulin secretion-sensitivity index (ISSI) than the NGT group ($p{\leq}0.001$ for all). Moreover, the GIGT group had lower ISOGTT, HOMA-B, first and second phase insulin secretion, and ISSI than the NGT group (p < 0.001 for all). Among the GIGT subjects, the 1-hour plasma glucose abnormal levels group showed significantly greater weight gain during pregnancy and higher values in the 50-g OGCT than the other two groups. Moreover, the 1-hour and 2-hour abnormal levels groups had poorer insulin secretion status than the 3-hour abnormal levels group. Conclusions: Korean women with GDM show impairments of both insulin secretion and insulin sensitivity. In addition, GIGT is associated with both ${\beta}$-cell dysfunction and insulin resistance.

Background/Aims: To determine the efficacy and toxicity of docetaxel as a thirdline therapy for patients with relapsed gastric cancer who have undergone modified oxaliplatin-fluorouracil (m-FOLFOX)-4 and modified irinotecan-fluorouracil (m-FOLFIRI) regimens. Methods: We analyzed 33 patients who had been histologically diagnosed with adenocarcinoma of the stomach and who had progressed after m-FOLFOX-4 and m-FOLFIRI regimens. Patients were treated with cycles of 75 mg/m2 docetaxel on day 1 every 3 weeks. Results: The median age of the patients was 56.0 years (range, 31.0 to 74.0), and 73% of the patients (24/33) had an Eastern Cooperative Oncology Group performance status of 0 or 1. All patients were evaluated in terms of tumor response: five (15%), nine (27%), and 19 (58%) patients experienced a partial response, stable disease, and progressive disease, respectively. The median time to progression was 2.1 months (95% confidence interval [CI], 1.63 to 2.58), and overall survival was 4.7 months (95% CI, 3.20 to 6.20), from the start of the docetaxel regimen. Assessing patients' toxicity profiles, the median number of cycles was 2.0 (range, 1.0 to 12.0). The major hematologic toxicities included grade 3 to 4 neutropenia (19/33, 58%), grade 3 to 4 thrombocytopenia (2/33, 6%), and grade 3 to 4 anemia (5/33, 15%). Neutropenic fever developed in three patients (3/33, 9%). The nonhematological toxicities were nausea and vomiting (10/33, 30%), abdominal pain (4/33, 12%), skin rash (1/33, 3%), and fluid retention (3/33, 9%). Conclusions: Docetaxel is a feasible third-line therapy regimen for patients with advanced gastric cancer after m-FOLFIRI and m-FOLFOX-4 regimens.

Background/Aims: The bedside index of severity in acute pancreatitis (BISAP) is a new, convenient, prognostic multifactorial scoring system. As more data are needed before clinical application, we compared BISAP, the serum procalcitonin (PCT), and other multifactorial scoring systems simultaneously. Methods: Fifty consecutive acute pancreatitis patients were enrolled prospectively. Blood samples were obtained at admission and after 48 hours and imaging studies were performed within 48 hours of admission. The BISAP score was compared with the serum PCT, Ranson's score, and the acute physiology and chronic health examination (APACHE)-II, Glasgow, and Balthazar computed tomography severity index (BCTSI) scores. Acute pancreatitis was graded using the Atlanta criteria. The predictive accuracy of the scoring systems was measured using the area under the receiver-operating curve (AUC). Results: The accuracy of BISAP (${\geq}2$) at predicting severe acute pancreatitis was 84% and was superior to the serum PCT (${\geq}3.29ng/mL$, 76%) which was similar to the APACHE-II score. The best cutoff value of BISAP was 2 (AUC, 0.873; 95% confidence interval, 0.770 to 0.976; p < 0.001). In logistic regression analysis, BISAP had greater statistical significance than serum PCT. Conclusions: BISAP is more accurate for predicting the severity of acute pancreatitis than the serum PCT, APACHE-II, Glasgow, and BCTSI scores.

Background/Aims: Various pulmonary diseases may be associated with bronchial anthracofibrosis (BAF). Our aim was to identify a relationship between BAF and endobronchial tuberculosis (EBTB). Methods: In total, 156 patients, diagnosed with EBTB using bronchoscopy, between June 1999 and May 2008, were included. Clinical and bronchoscopic findings between patients with BAF (n = 72, BAF group) and without BAF (n = 84, non-BAF) were analyzed retrospectively. Results: The crude odds ratio (OR) of BAF for EBTB was 8.88 (95% confidence interval, 6.37 to 12.37). On multivariate analysis, adjusting for age, history of biomass smoke exposure, and comorbidities, the most significant independent factor for EBTB was a history of biomass smoke exposure (adjusted OR, 17.471; adjusted p < 0.001). EBTB was more frequent in the right lung, particularly the right middle lobar bronchus, in the BAF group. Actively caseating, edematous-hyperemic, and ulcerative were the major types, with 77 (49%), 33 (21%), and 31 cases (20%), respectively. The BAF group had more ulcerative type, while the non-BAF group had more actively caseating type. The duration of EBTB treatment was similar between the groups. No significant difference was observed in the development of complications during treatment and posttreatment bronchostenosis between the groups. Conclusions: These findings suggest that BAF may be a risk factor for EBTB and affect the location and morphological type at the time of EBTB development.

Background/Aims: ${\beta}$-Cell apoptosis caused by increased endoplasmic reticulum (ER) stress is an important pathogenic component of type 2 diabetes mellitus. In theory, sulfonylureas, used for the treatment of diabetes, can contribute to ER stress. We assessed changes in ER stress in pancreatic ${\beta}$-cells under glucotoxic or glucolipotoxic conditions using low concentrations of the sulfonylurea, glibenclamide (GB). Methods: Low concentrations of GB (10 or 100 nM) were added to INS-1 cells cultured under glucotoxic or glucolipotoxic conditions. The degree of viability, level of apoptosis and levels of markers associated with ER stress were measured. Results: Apoptosis decreased in response to low concentrations of GB under glucolipotoxic but not glucotoxic conditions. Most ER stress markers decreased upon the addition of GB. Under glucotoxic conditions, changes in the levels of ER stress markers were not consistent. However, all decreased significantly under glucolipotoxic conditions. Conclusions: Low concentrations of GB exerted antiapoptotic effects through the attenuation of ER stress under glucolipotoxic conditions.

Background/Aims: We investigated the incidence and clinical characteristics of renal cell carcinoma (RCC) in the native kidney of renal transplant recipients. Methods: Between 1991 and 2010, 1,425 patients underwent kidney transplantation at our institution. We retrospectively evaluated the clinical features and outcomes in renal transplant patients with RCC in the native kidney after renal transplantation. Results: The patients included three males and two females with a mean age of 63 years (range, 52 to 74). The incidence of RCC was 0.35%. The median interval between renal transplantation and RCC occurrence was 16.2 years (range, 9 to 20). All of our patients with RCC had developed renal cysts either before (n = 3) or after (n = 2) renal transplantation. The mean duration of dialysis was 12 months (range, 2 to 39). Of the five patients, four underwent dialysis treatment for less than 8 months. All the RCCs were low grade at the time of diagnosis. Four patients underwent radical nephrectomy, and one patient refused the operation. The four patients who underwent radical nephrectomy showed no evidence of local recurrence or distant metastasis during the median follow-up of 2.9 years. However, the patient who did not undergo surgery developed spinal metastasis from the RCC 6 years later. Conclusions: This study suggests that the follow-up period is an important factor for the development of RCC in renal transplant recipients, and more vigorous screening with a longer follow-up period is required in renal transplant recipients.

Hemophagocytic syndrome (HPS) is an uncommon hematological disorder that manifests as fever, splenomegaly, and jaundice, with hemophagocytosis in the bone marrow and other tissues pathologically. Secondary HPS is associated with malignancy and infection, especially viral infection. The prevalence of cytomegalovirus (CMV) infection in ulcerative colitis (UC) patients is approximately 16%. Nevertheless, HPS in UC superinfected by CMV is very rare. A 52-year-old female visited the hospital complaining of abdominal pain and hematochezia for 6 days. She was diagnosed with UC 3 years earlier and had been treated with sulfasalazine, but had stopped her medication 4 months earlier. On admission, her spleen was enlarged. The peripheral blood count revealed pancytopenia and bone marrow aspiration smears showed hemophagocytosis. Viral studies revealed CMV infection. She was treated successfully with ganciclovir. We report this case with a review of the related literature.

Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by emotional or physical stress. In addition, the few drugs reported to precipitate ABS were either illegal or strictly controlled for medical use. This paper reports a case of ABS precipitated by a dietary supplement. Our case accentuates the potential risk of dietary supplements containing synephrine, which is uncontrolled and available to the general public. Therefore, the Korea Food and Drug Administration should regulate these dietary supplements, and warn healthcare workers and the general public of the potential hazards of the indiscriminate abuse of dietary supplements.

Mediastinal ectopic thyroid is a very rare condition, with few reported cases in the literature and no reported cases in Korea. This report describes an asymptomatic 65-year-old man with a right paratracheal mass compressing the superior vena. Additionally, the epidemiology, clinical manifestation, diagnosis, and management of mediastinal ectopic thyroids are discussed. A mediastinal ectopic thyroid should be considered in the differential diagnosis of all mediastinal masses. Surgical excision is recommended for both the diagnosis and treatment of this condition, because of its potential for malignancy and compression of mediastinal structures. This case demonstrates the clinical importance of mediastinal etopic thyroid.

Hemorrhagic fever with renal syndrome (HFRS) is an acute viral disease characterized by fever, hemorrhage, and renal failure. Among the various hemorrhagic complications of HFRS, the spontaneous rupture of an arteriovenous malformation of the testicular vessels with a retroperitoneal hematoma is a rare finding. Here, we report a case of HFRS complicated by a massive retroperitoneal hematoma that was treated with transcatheter arterial embolization.