1993년 가톨릭 의과대 본과에 들어간 세 명의 젊은 의학도는 같은 의문을 품었습니다. 우리가 만든 의학교과서는 왜 없을까? 우리는 왜 외국서적으로만 공부해야 할까? 외국의 의대생이 우리가 만든 의학교과서로 공부하게 할 순 없을까? 이런 의문에 답을 내고, 또 그 답을 실현시키기까지 15년의 세월이 흘렀습니다. 20대 청년에서 이제 중년의 의사가 된 지금, 그 15년의 이야기를 15분의 메시지로 전합니다.

1. 조재형
가톨릭의과대학 伽서울성모병원 伽내분비내과 伽조교수 伽
우리 伽의학교과서의 伽세계진출,,
그 伽1155년의 伽기록

2. Ideas, dreams ---

3. 현실과 꿈의 시간차!
경험 약간의 돈
도움이 지위
A product Dreams come
true!
Human Network A result
years
0 5 10 15

4. 우 리 도
1981년 초등학생 4학년 의 꿈!
낼
갈 수 있 다

5. An inspiration!
1996년 의 학과 4학년 의 꿈!

7. J& 2
Cutaneous Hematologic Vascular
al
J
O
Systemic
et
cu
R onj cle nd
20
el
et u ri ro
0
la
C is sy
in nc ti m
Anemia (of chronic ds) Thrombosis in vessels
sk
r
Malar rash
al ti s
ia
lo
ep ca
lg
†Hemolytic anemia ‡ Lupus anticoagulant (LA) and Fatigue, malaise
va val
cu
Si
Discoid rash
ya
sc /
c
us
† Leukopenia (<4000/µL) ‡ Anti-cardiolipin (aCL) ab Fever, Nausea
ly os y M
ul
Photosensitivity
iti
M
po er th a ,
Lymphopenia (<1500/ µL) : associated with clotting. Anorexia
s
on pa gi
Oral ulcers
N yo ral
th e † Thrombocytopenia <100,000/ µL) Cerebral emboli Weight loss
tis Alopecia
M rth
ar iv
ri
e
Splenomegaly
A
Vasculitis
Neurologic
(CNS lupus)
Cardiopulmonary Cognitive dysfunction (mc)
Mood disorder
Pleurisy, Pericarditis
Myocarditis, arrhythmia
Endocarditis, CAD (MI)
Systemic Lupus Erythematosus Headache, Seizure
Psychosis, CVA
Polyneuropathy
Pleural effusion Autonomic dysfunction
Lupus pneumonitis Optic neuritis, SAH
Heart failure,
Pulmonary hypertension
*The most common cause
of pulmonary infiltrate in Neonatal lupus SLE in pregnancy Lumbar puncture
2001년 함께 꿈을 꾸다!
patients with SLE is infection Caused by transmission (when the Dx of CNS lupus is in doubt
of maternal anti-Ro Fertility rates : normal or when infection is a possible cause
across the placenta Spontaneous abortion and still birth are frequent (10-30%) of symptoms)
Transiet skin rash and ; Tx : low-dose heparin (e.g., 5000U S.C. twice a day) MRI with contrast
Renal (lupus nephritis) (rarely) permanent heart * if contraindicated to heparin, low-dose aspirin or (acute and chronic lesion of SLE)
heart block low-to moderate dose glucocorticoid may be used. CT (R/O bleeding or mass lesion)
Proteinuria >500mg/24hr Transient thrombocytopenia Glucocorticoid : do not cause fetal abnormality because Neurologic problems
Cellular casts from maternalanti-PLT ab. corticosteroid are inactivated by placental enzymes, usually improve with
Nephrotic syndrome immunosuppressive tx
Renal failure : recurrence in 1/3 of patients
Hematuria † (with the exception of deficits resulting
Hemolysis is usually responsive to high-dose GC from large infarcts)
* resistant case may respond to splenectomy
Leukopenia is common but is rarely associated
A slow rise in serum Rapidly deteriorating renal function with infection : does not require treatment
Cr. To 3mg/dL and active urine sediment require Severe thrombocytopenia with bleeding or Gastrointestinal
: should be biopsied prompt aggressive tx without biopsy purpura should be treated with high-dose GC
* If the platelet count fail to reach acceptable Lupus peritonitis (nausea, diarrhea,
level in 2 weeks, cytotoxic drugs, cyclosporins, vague discomfort)
If they fail danazole, and/or splenectomy should be considered.
Pathology to respond
Vasculitis of intestine
‡ (the most dangerous)
LA is recognized by prolongation of PTT and : presenting with acute crampy abd. pain,
Mesangial or mild focal proliferative nephritis maintain failure of added normal plasma to correct the prolongation vomiting, diarrhea,
good renal function (do not require treatment) LA, aCL : thrombocytopenia, recurrent venous or arterial : Intestinal perforation (immediate surgery)
Diffuse prolierative nephritis develop renal failure if untreated clotting, recurrent fatal loss, vascular heart disease. Pseudoobstruction
(require tx with high-dose glucocorticoid and cytotoxic agents) LA is associated with hypoprothrombinemia or thrombocytopenia. (*surgery shoud be avoided unless frank
*A high proportion of sclerotic glomeruli : suggest that these Bleeding may occur. obstruction is present)
patients are unlikely to respond to immnosuppressive tx and *Bleeding syndrome usually respond to GC. Acute pancreatitis
are candidates for dialysis ro trnasplantation but clotting syndrome do not. Elevated serum transaminase levels

8. 孔子 는 登東山 而小魯하시고 登太山 而小天下

9. 2002년 다시 시작된 작업 !
Reticulocyte production index Risk factors for osteoporosis fracture Factors affecting peak bone mass
Nonmodifiable Gender
Fracture hx as an adult
Race, Genetic factor, Gonadal steroids
Hx of fracture in first degree relative
Index ≥ 2.5 Growth hormone, Timing of puberty
Index < 2.5 Female, Advanced age
Caucassian race, Dementia Caclium intake, exercise
Search bleeding focus and treat
Hemolysis or Hemorrhage Modifiable
IDA Anemia of chronic Current cigarette smoking, Alcoholism
disease Low body weight, Impaired eyesight Peak Bone mass : at age of 30-35 years
Hemorrhage
Serum iron   Estrogen def, Recurrent falls
Findings of acute
Serum total iron-binding capacity  Low normal - or chronic blood Low calcium intake, Inadequate physical activity
※ If estrogen deficiency :
Transferrin saturation  Low normal - loss on history or Poor health
physical examiantion IL-1, IL-6, TNF ↑ → osteoclast mediated bone resorption ↑
Serum ferritin  Normal -  MCV
Serum soluble transferrin receptor  
No symptoms or
Bone marrow iron stores  
signs of blood loss
Iron-containing normoblasts   Management of Type I osteoporosis : Estrogen ↓ ⇒ Ca resorption ↑ ⇒ PTH ↓ 1,25(OH)2D3 ↓
in the bone marrow
[ General measures of hemolysis ] the fractures Type II osteoporosis : 1,25(OH)2D3 ↓ ⇒ intestinal Ca absorption ↓ ⇒ PTH↑ ⇒ Ca resorption ↑
Reduction in serum haptoglobin
Differential diagnosis Hemolysis Presence of urine hemoglobin 2ndary causes (secondary osteoporosis)
[ Further evaluation ] and/or urine hemosiderin Fracture
Serum iron, TIBC, ferritin,  IDA (severe)
Increased LDH and serum Osteoporosis Hypogonadal state : Turner syndrome,
Anorexia nervosa, Kleinfelter
unconjugated bilirubin Endocrine dis: Cushing’s syndrome
soluble transferrin receptor ; Vertebra fracture
 Anemia of chronic disease
Drug induced osteoporosis
upper lumbar vertabra : most common Hyperparathyroidism
(± bone marrow iron stain)
(some cases) Acquired
+ Thyrotoxicosis
[ Further evaluation ] Hip fracture
 Thalassemia trait Immune hemolysis Colles’ fracture IDDM
Hemoglobin electrophoresis, Low Direct Coombs’ test,
: Early ambulation is recommended. Diagnosis Acromegaly
(reticulocyte count may be elevated) -Autoimmune quantitation of red blood
hemoglobin A2 and Adrenal insufficiency
hemoglobin F levels, -Drug-induced cell surface antibodies,
 Sideroblastic anemia Nutritional and GI dis : Malnutrition
globin DNA alalysis, -Alloimmune cold agglutinin titer
(some cases) Parenteral nutrition
globin chain systhesis ratios gastrectomy
 Lead poisoning (rare in adults) Traumatic (microangiopathic and FDA-Approved Indications for BMD tests
Direct and indirect Reumatologic dis: RA, AS
macroangiopathic) Hemolysis Coombs’ test,
- TTP/HUS/HELLP Estrogen deficient women at clinical risk of osteoporosis Hematologic : MM. Lymphoma, leukemia
quantitation of red blood
- DIC cell surface antibodies, Verterbral abnormalities on X-ray suggestive of osteoporosis
PLT count, WBC count with
- Vasculitis cold agglutinin titier Glucocoriticoid treatment equivalent to ≥7.5mg of prednisolone,
differential, BM aspirate and
biopsy - Eclampsia or duration of therapy >3months Drgus
 Bone marrow aplasia/hypoplasia Primary hyperparathyroidism
- Malignant hypertension : Glucocortuciud
Renal function test  Renal insufficiency - Prosthetic heart valves Monitoring response to an FDA-approved medication for osteoprosis Cyclosporin
History and physical exam.
- Arterial grafts of hypertension, pregnancy, Repeat BMD evaluation at >23-month intervals, or more frequently, Cytotoxic drugs
BM biopsy with stains
 Pure red cell aplasia prosthetic heart valves or if medically justified. Anticonvulsants
Hypersplenism vascular grafts,
for collagen (trichrome stain)  Myelofibrosis Excessive alcohol
systemic vasculitis,
and reticulin (siliver stain) Excessive thyroxine
 Myelophthisis Normal Membrane abnormalities neurologic changes, fever?; DEXA(BMD) : T score <-2.5
- Acanthocytes (spur cells) Schistocytes, anemia, and Aluminum
destructive thrombocytopenia; Biochemical markers : monitoring the responsiveness Heparin
BM aspirate and biopsy  Myelodysplasia (most cases) - Echinocytes (burr cells) BUN/Cr; Urinalysis;
(including Prussian blue DIC study
to treatment GnrH agonist
- PNH
stain of iron),  Anemia of chronic disease (most cases)
- Thermal injury (burns)
Bone formation markers Lithium00
karyotype analysis Acid hemolysis (HAM) or serum bone-specific alkaline phosphatase
 Mixed microcytic and macrocytic
Infection sucrose hemolysis test,
anemias
flow cytometry analysis of
serum osteocalcin
- Malaria, Babesiosis,
 Iron deficiency (mild to moderate) Bartonellosis, Clostridia toxin GPI-anchored cell serum propeptide of type I procollagen
surface proteins Bone resorption markers. Glucocorticoid induced osteoporisus
 Physiologic anemia Osmotic damage (e.g., CD55, 59) : inhibit osteoblast fuction, increase osteoblast apoptosis
- Fresh water drowning stimulation of bone resorption, increase of urinary
Treatment recommedations
calcium loss impairment of the absorption of calcium
(from National Osteoporosis Foundation) across the intestine
Serum vit. B12 level,
Inherited/Congenital : Bone loss – rapid loss first 6-12 months after start of
Treatment
urine (± serum) methylmalonic
1. Women with no risk factors should begin therapy glucocorticoid
acid level, RBC membranopathies
 Cobalamine (vit B 12 )def. if their T score is -2 or below; and Tx :Risk facotrs reduction, Exercise
BM aspirate, Schilling tests
-Spherocytosis
 Folate def.
-Eliptoctyosis
2. Women with risk factors should begin therapy Bisphosphonate (residronate)
if their T score is -1.5 or below. Calcium (1000mg) + calcitriol (0.5 – 1.0µg)
Red blood cell folate level,  Treatment with drugs that interfere with -Stomatocytosis Calcitonin
serum folate level, BM aspirate DNA sysnthesis and cell division
RBC Enzymatopathies
 Prior cancer chemotherapy High -G6PD deficiency
-Pyruvate kinase def.
 Myelodysplasia (some cases)
Thyroid function test
Hemoglobinopathies
Pharmacologic treatment
 Hypothyroidism Risk factors
-Thalassemias
Liver function test  Liver disease
Reduction Antiresoptive drug Formation stimulator
-Hemoglobin S,C,D,E
HRT(ERT)† Lowdose intermittent PTH
Exercise SERM Fluoride
J&J Caclium : 1000=-1200mg of elemental caclium Anabolic steroid
Bisphhosphonate (mnostly derivatives of testosterone
Vit D 20µg or 800 IU primarly as antiresorptive agents J&J
Calcitonin : might have analgesic effect may also stimulate osteoblst acitivity)

10. 2003년 도전의 시작!
‘ 꿈은 매 우 구체적이 어 야한다!’
1. 아마존닷컴 에 꽂힌 다.
2. 하바드의 대 학생들이 우리 책으로 공부하게 한다.

11. Proposal

12. To
Oxford
University
Press
To
McGraw
Hill

13. 꿈을찾아
여 행을 떠 나다!

14. To England

16. 8개월의 그리고,
기다림 결과는?

17. 이 제 어 떻 게!

18. 친구의
전화 한통!
무언 가를
할때
죽는 척이
아니 라
정말
죽을 것
같아야한다!

19. 범문사 (현, E-public)
Proposal in
Korean
임상강사
군의관 공보의

20. 2004, 1월. 드디 어 계 약!
Adobe illustrator!?
미 친 작업 !

21. Wonju, 2004

24. 또 한번 의 여 행!

25. To America

27. 제2의 내 과교과서
1쇄 2쇄
2,000
1,500
1,000
한국
몽골
? 500
0
타국

28. 아직, 꿈은 이 루어 지지 않았다!

29. Get Friends!
130명 의 참여
전문 illustrator의 참여
1,000 page분량
푸랑크푸르트 세계 도서전시회
LWW and Mcgraw Hill과 교섭중

31. 2010.4.21. 2nd. Ed

32. 2010.4.22. On the publication day

33. To Amazon

34. 중앙일보, 2010.11.1.

35. Korea Herald, 2010.11.19.

36. 새로운 시작을 꿈꾸며!

37. 새로운 도전
B OO K
i
Producing & Sharing Anywhere

38. 감사합니 다!