A Case of Plummer-Vinson Syndrome Associated with Crohn's Disease / 대한소화기학회지

Plummer-Vinson syndrome manifests as cervical dysphagia, iron deficiency anemia, an upper esophageal web, and atrophic glossitis. The cause of the esophageal web is thought to be iron deficiency anemia; however, the cause of Plummer-Vinson syndrome has not been established. Crohn's disease is usually accompanied by malnutrition and iron deficiency anemia; however, no case of concomitant Crohn's disease and Plummer-Vinson syndrome with aggravated malnutrition and anemia has been previously reported. Here, we report on a rare case of Plummer-Vinson syndrome in a Crohn's disease patient, which caused malnutrition and constipation.

A Case of Multiple Primary Cancer with Follicular Lymphoma

The incidence of multiple primary cancer (MPC) is low but has been reported occasionally. Although follicular lymphoma is rare in Korea, the incidence is reported to be gradually increasing. We report a case of synchronous and metachronous MPC consisting of esophagus (squamous cell carcinoma), stomach (adenocarcinoma), and ampulla of Vater (extranodal follicular lymphoma grade 1) in a patient diagnosed as follicular lymphoma (grade 3a) six years ago. In a complicated case like ours, concurrent therapeutic control of synchronous MPC and metachronous hematological malignancy is challenging; meticulous examination and prioritized target therapy are essential for patients' survival.

Analysis of Death of Burn Patients in a Burn Specialized Hospital: A Retrospective Clinical Study

PURPOSE: Burns are one of the most important causes of mortality. We tried to analysis of death in severely burned patients in a single burn specialized hospital. METHODS: We reviewed the records of patients admitted to the intensive care unit for 5 years, from 2007 to 2011. Information was collected on age, sex, type of burn, burn surface area, length of intensive care unit stay, presence of inhalation injury and causes of mortality by chart review. RESULTS: During 5 years, 56 patients were died in our intensive care unit. The average was 51.6 years and the sex ratio was 1.95:1 for males and females. The mean burn surface area (BSA) was 67.2%. Eight (32.1%) of the patients died within 48 hrs. The hospital stay of the death was from 1 to 40 days (average 7.6 days). In outdoor accidents, sex ratio and BSA were 4.60:1 (P=0.023) and 75.4+/-22.7% (P=0.021), respectively, while 1.00:1 and 58.8+/-29.7%, respectively, in indoor accidents. CONCLUSION: The mortality in severe burn patient was 12.5%. In accidents occurred outdoors, male was predominant. In outdoor accidents, the BSA was larger than that of indoor disasters.

Epidemiology of Burn Patients Underwent Mechanical Ventilation Therapy: 4 Year Retrospective Study

PURPOSE: In severe burn injured patients, mechanical ventilation therapy (MVT) is often performed. However, little is known about the mortality and clinical outcomes in these patients. METHODS: A retrospective review of burn patients underwent MVT from January 2008 to December 2011 was conducted. The charts of patients were reviewed. RESULTS: Thirty hundred forty five patients were managed in the intensive care unit during 4 years and 67 patients were received MVT. Among them, 34 (50.7%) patients were intubated before arrival. Mean age was 47.8 years and mean burn surface area (BSA) was 53.4%. Thirty nine patients were died and mortality was 58.2%. The BSA in dead patients was larger (68.9+/-24.9%) than those patients who lived (31.8+/-18.4%) (P<0.001). There were no significant differences in the incidence of inhalation injury and age between survivors and non-survivors. CONCLUSION: The mortality rate was high in patients underwent MVT. BSA is the most important risk factor of mortality in these patients.

Central Venous Catheter-related Infection in Major Burn Patients: Comparison of Subclavian Vein and Femoral Vein / 대한구급학회지

BACKGROUND: A central venous catheter (CVC) is usually inserted in patients with severe burns and the selection of the CVC is often difficult due to widespread burned skin. We investigated the incidences of colonization and catheter-related blood stream infection (CRBSI) according to the insertion site of the CVC in major burn patients METHODS: In 63 adult massive burn patients in the intensive care unit, 93 CVCs (47 polyurethane standard CVCs and 46 Oligon anti-mocrobial CVCs) were randomly inserted via the subclavian vein (SCV group, n = 66) or femoral vein (FEV group, n = 27). All catheter tips removed were routinely cultured. Bacterial findings from the burn wound and peripheral blood were also monitored in all patients RESULTS: There was no significant difference in the average insertion length of the CVC (14.3 +/- 6.8 days in SCV and 13.6 +/- 3.8 days in FEV) between the two groups. There were no significant differences in CVC colonization (48.5% in SCV and 63.0% in FEV) and CRBSI (7.6% in SCV and 11.1% in FEV) between the two groups. Logistic analysis found that the use of polyurethane standard CVC is significantly associated with increased risk of CVC colonization (odds ratio = 2.68) CONCLUSIONS: The placement of the CVC via the femoral vein does not increase the incidence of CVC colonization in massive burn patients. The use of Oligon anti-microbial CVC may be helpful to reduce CVC colonization in major burn patients.

Antimicrobial Central Venous Catheter Dose Not Reduce Catheter-related Bacteremia in Major Burn Injured Patients

PURPOSE: We previously reported that antimicrobial central venous catheter (CVC) reduced catheter colonization in major burn patients. In this study, we investigated whether antimicrobial CVC could reduce catheter-related blood stream infection (CRBSI) in major burn patients. METHODS: Burn patients with over 20% of total body surface area were randomly assigned to undergo catheterization with standard CVC (STD group, n=50) or antimicrobial Vantex(R) CVC (VTX group, n=50). Upon removal of CVC, bacterial cultures for wound, catheter tip, and blood were performed. RESULTS: Colonization rate was significantly decreased in VTX group (42%) compared to STD group (64%) (P0.05). CONCLUSION: Even though the antimicrobial CVC could reduce the catheter colonization, the CRBSI rate was not reduced by antimicrobial CVC in major burn patients.

Emergence Agitation after Sevoflurane Anesthesia in Burn Injured Children

PURPOSE: Sevoflurane is a well accepted anesthetic in children but results high incidence of undesirable emergence agitation (EA). We investigated the EA in burn injured children. METHODS: In 219 un-premedicated burn injured children aged 2~8 years, mask induction with sevoflurane was performed. On arriving operating room, modified Yale preoperative anxiety scale (m-YPAS) was checked. In the postanesthesia care unit, EA scale was recorded as follows; EA1 (no EA), EA2 (mild EA) and EA3 (marked EA). RESULTS: The incidence of EA was 50.2%. The m-YPAS was significantly higher in EA2 and EA3 compared to EA1 (P<0.001). Burn surface area was significantly wider in EA3 compared to EA1 (P<0.05). In deep second-degree burned children, the incidence of EA1 was greatest, whereas EA3 was the greatest in third-degree burned children. CONCLUSION: The incidence of EA after sevoflurane anesthesia in burn injured children was higher as the burn surface areas was greater. In addition, the symptoms of EA in third-degree burned children were more severe than in second-degree burned children.

Effect of Ascorbic Acid at Early Fluid Resuscitation in Severe Burn Injured Patients

PURPOSE: Ascorbic acid is a potent antioxidant capable of scavenging oxygen free radicals. We investigated the effect of ascorbic acid on initial management of a major burn. METHODS: A total of twenty two patients with extent of burn injury greater than 30% of the body surface area (BSA) were enrolled. Early fluid resuscitation was performed with Parkland formula ( or =40% BSA). In ascorbic acid group, ascorbic acid was continuously infused at a dose of 30 mg/kg/h during first 24 hours of fluid resuscitation. Target urine output was 0.5~1 ml/kg/h. RESULTS: There were no significant differences in age, sex, and BSA among the groups. In the cases of Parkland formula, there was no significant difference in the fluid requirement between control group (4.26+/-1.29 ml/kg/%burn) and ascorbic acid group (3.53+/-0.87 ml/kg/%burn). However, in the cases of modified hypertonic formula, there was significant difference in the fluid requirement between control group (3.31+/-0.95 ml/kg/%burn) and ascorbic acid group (2.34+/-0.35 ml/kg/%burn). CONCLUSION: High-dose ascorbic acid reduces fluid requirement at early fluid resuscitation in severely burned patients managed with modified hypertonic formula.

Epidemiology in Preschooler Burn Injuries in a Single Burn Unit Hospital for 3 Years

PURPOSE: Burns are an important cause of injury to young children. The aim of this study was to investigate epidemiology in preschooler's burns. METHODS: A retrospective study was reviewed age, sex, burn surface area, and burn type in preschool children underwent burn surgery. Children were classified into three age groups: infant group ( or =10% of the body surface area) in groups of infant, toddler, and early childhood were 7.9%, 5.6%, and 4.7%, and the mean burn size were 18.7+/-1.7% (P=0.003 vs. toddler group), 13.7+/-0.4%, and 17.7+/-2.7%, respectively. CONCLUSION: The major etiology in preschool children' burns was scalding. Toddler was most affected age group. In severe burns, infant group showed larger burn size than toddler group.

Rocuronium bromide induced anaphylaxis in a child: A case report / 대한마취과학회지

Anaphylaxis or anaphylactoid reaction in pediatric patient during anesthesia is rare. We report a rocuronium induced anaphylactic reaction in a 33-month-old female. The patient was scheduled to undergo escharectomy due to injuries suffered from a major burn. Shortly after administration of rocuronium, the patient developed severe hypotension, tachycardia, and hypoxia. A similar reaction occurred after administration of rocuronium on subsequent anesthesia. She underwent uneventful anesthesia with volatile induction and maintenance of anesthesia with sevoflurane on her next 7 operations without using of muscle relaxant.

Case of Malarial Hepatitis by Plasmodium Vivax / 대한소화기학회지

Malarial infection is one of the most important tropical diseases, but also increasing in the temperate regions. Severe malaria with organ dysfunction is commonly associated with Plasmodium falciparum, but rarely with Plasmodium vivax. Malarial hepatitis is also unusual in P. falciparum and very rare in P. vivax. Only 3 cases of malarial hepatitis caused by P. vivax have been reported in the world. Because the presence of hepatitis in malaria indicates a more severe illness with higher incidence of other complications and poor prognosis, malarial patients should be meticulously monitored for hepatic dysfunction with or without jaundice. We report here a case of malarial hepatitis caused by P. vivax that was presented by fever, general ache, nausea, fatigue, and significant elevation of aminotransferase and bilirubin.

A Case of Hemorrhagic Fever with Renal Syndrome with Stress-induced Cardiomyopathy / 대한신장학회지

Hemorrhagic fever with renal syndrome is an acute febrile disease with high fever, hemorrhagic symptoms, renal failure. Stress-induced cardiomyopathy is a newly described clinical entity characterized by transient left ventricular apical ballooning and left ventricular apical dyskinesis, with no stenosis on the coronary angiogram. We experienced a rare case of stress-induced cardiomyopathy associated with hemorrhagic fever with renal syndrome.

Volatile Induction and Maintenance of Anesthesia without Intravenous Access in Mild to Moderate Burn Injured Pediatric Patients

PURPOSE: Peripheral intravenous (I.V.) access is a common but stressful procedure in children, their parents and medical staffs. We evaluated the efficacy of volatile induction and maintenance of anesthesia (VIMA) without intravenous access for brief procedures in mild to moderate burn-injured pediatric patients. METHODS: VIMA without I.V. was conducted to healthy pediatric patients. Adverse events such as cough, breath holding, airway obstruction, arrhythmia, bradycardia and tachycardia, etc. were evaluated. RESULTS: From July 2008 to December 2009, 1,495 cases of VIMA with sevoflurane were performed in 859 children. Burn-injured patients were 94.9% and patients with hypertrophic scar were 5.1%. Scalding burn and contact burn were 90.1% of the burn-injured patients. Mean anesthesia duration was 29.3+/-6.2 min. In 1,495 VIMA cases, 47 cases had cardiovascular adverse events, including tachycardia (36), bradycardia (7), arrhythmia (3), and hypertension (1). All of these cardiovascular events returned normal after anesthesia. The respiratory adverse events occurred in 72 cases, including cough (49), breath holding (10), partial airway obstruction (8), hypoxia (4), and laryngospasm (1). None of the patients had bronchospasm. Most of the respiratory adverse events could be controlled by manual ventilation with mask, and oropharyngeal airway or laryngeal mask insertion. In four cases with hypoxia, the duration was less than 1 minute and these cases were no eventful after anesthesia. CONCLUSION: VIMA without I.V. access can be effective in brief procedures with mild to moderate burn-injured pediatric patients, even though a longer period of study may be required to assess the efficacy and safety.

A Case of a Patient Presenting with Upper Gastrointestinal Bleeding Due to Direct Stomach Invasion by Hepatocellular Carcinoma / 대한소화기내시경학회지

Gastrointestinal bleeding is a common complication of hepatocellular carcinoma, and the most common causes are esophageal varix, gastric varix and a bleeding ulcer. Hepatocellular carcinoma rarely invades the gastrointestinal tract, and this has been shown to occur in 0.7~2% of the clinical hepatocellular carcinoma cases. A 52-year old male who had a history of a huge hepatocellular carcinoma on the left lobe of the liver and this had been by chemoembolization was admitted due to hematemesis and melena. Esophagogastroduodenoscopy showed a huge fungating mass with easy contact bleeding in the lesser curvature of the gastric body. The histology was consistent with the diagnosis of metastatic hepatocellular carcinoma and results of the CT scan supported this finding. This case illustrates a rare event of direct invasion of hepatocellular carcinoma into the stomach and this was followed by gastrointestinal hemorrhage.

Effectiveness of Antimicrobial Central Venous Catheter for Reducing Catheter Colonization in Major Burn Injured Patients

PURPOSE: Central venous catheterization is associated with infection. We evaluated the colonization rate in the two different kinds of central venous catheter (CVC) in patients with major burn injuries. METHODS: Eighty four burn patients with over 20% of total body surface were randomly assigned to undergo catheterization with standard CVC (STD group) or antimicrobial Vantex(R) CVC (VTX group). Following catheter removal, the distal tip was aseptically removed and cultured. Burn injured skin was also cultured. RESULTS: There was no significant difference in characteristic of patients and catheterization, and the severity of burn between the two groups. The overall CVC colonization rate was significantly decreased in VTX group (40.0%, 29.9 in 1,000 catheter-days) compared to STD group (64.1%, 43.9 in 1,000 catheter-days) (P=0.031). In case of the distance between the catheterization site and burn injured skin was less than 10 cm, the CVC colonization rate was higher in STD group compared to VTX group (P=0.015). CONCLUSION: Central venous catheterization with antimicrobial Vantex CVC lowered catheter-related colonization in major burn patients. The decrease in colonization rate with Vantex CVC compared with standard catheter is more dramatic when the distance between burn injured skin and CVC placement site is closer.

Management of Hypertrophic Scar after Burn Wound Using Microneedling Procedure (Dermastamp(R))

PURPOSE: Hypertrophic scars after burn wound management remain a difficult problem for many burn surgeons despite of new treatment option is developed. After burn wound healed with scarring or pigmentation, the patient suffer in daily life with the cosmetic results and scar symptoms. Dermastamp(R) is new treatment modality on burn scar management in our burn center. Dermastamp(R) is stamp shaped and it contains 0.8 mm or 2.1 mm long multiple stainless steel needles. Dermastamp(R) was simply pressed down on the scar 3~4 times and makes 200~300 holes on 1 cm2 scar area. Dermastamping breaks the dense collagen fiber and fibroblast in the scar tissue and rearranges collagen fiber and fibroblast in the scar tissue. METHODS: The 51 patients were selected. The group consisted of 26 male and 25 female patients. 21 patients were adult and 30 patients were children. Stamping area of the 18 patients was below 25 cm2, 6 patients were in 25 to 100 cm2, and 27 patients were above 100 cm2, stamping area. They received Dermastamp(R) treatment 3 to 23 times in every 1 or 2 weeks interval at least 2 months. The 33 patients received Dermastamp(R) under local anesthesia and other 18 patients received under volatile induction anesthesia. Hypertrophic scar is evaluated with Vancouber Scar Scale (VSS) score by two surgeons and scar height using Sonography (17 patients). And pathologic study (17 patients) was done on volunteer cases. RESULTS: Clinically improvements with VSS score (1 to 6 points down) were noted in all patients group. Scar height was lowered (0.8 to 3.6 mm) on sonography and pathologic report revealed collagen fiber rearrangement and scar height thinning in examined group. CONCLUSION: Microneedling procedure is a effective modality of management on hypertrophic scarring and pigmentation. Microneedling induces collagen fiber rearrangement on scar tissue and thinner the scar height in pathology and improves clinical evaluating with VSS score and patients symptoms.

A Study of the Use of EEG Analysis to Evaluate the Depth of Anesthesia Using Bispectrum Analysis Method / 대한마취과학회지

BACKGROUND:In this study, a distribute characteristics on the bispectral coupling of EEG were examined according to the depth of anesthesia by using bispectum analysis a type of nonlinear signal processing. METHODS: 25 patients during the general anesthesia were studied. In the preprocess, base line correction and linear detrend was used. During the awakening state, preoperatively and postoperatively, appearance rate of bispectral coupling was observed that a strong appearance rate was represented in major frequency zone such as (15, 15) Hz but weak appearance rate investigated in the other minor frequency zone. Whilst anesthetized, a strong appearance rate revealed the low frequency range below (10, 10) Hz and a weak appearance rate viewed in the other frequency range. As such was compared with the delta ratio and spectrum edge frequency (SEF). RESULTS: The delta ratio showed significantly lower values at induction (3.60 +/- 0.98) and during the maintenance (5.0+/-1.74) of anaesthesia than preoperatively (10.30 +/- 2.44) and postoperatively (13.03 +/- 2.29)(P < 0.05). These results were consistent with the trend of delta ratio, namely that the index of evaluation for the depth of anesthesia, known as the reflex of the conscious level of patient's during anesthesia. While these results were not consistent with SEF analysis results that the index of evaluation for suppression level of patient's during recovery stage of anesthesia. SEF shows lower values at maintenance (17.00 +/- 1.22) and postoperatively (12.20 +/- 1.53) than preoperatively (22.50 +/- 1.75) and at the induction (22.40 +/- 1.18) of anesthesia(P < 0.05). CONCLUSIONS: The bispectrum analysis method provided useful information about the index of evaluation according to the level of unconsciousness and suppression among other evaluation factor on depth of anesthesia.

Subclavian Artery Occlusion: 4 Cases Report and Summary of Korean Literature

Occlusion or stenosis of subclavian artery by atherosclerosis is uncommon pathology compare to atherosclerosis of lower extremity. Most of the cases involve left subclavian artery and show vertebral-basilic ischemia and/or arm ischemia. Surgical intervention including bypass or transposition are performed to relieve the symptoms of obstruction but percutaneous intraluminal angioplasty and insertion of stent also be done with comparable results. Here we report 4 cases of symptomatic subclavian artery occlusion which have been managed by authors, and summarize all the cases reported in korean literature.

Effects of HLA Matching on Graft Survival in Cyclosporine Treated Primary Living Donor Renal Transplantation / 대한이식학회지

There still is debates on the effect and the value of HLA matching on graft survival in clinical renal transplantation. A few reports were presented in Korea about the effect, where over 95% of kidneys have been taken from living donor, and the results are inconclusive. So, we analysed 329 cyclosporine treated first living donor renal transplantation performed in Keimyung University Dongsan medical center, from Nov. 1982 to Feb. 1996 to determine the effect of HLA matching on graft outcome. Significant survival benefits were observed at 5 years between HLA-B 0 mismatch(MM) and more than 0 MM (89.73% vs 64.68, 60.26%, p<0.05), A+B 0 MM and more than 0 MM(94.28% vs 63.94, 63.43, 56.25%, p<0.05), B+DR 0 MM and 2, 3 MM(89.59% vs 61.82, 64.98%, p<0.05), and A+B+DR 0 MM and 3, 4 MM(92.57% vs 56.82, 63.19%, p<0.05). But HLA-A or DR mismatch alone seemed to have no effect on graft survival. Our results showed some beneficial effect of HLA match on renal graft survival but yet inconclusive due to small size of the number.