Implementation of Medical Information Exchange System Based on EHR Standard / 대한의료정보학회지

OBJECTIVES: To develop effective ways of sharing patients' medical information, we developed a new medical information exchange system (MIES) based on a registry server, which enabled us to exchange different types of data generated by various systems. METHODS: To assure that patient's medical information can be effectively exchanged under different system environments, we adopted the standardized data transfer methods and terminologies suggested by the Center for Interoperable Electronic Healthcare Record (CIEHR) of Korea in order to guarantee interoperability. Regarding information security, MIES followed the security guidelines suggested by the CIEHR of Korea. This study aimed to develop essential security systems for the implementation of online services, such as encryption of communication, server security, database security, protection against hacking, contents, and network security. RESULTS: The registry server managed information exchange as well as the registration information of the clinical document architecture (CDA) documents, and the CDA Transfer Server was used to locate and transmit the proper CDA document from the relevant repository. The CDA viewer showed the CDA documents via connection with the information systems of related hospitals. CONCLUSIONS: This research chooses transfer items and defines document standards that follow CDA standards, such that exchange of CDA documents between different systems became possible through ebXML. The proposed MIES was designed as an independent central registry server model in order to guarantee the essential security of patients' medical information.

Spontaneous Jejunal Intussusception after a Colectomy: A Rare Cause of Postoperative Intestinal Obstruction: A Case Report

Intussusception is a rare cause of intestinal obstruction in adults and is most often due to a primary abnormality of the bowel, which serves as the leading point. Idiopathic intussusception in adults is distinctly uncommon, comprising 10% of diagnosed intussusceptions. We report a case of a spontaneous jejunal intussusception in a 48-year-old man that developed shortly after an open colectomy. The 48-year-old man, with no history of a laparotomy, underwent a left hemicolectomy and a left hemihepatectomy for descending colon cancer with liver metastasis. For 14 postoperative days, the patient complained of ileus, and conservative management with a long intestinal tube failed. When the patient underwent a laparotomy, intussusception of the mid jejunum was observed. The intussusception was resected, and no underlying bowel abnormality was identified. This report highlights the importance of considering this rare etiology in patients with ileus who have recently undergone a laparotomy.

Treatment Patterns for Colorectal Cancer Patients at the National Cancer Center Korea in 2003

PURPOSE: In Korea, colorectal cancer (CRC) is one of the most sharply-increasing malignancies, and the National Colorectal Cancer Screening Program for persons over 50 years of age began in 2004. To determine the effectiveness of the program, comparative data regarding CRCs treated prior to 2004 must be analyzed. The present study assessed CRC status at diagnosis and treatment patterns in 2003. METHODS: In 2003, 503 patients were newly diagnosed with CRC and were treated at the Center for Colorectal Cancer, National Cancer Center (NCC). Clinical data were retrospectively reviewed. RESULTS: The 503 patients included 256 colon and 247 rectal cancer patients. Of the 256 colon cancer patients, 5 (2.0%) were diagnosed during screening colonoscopies and were successfully treated using an endoscopic mucosal resection (EMR), and 17 (6.6%) received only palliative chemotherapy because of distant metastases. Forty patients (15.6%) were treated with palliative surgery and chemotherapy, and 194 (75.8%) with curative surgery with or without adjuvant chemotherapy. Of the 247 rectal cancer patients, 9 (3.6%) were treated with an EMR, 20 (8.1%) with palliative chemotherapy with or without radiotherapy, 19 (7.7%) with palliative surgery and chemoradiotherapy, and 199 (80.6%) with curative surgery with or without chemoradiotherapy. Treatment with curative intent was possible in 199 of 256 (77.7%) colon cancer patients and in 208 of 247 (84.2%) rectal cancer patients. CONCLUSIONS: Only 12.1% of colon and 8.5% of rectal cancer patients were diagnosed early and treated without adjuvant therapies at the NCC in Korea in 2003.

Three cases of right coronary anomaly confirmed by multi-detector computed tomography / 대한내과학회지

Congenital anomaly of the right coronary artery is a very rare disease. It can cause syncope, angina pectoris, acute myocardial infarction, ventricular fibrillation and sudden cardiac death during exercise in the young population. The dominancy of the coronary artery, and the site, shape and pathway of the right coronary artery seems to play a key role in developing those above mentioned events. Especially, it has been known that the right coronary artery that courses between the aorta and pulmonary trunk increases the risk of sudden death. Therefore, precise evaluation is needed to diagnose the presence and type of coronary artery anomaly. Nowadays, multi-detector computed tomography is used to diagnose coronary anomalies and this provides clear images of coronary anomaly in a safe and noninvasive way. We report here on three cases of right coronary anomaly that coursed between the aorta and pulmonic trunk, and this was confirmed by multi-detector computed tomography.

Spontaneous Total Necrosis of Hepatocellular Carcinoma

We describe a case of spontaneous total necrosis of hepatocellular carcinoma (HCC). Contrast-enhanced CT scanning revealed a hypoattenuating mass during both the hepatic arterial and portal venous phase. During the latter, subtle capsular enhancement was noted. Ultrasonography demonstrated the presence of a hypoechoic mass with a peripheral hyperechoic rim. The patient underwent tumorectomy, and a totally necrotic mass was found. Microscopic examination revealed necrotic tissue with HCC ghost cells, suggesting spontaneous total necrosis of HCC.

Ruptured Corpus Luteal Cyst: CT Findings

OBJECTIVE: To evaluate the CT findings of ruptured corpus luteal cysts. MATERIALS AND METHODS: Six patients with a surgically proven ruptured corpus luteal cyst were included in this series. The prospective CT findings were retrospectively analyzed in terms of the size and shape of the cyst, the thickness and enhancement pattern of its wall, the attenuation of its contents, and peritoneal fluid. RESULTS: The mean diameter of the cysts was 2.8 (range, 1.5-4.8) cm; three were round and three were oval. The mean thickness of the cyst wall was 4.7 (range, 1-10) mm; in all six cases it showed strong enhancement, and in three was discontinuous. In five of six cases, the cystic contents showed high attenuation. Peritoneal fluid was present in all cases, and its attenuation was higher, especially around the uterus and adnexa, than that of urine present in the bladder. CONCLUSION: In a woman in whom CT reveals the presence of an ovarian cyst with an enhancing rim and highly attenuated contents, as well as highly attenuated peritoneal fluid, a ruptured corpus luteal cyst should be suspected. Other possible evidence of this is focal interruption of the cyst wall and the presence of peritoneal fluid around the adnexa.

Recurrent Pyogenic Cholangitis: Clinico-Pathologic Correlation of Focal Attenuation Differences on Multi-Phasic Spiral CT

PURPOSE: To determine the clinical and the pathologic significance of the focal attenuation differences (FAD) and bile duct wall enhancement occurring in recurrent pyogenic cholangitis (RPC) and seen at multiphasic spiral CT. MATERIALS AND METHODS: Among the multiphasic (non-contrast, arterial and portal or delayed phase) spiral CT findings of 60 consecutive patients, two types of FAD were noted during the non-contrast phase. These were Type A (iso) and Type B (low attenuation), and their distribution pattern (lobar versus patchy, multifocal) and the and the presence or absence of bile duct wall enhancement were recorded. The radiologic findings were correlated with the clinical and pathologic findings. RESULTS: Two types of FAD were noted in 40 of the 60 patients. Active in flammation was present in 19 of the 27 with Type-A and in ten of the 15 in whom the presence of RPC was pathologically proven. Ten of the 13 with Type-B FAD were in a subclinical state, and nine of the ten in whom RPC was pathologically proven had chronic inflammation. Among 20 patients who did not have FAD, RPC was subclinical in 18 and dormant in nine of the eleven in whom its presence was pathologically proven (p<0.001). Clinico-pathologic correlation with bile duct wall enhancement and the distribution pattern of FAD showed no statistical significance. CONCLUSION: The inflammatory activity of RPC can be predicted by analysis of the FAD seen at multiphasic spiral CT.

Pseudoaneurysm after Pancreatoduodenectomy: Diagnosis and Embolization on Angiography

PURPOSE: To evaluate the efficacy of angiography in the diagnosis and treatment of pseudoaneurysm manifesting arterial hemorrhage as a significant complication following pancreatoduodenectomy. MATERIALS AND METHODS: For 51 months, of a total of 298 patients who had undergone pancreatoduodenectomy, 19 patients (6.4%) developed clinically significant hemorrhage and nine patients proved to have a pseudoaneurysm on angiography. These nine patients (3.0%) were managed by transcatheter arterial embolization. We analyzed clinical feature, angiographic findings and hemostatic effect of embolization retrospectively. RESULTS: In nine patients (3.0%), pseudoaneurysm was diagnosed on angiography (common hepatic artery in four, gastroduodenal artery in three, proper hepatic artery in one, and left gastroepoploic artery in one patient). The size ranged from 0.3 cm to 6.5 cm (mean 1.9 cm). And extravasation was noted in five patients (55.6%). The remained ten patients showed no evidence of bleeding on angiography. Those who manifested as early bleeding (within two weeks) or delayed bleeding (later than two weeks) were five and four patients respectively. Before the onset of major bleeding, among the nine pseudoaneurysm patients, seven patients (77.8%) had experienced percutaneous drainage due to intra-abdominal fluid collection with or without abscess resulting from anastomotic leak, and all nine patients had had preliminary minor bleeding. The angiogram demonstrated an exact site of bleeding as a pseudoaneurysm followed by transcatheter arterial embolization (microcoil in eight patients, gelfoam in one) and achieved complete hemostasis yielding a success rate of 100%. Overall, no patients experienced complications related directly to the transcatheter arterial embolization technique. During the follow-up period (72-1,336days, mean 640), no recurrence of bleeding was noted. CONCLUSION: Although pseudoaneurysm is a rare complication, it is important as a cause of hemorrhage after pancreatoduodenectomy. Angiography followed by transcatheter arterial embolization allows early diagnosis and hemostasis of pseudoaneurysm and minimizes the need for high-risk emergency surgery.

The Usefullness of the Transrectal Ultrasonography in the Diagnosis of the Prostate Cancer: Comparison with Systemic Sextant Biopsy

PURPOSE: To retrospectively compared the usefulness of the transrectal ultrasonography LEAVE A SPACE(TRUS) and systemic sextant biopsy in the diagnosis of prostate cancer. MATERIALS AND METHODS: A total of 84 patients with clinical and laboratory findings suggestive of prostate cancer underwent TRUS and systemic sextant biopsy. Nine patients with diffuse prostatic lesion had been excluded from the list. Following sonographic evaluation, additional targeted biopsy for the focal lesion was performed in 14 patients. A total of 464 biopsy specimens were obtained and retrospectively compared with the sonographic findings. RESULTS: For cancer, the sensitivity, specificity and false-positive rate of TRUS were 48%, 97% and 53%, respectively. The hypoechoic nodules seen in prostate cancer were more commonly located in the outer half of the peripheral zone of the prostate, while most BPH lesions were located in the inner half of this zone. Between prostate cancer and BPH there was a statistically significant difference in the location of hypoechoic nodules revealed by TRUS (p=0.01). CONCLUSION: The location of the hypoechoic nodules provides useful information for differentiating between BPH nodoles and malignant prostatic nodules and may reduce the false-positive rate of TRUS in the diagnosis of prostate cancer.

Sclerotherapy of Peritoneal Inclusion Cysts: Preliminary Results in Seven Patients

OBJECTIVE: To evaluate the technical feasibility and the clinical effectiveness of sclerotherapy for the treatment of peritoneal inclusion cysts (PICs). MATERIALS AND METHODS: Between June 1996 and February 2001, eight PICs in seven female patients aged 28-43 (mean, 36) years were instilled with sclerosant (povidone-iodine in three, ethanol in three, both povidone-iodine and ethanol in one). All seven patients subsequently experienced less abdominal pain. After drainage via an 8.5-Fr pigtail catheter inserted in the PICs (transabdominally in six cases, transvaginally in one), sclerosant equivalent in volume to about one-third that of drained fluid was introduced daily until the drained volume was less than 5ml. Follow-up by means of clinical procedures and ultrasound was performed every three months, at which time the success rate, possible complications and recurrence were determined. RESULTS: Sclerotherapy was technically successful in all seven patients, though immediately after the procedure, minor complications were noted in three patients (mild pain in two, mild fever in one). During the follow-up of 4-60 (mean, 24.7) months, sclerotherapy proved successful and without long-term complications in all seven patients: lower abdominal pain disappeared and the diameter of the cysts decreased more than 50%, with complete regression in four cases. During the follow-up period there was no recurrence. CONCLUSION: Sclerotherapy following catheter insertion is technically feasible and effective for the treatment of PICs.

A Case Report of Balloon Angioplasty for Coarctation of Aorta in Adult

For the treatment of coarction of aorta, surgical intervention has been known as a standard therapy.During last decade balloon angioplasty for coarctation of the aorta has been reported as a successful and safe procedure in about 300 cases. This angioplasty was done mainly in infants and children, and little cases in adults and adolescents. A 22 year-old adult with coarctation of aorta have recieved balloon angioplasty. He visited to emergency room due to severe headache and the blood presure of arm was 240/130mmHg at emergency room. The blood pressure at ward was 168/92mmHg in upper extremities, 104/82mmHg in lower extrimities. His aortogram showed coarctation of thoracic aorta below left subclavian artery. The pressure gradient beween ascending aorta and right femoral artery was decreased from 60mmHg to 0mmHg after balloon dilatation (2 times, balloon diameter 18mm). There were no significant complications. The follow-up magnetic resonance image in 4 month after balloon angioplasty showed no evidence of restenosis or saccular aneurysm. Initial hypertension turned to normal blood pressure in 4 months after balloon angioplasty. This adult case of successful balloon angioplasty for coarctation of aorta is the first case reported in Korea.

Analysis of Time Delay to Affect Thrombolytic Therapy in Patients with Acute Myocardial Infarction

BACKGROUND: Early reperfusion therapy with thrombolytic agents or primary PTCA is most important to salvage ischemic myocardium in acute myocardial infarction(AMI). Timely reperfusion of jeopardized myocardium clearly improves hemodynamics, decreases infarct size and improves survival. The extent of protection appears to be directly related to the rapidity of reperfusion after onset of coronary occlusion. Although the intravenous thrombolysis is a feasible therapy in the patients with evolving AMI, the benifit of thrombolytic therapy decreases because of the time delay after onset of symptom. This study was perfomed to analyze the factors time delay between onset of symptom and the thrombolytic therapy with retrospective and prospective questionaire in the patients with AMI. METHOD: Eighty one patients with AMI were included in this study who came to the emergency room(ER) of Chungnam National University Hospital(CNUH) from Feburary 1995 to October 1996. Delay between door and thrombolytic therapy was defined as hospital time delay. RESULTS: Thrombolytic therapy(rt-PA or urokinase iv) was done in 60 patients(74.1%) and mean prehopital time delay was significantly decreased in the patients with thrombolytic therpapy when compared with those without thormbolytic threapy(462+/-90 vs 1375+/-473 minutes, p=0.005). There were no singificant factors for prehospital time delay such as age, sex, redsidence, ER near residence, transfer time to ER near residence, family status, family history of AMI, severity of chest pain, presence of risk factors of cardiovascular disease(CVD), previous CVD, degree of education, history of other disease and routine check, transfer methods. The only 8 patients(9.8%) knew about AMI and 7 patients among these patient came to ER earlier and received thrombolytic therapy. From 57 referred patients, 40 patients(70.2%) received reperfusion therapy and only 30 patients(52.6%) had recored EKG in the referred hospital. In the analysis of hospital delay from patient's arrival to the thrombolytic therapy, the arrival time at weekdays and weekend had no differences, but hospital delay were significantly prolonged when patients arrived at ER in the night. CONCLUSION: Since prehospital time delay is a most important factor of time delay for the effective thrombolytic therapy in AMI, the pubic education program and effective transport system are needed. And routine record of EKG in patient with chest pain in the local hospital is very helpful to start effective thromolytic therapy at ER. The well designed prospective study with more patinets in our local region is essential to get more accurate information about transport system and to improve survival rate in patients with AMI.