Perioperative lung-protective ventilation strategy reduces postoperative pulmonary complications in patients undergoing thoracic and major abdominal surgery / 대한마취과학회지

The occurrence of postoperative pulmonary complications is strongly associated with increased hospital mortality and prolonged postoperative hospital stays. Although protective lung ventilation is commonly used in the intensive care unit, low tidal volume ventilation in the operating room is not a routine strategy. Low tidal volume ventilation, moderate positive end-expiratory pressure, and repeated recruitment maneuvers, particularly for high-risk patients undergoing major abdominal surgery, can reduce postoperative pulmonary complications. Facilitating perioperative bundle care by combining prophylactic and postoperative positive-pressure ventilation with intraoperative lung-protective ventilation may be helpful to reduce postoperative pulmonary complications.

Remifentanil dose for laryngeal mask airway insertion with a single standard dose of propofol during emergency airway management in elderly patients / 대한마취과학회지

BACKGROUND: This study determined the dose of remifentanil to use during insertion of a Classic(TM) laryngeal mask airway (LMA, The Laryngeal Mask Co., Nicosia, Cyprus) in elderly patients during emergency airway management when combined with a single dose of propofol. METHODS: Patients aged 65-80 years were enrolled. Anesthesia was induced with propofol 1 mg/kg, and then a blinded dose of remifentanil was infused over 30 s after confirming the patient's loss of consciousness. The dose of remifentanil was determined using Dixon's up-and-down method, starting at 0.5 microg/kg (a step size of 0.1 microg/kg). Insertion of the LMA was attempted 60 s after loss of consciousness. RESULTS: In total, 23 patients were recruited and the mean age +/- standard deviation was 72 +/- 3 years. The effective dose for successful LMA insertion in 50% of the patients (ED50) was 0.20 +/- 0.05 microg/kg. No patient needed more than 0.3 microg/kg. CONCLUSIONS: Remifentanil 0.20 +/- 0.05 microg/kg with propofol 1 mg/kg resulted in excellent LMA insertion in 50% of elderly patients without significant hemodynamic changes during emergency airway management.

NF-kappaB Activation in T Helper 17 Cell Differentiation

CD28/T cell receptor ligation activates the NF-kappaB signaling cascade during CD4 T cell activation. NF-kappaB activation is required for cytokine gene expression and activated T cell survival and proliferation. Recently, many reports showed that NF-kappaB activation is also involved in T helper (Th) cell differentiation including Th17 cell differentiation. In this review, we discuss the current literature on NF-kappaB activation pathway and its effect on Th17 cell differentiation.

Tangalle Sri Lanka Emergency Medical Center: To Implement a New Operating and Management System Through Means of Surveys

PURPOSE: This study was conducted in the base hospital of Tangalle, Sri Lanka, in order to improve a new emergency operating system. METHODS: Emergency staff and patients were surveyed based on the five point Likert scale. Doctors and nurses were asked to rate their level of satisfaction regarding their relationship with patients. Patients were asked to rate their level of satisfaction with doctors, facilities, and the environment in the hospital. RESULTS: Doctors were overall satisfied with their job, scoring an average of 3.7. They were displeased with limitation of autonomous decision making on medical treatment, which they gave a score of 2.80. Nurses were generally satisfied with emergency services, with a score of 4.53. Nurses feel discomfort in non-specialized training (3.02). They also sense a lack of opportunities in their hospital (3.12). Patients' findings indicate that most patients were satisfied (4.2) and were displeased with wait time (3.429) and the attention that was given to each patient (3.92). When asked if they would recommend their physician to others and were willing to come back to their physician, outcomes were generally positive, receiving scores of 4.1, respectively. CONCLUSION: Findings showed that in order to create a well-structured system in the emergency centers around the Tangalle area, it is crucial to meet the needs of both patients and the emergency staff. Patients must have a sense of rapid treatment as well as privacy. Training should be provided to the staff so that they are better informed in quality care and up to date on recent studies.

A Closed-Suction Catheter with a Pressure Valve Can Reduce Tracheal Mucosal Injury in Intubated Patients / 대한구급학회지

BACKGROUND: Endotracheal suctioning is associated with complications that include bleeding, infection, hypoxemia, cardiovascular instability, and tracheal mucosal injury. Recently, a closed-suction catheter with a pressure valve (Acetrachcare, AceMedical Co., Republic of Korea) was developed. We hypothesized that this new catheter might reduce tracheal mucosal injury compared to a conventional closed-suction catheter (Trachcare, Kimberly-balla RD, USA). METHODS: This prospective, randomized study enrolled medical and surgical patients who required mechanical ventilation for more than 48 hours. Patients were randomized into two groups: one group was suctioned with the conventional closed-suction catheter (CCC) and the other group was suctioned with the closed-suction catheter with pressure valve (CCPV). Bronchoscopy was performed 48 hours later, and the severity of tracheal mucosal injury was graded on a 5-point scale, as follows: 0 = normal; 1 = erythema or edema; 2 = erosion; 3 = hemorrhage; and 4 = ulceration or necrosis. RESULTS: A total of 76 patients (37 with CCPV and 39 with CCC) were included. There were no significant differences between the groups regarding demographic characteristics, changes in hemodynamic parameters during suction, incidence of pneumonia, length of intensive care unit (ICU) stay, or ICU mortality. On bronchoscopic evaluation, the use of the CCPV led to a significant decrease in tracheal mucosal injury (median tracheal mucosal injury grade 1 [IQR 0-1] vs. 2 [IQR 1-3], p = 0.001). CONCLUSIONS: We conclude that the novel closed-suction catheter with pressure valve may reduce tracheal mucosal injury compared to conventional catheters.

Cardiopulmonary resuscitation with assisted extracorporeal life support during cardiac arrest caused by drug-eluting stent thrombosis: a case report / 대한마취과학회지

Discontinuation of dual antiplatelet therapy within 12 months after drug-eluting stent (DES) implantation increases the possibility of stent thrombosis. We now report the case of a 66-year-old man who suffered a cardiac arrest due to stent thrombosis after an elective laparoscopic anterior resection. Ten month ago, he underwent DES implantation and then had been taking dual antiplatelet therapy. Nine days prior to the surgery, he discontinued dual antiplatelet therapy. Forty minutes after intensive care unit admission, cardiac arrest occurred. However, his cardiac rhythm did not restore in spite of resuscitation, so immediately veno-arterial extracorporeal membrane oxygenation (ECMO) was implanted. Four days after the surgery, he was weaned from ECMO support, recovered completely, with no cardiopulmonary or neurological sequelae.

Malignant Cerebral Infarction after Pulmonary Resection for Lung Cancer / 대한구급학회지

Malignant cerebral infarction as postoperative complication after pulmonary resection occurs rarely, but can be rather serious. We report a case of 81-year-old man who suffered from malignant cerebral infarctions after pulmonary resection for lung cancer. He had a history of well-controlled hypertensions, but no evidences of arrhythmia, and neither stenosis nor atheroma in the carotid arteries and intracranial arteries. There were no specific events during his operation except that an inadvertent left carotid artery puncture occurred during the central line insertion. In intensive care unit (ICU), he had a delayed recovery of consciousness and dysarthria with right hemiplegia. Computed tomography revealed malignant middle cerebral infarctions due to the occlusion of left middle cerebral artery. It could be the thromboembolism due to pulmonary resections or carotid artery punctures in the patient without high risk factors.

A Clinical Review of Acute Poisonings in Geriatric Patients from Rural Gangwon Province

BACKGROUND: Recently, there has been an increase in acute poisonings in the elderly, which may be associated with attempts at suicide. The purpose of this study was to compare and analyze the clinical aspects and outcomes of acute poisonings in aged individuals with those of younger individuals. METHODS: We performed a retrospective analysis of 207 patients seen in the emergency department (ED) with acute poisoning from January 2009 to December 2010. Two groups were created, >65 years and 65 group and 0.3% in the 65 years than in those <65 years. As motive for suicide, health problem was cited more often in the older group (p=0.000). The older group had fewer interviews with psychiatrists and were more often diagnosed with depressive disorder (p=0.010, p=0.041, respectively). PSS and mortality were higher in the older group (p=0.002, p=0.010, respectively). CONCLUSION: A better understanding for the cause of poisonings and the poisonous substance used in the aged population is needed. And because of the more serious effects of acute poisonings to the elderly patient, they should readily receive regular comprehensive care including psychiatric care.

Comparison of Injuries Related with All-Terrian Vehicles (ATVs) and Motorcycles (MCs)

PURPOSE: All-terrain vehicle (ATV)-related injuries have increased since the introduction of ATVs to Korea. The purpose of this study is to compare patients with ATV-related injuries (PATV) to patients with motorcycle (MC)-related injuries (PMC). METHODS: We retrospectively analyzed the clinical records of PATV and PMC who visited an emergency center in 2008. The cases of PMC were 164, and those of PATV were 52. RESULTS: While PMC are seen evenly in the first half year and the second half year, PATV are seen mainly the first half year (from March to June: 73%). For PMC the most frequent injury mechanism was collision with another vehicle, while for PATV, it was side overturn/roll over. The injury severity score (ISS), the revised trauma score (RTS), the trauma score and the injury severity score (TRISS) were 5.6+/-5.6, 7.7+/-0.7, 5.0+/-2.1 for PMC and 7.1+/-7.5, 7.7+/-1.1, 5.5+/-1.5 for PATV, respectively. The most common injury sites were the lower extremities for PMC and the face for PATV. The rates of admission, surgery and the length of hospital stay were similar between PMC and PATV. CONCLUSION: This study shows that the risk of ATV accidents is similar to that of MC accidents. We recommend that the same safety standards and regulations that are applied to MCs should be used for ATVs. Safe and enjoyable paths have to be sought for drivers of ATVs.

Clinical Analysis of Elderly Patients with Acute Abdominal Pain in Emergency Department

BACKGROUND: As the elderly population increases, elderly patients visiting emergency departments (ED) with acute abdominal pain will also likely increase. The underlying causative diseases in these older patients are different from younger patients, usually more serious. Thus, correct diagnosis is very important, but difficult. There needs to be a better understanding of the characteristics of the elderly patient with acute abdominal pain seen in the ED. METHODS: We retrospectively reviewed the medical records of 98 elderly patients (>or=65 years) and 109 adult controls (<65 years) visiting an ED at one general hospital looking at the final diagnoses, characteristics of abdominal pain, admissions, and surgeries. RESULTS: Hepatobiliary tract diseases and bowel obstruction were more common in the elderly patients. The elderly had more admissions and surgeries than younger patients. In addition, they were more likely to have a fatal disease such as myocardial infarction. CONCLUSION: There is a difference in the underlying diseases causing acute abdominal pain in the elderly patients versus younger patients. In terms of frequency of admission and surgery, the elderly present with more serious and fatal diseases. We must consider these features when seeing an elderly patient with acute abdominal pain in an ED.

The Comparison between Transanal and Transvaginal Ultrasonography of Anal Sphincter in Normal Women

PURPOSE: The purpose of this study was to evaluate the normal value of the anal canal structures by transvaginal sonography in normal woman and compare this technique with the more commonly used transanal technique. METHODS: Transvaginal ultrasonography was performed in 25 parous patients between 4th and 8th decade of age, using a Bruel and Kajer type-1890. This procedure was followed by transanal sonography using the same system. The thickness of mucosa and submucosa, internal and external anal sphincter and puborectalis muscle were measured by both methods. RESULTS: The thickness of mucosa- submucosa, internal anal sphincter, external anal sphincter and puborectalis muscle by transvaginal sonography were 2.84 0.2 (2.6~3.0) mm, 2.98 0.4 (2.6~3.3) mm, 7.4 0.3 (7.1~7.7) mm, 7.5 0.5 (7.4~7.6) mm respectively(mean value standard deviation and range). The detection rate of external anal sphincter and puborectalis muscle by transvaginal sonography were between 55.5% (5/9) and 71.4% (5/7). CONCLUSIONS: The thickness of internal anal sphincter was increased with age(p<0.05). The thickness of mucosa-submucosa, internal anal sphincter measured.

Clinical Analysis of Fournier's Gangrene Caused by a Perianal Abscess

PURPOSE: Fournier's gangrene is a rapidly progressive fulminant infection of the perineum and abdominal wall along with the scrotum in men and the vulva in women. If the effective surgical treatment is delayed, the patients result in fatal. Modern surgical series report a mortality of 8-67%. Objective: The aims of this study were to examine the outcomes of 20 consecutive patients with Fournier's gangrene caused by a perianal abscess and to identify the factors leading to improved survival in these patients. METHODS: The medical records of all patients who had been treated at Chosun University Hospital between January 1991 and December 1999 for Fournier's gangrene caused by a perianal abscess were retrospectively reviewed. RESULTS: Twenty patients were identified (mean age 47 years, range 20-66). The sexual ratio was 2.3:1 (male:female). The etiologies included perianal fistula (35%), unknown (35%), hemorrhoidectomy (10%), rectal cancer perforation (10%), and injection therapy (10%). Associated conditions included diabetes mellitus (50%), liver cirrhosis (10%), pulmonary tuberculosis (5%), intestinal tuberculosis (5%), ulcerative colitis (5%), Crohn's disease (5%) and iron deficiency anemia (5%). Escherichia coli and bacteroid fragilis were most commonly identified. All 20 patients initially received multiple incisions and debridement. At the time of first surgery, a diverting colostomy was required in 35% of the cases and a ileostomy in 5%. Over the past 10 years, the survival rate of patients with Fournier's gangrene caused from perianal abscess has been high (100%). CONCLUSION: The keys to a successful outcome included early diagnosis, prompt surgical intervention with radical debridement, prompt fluid resuscitation, rapid initiation of broad-spectrum antibiotics, and hemodynamic support in an intensive care setting.

Clinical Significance of CEA Level of Peripheral Vein, Inferior Mesenteric Vein, Bile, and Peritoneal Fluid in Sigmoid Colon and Rectal Cancer

Carcinoembriogenic antigen (CEA) was widely used as a marker for staging and detection of recurrence and metastases, and evaluation of response of radical opertion or chemotherapy in colorectal cancer patients. METHODS: We examined 50 patients with sigmoid colon and rectal cancer patients who had a radical operation between 1994 May and 1995 April. We checked the level of CEA of peripheral blood preoperatively and postoperatively, and inferior mesenteric vein, bile of gall bladder and peritoneal fluid during surgery. We review clinical characters of the patients, and analyzed the importance of CEA level. RESULTS: The mean CEA levels of peripheral blood (postoperation), inferior mesenteric vein, bile, peritoneal fluid were 5.35+/-2.65, 13.23+/-2.13, 9.23+/-1.65, 7.42+/-2.34 ng/ml respectlively. The mean CEA level of inferior mesentiric vein (13.23+/-2.13 ng/ml) was significantly higher than that of preoperative peripheral blood (8.13+/-2.34 ng/ml) (p<0.05). Falling of postoperative peripheral blood CEA level was also significantly lower than that of preoperative level (p<0.05). CONCLUSIONS: Level of postoperative peripheral blood was related to recurrence rate and survival rate, but tumor size, tumor location, tumor differentiation, Dukes' stage were not related to the CEA level. Bile and peritoneal fluid CEA levels were related with the liver metastasis or local recurrence respectively. We suggest that CEA was useful indicator for evaluation, management, and prognosis of colorectal cancer not only preoperatively but also postoperatively.

The Prognostic Value and Reciprocity of p53 and bcl-2 Expression in Colorectal Carcinoma

p53 is a tumor suppressor gene product identified in a wide range of tumor including colorectal carcinoma. Genetic alterations in the p53 tumor suppressor gene are common in human colorectal carcinoma. bcl-2 is a protooncogene that inhibits apoptosis. The products of mutant p53 gene and bcl-2 have been associated with prognosis in several malignancies including colorectal carcinomas. This study was undertaken to evaluate values of p53 and bcl-2 oncoproteins as prognostic factors relative to clinicopathological factors and correlation of their expression. Analyses were made on achieval pathologic tissues of 80 patients with colorectal carcinomas including 34 patients able to follow-up over 5 years. The oncoproteins were localized using commercially available monoclonal antibodies:DO-7 for p53, clone124 for bcl-2. Expression of bcl-2 was cytoplasmic, whereas nuclear p53 expression was localized in carcinoma cells. The patients were 17 to 83 years of age. The expression of p53 and bcl-2 was determined respectively in 30 (37.5%) and 21 (26.3%)cases. The expression of p53 nuclear expression was not correlated with tumor location, size, histologic grade, Duke's classification, regional lymph node metastasis and tumor recurrence. The cytoplasmic expression of bcl-2 was not correlated with tumor location, size, histologic grade, Duke's classification, regional lymph node metastasis and recurrence. Univariate analysis showed that patients with p53 nuclear expression were not associated with poorer overall survival than patients with p53 negative, and also showed in patients with bcl-2 expression. The expression of p53 did not affect to that of bcl-2. We concluded that the p53 nuclear and bcl-2 cytoplasmic expression were not independent prognostic factors in colorectal carcinomas. Evidence of reciprocity of bcl-2 and p53 expression was not found.