Preoperative Iron Supplementation and Restrictive Transfusion Strategy in Hip Fracture Surgery

BACKGROUND: Hip fracture surgery (HFS) is often associated with perioperative blood loss, and it frequently necessitates transfusion. However, the hemoglobin (Hb) threshold for transfusion remains controversial in hip fracture patients. We evaluated the usefulness of the restrictive strategy and preoperative intravenous iron supplementation in HFS. METHODS: We retrospectively reviewed the medical records of 1,634 patients (> 60 years of age) who underwent HFS between May 2003 and June 2014 and were followed up for 1 year or more after surgery. We used the liberal transfusion strategy until May 2009 to determine the transfusion threshold; afterwards, we switched to the restrictive transfusion strategy. Patients with the restrictive transfusion strategy (restrictive group) received intravenous iron supplementation before surgery. We compared the transfusion rate, morbidity, and mortality of the restrictive group with those of the patients with the liberal transfusion strategy (liberal group). RESULTS: Preoperative intravenous iron supplementation was not associated with any adverse reactions. The transfusion rate was 65.3% (506/775) in the liberal group and 48.2% (414/859) in the restrictive group (p < 0.001). The mean hospital stay was shorter in the restrictive group (21.5 vs. 28.8 days, p < 0.001). There was no significant difference in the postoperative medical complications including myocardial infarction and cerebrovascular event. Mortality at postoperative 30, 60, and 90 days was similar between the two groups. CONCLUSIONS: Our blood management protocol involving restrictive strategy combined with preoperative intravenous iron supplementation appears to be effective and safe in HFS of elderly patients.

Which Index for Muscle Mass Represents an Aging Process?

BACKGROUND: Although studies and interest in sarcopenia have increased, it is still a matter of debate which muscle mass index better represents the aging process. We compared 3 indices for muscle mass (appendicular skeletal muscle mass [ASM]/weight, ASM/height2, and the body mass index [BMI]-adjusted muscle mass index [ASM/BMI]) to determine which better reflected the aging process in terms of the decline in bone mineral density (BMD), visual acuity (VA), hearing power, renal function, pulmonary function, and handgrip strength. METHODS: We performed a retrospective cross-sectional study using the Korea National Health and Nutrition Examination Survey in the Korean population. Between 2008 and 2011, a total of 14,415 men and 17,971 women aged 10 years or older participated in the study. We plotted the changes in the 3 indices of muscle mass and compared these with changes in BMD, VA, hearing power, renal function, pulmonary function, and handgrip strength according to each age group. RESULTS: The ASM/BMI showed similar changes in terms of surrogate markers of the aging process, while the ASM/weight and ASM/height2 showed no correlation. CONCLUSIONS: Among muscle indices for sarcopenia, only the ASM/BMI represented the aging process.

Usefulness of the Syringe Aspiration Technique for Detecting the Position of Endotracheal Tube

PURPOSE: The study was conducted to evaluate the usefulness of syringe aspiration technique (SAT) to correctly differentiate between esophageal and tracheal intubation in emergency department. METHODS: This study, which was comprised of a prospective series of cases, was conducted in the emergency department of an university hospital. A 50 mL catheter-tip syringe was attached to the end of the tracheal tube following intubation. The syringe plunger was then withdrawn or aspirated with 50 mL of air. The ability to withdraw air into the syringe without resistance and without syringe plunger rebound was considered evidence of tracheal intubation. If resistance was met as the syringe was aspirated or if the syringe plunger rebounded following aspiration, esophageal intubation was assumed. RESULTS: Seventy patients were enrolled in the study. Tracheal intubation was performed in 46 patients, and esophageal intubation was performed in 24 patients. Of the 46 tracheal intubations, the SAT correctly indicated tracheal placement in 45 and was indeterminate in 1 case because of blockage of the endotracheal tube by gastric material resulting from aspiration. All 24 esophageal intubation were corrected identified. CONCLUSION: This study suggests that the SAT is a safe and effective device for determining endotracheal tube position in patients with various clinical conditions requiring urgent airway control in the emergency department.

Painless Aortic Dissection Presenting as Acute Ischemic Stroke: Administ-ra-tion of Tissue lasminogen Activator

Acute aortic dissection is a catastrophic, often life threatening event that usually presents as a sudden, severe, exquisitely painful, ripping sensation in the chest or back. Painless dissection occurs in approximately 5% of the patients, and the diagnosis may often be delayed. It can be associated with neurologic sequelae, such as ischemic stroke, spinal cord ischemia, ischemic peripheral neuropathy, in as many as one-third of the patients. As an initial manifestation, neurologic deficit is seen in about 20% of patients. The diagnosis of ischemic stroke in patients who present within a 3-hour time window is generally made on clinical grounds before administration of thrombolytic therapy. The etiology of the stroke is not definitely determined until well after the patient has received recombinant tissae plasminogen activator. It is likely that poor outcomes will occur in ischemic stroke resulting from aortic dissection if r-tPA is administered intravenously. Therefore, it is important to clinically recog-nize this possibility. We report the case of a patient who presented with symptoms consistent with acute ischemic stroke and was given r-tPA. Further investigation demon-strated an aortic dissection as the cause of her stroke.

Effects of Continuous Descending Aortic Balloon Occlusion on Brain Ischemia during Cardiopulmonary Resuscitation in Rabbits

PURPOSE: A recent report introduce a new option for cardiopulmonary resuscitation by using of a continuous descending aortic balloon occlusion. The aim of the present study was to evaluate the effect of balloon occlusion of the descending aorta during cardiopulmonary resuscitation on brain ischemia. METHODS: Twelve rabbits were enrolled in this study. A 4 French Swan-Ganz catheter was advanced through the right femoral artery into the descending aorta. Ventricular fibrillation was induced with an AC current delivered through an electrode catheter advanced into the right ventricle. After 3 minutes of untreated ventricular fibrillation, the rabbits were randomized in two groups: (1) chest compression without balloon occlusion (control group) and (2) chest compression with balloon occlusion of the descending aorta (experimental group). The balloon was inflated for 3 minutes during resuscitation. Defibrillation was attempted at 3 minutes after start of chest compression. At 24 hours after return of spontaneous circulation, brain tissues were fixed in 4% paraformaldehyde and stained with hematoxylin eosin. Then, the ischemic cells in the hippocampal CA1 area were counted. RESULTS: There was significant difference in ischemic neuronal cells between the two groups (control group: 41.8 +/-10.9%, experimental group: 16.8+/-6.8%, p < 0.05). In the experimental group, carotid blood flow was better than it was in the control group during chest compression (control group: 2.4+/-1.0 mL/min, experimental group: 7.6+/-1.9 mL /min, p < 0.05). CONCLUSION: These results suggests that balloon occlusion of the descending aorta during resuscitation decreases brain ischemia in rabbits during cardiac arrest.

Spontaneous Rectus Sheath Hematoma with Hypovolemic Shock

Rectus sheath hematoma of the abdominal wall is a well-recognized, but uncommon condition, caused by a tear in an epigastric vessel and characterized by sudden onset of severe abdominal pain and palpable mass. In most cases, a precipitating cause can be demonstrated. Causes include external trauma, strenuous activities, coughing, lifting, sneezing, vomiting, straining while urinating or defecating, golfing, pregnancy and the puerperium, anticoagulation therapy, infection, chronic diesase, arteriosclerosis, hypertension, prior paracentesis or laparotomy, inadequate hemostasis or excessive retraction in surgery, and idiopathy. Unfortunately, the correct diagnosis often is missed, and the hematoma is found only during an exploratory laparotomy. Treatment should be conservative in most instances. Although the mortality rate for patients with rectus sheath hematoma is low, the condition may be fatal if the volume of the hemorrhage is large and if treatment is delayed. Hence, it should be included in the differential diagnosis of any patient who presents to the emergency department with acute onset of abdominal pain. Our purpose is to familiarlize emergency physicians with the pathophysiology, the diagnosis, and the treatment of rectus sheath hematoma. We describe a patient with fatal rectus sheath hematoma presenting to the emergency department and give a review of the literature.

Effect of Pentoxifylline on the Cerebral No-reflow Phenomenon after Cardiac Arrest in Rat

BACKGROUND: Successful resuscitation of the brain requires unimpaired blood recirculation. However, unfortunately there are several factors against the successful recirculation. No-reflow phenomenon, characterized by a lack of reperfusion after cerebral ischemia, is the most important pathogenic factor during the early period of spontaneous circulation(ROSC). This study addresses question that pentoxifylline(PTX) ameliorates no-reflow phenomenon after cardiac arrest. METHODS: Fourteen rats were divided three group ; Sham group(n=2), 12 minutes cardiac arrest group without PTX(group I, n=6), and 12 minutes cardiac arrest group pretreated with PTX(group II, n=6). Group II were premedicated by intravascular injection of 5mg/kg PTX into the external jugular vein before 5minutes of the arrest-induction. We induced cardiac arrest with endotracheal clamping and muscle relaxant. And then, resuscitation was initiated. Arterial blood samples were drawn at the femoral artery before 5 minutes of arrest-induction and at the 5 minutes after restoration of ROSC. Reperfusion of brain was visualized by injection of 0.3g/kg of 15% FITC-albumin at 5 minutes after restoration of ROSC, and the animals were decapitated 2 minutes later. The left hemisphere was fixed with 4% formalin, and coronal sections of 200um thickness at three different standard levels of the rat brain were investigated with fluorescence microscopy. Density of microvasular filling were identified and calculated. RESULTS: Our observation demonstrated that 1. There were no significant differences of blood pressures, heart rates, and results of blood gas analysis between group I and II during the prearrest steady state. 2. There were no significant differences of blood pressures, heart rates, and results of blood gas analysis between group Iand II at 5minutes after ROSC. 3. Group II premedicated with PTX, showed significant increased capillary refiling(0.310+/-0.035)than group I without PTX(0.181+/-0.040). CONCLUSIONS : The results showed that during the prearrest steady state, premedication of PTX ameliorated the no-reflow phenomenon in the rat model of the asphyxial arrest. Further experimental studies are required to focus on the effects of postarrest infused PTX, The neurologic outcome, and the clinical applications.

Atypical High Attachment of Wrisberg Ligaments in Discoid Menisci

No abstract available.

Diagnosis of Acute Anterior Cruciate Ligament Injuries / 대한정형외과학회잡지

The purposes of this study were to evaluate the diagnostic modalities of the acute rupture of anterior cruciate ligament(ACL) and to know the differences hetween complete and partial ACL rupture preoperatively, analyzing the methods of physical examimation and the clinical features in acutely injured patient. We analyzed the anterior drawer test, Lachman test, KT-2000 arthrometer, MRI findings and associated injuries in the 35 patients who were confirmed to have ACL rupture by arthroscopy of the knee joint, performed within a month after trauma. We divided the patients by arthroscopy into 2 groups: complete rupture group and the partial rupture group. Among the 35 cases of ACL rupture, there were 10 cases of partial rupture and 25 cases of complete rupture. The Lachman s test was the most sensitive method of the physical examinations in detecting acute ACL injuries, with 90% and 92% positive rate in each group retrospectively. KT-2000 arthrometer with more than 3mm side-to-side difference showed all positive findings except one. The findings of ACL rupture in MRI were discontinuity, increased signal intensity, ahnormal course of ACL fibers and so on. The sensitivity of MRI in diagnosing the acute injuries of ACL was 97.2% hut had difficulties in differentiating the complete from partial rupture. Associated injuries of the ACL injured knee were medial and lateral meniscus tear and medial collateral ligament injury. The diagnosis of acute ACL rupture was made possihle hy physical examinations and with use of the KT-2000 arthrometer and MRI was useful in detecting the ACL rupture or associated injuries but not in differentiating complete from partial rupture of the ACL.

2 Cases of Alcohol-Induced Rhabdomyolysis with Acute Renal Failure

Rhabdomyolysis is a biochemical and clinical syndrome caused by lysis of skeletal muscle cell and release of muscle cell contents into the Circulation. In addition to traumatic cause, various nontraumatic causes have been reported. Rhabdomyolysis has frequently been associated with seamy aspects of life and society: alcoholic abuse, drug addiction, sadistic drill exercise, war events and attempted suicide. The abuse of alcohol causes many hazards in many organs. One of these is acute alcoholic myopathy that may present as a fulminent syndrome of muscle pain and tenderness associated with rhabdomyolysis and acute renal failure. Because the prognosis of adequately treated rhabdomyolysis is excellent, early recognition and prompt management aye essential in emergency situation. We experienced two typical cases of alcohol-induced rhabdomyolysis with acute renal failure and report these cases with literature review.

Deferoxamine Pretreatment Reduces Infarct Size of Acute Myocardial Infarction in a Rabbit Model

BACKGROUND: Reperfusion of ischemic myocardium has been postulated to result in a specific oxygen radical mediated tissue injury. Iron may liberate during ischemia and we hypothesized that administration of the iron chelator, deferoxamine during ischemia would result in improved recovery after postischemic reperfusion. PURPOSE: To test whether iron-catalyzed processes contribute to myocardial necrosis during ischemia and reperfusion, deferoxamine was administered to block iron catalyzed hydroxyl radical formation in rabbits. METHODS: Eleven rabbits were divided into two groups: control group (n=5) and deferoxamine pretreatment group (n=6). the left circumflex coronay artery was ligated for 30 minutes and reperfused for 180 minutes. Area at risk (AR) was measured by non-stained area with ethylene blue injection into left atrium after left circumflex coronary artery ligation. Infarct size was measured by weighing after tripheyltetrazolium chloride staining. Heart rate was measured using electrocardiographic recording and systemic blood pressure was monitored by pressure transducer connected to the catheter in the left ventricle. RESULTS: 1. There was no significant difference of heart rate and blood pressure in deferoxamine pretreatment group compared with control group. 2. There was significant decrease of serum iron concentration after continuous infusion of deferoxamine compared with serum iron concentration before ligation of coronary artery (P<0.05). 3. There was no significant difference of area at risk between control and deferoxamine pretreatment group. 4. Area at necrosis to area at risk was significantly reduced in deferoxamine pretreatment group compared with control group (P<0.05) The results suggest that deferoxamine infusion prior to coronary artery occlusion has a significant benefit in reducing infarct size in this model.

Correlation Analysis between END-tidal CO2 Tension and Arterial CO2 Tension in Nonintubated Emergency Department Patients with Respiratory Distress

BACKGROUND: The end-tidal carbon dioxide tension(ETCO2) is defied as a partial pressure of carbon dioxide at the end of an exhaled breath.)he purpose of this study is to determine the correlation between ETCO2 and arterial carbon dioxide tension(PaO2) in nonintubated abated patients with respiratory distress in emergency department(ED). METHODS: A prospective non-blind study was performed in ED of our university hospitals. Participants included all nonintubated adult patients with respiratory distress requiring arterial blood gas analysis. ETCO2 was measured with a capnography monitor during tidal volume breathing. ETCO2 were recoreded at the time of arterial blood gas sampling. The correlation between ETCO2 and PaCO2 was analysed in all patients and in subgroups by simple linear regression. RESULTS: Sixty patients were enrolled. In all patients, ETCO2 was 5.72mmHg lower than PaCO2 and correlated well with PaCO 2(r2=0.716). ETCO2 correlated best with PaCO2) in patients who were either acidotic or non-smoking. CONCLUSION: ETCO2 correlate well with PaCO2 in nonintubated patients with respiratory distress in ED. ETCO2 may be sufficient to reflect PaCO2 in selected patients and obviate the need far repeat arterial blood gas determination.

A Clinical Evaluation for The Initial Diagnosis of Renal Infraction in Emergency fdedical Center

To evaluate appropriate diagnostic studies for renal infarction in emergency medical center, we analysed 33 patients of renal infarction treated in this hospital for last 8 years. Eleven patients, 4 trauma associated and 7 aortic disease associated patients were excluded. They are 11 males and 11 females with a mean age of 51 years. Fourteen came to the emergency medical center and seven came to the outpatient department, in the other one patient renal infarction was developed during hospitalization with other disease. On their past history they had hypertension in 9, valvular heart disease in 5, and diabetic mellitus in 4 patients. Abdominal or flank pain was noted in 17 of 22(77%). The other symptoms were vomiting, nausea, fever and so on. On microscopic examination of initial urine in hospital, 5 patients showed more than 10 red blood cells by high power field examination. The mean lactic dehydrogenase level was 1,239 I.U/L(normal range 218-4721.UA), while the mean aspartate aminotransferase and mean alanine aminotransferase were 511.U/L(normal range 13-36 I.U/L) and 44 I.U/L(normal range 5-331.U/L). Abdominal ultrasonography showed positive findings in 5 of 16(31%), of which 3 were confirmed by Doppler ultrasonography In 18, computed topography was done and all those showed positive findings of renal infarction(100%). In conclusion, it is important that identify the elevated lactic dehdrogenase level in case of any suspicion about renal infarction and confirm by computed tomography.

Trans - Posterior Septum Posterior Arthroscopic Portals in the Knee Joint

This paper introduces a safe arthroscopic technique passing through the posterior septum from the posteromedial cotnpartment to the posterolateral compartment, or vice versa, without damage to the PCL, capsule, and/or neurovascular structures. The posterior septum is triangular, bounded by the PCL anteriorly, the posterior portion of the femoral I.ntercondylar notch superiorly, the posterior capsule posteriorly, and devicles the posterior compartment of the knee joint into the posteromedial and posterolateral compartments. The middle genicular vessel pierces the posterior capsule and runs along the superior border of the posteriorseptum. There are no dangerous important structures at the central portion of the triangle of the posterior septum. This arthroscopic posterior portal technique is devided 4 steps. The first step is to make a posteromedial portal under direct arthroscopic visualization. The second step is to make a posterolateral portal. The third step is to make a hole at the posterior septum and to examine throposterolatera] compartment. The fourth step is to examine the posteromedial compartment through the posterior septum. This technique provides complete visualization of the posterior compartment of the knee joint, including the posterior aspect of the both femoral condyles, the posterior hom of both menisci, the PCL, the meniscofemoral ligament (Wrisberg s ligament), the posterior aspect of the pop liteal tendon, the femoral attachment of the ACL, the posterior septum and the posterior capsule. We have used this technique from October, 1994 to June, 1996 in 58 knees; arthroscopic total synovectomy in 43, removal of the loose bodies located behind the PCL in 8, PCL re!construction in 4, meniscal repair with all inside suture technique in 3. In conclusion, this procedure is very helpful in performing arthroscopic total synovectomy in chronic, acute, hemophilic, and crystal induced synovitis, in removing encapsulated loose bodies located behind the PCL, and in suturing peripheral tears of the posterior hom of the medial rneniscus with an all inside suture technique.

Discoid Lateral Meniscus Tear Detected in Below 4 Years Old Age

Torn discoid lateral meniscus has been numerously reported in diagnosis and treatment. But discoid meniscus in children of which clinical pictures were thought to be different from adults was rarely known. We experienced 2 cases of discoid meniscus tear in children whose ages were below 4 years old and report with references.

The Comparison of Analgesic and Hemodynamic effects in Different Nitrous Oxide Concentration

BACKGROUND: Nitrous oxide is a safe analgesics which has analgesic and sedative effects without loss of consciousness. The advantage of Nitrous oxide is that it has a rapid onset time and that we can modulate duration of its action. The purpose of this experiment is to obtain the safe and effective concentration of Nitrous oxide in Emergency Department as use of analgesics and sedative drugs. METHODS: Twenty volunteers were investigated according to double blind method. Nitrous oxide was administrated to volunteer subjects at different concentrations ; 33%, 50%, 67% each. Then we evaluated the Pain score, Blood pressure, Heart rate, Respiratory rate, Oxygen saturation and its side effects. RESULTS: Pain Score were 8.4+/-2.1 at 33%, 6.1+/-1.5 at 50%, and 3.65+/-2.2 at 67% of Nitrous oxide. Pain Score is decreased significantly following administration of Nitrous oxide at concentration of 50%, 67%(P<0.05). There was no difference between preadministration group and postadministration group. While no remarkable change in systolic blood pressure, heart rate, and oxygen saturation. Respiratory rate showed significant increase when 679o of Nitrous oxide was administrated. There was no side effect in administration of 33% of Nitrous oxide. When 50% of Nitrous oxide was administrated, there were dizziness 5(25%), paresthesia 2(10%), nausea 1(5%), palpitation 1(5%) and hyperethesia 1(5%). At 679o of Nitrous oxide, there were nausea 7(35%), dizziness 6(30%), paresthesia 5(25%), headache 5(25%), diplopia 2(10%), dysphoria 2(10%), salivation 1(5%), dyspnea 1(5%), nystagmus 1(5%), tinnitus 1(5%) and euphoria1 (5%). Incidence of side effect increased as the concentration of Nitrous oxide was increased. CONCLUSION: We can conclude that safe and effective concentration of Nitrous oxide is 50% as analgesics and sedative drugs in the emergency department.

Cure of severe hypothermia due to loss of consciousness after drug intoxication of inhaled hydrocarbons, Case 1

A 19-year-old man had a good neurologic recovery from a severe hypothermia(19 degrees C) and a prolonged coma following active infernal rewarming. From inhaling hydrocarbons, he was left unconscious on the cold floor for 24 hours. As soon as the patient was brought into the emergency medical center, he was early evaluated arid treated aggressively. ECG showed Osborn(J) wave on all leads. The temperature o( patient was increased by 2-3 degrees C per hour through active external rewarming (by heating blankets and warm bag) and active infernal rewarming (by airway rewarming, warmed IV fluids, gastrointestinal tract irrigation, and bladder irrigation). The temperature reached 36 degrees C after 6 hours. Active infernal rewarming provides rapid core rewarming with the additional benefit of circulatory support during the period of cardiac instability.

T lymphocyte responses to house dust mite in asthmatic children / 소아알레르기및호흡기학회지

No abstract available.

A case of peripartum cardiomyopathy / 대한산부인과학회잡지

No abstract available.

Clinical Review of Tuberculous Meningitis in Children

No abstract available.