Neutrophil extracellular traps and heparin-induced antibodies contribute to vascular access thrombosis in hemodialysis patients

Background@#Anti-heparin/platelet factor 4 (PF4) antibodies may trigger severe thrombotic complications in hemodialysis (HD) patients. Tetrameric PF4 has a high affinity for extracellular DNA, which is a key component of neutrophil extracellular traps (NETs); therefore, the interactions between anti-heparin/PF4 antibodies and NETs can contribute to prothrombotic events. This prospective observational study included both incident and maintenance HD (MHD) patients. @*Methods@#Anti-heparin/PF4 antibody levels were measured by enzyme-linked immunosorbent assay; an optical density > 1.8 was regarded as clinically significant. In incident HD patients, we additionally measured serum nucleosome levels as representative markers of NETs, and the contributions of anti-heparin/PF4 and increased serum nucleosome levels to the primary functional patency loss of vascular access was assessed. @*Results@#The frequency of anti-heparin/PF4 antibodies was significantly higher in incident HD patients compared to MHD patients (23.6% vs. 7.7%). Serum nucleosome levels, as well as the white blood cell counts, neutrophil counts, and high-sensitivity C-reactive protein levels, were significantly higher in anti-heparin/PF4 antibody-positive patients compared to the control. Platelet counts tended to be lower in the patients with anti-heparin/PF4 of >1.8 than in the controls. Relative risk calculations showed that the presence of anti-heparin/PF4 antibodies increased the risk of primary functional patency failure by 4.28-fold, and this risk increased further with higher nucleosome levels. Furthermore, in the anti-heparin/PF4 antibody-positive group, the time to first vascular intervention was much shorter, and the risk of repeated intervention was higher, compared to the controls. @*Conclusion@#In incident HD patients, the presence of anti-heparin/PF4 antibodies was associated with increased NET formation; this could be a strong predictor of vascular access complications.

A Korean perspective on the 2019 Kidney Disease Outcomes Quality Initiative guidelines for vascular access: what has changed and what should be changed in practice?

The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines are developed by the National Kidney Foundation in the United States; however, the guidelines have an impact on most international societies, including those in Korea. The KDOQI recently released the updated 2019 guidelines for vascular access based on numerous papers and controversies concerning vascular access since 2006, when the first guidelines were published. The new KDOQI guidelines have undergone significant changes compared to previous guidelines, including a change in the philosophy regarding a patient-centered approach using an end-stage kidney disease “Life-Plan.” In addition, there are newly developed or revised definitions and some key differences from previous guidelines. The process of adapting guidelines needs to be individualized to hemodialysis practice in each country, while agreeing with general principles and philosophy; therefore, we summarize changes in the updated guidelines and discuss the application and implementation of the new principles and concepts of the guidelines for vascular access care in Korea.

A Korean perspective on the 2019 Kidney Disease Outcomes Quality Initiative guidelines for vascular access: what has changed and what should be changed in practice?

The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines are developed by the National Kidney Foundation in the United States; however, the guidelines have an impact on most international societies, including those in Korea. The KDOQI recently released the updated 2019 guidelines for vascular access based on numerous papers and controversies concerning vascular access since 2006, when the first guidelines were published. The new KDOQI guidelines have undergone significant changes compared to previous guidelines, including a change in the philosophy regarding a patient-centered approach using an end-stage kidney disease “Life-Plan.” In addition, there are newly developed or revised definitions and some key differences from previous guidelines. The process of adapting guidelines needs to be individualized to hemodialysis practice in each country, while agreeing with general principles and philosophy; therefore, we summarize changes in the updated guidelines and discuss the application and implementation of the new principles and concepts of the guidelines for vascular access care in Korea.

Cerebral Venous Infarction Due to Brachial Artery-Jugular Vein Jump Graft in a Hemodialysis Patient

Hemodialysis patients rarely experience neurologic symptoms related to their vascular accesses. However, occlusion of venous drainage induces extreme venous hypertension and in rare cases cause intracranial venous congestion. We report a patient with cerebral venous infarction resulting from reflux flow into the cranium induced by an arteriovenous jump graft to the internal jugular vein. Clinicians should take into account the possibility of neurologic deficit related to intracranial venous hypertension in hemodialysis patients.

Outcomes of vascular access in hemodialysis patients: Analysis based on the Korean National Health Insurance Database from 2008 to 2016

BACKGROUND: Controversies exist whether arteriovenous fistula (AVF) placement is preferred over arteriovenous graft (AVG) for elderly patients. Current guidelines did not offer specific recommendations. Thus, this study was conducted to analyze the all-cause mortality and primary patency associated with various vascular access (VA) types according to age group. METHODS: This retrospective observational study investigated the Korean insurance claims data of chronic kidney disease patients who began hemodialysis between January 2008 and December 2016. We investigated all-cause mortality associated with initial VA in incident hemodialysis patients and primary patency between AVF and AVG according to age group. RESULTS: The proportion of patients with a tunneled dialysis catheter (TDC) that was first placed for VA increased from 18.4% in 2008 to 52.3% in 2016. Incident hemodialysis patients with a TDC or AVG for the initial VA had significantly higher mortality risk than patients with an AVF, except for patients over 85 years, who showed no significant difference in all-cause mortality regardless of VA type. In the patency analysis on initial AV access, AVG had significantly poorer primary patency than AVF in all age groups. CONCLUSION: AVF had better patency than AVG in all age groups; however, the benefit of AVF attenuated in the older age groups. The mortality rate between AVF and AVG was not significantly different in patients over 85 years. Therefore, a “patient-first” approach should be emphasized over a “fistula-first” approach in AV access creation for incident hemodialysis patients older than 85 years.

Current treatment status and medical costs for hemodialysis vascular access based on analysis of the Korean Health Insurance Database

BACKGROUND/AIMS: The Republic of Korea is a country where the hemodialysis population is growing rapidly. It is believed that the numbers of treatments related to vascular access-related complications are also increasing. This study investigated the current status of treatment and medical expenses for vascular access in Korean patients on hemodialysis. METHODS: This was a descriptive observational study. We inspected the insurance claims of patients with chronic kidney disease who underwent hemodialysis between January 2008 and December 2016. We calculated descriptive statistics of the frequencies and medical expenses of procedures for vascular access. RESULTS: The national medical expenses for access-related treatment were 7.12 billion KRW (equivalent to 6.36 million USD) in 2008, and these expenses increased to 42.12 billion KRW (equivalent to 37.67 million USD) in 2016. The population of hemodialysis patients, the annual frequency of access-related procedures, and the total medical cost for access-related procedures increased by 1.6-, 2.6-, and 5.9-fold, respectively, over the past 9 years. The frequency and costs of access care increased as the number of patients on hemodialysis increased. The increase in vascular access-related costs has largely been driven by increased numbers of percutaneous angioplasty. CONCLUSIONS: The increasing proportion of medical costs for percutaneous angioplasty represents a challenge in the management of end-stage renal disease in Korea. It is essential to identify the clinical and physiological aspects as well as anatomical abnormalities before planning angioplasty. A timely surgical correction could be a viable option to control the rapid growth of access-related medical expenses.

The Epidemiology of Myasthenia Gravis in Korea

PURPOSE: An epidemiological study of myasthenia gravis (MG) has not been performed in Korea. The purpose of this study was to estimate the prevalence and incidence of MG in Korea. MATERIALS AND METHODS: Health Insurance Review and Assessment (HIRA) data from 2010 to 2014 were searched for MG codes as defined by the International Classification of Diseases, 10th revision. After identifying MG cases, we estimated the prevalence and annual incidence of MG based on the HIRA database and Korean population data. RESULTS: During the study period, 10138 MG cases were identified. The prevalence of MG was 10.42 cases per 100000 people in 2010 and this increased every year to 12.99 cases per 100000 people in 2014. The average incidence of MG between 2011 and 2014 was 0.69 cases per 100000 person-years. The prevalence and incidence were higher in the older (> or =50 years) age group than in the younger (<50 years) age group [prevalence: 9.26 vs. 19.24 per 100000, relative risk 2.077, 95% confidence interval (CI) 1.976-2.183, p<0.001; incidence: 0.47 vs. 1.18 per 100000, relative risk 2.490, 95% CI 2.006-3.091, p<0.001]. CONCLUSION: This study was the first nationwide population-based epidemiological study of MG in Korea. The prevalence and incidence of MG were consistent with those of previous studies. We found an increase in the prevalence of MG and a predominance of elderly MG patients.

Clinical outcome of percutaneous thrombectomy of dialysis access thrombosis by an interventional nephrologist

BACKGROUND: Traditionally, the treatment of a thrombosed dialysis access in hemodialysis patients in Korea has been primarily performed by vascular surgeons and interventional radiologists. The objective of this study was to evaluate the outcome of percutaneous thrombectomy procedures performed by an interventional nephrologist. METHODS: From October 2010 to May 2014, 75 consecutive percutaneous thrombectomies were performed on 42 patients treated with maintenance hemodialysis. All percutaneous thrombectomy procedures were performed by an interventional nephrologist in a single hospital in Jeju, Korea. The thrombosed arteriovenous graft and arteriovenous fistula were declotted by thromboaspiration mechanical thrombectomy or pharmacomechanical thrombolysis. Kaplan-Meier survival analysis was performed to analyze the primary and secondary patency after the initial successful thrombectomy. Success and complication rates were identified and compared with the recommendations of the Kidney Disease Dialysis Outcomes Quality Initiative (KDOQI) guideline. RESULTS: The overall clinical success rate was 89.3% (67/75). In the successful cases, the postintervention primary (unassisted) patency rates at 30 days, 90 days, and 180 days were 79.9%, 56.6%, and 25.6%, respectively. The secondary patency rates at 30 days, 90 days, and 180 days were 92.2%, 85.7%, and 83.7%, respectively. There were no major complications, and all complications were treated successfully during the procedure. CONCLUSION: The clinical success rate and primary patency rate at 3 months exceeded the recommendations of the KDOQI guideline, and were comparable to that of other reports. Percutaneous thrombectomy by an interventional nephrologist was safe and effective.

A Case Study of Ischemic Monomelic Neuropathy with Brachial-Cephalic Arteriovenous Fistula / 대한혈관외과학회지

Ischemic monomelic neuropathy (IMN) is recognized as a rare ischemic neuropathy caused by vascular access originating from the brachial artery leading to hemodialysis. IMN is characterized by acute painful muscle weakness shortly after surgery and neuronal axon loss without necrosis of adjacent tissues. In chronic diabetic patients with polyneuropathy, brachial vascular access surgeries include the risk of IMN, necessitating immediate surgical treatment such as banding or ligation. In the above case, we chose to close brachial-cephalic arteriovenous fistula for IMN with no short-term neurologic improvement, however, significant neurological and clinical improvement was observed in long-term follow-up. Here, we present a case of IMN with serial nerve conduction evaluations indicating the improved long-terms outcomes.

The Effect of Autotransfusion System in Minimally Invasive Total Knee Arthroplasty

PURPOSE: To evaluate the effect of autotransfusion system in minimally invasive total knee arthroplasty (TKA). MATERIALS AND METHODS: Seventy-one patients who underwent unilateral minimally invasive TKA between October 2009 and June 2010 were selected. The first group included 36 patients who received standard vacuum drainage and the second group, 35 patients who underwent autologous retransfusion drainage. In the first group, allogeneic blood transfusion was performed if the postoperative hemoglobin level was <7.0 g/dL or 7.0-8.0 g/dL with the presence of a medical complication and an anemic symptom. The second group received autotransfusion and allogeneic transfusion additionally according to the same criteria. Changes in the pre- and postoperative hemoglobin level, amount of auto- or allotransfusion, and frequency of allogeneic transfusion were assessed. RESULTS: Allogeneic transfusion was required in 13 patients (36.1%) in the first group and four patients (11.4%) in the second group. The mean allogeneic transfusion volume was significantly low in the second group compared to the first group (64.4 mL vs. 278.9 mL; p<0.05). The hemoglobin level on the 1st postoperative day compared to the preoperative level decreased by 22.6% in the first group and 11.7% in the second group. The postoperative hemoglobin level was higher in the second group (p<0.05). CONCLUSIONS: Minimally invasive unilateral TKA with an autotransfusion system can be beneficial in patients with no medical complications because of the decreased allogeneic transfusion.

Web-Based Integrated Public Healthcare Information System of Korea: Development and Performance / 대한의료정보학회지

OBJECTIVES: The Web-based integrated public healthcare information system (PHIS) of Korea was planned and developed from 2005 to 2010, and it is being used in 3,501 regional health organizations. This paper introduces and discusses development and performance of the system. METHODS: We reviewed and examined documents about the development process and performance of the newly integrated PHIS. The resources we analyzed the national plan for public healthcare, information strategy for PHIS, usage and performance reports of the system. RESULTS: The integrated PHIS included 19 functional business areas, 47 detailed health programs, and 48 inter-organizational tasks. The new PHIS improved the efficiency and effectiveness of the business process and inter-organizational business, and enhanced user satisfaction. Economic benefits were obtained from five categories: labor, health education and monitoring, clinical information management, administration and civil service, and system maintenance. The system was certified by a patent from the Korean Intellectual Property Office and accredited as an ISO 9001. It was also reviewed and received preliminary comments about its originality, advancement, and business applicability from the Patent Cooperation Treaty. It has been found to enhance the quality of policy decision-making about regional healthcare at the self-governing local government level. CONCLUSIONS: PHIS, a Web-based integrated system, has contributed to the improvement of regional healthcare services of Korea. However, when it comes to an appropriate evolution, the needs and changing environments of community-level healthcare service and IT infrastructure should be analyzed properly in advance.

Anti-NMDA Receptor Encephalitis Which Has Shown Clinical Symptoms of Schizophrenia

Encephalitis associated with antibodies to the N-methyl-D-aspartate (NMDA) receptor has variable clinical manifestations and treatment responses. Anti-NMDAR encephalitis is often associated with ovarian teratoma, but some cases without tumor have been reported. Here, we describe a patient who has shown psychiatric symptoms, memory impairment and been diagnosed as schizophrenia for one year and had anti-NMDA receptor antibody. The patient showed atypical clinical course compared to previous cases with anti-NMDA receptor encephalitis.

Effect of Combination Graft of Choukroun's Platelet-rich-fibrin with Silk Fibroin Powder in the Peri-implant Defects

A Case of Postprandial Hypotension in the Intensive Care Unit Treated With Acarbose

Postprandial hypotension (PPH) has not been described as a cause of hypotension after the return of spontaneous circulation (ROSC) in the intensive care unit (ICU). A 74 year old man underwent cardiopulmonary resuscitation (CPR) due to monomorphic ventricular tachycardia. After the ROSC, inotropic agents were not reduced but increased. PPH had occurred, according to the flow sheet, so a provocation test was performed. We noted hypotension but no serum hypoglycemia or tachycardia. The hypotension was diagnosed as PPH. We chose acarbose for treatment; thus, the inotropic agents were discontinued. This is the first case in which hypotension occurred in a patient recovering after CPR in the ICU and that the PPH was treated with acarbose. PPH should be considered and treated to manage hypotension in elderly patients in the ICU.

The Effect of ER:YAG Laser & ER,CR:YSGG Laser on the Tissue of the Inflammation-Induced Mouse

First Metatarsal Dorsal Close Wedge Osteotomy Combined with Medial Cuneiform Plantar Open Wedge Osteotomy for the Treatment of a Cavus Foot / 대한정형외과학회잡지

PURPOSE: We wanted to analyze the results of the 1st metatarsal dorsal close wedge osteotomy (MTDW) combined with medical cuneiform plantar open wedge (MCPOW) for treating forefoot deformity of a cavus foot. MATERIALS AND METHODS: We retrospectively analyzed 30 patients. Their mean age was 21.5 years (SD 10.6 years) and the average follow-up period was 2.3 years. Thirty-four cases of thirty patients were classified as group A, as classified by the 1st MTDW combined with the MCPOW, 16 feet (14 patients) were group B by the 1st MTDW or MCPOW, 12 feet (10 patients), and group C by triple arthrodesis, 6 feet (6 patients). We evaluated the ankle dorsiflexion, plantarflexion, heel alignment, and the Maryland foot score (MFS) preoperatively and the last follow-up, and we analyzed the radiologic Hibb, Meary, calcaneal pitch and tibiotalar angles. RESULTS: The ankle dorsiflexion (p=0.01), plantar flexion (p=0.03) and heel alignment (p=0.02) of group A were significantly improved more than that of groups B and C. The MFS of group A revealed better than group B and C (p=0.01). The Meary (p=0.01), Hibb (p=0.02) and calcaneal pitch angle (p=0.02) of group A were significantly improved more than that of groups B and C. CONCLUSION: 1st MTDW combined with MCPOW osteotomy that focuses at the apex of the deformity for correction of a cavus foot can obtain better clinical and radiological results than other surgical procedures.

Analysis of the Recurrence after Surgical Treatment of the Hemangioma in the Extremities / 대한골관절종양학회지

PURPOSE: To analyse the risk factors for recurrence of hemangiomas in extremities after surgical treatment and to compare with those of trunk. MATERIALS AND METHODS: 120 cases of hemangioma with surgical treatments from June 1998 to September 2009 were analysed. 53 cases with surgical treatment on trunk in the same period were set to be the control group. We analyze several factors: age, location, site, size, histologic types and correlation between recurrence and each risk factor using logistic regression analysis. RESULTS: Recurrence rate was 11.7% in extremities and 9.4% in trunk. There were no correlation between recurrence and age, site, size, histologic type. But, there was stastically significant correlation between recurrence rate and location, especially hand, forearm, feet in extremities and head and neck in trunk. CONCLUSION: Recurrence after surgical treatment of hemangioma is highly prevalent in anatomical location such as, hand, foot and forearm those are difficult to achieve complete resection because of close to neurovascular structures. Careful observation should be needed owing to incomplete resection can occurs recurrence.

The effect of hyaluronic acid on anti-inflammatory action in mouse

PURPOSE: The purpose of this study was not only to evaluate the relative mRNA expression of interleukin-1beta(IL-1beta), cyclooxygenase2 (COX-2) and prostaglandin E2 (PGE2) by RT-PCR analysis but to observe pattern of edema by light microscopic and electron microscope after topical apply of hyaluronic acid in inflammation-guided mouse. MATERIAL AND METHODS: Mice of this study were devided into 4 groups: Control group (no inflammation guided), Positive control (inflammation guided + vaselin apply), Protopic group (inflammation guided + protopic apply), Hyaluronic group (inflammation guided + hyaluronic acid apply). RESULTS: Hyaluronic group showed less expressions of IL-1beta, COX-2, PGE2 than those of positive control & protopic group. Hyaluronic group revealed a decreased inflammation than positive control & protopic group in Light Microscope. Hyaluronic group appeared decreased edema of ear compare to positive control & protopic group in Elecron Microscope. CONCLUSION: It was considered that hyaluronic acid has an antiinflammatory effect for intercepting the gene expression of cytokines related to inflammation.

The Serial Changes of the Serum Interleukin-6 and Interleukin-10 Concentrations in Patients who Received Therapeutic Hypothermia after Successful Cardiopulmonary Resuscitation

PURPOSE: We wanted to investigate the serial changes of the serum interleukin-6 (IL-6) and interleukin-10 (IL-10) concentrations, according to the neurological outcome, in patients who received therapeutic hypothermia after successful cardiopulmonary resuscitation. We also wanted to evaluate the usefulness of serum IL-6 and IL-10 as biochemical markers to predict the neurological outcome. METHODS: We prospectively evaluated 23 patients who received therapeutic hypothermia after successful cardiopulmonary resuscitation. Blood samples were taken at 0, 4, 12, 24 and 48 hours after the return of spontaneous circulation. We compared the IL-6 and IL-10 levels between the good (CPC 1 to 2) and poor (CPC 3 to 5) neurological outcome (NO) groups. RESULTS: The serum IL-6 level at 0 hr was significantly higher in the good NO group than that in the poor NO group. The periods of time that showed the greatest pattern of change between the good and poor NO groups were 4-12 hr for the IL-6 level and 0-4 hr for the IL-10 level. On the analysis of the ROC curve, the cut-off value for delta IL-10 (0-4 hr) was -5.4 pg/ml (AUC=0.827, sensitivity 80.0%, specificity 93.3%, p=0.032) and the cut-off value for delta IL-6 (4-12 hr) was 62.8 ng/ml (AUC=0.527, sensitivity 80.0%, specificity 34.0%, p=0.861, respectively). CONCLUSION: Our study suggests that the early delta IL-10 can be used as a neurological prognostic marker for patients who are undergoing therapeutic hypothermia after successful cardiopulmonary resuscitation.

Transtracheal High-frequency Jet Ventilation using a Two-lumen Central Venous Catheter for Laryngomicrosurgery: A case report / 대한마취과학회지

A 33 year old female patient was scheduled for laser laryngomicrosurgery to remove a polyp arising from the posterior one third of the vocal cord.A double lumen central venous catheter was inserted through the cricothyroid membrane and transtracheal high frequency jet ventilation was performed via the distal lumen.The proximal lumen was connected to a capnography monitor, enabling breath by breath monitoring of PETCO2.The surgery was successfully completed, and the patient was discharged from the post anesthesia care unit (PACU) three hours after surgery without any complication.