Acute Physiology and Chronic Health Evaluation II Score and Sequential Organ Failure Assessment Score as Predictors for Severe Trauma Patients in the Intensive Care Unit / 대한구급학회지

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). METHODS: We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. RESULTS: The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. CONCLUSIONS: In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

Acute Physiology and Chronic Health Evaluation II Score and Sequential Organ Failure Assessment Score as Predictors for Severe Trauma Patients in the Intensive Care Unit / 대한중환자의학회지

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). METHODS: We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. RESULTS: The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. CONCLUSIONS: In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

A Case of Tumor Necrosis Factor-alpha Inhibitors-induced Pustular Psoriasis

Anti-tumor necrosis factor (TNF)-alpha agents promise better disease control for the treatment of ankylosing spondylitis resistant to classical disease-modifying treatments. Etanercept, a recombinant human TNF receptor fusion protein, is used to treat a variety of TNF-alpha-mediated diseases by inhibiting the biological activity of TNF-alpha. We experienced a case of pustular psoriasis in a 32-year-old man during anti-TNF-alpha therapy with etanercept. He had a history of ankylosing spondylitis for 2 years. Two years after treatment of etanercept, erythematous pustules developed on his palms and soles. He had no previous history of pustular psoriasis. The skin lesion improved as the etanercept therapy was stopped, but pustular skin eruption recurred as adalimumab, a different TNF-alpha inhibitor, was administered to manage his ankylosing spondylitis. Several TNF-alpha inhibitors have different molecular structures, but these inhibitors might have a similar potency to induce pustular psoriasis from this case.

A Case of Hydroxychloroquine Induced Acute Generalized Exanthematous Pustulosis Confirmed by Accidental Oral Provocation

Acute generalized exanthematous pustulosis (AGEP) is a clinical reaction pattern that is principally drug induced and this is characterized by acute, nonfollicular sterile pustules on a background of edematous erythema. Hydroxychloroquine (HCQ) has been widely used to treat rheumatic and dermatologic diseases and HCQ has been reported to be an uncommon cause of AGEP. A 38-year-old woman with a 1-year history of dermatomyositis and polyarthralgia was treated with HCQ due to a lack of response to a previous medication. Three weeks after starting HCQ therapy, the pustular skin lesion developed and then this resolved after the HCQ was withdrawn and steroid treatment was started. A similar pustular eruption developed after HCQ was accidentally readministered.

Intramuscular Ganglion Cyst of the Gastrocnemius Muscle / 대한피부과학회지

Ganglion cysts are common lesions that are most often found around the hands and feet. Ganglia around the proximal tibiofibular joint usually occur within the synovial membrane, tendon sheath or peroneal nerve, but they rarely occur within muscle. We report here on a case of a 60-year-old man who complained of an asymptomatic deep seated mass in the proximal part of the right calf that he'd had for more than two years. On magnetic resonance imaging, the lesion appeared as a cystic lesion within the gastrocnemius muscle without communication with the knee joint. To the best of our knowledge, intramuscular ganglion cyst has never been reported in the Korean dermatologic literature.

A Case of Bullous Dermatomyositis Associated with Adenocarcinoma of the Lung / 대한피부과학회지

Dermatomyositis is a rare progressive autoimmune disease characterized by inflammatory myopathy that classically manifests several characteristic cutaneous findings, such as Gottron's papules, periorbital heliotrope rashes, poikiloderma, and reticular telangiectasis. However, there exist a wide variety of atypical cutaneous features in dermatomyositis. We describe a case of bullous DM with preceding adenocarcinoma of the lung in a 62-year old woman. To our knowledge, this is the 2nd report in the Korean literature of a bullous eruption in dermatomyositis.

A Case of Uncommon Acquired Dermal Melanocytosis / 대한피부과학회지

Dermal melanocytosis includes a variety of congenital and acquired conditions characterized by a sparse population of intradermal dendritic, variably pigmented, spindle-shaped melanocytes. Mongolian spot, Ota's and Ito's nevi are usually present at birth or appear in early childhood. But, several types of acquired dermal melanocytosis that usually appear in adults have been reported. A 47-year-old woman presented with asymptomatic, multiple, symmetric, brownish to black colored macules on the nasal ala, both palms and both feet dorsum that had been there for 10 years. Histopathologic findings showed that some scattered spindle-shaped cells containing melanin pigment in the upper dermis were positive for Fontana-Masson stain and these cells were positive for S-100 protein and MART-1.

A Case of Uncommon Acquired Dermal Melanocytosis / 대한피부과학회지

Dermal melanocytosis includes a variety of congenital and acquired conditions characterized by a sparse population of intradermal dendritic, variably pigmented, spindle-shaped melanocytes. Mongolian spot, Ota's and Ito's nevi are usually present at birth or appear in early childhood. But, several types of acquired dermal melanocytosis that usually appear in adults have been reported. A 47-year-old woman presented with asymptomatic, multiple, symmetric, brownish to black colored macules on the nasal ala, both palms and both feet dorsum that had been there for 10 years. Histopathologic findings showed that some scattered spindle-shaped cells containing melanin pigment in the upper dermis were positive for Fontana-Masson stain and these cells were positive for S-100 protein and MART-1.

A Pig to Canine Auxiliary Hepatic Xenotransplantation Model: Prevention of Hyperacute Rejection via Blocking the Kupffer Cells and Regulating the Complement Family

PURPOSE: We designed a pig to canine liver xenotransplantation model to study the diverse immunologic and hemodynamic consequences that follow xenotransplantation and hyperacute rejection. METHODS: The animals were divided into two groups: the cobra venom factor and Gadolinium chloride treatment group (CVF+Gd group) (3 cases) and the control group (3 cases). The donor pig's whole liver was harvested, and then the harvested pig's whole liver was transplanted into a dog after the dog underwent left hepatectomy. After reperfusion of the graft, blood samples were taken 20, 40 and 60 minutes after reperfusion, and the liver, lung and kidney tissues were taken 1 hour after reperfusion. RESULTS: In the control group, the grafts showed a patchy hypoperfused liver surface and it felt rubbery solid compared to the CVF+Gd group. The serum total protein, albumin, fibrinogen and platelets decreased abruptly and there were no significant differences between the two groups. The serum PT, PTT and FDP were increased in both groups and the CVF+Gd group showed a more obtuse slope than the control group. We could not find any intravascular pathologic changes on the microscopic findings of the graft. Only scant intravascular fibrin deposition was found. Hepatocellular vacuolization and sinusoidal dilatation were also found. There were patches of necrosis without any zonal distribution, intrasinusoidal neutrophil sequestration and interstitial hemorrhage. These findings were milder in the CVF+Gd group. CONCLUSION: The pig to canine partial auxiliary liver xenotransplantation model is feasible and it is a good model before starting to perform pig to primate liver xenotransplantation. In the CVF+Gd group, pathologic findings like patch hepatocyte necrosis etc. were less severe. As there were no corresponding vascular pathologic findings, these findings are not the direct effect of CVF and gadolinium treatment, and so other factors like Ischemia- reperfusion injury should be considered.

Differences in Bacterial Translocation Across the Large andSmall Bowel Walls after Ischemia and Reperfusion Injury

PURPOSE: Bacterial translocation is a major problem after ischemic bowel injuries such as mesenteric vessel obstruction or bowel strangulation. In this study, we investigated the differential character of bacterial translocation from the large and small bowel using Escherichia coli labeled with technetium 99m (99mTc-E.coli). METHOD: Male Sprague-Dawley rats weighing 200~300 g underwent laparotomy. The superior mesenteric artery and marginal arteries of the proximal jejunum and distal colon were occluded for 30 minutes and then re-perfused for 4 hours. A suspension containing 99mTc-E.coli was injected into the lumen of the proximal colon (group 1) and distal ileum (group 2). In the sham operation group (groups 3, 4), 99mTc-E.coli was also injected in the same manner without induction of ischemia and reperfusion injury. Two hours after E. coli injection, blood, mesenteric lymph nodes (MLN), liver, spleen, and lung were collected for quantitative analysis of radioactivity. Large and small bowel specimens were also harvested for microscopic examination. Student's t-test was used for statistical analysis. P< or =0.05 was considered statistically significant. RESULT: Compared with group 1, group 2 showed a significant increase in 99mTc-E.coli translocation from the lumen to all organs investigated, except with regard to MLN. The sham operation group (groups 3, 4) showed scanty bacterial translocation. The mucosal epithelial cell layers of both groups (groups 1, 2) were comparatively intact. CONCLUSION: The 99mTc-E.coli method was found to be suitable for studies of bacterial translocation from the small and large bowels. Bacterial translocation is much more likely to occur across the small bowel wall than across the large bowel wall.

The Role of HMGB1 and the Effect of Ethyl Pyruvate on Ischemia and Reperfusion Injury of Rat Kidney / 대한이식학회지

PURPOSE: High mobility group box-1 (HMGB1) was identified as a DNA binding protein that functions as a co-factor for proper transcriptional regulation in somatic cells. Extra- cellular HMGB1 acts as a potent pro-inflammatory cytokine that contributes to the pathogenesis of diverse inflammatory and infectious disorders. Ethyl pyruvate (EP), a stable aliphatic ester derived from pyruvic acid is the first described pharmacological inhibitor for HMGB1 secretion. We designed this study to identify the change of HMGB1 expression in rat kidney tissues of ischemia reperfusion injury and the effect of EP on the expression of HMGB1. METHODS: Sprague-Dawley rats (200~300 g) were subjected to 40 minutes of renal warm ischemia. The animals were divided into three groups: sham group without warm ischemia, the EP group (EP given before ischemia), and the ischemic control group. Kidneys were harvested and serum creatinine, IL-1 and IL-6 were measured at 6hours, 1 day, 3 days and 5 days after reperfusion. Immunohistochemical stain of HMGB-1 was done. RESULTS: Serum creatinine and IL-1 level were elevated in ischemic control group and EP injection group. In EP injection group, serum creatinine and IL-1 level were lower than the ischemic control group. In the rat 40minutes ischemia reperfusion model, HMGB1 expression was increased at 6 hours after reperfusion. which was decreased gradually at 1 day, 3 days, and 5 days after reperfusion. HMGB1 expression was more distinct at outer medullary area. intraperitoneal EP injection has no effect on the expression of HMGB1. CONCLUSION: From these results, we deduced a conclusion that the preventive effect of EP on the rat kidney ischemia reperfusion injury is not by the decreased expression of HMGB1 but by the prevention of the release of the HMGB1.

Effect of Pre-reperfusion Intravascular Rinsing in a Canine Acute Limb Ischemia Model

PURPOSE: Reperfusion after acute ischemia is associated with high rates of morbidity and mortality due to the ischemic injury itself and the following myonephropathic metabolic syndrome, in spite of complete revascularization. Therefore, we attempted to verify the difference in reperfusion injury with or without pre-reperfusion intravascular rinsing in a canine acute limb ischemia model. METHOD: We used five female mongrel dogs. Complete acute hind limb ischemia was induced by infrarenal aortic and bilateral femoral artery clamping for 8 hours. We divided the dogs into two groups. In the rinse group (RG): three dogs were declamped with intravascular rinsing, and in the non-rinse group (non-RG): two dogs were declamped without any additional procedures. The perfusate solution was infused through both femoral arteries and was drained via both femoral veins. Serial blood samples were obtained four times. The gastrocnemius muscles were biopsied 3 days after reperfusion. RESULT: The results at preischemia, just before, 30 min, and 3 days after reperfusion were as follows: Creatine phosphokinase (CK) was 204, 1031, 1373, and 443 (IU/L) in the RG and 159, 3855, 6345, and 5455 (IU/L) in the non-RG. Lactate dehydrogenase (LDH) was 177, 248, 173, and 232 (IU/L) in the RG and 95, 508, 638, and 878 (IU/L) in the non-RG. Aspartate transaminase (AST) was 23, 50, 43, and 42 (IU/L) in the RG and 19, 118, 154, and 399 (IU/L) in the non-RG. Potassium (K) was 5.7, 5.8, 5.4, and 4.0 (mEq/L) in the RG and 5.4, 5.5, 5.7, and 5.3 (mEq/L) in the non-RG. Muscle injury in the non-RG was more severe than in the RG. CONCLUSION: There was a considerable difference between the groups in the CK, LDH and AST levels and the muscle biopsy findings. The results showed that the intravascular rinsing provided beneficial effects in reperfusion injury acute limb ischemia.

Plexiform Neurofibroma Involving the Ascending Colon and its Mesentery in a Child

The neurofibromatosis type 1 (NF-1) is a rare hereditary disease of autosomal dominant fashion with the overall incidence of one in 3,000. It is characterized by cafe-au-lait spots of skin, multiple cutaneous neurofibromas and a broad spectrum of clinical finding. Plexiform neurofibroma is a frequent complication of NF-1 but symptomatic involvement of the gastrointestinal tract in children with NF-1 is rare. It may present with complications such as obstruction, dysfunction, pain and hemorrhage. We report that a 13-year-old female diagnosed with NF-1 at the age of 10 years had abdominal pain and showed huge plexiform neurofibromas of right mesocolon in abdominal cavity. She also presented with multiple cafe-au-lait spots and axillary freckling. She was performed a right hemicolectomy with complete excision of the mass and had an uneventful course.

A Case of Persistent Primary Hyperparathyroidism Caused by Parathyroid Carcinoma Recurred Along Esophagus / 대한내분비외과학회지

Primary hyperparathyroidism is most commonly caused by an adenoma but rarely by carcinoma of the parathyroid gland. The common clinical manifestations were bone pain, recurrent urinary stone and asymptomatic. Parathyroid carcinoma is different from the parathyroid adenoma in that the invasion to the surrounding tissue or metastasis to the regional lymph nodes and persistent hyperparathyroidism are common in parathyroid carcinoma. It is important that radical en-bloc resection of parathyroidal mass including the lobe of the thyroid that is on the same side and post op follow up is important as well. There is the need of radical surgery even in recurrence of metastatic parathyroid carcinoma for improving hypercalcemia. We experienced a 50-year-old man with primary hyperparathyroidism caused by a parathyroid carcinoma in the left lower parathyroid which was confirmed by histopathologic findings. He was cured by using en-bloc resection of the parathyroid including the left lobe of the thyroid and a left side modifed radical neck dissection. But after 2 months hypercalcemia occurred again and therefore examination with computed tomography, endoscopic ultrasonography and esophagogram revealed a metastasis to the upper and mid esophagus. We opened the chest cavity and resected the surrounding mass of the esophagus. the mass was confirmed to be metastatic tissue from parathyroid carcinoma by histopathologic finding. therefore we report this case.

A Clinical Review of Initial 20 Cases of a Laparoscopic Adrenalectomy / 대한내분비외과학회지

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors since it has many advantages; a more rapid and comfortable recovery, shorted hospitalization, and fewer complications. The purpose of this study was to report the initial 4 years experiences of LA and describe the unusual findings encountered during the operations. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Several techniques of LA have been described already. We prefer the transabdominal approach in the lateral decubitus position using 3 or 4 trocars. RESULTS: 20 patients had all unilateral tumor. The pathological findings were 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. 18 cases of 20 patients were successfully operated by laparoscopic procedure and 2 cases were converted to open adrenalectomy. The reasons of conversion were sudden cardiac arrest due to unknown origin and intraoperative bleeding due to periadrenal massive fat. During the laparoscopic operation, 2 patients showed abnormal EKG findings. The pathologies of those patients were non-catecholamine-secreting cortical adenomas. After operation, they have been completely normal in EKG. The average operating time for the complete laparoscopic adrenalectomies was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There was no postoperative complication and no operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: The LA is relatively fast and safe method and is accepted as the preferred procedure for the adrenal tumors but it should be well prepared perioperatively. Surgeons and anesthesiologists should be aware of those possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.