Risk of Clostridium difficile Infection with the Use of a Proton Pump Inhibitor for Stress Ulcer Prophylaxis in Critically Ill Patients

BACKGROUND/AIMS: Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are commonly prescribed for stress ulcer prophylaxis (SUP) in critically ill patients. Several studies have suggested that the use of PPIs is a potential risk factor for Clostridium difficile infection (CDI). We compared the incidences of CDI in the PPI group and H2RA group for SUP in critically ill patients. METHODS: From August 2005 to July 2012, the incidences of CDI were retrospectively analyzed in patients who were admitted directly to intensive care units and stayed for more than 3 days. SUP-related CDI was defined as a CDI diagnosed during the SUP period. Patient clinical data were analyzed to identify potential risk factors for SUP-related CDI. RESULTS: Of the 1,005 patients enrolled (444 patients received PPI and 561 received H2RA), 38 (3.8%) were diagnosed with SUP-related CDI. The incidence of SUP-related CDI was considerably higher in patients who received PPI than in those who received H2RA (6.7% vs 1.8%). PPI use for SUP (odds ratio [OR], 3.3; confidence interval [CI], 1.5 to 7.1; p=0.003) and diabetes mellitus (OR, 2.3; CI, 1.2 to 4.7; p=0.019) were independent risk factors for SUP-related CDI. CONCLUSIONS: PPI therapy is associated with a higher risk of SUP-related CDI than H2RA therapy in critically ill patients.

Hepatic Venous Pressure Gradient Predicts Long-Term Mortality in Patients with Decompensated Cirrhosis

PURPOSE: The present study aimed to investigate the role of hepatic venous pressure gradient (HVPG) for prediction of long-term mortality in patients with decompensated cirrhosis. MATERIALS AND METHODS: Clinical data from 97 non-critically-ill cirrhotic patients with HVPG measurements were retrospectively and consecutively collected between 2009 and 2012. Patients were classified according to clinical stages and presence of ascites. The prognostic accuracy of HVPG for death, survival curves, and hazard ratios were analyzed. RESULTS: During a median follow-up of 24 (interquartile range, 13-36) months, 22 patients (22.7%) died. The area under the receiver operating characteristics curves of HVPG for predicting 1-year, 2-year, and overall mortality were 0.801, 0.737, and 0.687, respectively (all p17 mm Hg, respectively (p=0.015). In the ascites group, the mortality rates at 1 and 2 years were 3.9% and 17.6% with HVPG 17 mm Hg, respectively (p=0.044). Regarding the risk factors for mortality, both HVPG and model for end-stage liver disease were positively related with long-term mortality in all patients. Particularly, for the patients with ascites, both prothrombin time and HVPG were independent risk factors for predicting poor outcomes. CONCLUSION: HVPG is useful for predicting the long-term mortality in patients with decompensated cirrhosis, especially in the presence of ascites.

IgG4-related Sclerosing Cholangitis Presented as a Mass in the Liver / 대한췌담도학회지

Autoimmune pancreatitis or IgG4-related sclerosing cholangitis often involves the liver. Most common lesion involving the liver is shown as mass or masses often referred as inflammatory pseudotumor. Inflammatory pseudotumor usually needs to be discriminated with malignancy. Here we report a case of IgG4-related sclerosing cholangitis with liver involvement presented as a mass. It was proven by biopsy and did not show any evidence of autoimmune pancreatitis. The mass infiltrated around the portal tract and portal vein thrombosis was also present.

Long-term Successful Treatment of Massive Distal Duodenal Variceal Bleeding with Balloon-occluded Retrograde Transvenous Obliteration / 대한소화기학회지

Duodenal variceal bleeding in patients with portal hypertension due to cirrhosis or other causes is uncommon. We report on a case of a 55-year-old male with an ectopic variceal rupture at the distal fourth part of the duodenum who presented with massive hematochezia and shock. Shortly after achievement of hemodynamic stability, due to the limitation of an endoscopic procedure, we initially attempted to find the bleeding focus by abdominal computed tomography, which showed tortuous duodenal varices that drained into the left gonadal vein. He was treated with first-line balloon-occluded retrograde transvenous obliteration (BRTO), resulting in a favorable long-term outcome without rebleeding three years later. This case suggests that BRTO may be a first-line therapeutic option for control of ruptured duodenal varices, especially at a distal location.

Splenic Hemorrhage with Hemoperitoneum Caused by a Snakebite / 대한구급학회지

In Asia, snakebites are estimated to affect 4 million people every year, and of these, 100,000 people are estimated to die. In Korea, snakebites occur frequently from the spring to the fall, but their importance is often overlooked. Fatal complications, including acute respiratory distress and acute kidney injury, can occur, and in some cases, severe hemorrhage results from coagulopathy. There have been only a few cases of snakebite-induced liver or intestinal bleeding, but to our knowledge, spontaneous bleeding from the spleen has not been previously reported. Here, we report the case of a 61-year-old male who visited the emergency room with abrupt abdominal pain due to hemoperitoneum associated with splenic hemorrhage after a snakebite.

A Case of Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes / 대한소화기학회지

Spontaneous bacterial peritonitis (SBP) is a life-threatening complication in patients with ascites caused by advanced liver disease. While gram negative bacteria, such as Escherichia coli and Klebsiella pneumonia are the common pathogens, Listeria monocytogenes has been recognized as a very rare pathogen. Empirical treatment with third generation cephalosporins does not provide adequate antibiotics coverage against L. monocytogenes. Diagnosis is often delayed as it requires confirmation from ascitic fluid culture. Herein, we describe the first case of SBP caused by L. monocytogenes in a patient with advanced alcoholic liver cirrhosis in Korea. Clinicians should be aware of the atypical pathogens, especially in patients with inadequate response to empirical antibiotics.

A Case of Primary Ovarian Lymphoma Presenting as a Rectal Submucosal Tumor

Primary ovarian lymphoma is a rare malignancy whose symptoms or signs are usually nonspecific. In this article, we report a very rare case initially presenting as a rectal submucosal-tumor-like lesion with a defecation disturbance caused by primary ovarian lymphoma with bilateral involvement. A 42-year-old woman visited chungnam national university hospital complaining of persistent defecation disturbance for 6 months. Colonoscopy demonstrated compression of the rectum by an extrinsic mass mimicking a rectal submucosal tumor. Magnetic resonance imaging detected bilateral ovarian tumors, 9.3 cm and 5.4 cm each in diameter, compressing the rectum without enlarged lymph nodes. The diagnosis was established following a bilateral adnexectomy and histological studies of the excised tissue. The tumor was classified as a diffuse large B-cell lymphoma. The patient was prescribed six cycles of standard CHOP (cyclophosphamide, hydroxydaunorubicin, vincristine, prednisolone) regimen and is presently on treatment.

In-hospital Cardiopulmonary Resuscitation: Incidence and Survival Rate according to the Utstein Template / 대한마취과학회지

BACKGROUND: Cardiopulmonary resuscitation (CPR) is one of the most important medical procedures. However, we could not find any survival rates from in-hospital cardiopulmonary resuscitation in Korea. The objective of this study was to report outcomes according to a Utstein template for in-hospital CPR and to use this report as basic material to enhance our CPR skills and outcome. METHODS: We reviewed all medical records of arrest cases in our hospital in 2001, which were coded as CPR, care for arrest, defibrillation/cardioversion, and Ambu. The data was summarized and analyzed in Utstein style. Most of the data was described in percentage, and the t-test was used to compare survival rate by sex. A P-value below 0.05 was considered significant. RESULTS: In 2001, 218 patients was resuscitated in our hospital and 53 patients (24.3%) survived after CPR. Their mean survival was 10 days. Twenty-seven victims died within the first 24 hours after resuscitation. Nobody was discharged alive from our hospital. The time interval from collapse to CPR was 1.7 minutes, to intubation, 5.62 minutes, to epinephrine injection 7.4 minutes and to defibrillation, 23 minutes. Glascow coma scale and cerebral performance category were less than 8 and 4 for a majority of patients. CONCLUSIONS: In our hospital, we had a low survival rate and quality of life. To improve outcome, we should prepare a better education program and more equipment and well-trained personnel for CPR.

Lipopolysaccharide/Interferon-gamma Induced Nitric Oxide Production in C6 Glioma Cells: Modulation by Dexamethasone

BACKGROUND: Glial cell-derived nitric oxide (NO), and its regulation has significant implications for central nervous system pathophysiology. The aim of the present study was to see the production of NO in lipopolysaccharide (LPS)/interferon-gamma (IFN-)-treated C6 glioma cells and the effect of dexamethasone on NO production and apoptosis of LPS/IFN--treated C6 glioma cells. METHODS: The apoptosis of LPS/IFN- treated C6 glioma cell was examined with terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) method and the production of NO in culture medium was measured. The expression of iNOS mRNA was examined by semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR). The effect of the N-monomethyl L-arginine (NMMA) and dexamethasone on the apoptosis and NO production was also examined. RESULTS: Inducible nitric oxide synthase (iNOS) mRNA and NO production were markedly increased in LPS/IFN--treated C6 glioma cells. The expression of iNOS mRNA arose at 3 hours, peaked at 12 hours, and declined 24 hours after LPS/IFN--treatment. Accumulation of NO derivatives in the culture media was increased at least upto 48 hours after LPS/IFN-. The induction of iNOS expression and NO production in LPS/IFN--treated C6 cells was correlated with apoptotic cell death judged by TUNEL staining. After treatment of NMMA, one of the NOS inhibitors, NO production and apoptosis were markedly decreased. Dexamehasone treatment suppressed the NO production by concentration depenedent manner. CONCLUSIONS: From the above results it is concluded that the LPS/IFN- induced apoptosis of C6 cells is mediated by iNOS-derived NO and NO production and apoptosis was suppressed by dexamethasone.

A Reliability and Validity Study of A Clinician-Administered PTSD Scale / 신경정신의학

OBJECTIVES: The purpose of this study was to examine the reliability and validity of A ClinicianAdministered PTSD Scale(CAPS). METHODS: CAPS was administered to 28 PTSD subjects, 30 non-PTSD subjects, and 36 normal subjects. Interrater reliability for the CAPS was established by interviewing 10 PTSD subjects. The interviews were conducted by 2 interviewers simultaneously. The authors adminstered to all the subjects Impact of Event Scale(IES), Beck Depression Inventory(BDI), State Trait Anxiety Inventory I, II (STAI-I, II) for measuring concurrent validity. RESULTS: The value of Cronbach's alpha and interrater agreement were .95 and .89, respectively. The CAPS was highly correlated with IES(r=.80), BDI(r=.70), STAI-II(r=.56). But the CAPS was not correlated with STAI-I(r=.20). The CAPS showed an overall agreement with clinical diagnosis of 82.1%. CONCLUSIONS: The CAPS shows a reasonable degree of reliability and validity. The CAPS could be a valuable tool to diagnose PTSD.

Hematological Differences between Roller Pump and Centrifugal Pump in Cardiopulmonary Bypass / 대한마취과학회지

BACKGROUND: Prolonged extracorporeal circulation entails tremendous threats of red cell lysis, severe bleeding problems due to platelet injury and activation, and endothelial damages by sequestered leukocytes. In consideration of these problems, a new centrifugal pump was developed and tested clinically to evaluate its effectiveness. METHODS: We compared the effects of a centrifugal pump with those of a roller pump on hematological responses during cardiopulmonary bypass (CPB) in 20 coronary artery bypass surgery patients. The patients were divided into two groups of 10 each. The studied parameters included WBC counts, platelet counts, plasma Hb and D-dimer. Blood samples were taken after sternotomy, at 60 min, 120 min and 180 min after CPB start, and at 2 hr after CPB stop. RESULTS: No differences between the groups were found in bypass time, aortic cross clamp time, extracorporeal circulation flow and hematocrit. The centrifugal pump group demonstrated less platelet depletion (p<0.05), hemolysis (plasma Hb, p<0.05) and fibrinolysis (D-dimer, p<0.05). These differences were CPB time dependent and became statistically significant after 120 min bypass. CONCLUSION: We conclude that roller pump still can be safely used for standard cardiac procedures with bypass time less than 120 minutes and the centrifugal pump has significant potential to be safely applied to CPB for long ypass time in order to avoid postperfusion syndrome.

A Comparison of Nalbuphine, Midazolam, and Buprenorphine As Premedication Agents / 대한마취과학회지

BACKGROUND: Premedication traditionally has several goals: reduction of anxiety,pain, and secretions and provision of basal or background sedation. The purpose of this study was to evaluate the efficacy and side effects of nalbuphine, midazolam and buprenorphine as premedication agents. METHODS: Two hundred thirty three patients who were scheduled to have an elective operation were included in this randomized, double-blind study. Nalbuphine 0.2 mg/kg, midazolam 0.05 mg/kg or buprenorphine 0.005 mg/kg was given intramuscularly with atropine(0.01 mg/kg) one hour before arriving at operating room. Sedation, level of anxiety, subjective rating on the effect of premedication and side effects including emesis and etc. were evaluated. RESULTS: The sedation score and the level of anxiety were not significantly different among three groups. The subjective rating on the effect of premedication was significantly higher in midazolam group than other two groups(p<0.05). The frequency of preoperative emesis was not significantly different among three group. The frequency of postoperative emesis was significantly higher in buprenorphine group than other two groups(p<0.05). Buprenorphine group showed dizziness and flushing more frequently than the other two groups(p<0.05). CONCLUSION: The present study demonstrated that, as a premedicant, midazolam increase the patient's satisfaction and decrease lessen the incidence of postoperative emesis and buprenorphine increase the incidence the side effects such as postoerative emesis, dizziness and flushing.