The Relationship between the Left Atrial Volume and the Maximum P-wave and P-wave Dispersion in Patients with Congestive Heart Failure

PURPOSE: A maximum P-wave duration (Pmax) of > or = 110msec and a P-wave dispersion (PWD) > or = 40msec are accepted indicators of a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse, respectively. The left atrial (LA) volume has been reported to be strongly associated with a systolic and diastolic dysfunction and is considered to be an index of atrial remodeling. We aimed to investigate the relationship between LA volume and Pmax or PWD in patients with congestive heart failure (CHF). PATIENTS AND METHODS: Sixty-one patients with CHF were enrolled in this study. The study population was classified into four groups: two groups were divided according to the Pmax (> or = 110msec or or = 40msec or or = 110ms or a PWD > or = 40ms and those with a Pmax < 110ms or a PWD < 40ms. The LAVi was independently associated with a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse. The LAVi can be used to identify patients with a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse with reasonably good accuracy. CONCLUSION: We concluded that a disturbance in interatrial conduction and an inhomogenous propagation of the sinus impulse in patients with CHF is associated with an increase in the LA volume and a deleterious systolic and diastolic dysfunction.

Change of the P wave duration and P wave dispersion according to treatment strategy in patients with a acute myocardial infarction / 대한내과학회지

BACKGROUND: P wave dispersion (PWD) and P wave duration have been used to evaluate the discontinuous propagation of sinus impulse and the prolongation of atrial conduction time, respectively. This study was conducted to compare the change of the maximal P wave duration (Pmax) and PWD according to the treatment strategy used in patients with an acute myocardial infarction (AMI). METHODS: We retrospectively evaluated 86 patients that experienced an AMI. Patients were classified into three groups according to the treatment strategy: primary percutaneous coronary intervention (PCI), thrombolytic therapy, and delayed PCI. ECGs that were obtained from all patients on admission and on the second day were analyzed. The Pmax and minimum P wave duration (Pmin) were measured from a 12-lead ECG. The PWD was calculated as the difference between the Pmax and Pmin. RESULT: There was no significant difference in the age, gender, medication, coronary risk factor, ejection fraction, left atrial diameter, basal Pmax and PWD among the groups. However, there were significant differences in P max and PWD between the primary PCI group and the other groups on the second day after hospital admission. In the thrombolytic therapy and delayed PCI groups, the PWD was significantly lower in the patients with a patent infarct-related artery (IRA) than in patients without a patent IRA on the second day after hospital admission. CONCLUSIONS: These findings suggest that a primary PCI decreased the Pmax and PWD more than thrombolytic therapy or a delayed PCI.

Syndrome of Inappropriate Secretion of Antidiuretic Hormone Following Adjuvant Chemotherapy with Cisplatin plus Paclitaxel in Non-Small Cell Lung Cancer Patient / 결핵및호흡기질환

We report a case of pulmonary adenocarcinoma complicated by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) following adjuvant chemotherapy. A 51-year-old woman with stage IIIA adenocarcinoma received left lower lobe lobectomy in July, 2006. And then combination chemotherapy with paclitaxel and cisplatin was given to the patient. In five days after completion of second cycle of the chemotherapy, she visited emergency room because of general weakness and seizure. Her brain MRI was shown to be no evidence of brain metastasis. Serum sodium, urine and plasma osmolarities were 117mEq/L, 589 and 244mOsm/kg, respectively. She was improved with fluid restriction. Although occurrence of SIADH following chemotherapy is rare, physician should give an attention the potential for development of SIADH in the course of chemotherapyin non-small cell lung cancer patient.

Totally Laparoscopic Anatomic Liver Resection

PURPOSE: There have been several recent reports of laparoscopy-assisted procedure for limited, or a laparoscopic, resections of small lesion of the liver. However, there are few reports on total laparoscopic surgery in anatomic resections, which is due to high level of skill required for the procedure and the risk of an air embolism. The aim of this study was to determine the safety of total laparoscopic surgery in anatomic liver resections during our early experiences. METHODS: The 6 patients included in this study were all treated with a totally laparoscopic anatomic resection of the liver at Ewha Womans University, Mokdong Hospital between September 2002 and January 2003. All 6 cases were diagnosed with an intrahepatic duct (IHD) stone, with stricture and/or common bile duct (CBD) stones. Of these 6 cases, 2 underwent a totally laparoscopic left lateral segmentectomy of the liver. In the remaining 4 cases, totally laparoscopic left lobectomies and CBD explorations, with T-tube insertion, were performed. In all cases, 4 trocars were used. During the operation, the intraperitoneal pressure of the pneumoperitoneum was maintained between 8 and 12 mmHg using CO2. The instruments used included Ligasure(R), Autosonix(R), 0 degrees and 30 degrees camera, fan retractor, Endo(vascular)- GIA 30 , and a large LapBag(R). All cases were managed in the supine position, with 15 degrees of left tilting. The specimen were extracted through a 4 to 5 cm extension of the upper trocar site. The T-tube exited through a 12mm site in the right upper port, and a drain was inserted into the sub-hepatic area. RESULTS: The patients comprised of 5 women and a man, with a mean age of 50.2 years old. The mean operative time was 469.2 (+/-141.4) minutes. In one case, 2 pints of packed red blood cells had to be transfused during the operation. The mean time to diet was 3.3 days. The mean postoperaitve hospital stay was 11.7 days. There was no conversion to open surgery, morbidity or mortality. The mean extensional incision size for the extraction of the specimen was 4.3 cm. CONCLUSION: In the anatomic resection of the liver, especially for benign liver disease, a total laparoscopic resection could be another relatively safe option for selected cases.

Application of Laparoscopic Cholecystectomy in Patients with Previous Abdominal Surgery

PURPOSE: Previous abdominal surgery has been one of the relative contraindications of laparoscopic cholecystectomy (LC). Recently, the accumulation of experience and the development of skill have widened the indications of LC. The aim of this study was to elucidate the effectiveness and safety of LC in patients with a history of previous abdominal surgery. METHODS: The medical records of patients treated with LC at Ewha Womans University, Mokdong Hospital from March 1997 to December 2000 were reviewed. Operative results were compared between the previous abdominal-surgery group (Group A) and the non-operative history group (Group B). Group A consisted of 99 cases: 91 cases with one operation history, 7 with two, and 1 with three. Group B consisted of 99 cases randomly selected out of 437 cases without a history of previous abdominal surgery in the same period. We compared the mean operative time, conversion rate, rate of drain insertion, starting day of postoperative diet and hospital stay. RESULTS: In groups A and B, the mean ages were 52 and 51.4 years olds, the male to female ratios 1 : 2.7 and 1 : 1.08, and the mean operative times 88.8 and 91.1minutes (P=0.740), respectively. The conversion rates were 3% and the time of postoperative diet was 2.3 days in both groups. The rates of drain insertion were 21% and 15% (P=0.372), the hospital stay was 5.4 days and 5.6 days (P=0.769), the morbidity was 4% and 1% (P=0.371), respectively. There were no cases of mortality in either group. CONCLUSION: The operative results of the patients with a history of previous abdominal surgery were similar to those of the patients without an operative history. Laparoscopic cholecystectomy was an effective and safe method in the patients with a history of previous abdominal surgery.

Central Segmental Resection of Pancreas for Cystic Neoplasms in Head and Neck of Pancreas

PURPOSE: Pancreatic cystic neoplasm is a rare disease. It should be resected regardless of the presence of symptoms due to the possibility of malignancy. Standard pancreatic resection such as PPPD or distal pancreatectomy accompanies the loss of a significant amount of normal pancreatic parenchyma and may cause an impairment of normal pancreatic functions. On the contrary, pancreatic enucleation is known to have risks of pancreactic fistula or abscess. The aim of this study is to elucidate whether segmental resection of the pancreas is a safe and effective treatment in cystic neoplasms in the head and neck of the pancreas. METHODS: We reviewed the medical records of seven patients treated with central segmental resection of the pancreas for cystadenoma at Ewha Womans University Mokdong Hospital from December 2000 to April 2001. All lesions were located at the head and neck of the pancreas. A cephalic stump was sutured for closure of minute pancreatic ductal leakage and hemostasis, and the distal stump was anastomosed with a Roux-en-Y jejunal loop. Postoperative pancreatic functions, complications, and follow up results were analysed. RESULTS: The mean age of the patients was 48.14 (+/-9.55) years old. The pathological diagnoses were 4 cases of serous cystadenoma and 3 cases of mucinous cystadenoma. The mean size was 2.03 (+/-0.7) cm. The average operating time was 299.3 (+/-44.2) minutes. There were two cases of minor complications that were mild pancreatic fistulas without symptoms. There was no operative mortality, impairment of pancreatic function, or recurrence. The mean postoperative hospital stay was 23.6 days. CONCLUSION: Segmental resection of the pancreas can be a rational therapeutic option for cystic neoplasms in the head and neck of the pancreas in terms of the potential benefit of preserving pancreatic function.

Perigastric Devascularization with or without Fundectomy for Gastric Variceal Bleeding

PURPOSE: Catastrophic bleeding of the gastric varices has been considered a life threatening emergency. Sclerotherapy cannot easily control the bleeding, and there is a high risk of rebleeding despite successful intervention. Surgery is often necessary to save the life. The purpose of this study was to elucidate the role of surgery and analyze the factors determining operative mortality in gastric variceal bleeding. METHODS: A retrospective study was performed of 30 patients who underwent operation for gastric variceal bleeding with portal hypertension at Ewha Womans University Mok-Dong Hospital from Jul. 1994 to Feb. 2001. Among them, 23 patients received perigastric devascularization with fundectomy and the remainder received perigastric devascularization alone. RESULTS: There was one case of recurrent bleeding from esophageal varix at 8 months postoperative. This was controlled with sclerotherapy. The overall operative mortality rate was 30.0%. Preoperative hepatic functional reserve was a significant factor. The mortality rate was 0% (0/5) in Child-Pugh group A, 27.8% (5/18) in group B, and 57.1% (4/7) in group C (p<0.05). The preoperative success of intervention influenced postoperative outcomes. There was no mortality in the successfully controlled group (0/5). In the failure group, 5 of 7 patients expired (p<0.05). Preoperative transfusion amount was also a significant factor in determining survival. There was 15.8% (3/19) mortality rate in patients trans fused less than 10 units, and a 54.5% (6/11)rate in those receiving more than 10 units (p<0.05). CONCLUSION: This operative approach was effective for saving lives from an otherwise uniformly fatal disease. The rebleeding rate at the follow-up period was low. Proper selection of patients and an early surgical decision could lower the operative mortality.

The Relationship between Microvessel Count and the Expression of Vascular Endothelial Growth Factor, p53, and K-ras in Non-Small Cell Lung Cancer

Using immunohistochemical staining, we studied the relationship between the microvessel count (MC) and the expression of K-ras, mutant p53 protein, and vascular endothelial growth factor (VEGF) in 61 surgically resected non-small cell lung cancers (NSCLC) (42 squamous cell carcinoma, 14 adenocarcinoma, 2 large cell carcinoma, 2 adenosquamous carcinoma, and 1 mucoepidermoid carcinoma). MC of the tumors with lymph node (LN) metastasis was significantly higher than that of tumors without LN metastasis (66.1+/-23.1 vs. 33.8+/-13.1, p<0.05). VEGF was positive in 54 patients (88.5%). MC was 58.1+/-25.2 (mean+/-S.D.) in a x200 field, and it was significantly higher in VEGF(+) tumors than in VEGF(-) tumors (61.4+/-23.7 vs. 32.9+/-23.8, p<0.05). VEGF expression was higher in K-ras-positive or mutant p53-positive tumors than in negative tumors (p<0.05). MC was significantly higher in K-ras(+) tumors than in K-ras(-) tumors, although it did not differ according to the level of mutant p53 protein expression. Survival did not differ with VEGF, mutant p53, or K-ras expression, or the level of MC. In conclusion, there is a flow of molecular alterations from K-ras and p53, to VEGF expression, leading to angiogenesis and ultimately lymph node metastasis. Correlations between variables in close approximation and the lack of prognostic significance of individual molecular alterations suggest that tumorigenesis and metastasis are multifactorial processes.

Antioxidants in Serum and Induced Sputum of COPD Patients / 결핵

BACKGROUND: Although an oxidants and antioxidants imbalane has been considered in the pathogenesis of chronic obstructive pulmonary disease (COPD), there is a paucity of reports focussing on the smoking-induced changes of oxidants and antioxidants in COPD. METHOD: The concentration of antioxidants (ascorbic acid, uric acid, retinol, and α- &γ-tocopherol) was measured in the serum and induced sputum of 30 healthy controls and 34 stable COPD patients using high performance liquid chromatography (HPLC). The inhibition of lipid peroxidation as an index of antioxidant capacity was measured in the serum by a TBA assay. RESULTS: The serum concentration of ascorbic acid, α-tocopherol, and retinol were significantly lower in the patients with COPD than in healthy controls (484.8±473.3 vs 1497.8±819.2 pmol/L, p<0.001, 48.38±17.34 vs 73.96±26.29 pmol/L, p<0.001, and 9.51±8.33 vs 15.01±5.88 pmol/L, p<0.05, respectively, mean±SD). However, there were little differences in the ascorbic acid and uric acid concentrations in the induced sputum between the COPD patients and the controls. The induced sputum to serum ratio of ascorbic acid was significantly higher in COPD patients compared with healthy control (0.375 vs 0.085, p<0.05). In the normal controls, the serum ascorbic acid concentration was lower in smokers than in nonsmokers (1073±536 vs 1757±845 pmol/L, p<0.05), but the level was still higher than that of the COPD patients (p<0.05). The serum retinol levels were correlated with FEV1 in COPD patients (r=0.58, p<0.05). The products of lipid peroxidation were increased in normal smokers and COPD compared with normal nonsmokers (115.56±19.93 and 120.02±24.56 vs 91.87±20.71 µmol/µmol Pi of liposome, p<0.05). CONCLUSION: Cigarette smoking may induce the depletion of serum antioxidants and this depletion of antioxidants is suggested to play a role in the pathogenesis of COPD.

Recurrent Hemoptysis after Bronchial Artery Embolization / 결핵

BACKGROUND: To observe the immediate and long-term results of bronchial artery embolization(BAE) for hemoptysis and the factors influencing the recurrences. METHODS: This study involved 75 patients with massive, or moderate and recurrent hemoptysis, who underwent bronchial artery embolization(BAE) from 1994 to 1999. The underlying diseases included pulmonary tuberculosis in 35, bronchiectasis in 22, aspergilloma in 12, lung cancer in 3, and 3 with other diseases. RESULTS: After BAE, bleeding was controlled immediately in 61 patients(82.7%). One patient died of another medical problem, 3 patients were referred to surgery and 5 patients could not be followed-up. In the remaining 66 patients who were followed for more than one-year after BAE, 37(56.1%) patients had another hemorrhage(26 hemoptysis, 11 minor hemosputa). Among the recurred 37 subjects, 19(51.4%) experienced hemorrhage within 1 month after BAE, 31(83.8%) within 1 year, and 36(94.1%) within 3 years. The underlying lung diseases, the amount of bleeding and the extent of the involved lungs were factors affecting the outcome, especially blood loss >500cc was an important factor affecting the recurrence. BAE for two cases with lung malignancy was ineffective. Long-term control of bleeding (3-year cumulative non-recurrence) was achieved in 30 subjects(45.5%). CONCLUSION: Bronchial artery embolization(BAE) is effective as an initial treatment for moderate to massive hemoptysis. Because most of the recurrences occurred within 3 years, it is important to follow-up such patients for at least 3 years after BAE and the most significant factor affecting the prognosis was amount of blood loss.

Simultaneous elevation of serum parathyroid hormone(PTH) and parathyroid hormone-related protein(PTHrP) in a case of lung cancer with hypercalcemia / 결핵

The parathyroid hormone related protein(PTHrP) is the most common causative peptide of humoral hypercalcemia of malignancy. In contrast, the serum level of parathyroid hormone(PTH) is low to undetectable in the majority of patients with malignancy associated hypercalcemia. Few cases exist in which the production and secretion of PTH by malignant nonparathyroid tumors have been authenticated. To our knowledge, there is very rare case in which a nonparathyroid tumor expressed simultaneously both the PTH and PTHrP. We report a case of squamous cell carcinoma of the lung with hypercalcemia which presented with simultaneous elevation of serum PTH and PTHrP. Severe hypercalcemia (serum calcium, 7.5mEq/L) was found in a 65-year-old man who had a squamous cell carcinoma of the lung without any body metastasis and detectable parathyroid abnormalities on isotope scintigraphy. The serum level of intact parathyroid hormone (PTH) concentration was markedly elevated as measured in two site radioimmunoreactive PTH assays (intact PTH 150pg/mL ; normal 9~55). The serum level of a PTHrP was also increased as measured in C-terminal region specific radioimmunoassay (PTHrP 99.1 pmol/L ; normal 13.8~55.3). There are no evidences of coincidental primary hyperparathyroidism in parathyroid MIBI scan and other imaging studies including neck ultrasonography and computed tomography. These results suggest that simultaneous elevation of serum PTH and PTHrP in this patient can be caused by production of both PTHrP and PTH in other nonparathyroid lesions such as squamous cell carcinoma.