Maximally Tolerable Versus Low Doses of Propranolol in the Prevention of Esophageal Variceal Rebleeding / 대한내과학회지

BACKGROUND/AIMS: Beta-blockers have been used extensively to prevent esophageal variceal (EV) rebleeding in patients with liver cirrhosis. The aim of this study was to compare the rate of EV rebleeding according to the dose of beta-blocker, between maximally tolerable dose (MTD) and low dose (LD) groups. METHODS: A total of 95 patients, who were treated with emergent EV ligation for acute EV bleeding and have since then taken propranolol for 1 month or longer, were enrolled. Forty-nine patients took propranolol at the MTD (154.7 +/- 10.1 mg/day), and 46 patients took propranolol at the LD (39.1 +/- 5.8 mg/day). The end point was occurrence of EV rebleeding. RESULTS: The MTD and LD groups were well matched for age, sex, etiologies for cirrhosis, presence of ascites or encephalopathy, serum creatinine levels, and follow-up periods. The MTD group showed relatively lower Child-Pugh scores, mode for end stage liver disease (MELD) scores, and serum bilirubin, as well as shorter prothrombin time, but a higher dose reduction rate, as compared with the LD group. The rate of EV rebleeding was lower in the MTD group than the LD group (38.8% vs. 67.4%, p = 0.007). In the univariate analysis, the risk factors for EV rebleeding were Child-Pugh classification and dose of propranolol. However, the dose of propranolol was only a significant risk factor for EV rebleeding according to the multivariate analysis. CONCLUSIONS: The effect of propranolol on the prevention of EV rebleeding was superior in the MTD group than in the LD group.

Effect of Entecavir in Patients Who Lack Lamivudine Resistance after Lamivudine Treatment for Chronic Hepatitis B / 대한내과학회지

BACKGROUND/AIMS: The effect of entecavir (ETV) in treatment-naive chronic hepatitis B (CHB) is well established. This study aimed to assess the efficacy of ETV treatment at 0.5 mg/day in ETV-switch and ETV-retreatment groups of CHB patients without lamivudine (LMV)-resistance from LMV monotherapy. METHODS: Study subjects included 350 CHB patients who had been treated with 0.5 mg/day of ETV for at least 6 months. Patients were divided into two groups: an LMV-naive group (n = 263) and an LMV-experienced group (n = 87). The LMV-experienced group was further subdivided into an ETV-switch group (n = 43) and an ETV-retreatment group (n = 44) defined by the period between stopping LMV and restarting ETV. RESULTS: There were no significant differences in mean age, sex ratio, prevalence of liver cirrhosis and hepatitis B e antigen (HBeAg) positivity between the LMV-naive and -experienced groups. However, the LMV-naive group had higher aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels and a shorter ETV treatment duration than the LMV-experienced group. There were also distributional differences in the hepatitis B virus (HBV) DNA levels of LMV-naive and -experienced patients prior to ETV treatment. After ETV treatment, there were no significant differences between the two groups in the rates of undetectable HBV DNA at 6, 12 and 18 months; HBeAg loss and seroconversion; normalization of ALT; virologic breakthrough; and ETV-genotypic resistance. Lastly, the effect of ETV did not differ between the ETV-switch and -retreatment groups. CONCLUSIONS: The effect of ETV in the LMV-experienced group without LMV-resistance did not differ from that in the LMV-naive group. Furthermore, there was no difference in the effect of ETV between the ETV-switch and -retreatment groups.

Transient exposure to hydrogen peroxide inhibits the ubiquitination of phosphorylated IkappaBalpha in TNFalpha-stimulated HEK293 cells

During ischemia-reperfusion injury, brief pre-exposure to oxidative stress renders organs resistant to subsequent severe damage. NF-kappaB is a transcription factor that is involved in reperfusion-induced inflammatory and immune responses. The activity of NF-kappaB has been shown to be modulated by oxidative stress in various cell types through different pathways. We studied the effect of pre-exposure to oxidative stress on subsequent NF-kappaB activation in TNFalpha-stimulated HEK293 cells. The cells were transiently exposed to 0.5 mM H2O2 for 20 min, prior to stimulation with TNFalpha, and the subsequent expression of NF-kappaB-dependent genes and the levels of NF-kappaB signaling molecules were measured. Pre-exposure to H2O2 significantly delayed the TNFalpha-induced expression of an NF-kappaB reporter gene and inflammatory proteins (intercellular adhesion molecule-1 and IL-1beta). The degradation of inhibitor of NF-kappaB alpha (IkappaBalpha) and the nuclear translocation of NF-kappaB were also delayed by H2O2 treatment, whereas IkappaBalpha phosphorylation and IkappaB kinase activity were not changed. When we examined the ubiquitin/proteosome pathway in H2O2-treated cells, we could not detect significant changes in proteosomal peptidase activities, but we were able to detect a delay of IkappaBalpha poly-ubiquitination. Our results suggest that transient exposure to oxidative stress temporally inhibits NF-kappaB-dependent gene expression by suppressing the poly-ubiquitination of phosphorylated IkappaBalpha in HEK293 cells.

Clinical Evaluation of Toxocariasis Presenting as a Liver Abscess / 대한내과학회지

BACKGROUND/AIMS: Toxocariasis rarely causes a liver abscess. We assessed clinical and laboratory manifestations as well as therapeutic responses in patients with toxocariasis presenting as a liver abscess. METHODS: Fourteen patients with toxocariasis presenting as a liver abscess were analyzed retrospectively. Symptoms, occupational history, dietary habits, contact with pets, allergic disease, peripheral eosinophil count, serum immunoglobulin E (IgE) level, and invasion to other organs were evaluated. After treatment with albendazole, follow-up was conducted with abdominal computed tomography (CT) and the measurement of serum eosinophil and IgE levels. RESULTS: Among 568 patients with a liver abscess, 14 were diagnosed with active toxocariasis. The mean age of the patients was 48 years, and nine (64%) were men. Four (28.6%) patients had pain in the right upper quadrant of the abdomen or epigastric area, one had cough, and the others (64.3%) had no symptom. Pulmonary involvement was noted in five patients and colon involvement in one. Six (42.9%) patients had a recent history of eating raw meat. Initial laboratory findings showed increased eosinophil and IgE levels in all patients. The initial CT showed one or multiple ill-defined, hypodense lesions in the liver. After 1 month of albendazole treatment, eosinophil counts were normalized or had decreased in 13 (93%) patients. On follow-up CT, liver abscesses disappeared within 6 months after therapy in 92% of patients. CONCLUSIONS: Symptoms, laboratory findings, and treatment of a liver abscess caused by toxocariasis differ from those of a pyogenic liver abscess. Early serologic testing may increase diagnostic yield and efficacy of treatment in patients with a liver abscess and peripheral eosinophilia.

A Case of Steroid-induced Hyperinfective Strongyloidiasis with Bacterial Meningitis / 대한소화기학회지

Strongyloides stercoralis is a soil transmitted intestinal nematode that is endemic in the tropical and subtropical regions. In most individuals who are infected, chronic, usually asymptomatic, gastrointestinal infection persists. But, in immunocompromized hosts or in patients receiving immunosuppressive therapy, autoinfection of S. stercoralis may result in the dissemination of larvae, leading to fatal hyperinfection and increased rate of complications. We report a case of hyperinfective strongyloidiasis with bacterial meningitis in a patient receiving steroid therapy. Strongyloidiasis was diagnosed by the presence of filariform larvae of S. stercoralis in the bronchoalveolar lavage cytology and upper gastrointestinal endoscopic biopsy specimen. Her clinical symptoms had progressively aggravated and developed bacterial meningitis during treatment. She died despite aggressive antibiotic and antihelminthic therapy.

Esophageal Perforation after Change of a Percutaneous Endoscopic Gastrostomy Tube / 대한소화기내시경학회지

Percutaneous endoscopic gastrostomy (PEG) has become a widely used and safe method for long-term enteral feeding in patients who are unable to tolerate oral feeding. Although a number of complications can occur following PEG placement, most of these complications are not life threatening. Serious complications occur rarely after this procedure and they include peritonitis, visceral perforation, major gastrointestinal bleeding, and necrotizing fasciitis. An esophageal perforation following PEG placement is very rare and predisposing factors include Zenker's or epiphrenic esophageal diverticuli, esophageal strictures, and mass lesions. We recently experienced a case of distal esophageal perforation following a PEG tube change. The predisposing esophageal perforation factor in this case was uncertain, and we successfully treated the patient with surgical intervention.

Ectopic ovarian mixed epithelial tumor simulating colon cancer in a woman with a unicornuate uterus / 대한내과학회지

Ovarian malignancy can rarely present as a colonic mass and simulate colon cancer. Mullerian anomalies are congenital anatomic abnormalities of the female internal genitalia, of which a unicornuate uterus is a rare subtype. Several cases of gynecologic malignancies arising in Mullerian anomalies have been described. However, an ectopic ovarian malignancy in conjunction with a unicornuate uterus has never been reported. We report a case of ectopic ovarian mixed epithelial tumor, a very rare subtype of ovarian epithelial tumor, which presented as a colonic mass simulating colon cancer in a woman with a unicornuate uterus.

Ectopic ovarian mixed epithelial tumor simulating colon cancer in a woman with a unicornuate uterus / 대한내과학회지

Ovarian malignancy can rarely present as a colonic mass and simulate colon cancer. Mullerian anomalies are congenital anatomic abnormalities of the female internal genitalia, of which a unicornuate uterus is a rare subtype. Several cases of gynecologic malignancies arising in Mullerian anomalies have been described. However, an ectopic ovarian malignancy in conjunction with a unicornuate uterus has never been reported. We report a case of ectopic ovarian mixed epithelial tumor, a very rare subtype of ovarian epithelial tumor, which presented as a colonic mass simulating colon cancer in a woman with a unicornuate uterus.

Impact of Maximal Sterile Barrier during the Insertion of Central Venous Catheters in Adults Intensive Care Units / 병원감염관리

BACKGROUND: Catheter-related bloodstream infections (CR-BSIs) are common, costly, and potentially lethal. The purpose of this study was to ascertain the effect of maximal sterile barrier on CR-BSIs in intensive care units. METHODS: We monitored CR-BSIs in intensive care units of Sunlin Hospital in Pohang, before (September 2005 to May 2006) and after (June to December 2006) implementation of maximal sterile barrier. CR-BSIs were identified by using the definition of Centers for Disease Control and Prevention. RESULTS: During the intervention period, the proportion of conducting maximal sterile barrier was 84%. In the pre-intervention period, 10 episodes of CR-BSIs were recorded out of a total of 1,749 catheter-days, compared to 1 episode of CR-BSI out of a total of 1,277 catheter-days in the post-intervention period. The rate of CR-BSIs was significantly reduced from 5.72 to 0.57 per 1,000 catheter-days (P=0.03). CONCLUSION: Implementation of maximal sterile barrier resulted in a significant reduction in CR-BSIs.

The Effect of Trifluoroacetic Acid, a Metabolite of Isoflurane on the ATP-sensitive Potassium Channel in Rabbit Ventricular Myocytes / 대한마취과학회지

BACKGROUND: Activation of ATP-sensitive K+ channels (KATP channels) in the cardiac muscle produces cardioprotective effects during myocardial ischemia. Previous experimental evidence indicates that volatile anesthetics exert beneficial actions in ischemic myocardium and enhance functional recovery of stunned myocardium. More recently, volatile anesthetics have been demonstrated to produce cardioprotective effects in stunned myocardium in vivo, and these effects are blocked by a KATP channel antagonist. This finding suggests that KATP channel activation by isoflurane may mediate antiischemic effects. However, it was demonstrated that isoflurane inhibited KATP channel activity in rabbit ventricular myocytes. To explain the discrepancy, the present investigation tested the hypothesis that isoflurane and its metabolite, trifluoroacetic acid, contributes to the activation of KATP channels in rabbit ventricular myocytes. METHODS: Single ventricular myocytes were isolated from rabbit hearts by an enzymatic dissociation procedure. Single-channel currents were measured in inside-out patch configurations of the patch-clamp technique. The perfusing liquid was equilibrated with isoflurane by passing 100% O2 through a vaporizer. RESULTS: Isoflurane inhibited KATP channel activity without a change in the single-channel conductivity. Isoflurane decreased the burst duration and increased the interburst duration. In addition, isoflurane diminished the ATP sensitivity of KATP channels. Trifluoroacetic acid, a metabolite of isoflurane, enhanced the channel activity in a dose-dependent fashion. Trifluoroacetic acid increased the burst duration and decreased the interburst duration without a change in the single-channel conductivity. Isoflurane and trifluoroacetic acid diminished the ATP sensitivity of KATP channels. CONCLUSIONS: These results imply that isoflurane and its metabolite could mediate cardioprotective effects via KATP channel activation during myocardial ischemia.

A Perioperative Thromboelastographic Coagulation Study of Patients Treated with a Massive Transfusion of Fluids and Packed Red Cells during Total Hip Replacement Surgery / 대한마취과학회지

BACKGROUND: The high incidence of deep vein thrombosis (DVT) of lower extremities and a subsequent pulmonary embolism (PE) makes it the most common cause of death following total hip replacement surgery. Therefore, the authors measured the perioperative changes in the blood coagulation activity with a thromboelastography (TEG) in the patients treated with fluid and packed red cells (PRC). METHODS: Hemodilution was estimated with a measurement of hemoglobin (Hb), hematocrit (Hct), and platelet count. The changes in the coagulation factor activities were measured with TEG. Samples were obtained before skin incision (step 1); at the period that Hb and Hct ranged from about 10 g/dl to 30% (step 2); in the postanesthetic care unit (step 3); and on the postoperative first and third day (step 4, 5). RESULTS: Although Hct and Hb decreased to 9.4% statistically at step 2 only, platelet counts were significantly decreased in step 2 (10.6%), 3 (34.5%), 4 (32.5%), and 5 (33.6%) compared with step 1 (P < 0.05). At step 2, there were no significant changes in TEG parameters except r time, which decreased (21.5%) (P < 0.05). At step 3, r time, alpha angle, and maximum amplitude (MA) decreased, and k time and lysis 60 increased (P < 0.05). CONCLUSIONS: In spite of consumption and dilution of coagulation factors after massive fluids and PRC therapy during total hip replacement surgery, the increased activities of procoagulants and decreased fibrinolytic activities predisposed the body to initiate and maintain the thrombus.

Application of Polarized Light Irradiation to Meralgia Paresthetica / 대한마취과학회지

Meralgia Paresthetica is an uncommon and rare entrapment neuropathy involving the lateral femoral cutaneous nerve of the thigh. A lateral femoral cutaneous block has been used in order to alleviate pain and paresthesia in the affected area, but this procedure seems likely to be invasive or involve side effects. We performed a polarized light irradiation (SUPER LIZER HA-550(R), Tokyo Iken Co., Ltd, Japan) for a patient with Meralgia Paresthetica after the patient gave her informed consent. An entry was chosen 2.5 cm below and medial to the anterior superior iliac spine, and irradiation was applied with a cycle of 1 second on and 3 seconds off at 80% output for 8 minutes with 1200 mW output using a type-B probe a sum of eight times. Consequently, mild or moderate pain alleviation was obtained. When compared to pre-irradiation, the patient's symptoms were alleviated and satisfaction was high.