A retrospective analysis of the follicle-stimulating hormone starting dose in expected normal responders undergoing their first in vitro fertilization cycle: proposed dose versus empiric dose / 대한생식의학회지

OBJECTIVE: The purpose of this retrospective study was to evaluate the appropriateness of various follicle-stimulating hormone (FSH) starting doses in expected normal responders based on the nomogram developed by La Marca et al. METHODS: A total of 117 first in vitro fertilization cycles performed from 2011 to 2017 were selected. All women were expected normal responders and used a recombinant FSH and flexible gonadotropin-releasing hormone antagonist protocol. The FSH starting dose was empirically determined (150, 225, or 300 IU). The FSH starting dose indicated by La Marca's nomogram was determined using female age and serum anti-Müllerian hormone or basal FSH levels. If the administered dose was exactly the same as the proposed dose, the cycle was assigned to the concordant group (34 cycles). If not, it was assigned to the discordant group (83 cycles). Optimal ovarian response was defined as a total of 8–14 oocytes, hypo-response as 14 oocytes. RESULTS: Between the concordant and discordant group, ovarian response (optimal, 32.4% vs. 27.7%; hypo-response, 55.9% vs. 54.2%; and hyper-response, 11.8% vs. 18.1%) and the number of total or mature oocytes were similar. Ovarian hyperstimulation syndrome was rare in both groups (0% vs. 1.2%). The implantation rate, clinical pregnancy rate, miscarriage rate, and live birth rate were all similar. CONCLUSION: The use of the proposed FSH starting dose determined using La Marca's nomogram did not enhance the optimal ovarian response rate or pregnancy rate in expected normal responders. Individualization of the FSH starting dose by La Marca's nomogram appears to have no distinct advantages over empiric choice of the dose in expected normal responders.

Colon Perforation during Air Enema Reduction of Intussusception

PURPOSE: Although air enema reduction has been known as a good method of diagnosis and treatment of intussusception, it could develop colon perforation. However, there have been few studies about this complication. So we analyzed the risk factors of colon perforation during air enema reduction in patients with intussusception. METHODS: We reviewed the charts of 12 colon perforation patients during air enema reduction of intussusception, who were admitted to Gil Medical Center from Jan. 1990 to Dec. 2001. Their age, sex, major symptoms, length of time till hospital visit, types of intussusception, operative findings and pathologic reports were reviewed. RESULTS: Among 657 cases, 596 patients(90.7%) were successfully treated, but 12 patients(1.83%) failed in air enema reduction and had colon perforation. In patients with colon perforation the male to female ratio was 11 : 1, and average age was 5.3 months. The most common symptom at the time of hospital visit was vomiting(91.7%). Cyclic irritability(75.0%), bloody stool(75.0%) and abdominal mass(41.7%) were also noted. The average length of time between symptom onset and hospital visit was 44.7 hours. Types of intussusception were predominantly ileocolic, ileocecal, and ileoileocolic. The site of perforation was most commonly found at the proximal part of intussusception including ascending colon(50%) and transverse colon(50%). Most cases were uncomplicated, and had a single perforation. Pathologic reports showed hemorrhagic necrosis and mesenteric laceration at the site of colon perforation. Complications of colon perforation were tension pneumoperitonium(58.3%), requiring immediate decompression. CONCLUSION: The chance of colon perforation during air enema reduction increases in cases with small bowel obstruction on simple abdominal x-ray of a patient younger than 6 months, delay in time till hospital visit and higher air pressure during reduction. Therefore more careful investigation is needed in these cases.

Development and Application of the Critical Pathway in Perioperative Patients with Ventricular Septal Defect

BACKGROUND AND OBJECTIVES: Ventricular septal defect (VSD) is the most common congenital heart disease, and an effective cooperative practice system can change its therapeutic outcome. We tried to develop and find the effects of the application of the critical pathway (CP) in patients with VSD. MATERIALS AND METHODS: First, we reviewed the charts of patients diagnosed with VSD who had been operated on between January and December 1999, and the preliminary CP for the VSD completed. Second, the Delphi process was achieved by exchanging mail between two professional groups to establish the final CP for the VSD. This process was applied to thirteen patients having had operations at the Gil Heart Center between June and November 2000. On admission, the patients were informed of the practice, and their degree of satisfaction was anonymously surveyed prior to discharge. RESULTS: The CP for patients with VSD is composed of eight categories - monitoring, vital signs, laboratory tests, ventilator, diet (fluid-electrolyte balance), drugs, treatment, consultation and education. These were applied and evaluated daily from two days preoperatively, until the day of discharge (seven days postoperatively), to 13 of the 15 (86.7%) patients, as approved in the instruction manual. The duration of antibiotic injections significantly decreased from 5.3+/-1.3 days to 3.1+/-0.5 days (p=0.00002), as did that of thoracic tube insertion from 84+/-21 hours to 48+/-16 hours (p=0.0001). The degree of satisfaction of the parents was 4.2, the highest score possible being 5. CONCLUSION: Improvement in the quality of medicine can be achieved by developing and applying the CP to perioperative patients with VSD. Our conclusions from this study are only tentative as it was only applied to limited small number of cases.

Transcatheter Closure of Atrial Septal Defect Using Amplatzer Septal Occluder

BACKGROUND AND OBJECTIVES: Transcatheter occlusion (TCO) may be an alternative method for the surgical closure of a secundum atrial septal defect (ASD) below 20 mm in diameter. We performed this study in order to evaluate the safety and feasibility of an Amplatzer septal occluder for closing ASD bigger than 20 mm in diameter percutaneously. SUBJECTS AND METHODS: Thirty three of 39 patients presenting with ASD were included in this study (3 patients with a large defect over 32mm and 3 with multiple defects were excluded). The median age was 8.6 years (2.2 - 54) and median weight was 27 kg (10.7 - 85). The mean defect size was 15+/-3 mm as measured by transthoracic echocardiogram, 17+/-5 mm by transesophageal echocardiogram, and 21+/-6 (11 - 32) mm by balloon stretched diameter. The balloon stretched diameter was larger than 20 mm in 20 of 33 patients. The mean Qp/Qs was 2.3+/-0.7. The mean device size was 22+/-6 mm and the mean fluoroscopic time was 13+/-7 min. RESULTS: The device was successfully implanted in 29 of 33 patients. The 4 patients in which implantation failed showed a left disc protrusion into the right atrium. Three of these patients were treated surgically, and one underwent a successful second attempt of TCO 12 months after the first trial. Complete closure was obtained in 30 patients in follow-up. The complications encountered included;cobra-shaped deformity of the device (3), transient AV block (Wenckebach) (1), embolization of the radioopaque marker into the left atrial appendage (1), failure in the first device (1), and mild mitral regurgitation at 3 months follow-up due to device protrusion into the mitral valve (1). CONCLUSION: The Amplatzer septal occluder appears to be a promising device for TCO of ASD up to 32 mm in diameter, however, long-term follow-up in a large number of patients is warranted.

Influence of Epstin-Barr Virus Infection in Immune Thrombocytopenic Purpura in Childhood / 대한소아혈액종양학회지

PURPOSE: Acute immume thrombocytopenic purpura (ITP) is relatively common hematologic disease in children. Most acute ITP is recovered within 6 month spontaneously and the complication is rare. But 10~20% of the ITP patient became a chronic form. Infection with Epstein-Barr virus (EB virus) in developing country usually occurs during infancy and early childhood. Acute ITP associated with EB virus is likely to develop chronic ITP in current literatures. We studied the pattern of laboratory findings in long term follow up of ITP with EB virus infection. METHODS: One hundred and seventy nine patients diagnosed with ITP admitted to the division of pediatric hematology, Gachon Medical Center and Hanyang University Hospital between Mar. 1991 and Jun. 2001 were reviewed retrospectively. Serologic test for EB virus was available for 57 patients and 25 of them were follow up at least 6 months. Evidence of acute EB virus infection was defined as a positive Viral Capsid Antigen (VCA) IgM or positive Anti VCA IgG and negative Ebstein-Barr virus Nuclear Antigen (EBNA). Complete remission (CR) was defined as a recovery of platelet count of more than 100 109/L and partial remission (PR) as a recovery of platelet count of 50~100 109/L, maintained for at least 6 months. RESULTS: Sixteen out of 57 patients were associated acute EB virus infection. Of this group, 8 patients were follow up at least 6 months. Forty one of 57 with no evidence of acute EB virus infection, 17 were follow up at least 6 months. The clinical and laboratory data was not different significantly in children with and without acute EB virus infection in admission. In EB virus infection group of 6 months follow up, platelet count was significantly lower than control group in 6 months follow up (P=0.006). Five patients of 8 (63%) with acute EB virus infection had chronic ITP and 2 of 17 (12%) with no evidence of EB virus infection had chronic ITP in follow up 6 months. CONCLUSION: Patients with EB virus associated ITP tended to resolved more slowly than those without EB virus infection and also showed tendency to become chronic ITP.

Two Cases of Infantile Hemangioendothelioma of the Liver in Neonates

Infantile hemangioendothelioma(IHE) of the liver is a rare benign vascular tumor that presents most commonly in infants before the age of 6 months. IHE presents as abdominal mass, cutaneous hemangiomas, unexplained jaundice, bleeding disorders, or congestive heart failure. Death often results from congestive heart failure despite appropriate treatment with digoxin and diuretics. IHE also is associated with Kasabach-Merritt syndrome, anemia, intraperitoneal hemorrhage secondary to rupture, consumptive coagulopathy and vascular malformation involving brain, skin, gut, and other organs. Although children with asymptomatic lesions may experience spontaneous regression within a year, symptomatic lesions shoud be treated aggressively because this disease can progress rapidly and may be fatal. Treatment options are divided into medical treatment, interventional therapy including embolization, and surgical resection. Corticosteroid may hasten involution by inhibiting proliferation of endothelial and smooth muscle cells, and this trial is warranted in most cases before invasive procedures are used. If steroid therapy is unsuccessful, early definitive treatment using embolization or ligation of the hepatic artery, resectional surgery, and orthotopic liver transplantation shoud be considered. We experienced symptomatic IHE in two neonates. In the first case, she showed respiratory failure and consumptive coagulopathy, and symptoms were aggravated despite steroid therapy, so a left lobectomy was performed. In the second case, he presented high output cardiac failure, and was successfully treated by the coil embolization of left hepatic artery. This coil embolization of hepatic artery for treating IHE was the first case in Korea we know of.

Comparison of Brainstem Auditory Evoked Response in Normal Infants, Male and Female, Right and Left Ear

PURPOSE: Brainstem auditory evoked response(BAER) is used as screening test for hearing disorders, damages of the central nervous system and congenital anomalies. We studied the difference values according to gender and stimulation sites in normal full-term infants. METHODS: We performed BAER in 38 male and 28 female normal full-term infants, delivered in the Gil Medical Center, Gachen Medical School, from March to July 1996, aged one to seven days. Amplitude I, V, V/I and latency I, III, V and interpeak latency(IPL) I-III, III-V, I-V were measured at 90, 60, 45, 30 dB. Data were analyzed between both sex and between both ears with Student t-test. RESULTS: There were no significant difference in male and female group with the same side's stimulation. At 90 dB, amplitude I of left ear stimulation was significantly higher than right in male and female. Amplitude V/I of right ear stimulation was significantly higher than left ear stimulation in total only. At 90 dB, latency I of right was significantly longer than left in male and female. Latency III of right was longer significantly in total only. IPL I-III, I-V was significantly longer in left than right in male and total. At 60 dB intensity, all data except latency I in total, showed no significant difference. CONCLUSIONS: Interpreting BAER, stimulation site and intensity should be considered. and further studies will be needed for the evaluation of the difference between left and right ear.

The Differentiation of HL-60 Cells Causes to Lose their Ability to Express TNF mRNA / 대한면역학회지

It is well known that HL-60 cell, a human promyelocytic line, is differentiated into eosinophil-like cells in the presence of butyric acid, and thus the differentiated HL-60 cells have been used as a model system to study irnmunological properties of peripheral eosinophils which are thought to be terminally differentiated. To study whether HL-60 cells alter their capability of expressing cytokines during differentiation to eosinophil-like cells, we examined TNF mRNA levels in HL-60 cells treated with butyric acid by Ribonuclease Protection Assay (RPA). HL-60 cells were incubated for 3 days in the presence of butyric acid (0.5 mM), and stimulated with PMA and lipopolysaccharide (LPS). The levels of TNF mRNA decreased by 50 % and 95 % upon one and two days of post-treatment of butyric acid, respectively. The decreased pattern in TNF mRNA levels was also observed in HL-60 cells that have been treated with retinoic acid known as an inducer for differentiation of them. In accordance with these results, prominent azurophilic granules typical in eosinophils appeared in the cytoplasm of the differentiated HL-60 cells. The decreased expression of TNF mRNA was not attributable to the presence of serum, since increasing concentrations of serum had no effect. Furthermore, interleukin-5 (IL-5), which is known to be involved in activation and trafficking of eosinophils in vivo and in vitro, failed to affect TNF mRNA production when it was used in place of butyric acid. These data suggest that the differentiated HL-60 cells may have immunological resemblance to eosinophils in that they weakly produce the cytokine mRNA.

Clinical Evaluation of Syndromic and Nonsyndromic Intrahepatic Bile Duct Paucity / 대한소아소화기영양학회지

PURPOSE: The aims of this study were to evaluate the clinical manifestations and prognosis of the syndromic and nonsyndromic intrahepatic bile duct paucity (IHBDP). METHODS: We studied histology of 42 infants with neonatal cholestasis. Fourteen patients were diagnosed as IHBDP. We evaluated the clinical manifestations, courses and prognosis retrospectively. RESULTS: Underlying disease of the 42 infants with neonatal cholestasis were biliary atresia in 23, intrahepatic bile duct paucity in 14 (Alagille syndrome in 4 and nonsyndromic IHBDP in 10), neonatal hepatitis in 5 infants. The mean ratio of the bile ducts per portal tract was 0.087 (range: 0~0.5). The manifestations in 4 patients with Alagille syndrome demonstrated as follows: characteristic face in 3, chronic cholestasis in 4, posterior embryotoxon in 2, vertebral anomalies in 2, peripheral pulmonary stenosis in 2. One of 4 patients of Alagille syndrome improved cholestasis and the other 3 patients were remained their cholestasis and growth retardation. All patients of the nonsyndromic IHBDP were idiopathic. Seven out of 8 patients of nonsyndromic IHBDP showed improvement of cholestasis, and one patient received liver transplantation due to cirrhosis. CONCLUSION: This study suggested that IHBDP should be considered in the differential diagnosis of neonatal cholestasis. The outcome of idiopathic IHBDP was better than predicted.

Airway - Related Complications and SpO2 Changes of Deeply Anesthetized Versus Awake Extubation in Children / 대한마취과학회지

BACKGROUND: Tracheal extubation can be performed while patients are deeply anesthetized or when they are awake. Each technique has its own advantages and disadvantages. But necessity for deep extubating conditions, and what level of anesthesia is adequately deep, is still controversial. Clinical conditions of patients or the preference of the anesthesiologist has dictated the choice of extubation technique. METHOD: Anesthesia was induced and maintained as usual manners. The 49 healthy children between 3 and 12 year of age undergoing tonsillectomy and adenoidectomy were randomly assigned to group 1(extubation at 1 MAC of enflurane) and group 2(awake extubation). SpO2 and airway-related complications(cough, breath-holding, airway obstruction, and laryngospasm) were observed for 5 minutes after extubation with 100% O2 by mask, and SpO2 and heart rate were measured for 90 seconds during transportation to the recovery room with room air breathing. RESULTS: The total incidence of airway-related complications in group 2 were higher than in group 1. However, group 1 showed severer complications than in group 2 such as airway obstruction and laryngospasm. There was no differences between the two groups in SpO2 and heart rate changes with 100% O2 mask just after extubation and during transportation. Group 1 showed higher SpO2 than group 2 upon arrival in the recovery room. CONCLUSION: We concluded that in healthy children undergoing elective oral surgery, airway-related complications are likely to be influenced more by the skill, experience and preference of the anesthesiologist than by the method alone.

Total Intravenous Anesthesia for High Frequency Jet Ventilation in Laryngomicrosurgery / 대한마취과학회지

Total intravenous anesthesia(TIVA) is desirable technique for a number of reasons. The first is that it implies all the components of general anesthesia : hypnosis, amnesia, analgesia, and muscle relaxation by combination of several drugs and the lungs are ventilated with oxygen-enriched air. A combination of fentanyl-propofol were used as TIVA for laryngomicrosurgery (LMS) with high frequency jet ventilation(HFJV). 41 patients were studied. Glycopyrrolate was given 1 hour before anesthetic induction. Propofol 2 mg/kg was intravenously administered 1 minute after fentanyl 1.5 ug/kg intravenously injection for induction. Endotracheal intubation was performed after succinylcholine administration with internal diameter 4.0-6.0 mm LASER tube through oral cavity or 8 fr. polyethylene catheter through nasal airway. After then, HFJV was started with frequency 108-120 cycles/minute and driving pressure 2.0-2.5 kg/cm(2). The adequacy of ventilation was evaluated with arterial blood gas analysis. For maintenance a continuous propafol infusion of 10 mg/kg/hour was used for the first 10 minutes, followed by 8 mg/kg/hour for the next 10 minutes and 6 mg/kg/hour, thereafter. Continuous dripping of succinylcholine was used for muscle relaxation. The patients showed relatively stable hemodynamic status during procedure (Fig. 1). Two recovery times were as followed: the interval from cessation of infusion until opening eyes on command(4.90+/-3.41 min), and that until correct response to simple question (5.50+/-3.49 min). There was a correlation between total amount of propofol given to patients and recovery times(P<0.05)(Table 1). Interestingly. a group of patients weighed over 70 kg showed carbon dioxide retension on arterial blood gas analysis(Fig. 2). In conclusion, fentanyl-propofol cobination with muscle relaxant is proper regimen for TIVA in LMS with HFJV. More stable and better recovery are the main reasons. However, carbon dioxide retension should be consider to the patients weighed over 70 kg with the HFJV.