Nutritional Therapy Related Complications in Hospitalized Adult Patients: A Korean Multicenter Trial

PURPOSE: Nutritional therapy (NT), such as enteral nutrition (EN) or parenteral nutrition (PN), is essential for the malnourished patients. Although the complications related to NT has been well described, multicenter data on symptoms in the patients with receiving NT during hospitalization are still lacking. METHODS: Nutrition support team (NST) consultations, on which NT-related complications were described, were collected retrospectively for one year. The inclusion criteria were patients who were (1) older than 18 years, (2) hospitalized, and (3) receiving EN or PN at the time of NST consultation. The patients' demographics (age, sex, body mass index [BMI]), type of NT and type of complication were collected. To compare the severity of each complication, the intensive care unit (ICU) admission, hospital stay, and type of discharge were also collected. RESULTS: A total of 14,600 NT-related complications were collected from 13,418 cases from 27 hospitals in Korea. The mean age and BMI were 65.4 years and 21.8 kg/m2. The complications according to the type of NT, calorie deficiency (32.4%, n=1,229) and diarrhea (21.6%, n=820) were most common in EN. Similarly, calorie deficiency (56.8%, n=4,030) and GI problem except for diarrhea (8.6%, n=611) were most common in PN. Regarding the clinical outcomes, 18.7% (n=2,158) finally expired, 58.1% (n=7,027) were admitted to ICU, and the mean hospital days after NT-related complication were 31.3 days. Volume overload (odds ratio [OR]=3.48) and renal abnormality (OR=2.50) were closely associated with hospital death; hyperammonemia (OR=3.09) and renal abnormality (OR=2.77) were associated with ICU admission; “micronutrient and vitamin deficiency” (geometric mean [GM]=2.23) and volume overload (GM=1.61) were associated with a longer hospital stay. CONCLUSION: NT may induce or be associated with several complications, and some of them may seriously affect the patient's outcome. NST personnel in each hospital should be aware of each problem during nutritional support.

Prevalence of Malnutrition in Hospitalized Patients: a Multicenter Cross-sectional Study

BACKGROUND: Malnutrition is associated with many adverse clinical outcomes. The present study aimed to identify the prevalence of malnutrition in hospitalized patients in Korea, evaluate the association between malnutrition and clinical outcomes, and ascertain the risk factors of malnutrition. METHODS: A multicenter cross-sectional study was performed with 300 patients recruited from among the patients admitted in 25 hospitals on January 6, 2014. Nutritional status was assessed by using the Subjective Global Assessment (SGA). Demographic characteristics and underlying diseases were compared according to nutritional status. Logistic regression analysis was performed to identify the risk factors of malnutrition. Clinical outcomes such as rate of admission in intensive care units, length of hospital stay, and survival rate were evaluated. RESULTS: The prevalence of malnutrition in the hospitalized patients was 22.0%. Old age (≥ 70 years), admission for medical treatment or diagnostic work-up, and underlying pulmonary or oncological disease were associated with malnutrition. Old age and admission for medical treatment or diagnostic work-up were identified to be risk factors of malnutrition in the multivariate analysis. Patients with malnutrition had longer hospital stay (SGA A = 7.63 ± 6.03 days, B = 9.02 ± 9.96 days, and C = 12.18 ± 7.24 days, P = 0.018) and lower 90-day survival rate (SGA A = 97.9%, B = 90.7%, and C = 58.3%, P < 0.001). CONCLUSION: Malnutrition was common in hospitalized patients, and resulted in longer hospitalization and associated lower survival rate. The rate of malnutrition tended to be higher when the patient was older than 70 years old or hospitalized for medical treatment or diagnostic work-up compared to elective surgery.

Dexmedetomidine Oral Mucosa Patch for Sedation Suppresses Apoptosis in Hippocampus of Normal Rats / 대한배뇨장애요실금학회지

PURPOSE: Dexmedetomidine, an α2-adrenergic agonist, provides sedative and analgesic effects without significant respiratory depression. Dexmedetomidine has been suggested to have an antiapoptotic effect in response to various brain insults. We developed an oral mucosa patch using dexmedetomidine for sedation. The effects of the dexmedetomidine oral mucosa patch on cell proliferation and apoptosis in the hippocampus were evaluated. METHODS: A hydrogel oral mucosa patch was adhered onto the oral cavity of physiologically normal rats, and was attached for 2 hours, 6 hours, 12 hours, or 24 hours. Plasma dexmedetomidine concentrations were determined by liquid chromatography– electrospray ionization–tandem mass spectrometry–multiple-ion reaction monitoring (LC-ESI-MS/MS-MRM). Cell proliferation in the hippocampus was detected by Ki-67 immunohistochemistry. Caspase-3 immunohistochemistry, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining, and Western blotting for Bax and Bcl-2 were performed to detect hippocampal apoptosis. The levels of brain-derived neurotrophic factor (BDNF) and tyrosine kinase B (TrkB) in the hippocampus were also measured by Western blotting. RESULTS: Plasma dexmedetomidine concentration increased according to the attachment time of the dexmedetomidine oral mucosa patch. Hippocampal cell proliferation did not change due to the dexmedetomidine oral mucosa patch, and the dexmedetomidine oral mucosa patch exerted no significant effect on BDNF or TrkB expression. In contrast, the dexmedetomidine oral mucosa patch exerted an antiapoptotic effect depending on the attachment time of the dexmedetomidine oral mucosa patch. CONCLUSIONS: A dexmedetomidine oral mucosa patch can be used as a convenient tool for sedation, and is of therapeutic value due to its antiapoptotic effects under normal conditions.

Pentoxifylline Alleviates Perinatal Hypoxic-Ischemia-Induced Short-term Memory Impairment by Suppressing Apoptosis in the Hippocampus of Rat Pups / 대한배뇨장애요실금학회지

PURPOSE: Perinatal hypoxic-ischemic brain damage is a major cause of acute mortality and chronic neurologic morbidity in infants and children. We investigated the effects of pentoxifylline, a methylxanthine derivative and type-4 phosphodiesterase inhibitor, on short-term memory and apoptotic neuronal cell death in the hippocampus following perinatal hypoxic-ischemia in newborn rats. METHODS: We used a step-down avoidance task to evaluate short-term memory and 3ʹ-5ʹ-cyclic adenosine monophosphate (cAMP) assay to detect cAMP levels. We evaluated apoptosis using a terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay for evidence of DNA fragmentation, immunohistochemistry for caspase-3 levels, and western blot for Bcl-2 and Bax. RESULTS: Perinatal hypoxic-ischemic injury increased apoptotic cell death in the hippocampus, resulting in impaired short-term memory with decreased cAMP levels. Pentoxifylline treatment improved short-term memory by suppressing apoptotic cell death in the hippocampus with elevated cAMP levels. CONCLUSIONS: Pentoxifylline ameliorated perinatal hypoxic-ischemia in rat pups. This alleviating effect could be ascribed to the inhibition apoptosis due to increased cAMP production by pentoxifylline.

The comparison of monitored anesthesia care with dexmedetomidine and spinal anesthesia during varicose vein surgery

PURPOSE: The purpose of this study was to investigate the effectiveness and safety of monitored anesthesia care (MAC) using dexmedetomidine for its sedative and analgesic effect during varicose vein surgery. METHODS: Forty-two patients, who underwent varicose vein surgery, were divided into the MAC group (n = 20) or the spinal anesthesia group (n = 22) for randomized clinical trial. In the MAC group, dexmedetomidine was administered by a loading dose of 1 microg/kg for 10 minutes, followed by a maintenance infusion of 0.2-1.0 microg/kg/hr. Ketamine was used for intermittent injection. In the spinal anesthesia group, midazolam was used for sedation. Intraoperative vital signs, the number of adverse events, and the satisfaction of patients and surgeons concerning the anesthetic condition were compared between the two groups. RESULTS: Systolic blood pressure was intraoperatively significantly different over time between the two groups. The groups had statistical differences in the change in heart rate with regard to time. In the postanesthetic care unit, patients and surgeons in the MAC group had a lower satisfaction score, compared to patients and surgeons in the spinal anesthesia group. However, in the recovery period, patients had a positive perception concerning MAC anesthesia. In addition, without significant adverse events, the MAC group had a shorter time to possible ambulation, which indicated an early recovery. CONCLUSION: We believe that MAC using dexmedetomidine in combination with ketamine may be an alternative anesthetic technique for varicose vein surgery with regard to a patient's preference and medical condition.

Clinical Characteristics of Primary Epiploic Appendagitis

PURPOSE: Primary epiploic appendagitis (PEA) is a rare cause of an acute abdomen. It can be clinically misdiagnosed as either diverticulitis or appendicitis on clinical examination because the clinical symptoms and signs of PEA are non-specific. The present study was performed to describe the clinical characteristics of PEA and to assess the differences between PEA and diverticulitis. METHODS: We reviewed the clinical records and radiologic findings of 31 consecutive patients with PEA and compared them with those of patients with diverticulitis without complications. RESULTS: In most cases, abdominal pain was localized to the right (13 cases, 41.9%) or left (13 cases, 41.9%) lower quadrants. Gastrointestinal symptoms such as nausea and vomiting were infrequent, and localized tenderness without peritoneal irritation was common. All patients were afebrile, and only 4 patients (12.9%) showed leukocytosis. In all cases except one, a pericolic fatty mass with a hyperattenuated ring was observed on computed tomography. Patients with left PEA were younger than those with diverticulitis (41.4 +/- 11.9 vs. 69.7 +/- 13.3, P < 0.001), and the mean body mass index was higher in patients with left PEA (26.4 +/- 2.9 vs. 22.6 +/- 3.4, P = 0.01). Whereas one patient (6.7%) with left PEA showed leukocytosis, the incidence of leukocytosis in patients with diverticulitis was 80% (8/10) (P < 0.001). CONCLUSION: In patients with an acute abdomen showing localized tenderness without associated symptoms or leukocytosis, a high index of suspicion for PEA is necessary. For correct diagnosis and proper management, it would useful for surgeons to be aware of the computed tomographic findings and the natural course of the disease.

Clinical Outcomes and Risk Factors of Traumatic Pancreatic Injuries

PURPOSE: Even though traumatic pancreatic injuries occur in only 0.2% to 4% of all abdominal injuries, the morbidity and the mortality rates associated with pancreatic injuries remain high. The aim of this study was to evaluate the clinical outcomes of traumatic pancreatic injuries and to identify predictors of mortality and morbidity. METHODS: We retrospectively reviewed the medical records of 26 consecutive patients with a pancreatic injury who underwent a laparotomy from January 2000 to December 2010. The data collected included demographic data, the mechanism of injury, the initial vital signs, the grade of pancreatic injury, the injury severity score (ISS), the revised trauma score (RTS), the Glasgow Coma Scale (GCS), the number of abbreviated injury scales (AIS), the number of associated injuries, the initial laboratory findings, the amount of blood transfusion, the type of operation, the mortality, the morbidity, and others. RESULTS: The overall mortality rate in our series was 23.0%, and the morbidity rate was 76.9%. Twenty patients (76.9%) had associated injuries to either intra-abdominal organs or extra-abdominal organs. Two patients (7.7%) underwent external drainage, and 18 patients (69.3%) underwent a distal pancreatectomy. Pancreaticoduodenectomies were performed in 6 patients (23.0%). Three patients underwent a re-laparotomy due to anastomosis leakage or postoperative bleeding, and all patients died. The univariate analysis revealed 11 factors (amount of transfusion, AAST grade, re-laparotomy, associated duodenal injury, base excess, APACHE II score, type of operation, operation time, RTS, associated colon injury, GCS) to be significantly associated with mortality (p<0.05). CONCLUSION: Whenever a surgeon manages a patient with traumatic pancreatic injury, the surgeon needs to consider the predictive risk factors. And, if possible, the patient should undergo a proper and meticulous, less invasive surgical procedure.

Comparison of clinical outcomes and hospital cost between open appendectomy and laparoscopic appendectomy / 대한외과학회지

PURPOSE: Laparoscopic appendectomy has been recognized to have many advantages such as greater cosmetic results, less postoperative pain and shorter hospital stays. On the other hand, the cost of laparoscopic procedures is still more expensive than that of open procedures in Korea. The aim of this study is to compare clinical outcomes and hospital costs between open appendectomy and laparoscopic appendectomy. METHODS: Between January 1, 2010 and December 31, 2010, 471 patients were diagnosed with acute appendicitis. Of these, 418 patients met the inclusion criteria and were divided into two groups of open appendectomy (OA) group and laparoscopic appendectomy (LA) group. We analyzed the clinical data and hospital costs. RESULTS: The mean operation time for laparoscopic appendectomy (72.17 minutes) was significantly longer than that of open appendectomy (46.26 minutes) (P = 0.0004). The mean amounts of intravenous analgesics for OA group (2.00 times) was greater than that of LA group (1.86 times) (P < 0.0001). The complication rate was similar between the two groups (OA, 6.99% vs. LA, 10.87%; P = 0.3662). The mean length of postoperative hospital stay was shorter in LA group (OA, 4.55 days vs. LA, 3.60 days; P = 0.0002). The mean total cost covered by the National Health Insurance was more expensive in LA group (OA, 1,259,842 won [Korean monetary unit] vs. LA, 1,664,367 won; P = 0.0057). CONCLUSION: Clinical outcomes of laparoscopic appendectomy were superior to that of open appendectomy even though the cost of laparoscopic appendectomy was more expensive than that of open appendectomy. Whenever surgeons manage a patient with appendicitis, laparoscopic appendectomy should be considered as the procedure of choice.

Comparison of clinical outcomes and hospital cost between open appendectomy and laparoscopic appendectomy / 대한외과학회지

PURPOSE: Laparoscopic appendectomy has been recognized to have many advantages such as greater cosmetic results, less postoperative pain and shorter hospital stays. On the other hand, the cost of laparoscopic procedures is still more expensive than that of open procedures in Korea. The aim of this study is to compare clinical outcomes and hospital costs between open appendectomy and laparoscopic appendectomy. METHODS: Between January 1, 2010 and December 31, 2010, 471 patients were diagnosed with acute appendicitis. Of these, 418 patients met the inclusion criteria and were divided into two groups of open appendectomy (OA) group and laparoscopic appendectomy (LA) group. We analyzed the clinical data and hospital costs. RESULTS: The mean operation time for laparoscopic appendectomy (72.17 minutes) was significantly longer than that of open appendectomy (46.26 minutes) (P = 0.0004). The mean amounts of intravenous analgesics for OA group (2.00 times) was greater than that of LA group (1.86 times) (P < 0.0001). The complication rate was similar between the two groups (OA, 6.99% vs. LA, 10.87%; P = 0.3662). The mean length of postoperative hospital stay was shorter in LA group (OA, 4.55 days vs. LA, 3.60 days; P = 0.0002). The mean total cost covered by the National Health Insurance was more expensive in LA group (OA, 1,259,842 won [Korean monetary unit] vs. LA, 1,664,367 won; P = 0.0057). CONCLUSION: Clinical outcomes of laparoscopic appendectomy were superior to that of open appendectomy even though the cost of laparoscopic appendectomy was more expensive than that of open appendectomy. Whenever surgeons manage a patient with appendicitis, laparoscopic appendectomy should be considered as the procedure of choice.

Clinical Review of Pneumatosis Intestinalis

PURPOSE: Pneumatosis intestinalis (PI) is increasingly being detected in recent years with the more frequent use of computerized tomography (CT). The present study was performed to evaluate the clinico-radiologic characteristic presentation of PI and to determine the prognostic factors for mortality. METHODS: Fifteen patients who were diagnosed with PI on CT between June 2000 and May 2010 were retrospectively reviewed. Age, sex, location of PI, presence of portal vein gas, time to diagnosis, American Society of Anesthesiologists (ASA) classification, Acute Physiology And Chronic Health Evaluation II (APACHE II), acidosis, shock, and other associated findings were analyzed for their association with outcome. RESULTS: Fifteen patients (7 males and 8 females, average age, 60.3 years) were diagnosed with PI. Mortality rate was 47% (7 patients). The mortality rate in patients with septic shock, APACHE II score (18), acidosis (pH<7.36) were all 100%, 87%, 100%, respectively (P<0.05). Age, sex, location of PI, portal vein gas, time to diagnosis, ASA classification, associated findings did not show statistical difference. CONCLUSION: Shock, APACHE II score (18) and acidosis were associated with high mortality in patients with PI. So, more intensive management and interest are recommended in patients with shock, APACHE II score (18), and acidosis due to PI.

Preventive Effect of Pentoxifylline on Cyclosporine A-Induced Collagen Synthesis in Calf Pulmonary Artery Endothelial Cells

PURPOSE: Cyclosporine A (CsA) is a potent immunosuppressive agent, and it has been used to prevent rejection of transplanted organs and to treat autoimmune diseases. Many side effects of CsA, including various types of endothelial dysfunction, have been reported. Pentoxifylline (PTX) is a non-selective phosphodiesterase inhibitor that is used for the treatment of peripheral vascular diseases. METHODS: We investigated the effect of CsA on collagen synthesis and clarified whether PTX has protective effects against CsA-induced arterial vasculopathy using calf pulmonary artery endothelial cells. This study was carried out using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, reverse transcription- polymerase chain reaction (RT-PCR), Western blot analysis, nitric oxide (NO) detection, and cyclic guanosine monophosphate (cGMP) enzyme immunoassay. RESULTS: CsA treatment significantly increased the expression of collagen type I mRNA and protein and decreased the production of NO and cGMP. However, pre-treatment with PTX exerted anticollagen effect by suppressing the CsA-induced formation of collagen, but this effect of PTX was not modulated by NO and cGMP. CONCLUSION: Based on the present results, it is expected that PTX may have a protective effect against CsA-induced arterial vasculopathy, although the mechanism of PTX needs to be clarified in future studies.

Prognostic Factors for Complication and Mortality of Colonic Perforation

PURPOSE: The present study was performed to assess the outcomes in patients with colonic perforation and to determine the prognostic factors for mortality. METHODS: The cases of 42 patients who underwent surgery for colonic perforation between March 1999 and September 2008 were retrospectively reviewed. Age, sex, American Society of Anesthesiologists (ASA) classification, presence of preoperative shock, duration of symptoms, cause of perforation, location of perforation, degree of peritonitis, and the Mannheim Peritonitis Index (MPI) score were analyzed for their association with early outcome by using univariate and multivariate analyses. RESULTS: Diverticulitis (46%, 19 patients) and colorectal cancer (36%, 15 patients) were the most common causes of noniatrogenic colonic perforation, and the sigmoid colon was the most common site of perforation (60%, 25 patients). The postoperative mortality was 21.4% (9 patients). The mortality in patients with preoperative shock, with a MPI score of more than 25, and with Hinchey stage III or IV peritonitis were 70.0%, 57.1%, and 53.3%, respectively (P<0.001). No statistical difference was observed in postoperative mortality with regard to age, sex, ASA classification, duration of symptoms, cause of perforation, and location of perforation. According to the multivariate analysis, preoperative shock proved to be the only significant prognostic factor for mortality (P=0.027) (odds ratio: 19.8, 95% confidence interval: 1.4-276.9). CONCLUSION: Preoperative shock, a MPI score of more than 25, and Hinchey stage III or IV peritonitis were associated with high postoperative mortality in patients with colonic perforation. Especially, more intensive management and interest are required for patient s with preoperative shock due to colonic perforation.

Rectal Foreign Body (Glass Cup) Extracted by Laparotomy

Anorectal trauma associated with retained rectal foreign body is an infrequent clinical problem, but presents a challenge to physicians taking care of patients with this problem. We report a case of rectal foreign body (glass cup) extracted by laparotomy. A 49-year-old male with a history of alcoholism presented to the emergency room four days after inserting a glass cup into his rectum. He complained of vague anal pain and failure to pass flatus or stool for four days. He had attempted to extract the glass cup using various methods (digital, instrumental manipulation, enema), none of which was successful. Computed tomography revealed a glass cup lodged in the rectum, without complication. The patient was brought to the operating room, administered spinal anesthesia, and placed in lithotomy position after failure of extraction in the emergency room. Although the object was palpable, it could not be extracted either manually or by the use of forceps. We decided to perform an emergent laparotomy under general anesthesia. After the abdomen was opened, an attempt was made to milk the object toward the distal rectum. However, this proved to be impossible secondary to severe rectal mucosal edema. The glass cup was eventually extracted through performing a colotomy at the rectosigmoid junction, with primary repair. The patient's postoperative course was uneventful, and he was discharged on the eighth postoperative day.

Colonic Obstruction Caused by Sigmoid Volvulus Combined with a Transomental Hernia: A Case Report

The case of sigmoid volvulus combined with a transomental hernia is reported. A 70-year-old man was admitted to our hospital with mild abdominal pain and distension. Although no signs of peritoneal irritation were apparent, a plain abdominal X-ray showed a markedly dilated loop of the sigmoid colon, and CT revealed a whirl pattern of the sigmoid mesentery. These findings suggested sigmoid volvulus. Colonoscopic reduction was attempted as an initial nonoperative treatment, and an urgent laparotomy was performed after the reduction failed. The sigmoid loop was herniated through the great omentum, with torsion in the clockwise direction. The colon was manually untwisted in the counter-clockwise direction, and the sigmoid loop was released by dividing the great omentum. During this one-stage operation, intraoperative colonic irrigation, sigmoid resection, and primary anastomosis were performed. The postoperative course was uneventful. Although sigmoid volvulus combined with a transomental hernia is rare, urgent surgical intervention is essential on failure of endoscopic reduction.

Clinical Analysis of 473 Cases of Inguinal Hernia in Adult Patients

PURPOSE: This article compares the results of various methods of inguinal hernia repair in adults. METHODS: We retrospectively reviewed the medical records of 473 patients over 20 years of age who received an inguinal hernia repair procedure between January 2000 and June 2007. We analyzed the patients' clinical factors and outcomes, dividing them into five groups according to method of repair: Bassini group, Lichtenstein group, mesh plug group, Prolene Hernia System (PHS) group, and laparoscopic group. RESULTS: The mean number of used analgesics was significantly smaller in the PHS group than in other groups (P<0.05, PHS group: 0.46, Bassini group: 1.55, Lichtenstein group: 1.20, mesh plug group: 0.82, laparoscopic group: 1.44). The mean operation time was significantly shorter in the PHS group than in the other groups (P<0.05, PHS group: 45.18 min, Bassini group: 59.85 min, Lichtenstein group: 68.20 min, mesh plug group: 66.73 min, laparoscopic group: 83.33 min). Finally, the mean postoperative hospital staywas significantly shorter in the PHS group than in the other groups (P<0.05, PHS group: 2.93 day, Bassini group: 4.96 day, Lichtenstein group: 4.17 day, mesh plug group: 4.01 day, laparoscopic group: 5.11 day). Out of five groups, there was onecase of postoperative recurrence in the Bassini group. CONCLUSION: Mesh PHS operation is a more preferred method of inguinal hernia repair in adults because it offers a lower postoperative pain, shorter operation time, shorter postoperative hospital stay.

Skeletal Muscle Metastasis from Colorectal Cancer: Report of a Case

Metastases from colorectal cancer can occur by either lymphatic or hematogenous spread, and the sites most commonly involved are the liver and lung. Although skeletal muscle comprises a considerable portion of body mass and receives abundant blood supply, it is one of the most unusual sites of metastasis from any malignancies. We report a case of skeletal muscle metastasis from colorectal cancer. An 83-year-old female patient presented with a painful mass in the right posterior thigh. She had already undergone low anterior resection and right lobectomy of liver for rectal cancer with liver metastasis (T2N1M1) about 4 years ago. Although a follow-up computed tomography scan showed a metastatic solitary pulmonary nodule in the left lobe 2 years after the primary operation, she refused further aggressive treatment. Magnetic resonance imaging showed a localized mass in the semimembranosus muscle of the right thigh, and fine-needle aspiration cytology demonstrated clusters of atypical cells compatible with adenocarcinoma. The patient underwent excision of the painful mass located in the right semimembranosus muscle. Histologically, the thigh mass proved to be adenocarcinoma identical to the primary lesion. The patient died of heart failure on the 2nd postoperative day.

Pure Red Cell Aplasia (PRCA) due to Parvovirus B19 Infection after Kidney Transplantation / 대한이식학회지

The patient was a 39-year-old male with anemia persistent after a living-related renal transplantation. He was diagnosed to have pure red cell aplasia (PRCA) due to parvovirus B19 infection on the 6th week after the renal transplantation. Serum Parvovirus B19 DNA polymerase chain reaction (PCR) and anti-Parvovirus B19 IgM were positive and bone marrow aspiration biopsy showed giant pronormoblasts including prominent intranuclear inclusions. He has been receiving immunosuppressive therapy including oral cyclosporine A, prednisolone, mycophenolate mofetil (MMF). After diagnosis of pure red cell aplasia, we reduced the dose of cyclosporine A and maintained prednisolone, mycophenolate mofetil. We used intravenous immunoglobin(IVIG) 0.4 g/kg/ day for 5 days. Patient's serum reticulocyte count increased a week after the treatment from 0.1% to 3.8%, and patient's serum hemoglobin level normalized on the 4th week of the treatment. Presently, 20 weeks following the initiation of IVIG, his hemoglobin remains normal without recurrent symptom. We are planning to follow up the serum anti-parvovirus B19 IgM/IgG and parvovirus B19 DNA PCR examination.

Clinical Analysis of Appendicitis in the Elderly Over 60 Years of Age

PURPOSE: As average life expectancies are prolonged, the elderly population is steadily increasing. The increasing number of elderly persons has been accompanied by cases of acute appendicitis in the elderly. In order to understand the clinical significance and to improve the treatment of elderly patients with appendicitis. we analyzed patients over 60 years of age with appendicitis. METHODS: We retrospectively reviewed the medical records of 268 patients over 60 years of age who were pathologically diagnosed with appendicitis. We analyzed the patients' clinicopathologic factors and outcomes, dividing them into 3 age groups: 60~69, 70~79, 80 and over. RESULTS: Of the 268 patients, there were 109 male and 159 female. The sex ratio was 1:1.46. The numbers of patients in each group were 169 (63.1%) in the 60-69 group, 73 (27.2%) in the 70~79 group, and 26 (9.7%) in the over 80 group. There was no difference in the leukocyte count and the time delay in surgical treatment between the groups. In the older groups, compared to the younger groups, there were more frequent paramedian and median incisions in the operation (P=0.02), a longer duration of postoperative admission (P=0.001) and starvation after the operation (P<0.001). In the pathologic findings, the gangrenous and abscess stages of appendicitis were more frequent in the older groups than in the younger groups (P<0.001). CONCLUSIONS: Early aggressive diagnostic intervention, such as ultrasound and CT, is essential in managing appendicitis in elderly patients who complain of vague abdominal pain.

A Case of Mesenchymal Chondrosarcoma In Pancreas

Mesenchymal chondrosarcomas are very rare tumors, and they are more aggressive in comparison to the conventional type tumors. They can occur in any location containing mesenchymal cells, but most of them arise in the lower extremities, the leptomeninges and the eye orbits. Other sites are very uncommon and they represent approximately 1% of all chondrosarcomas; these rare tumor locations carry a poor prognosis. In this report, we present a case of extraskeletal mesenchymal chondrosarcoma of the pancreas. We could find only one case of extraskeletal mesenchymal chondrosarcoma with pancreatic metastasis from thigh in our PubMed-line search. We describe here a case of primary originating mesenchymal chondrosarcoma of the pancreas in a 40-year old man who presented with abdominal pain, and this is the first report of the pancreas as the primary origin of mesenchymal chondrosarcoma.

Abdominal Traumatic Handlebar Hernia

Traumatic abdominal wall hernia (TAWH) is an unusual type of hernia that may follow direct blunt trauma to the abdomen. Moreover, TAWH that is caused by bicycle handlebars is a rare finding. Despite an overall increase in the incidence of blunt abdominal trauma, the cases of TAWH remain rare, probably due to the elasticity of the abdominal wall for resisting the shear forces generated by a traumatic impact. Although the first case was described by Selby in 1906, very few cases of TAWH have been reported in the literature. Also, "Handlebar hernia" was described by Dimyan et al. in 1980. These injuries are localized hernias resulting from local blunt trauma to the abdominal wall from an object with insufficient force to penetrate the skin, yet this trauman is able to disrupt the deeper tissues of the muscle and fascia. The significance of such hernias is underestimated, and although they can be not immediately life-threatening, they can be fatal if associated with such complications as incarceration and strangulation. We describe here a case of traumatic handlebar hernia in a 55-year old man who presented with left lower quadrant pain that was caused by a motorcycle accident.