Development of a Checklist for Predicting Suicidality Based on Risk and Protective Factors: The Gwangju Checklist for Evaluation of Suicidality

Objective@#The aim of the study was to develop a checklist for mental health clinicians to predict and manage suicidality. @*Methods@#A literature review of the risk and protective factors for suicide was conducted to develop a checklist for evaluating suicidality. @*Results@#The fixed risk factors included sex (male), age (older individuals), history of childhood adversity, and a family history of suicide. Changeable risk factors included marital status (single), economic status (poverty), physical illness, history of psychiatric hospitalization, and history of suicide attempts. Recent discharge from a mental hospital and a recent history of suicide attempts were also included. Manageable risk factors included depression (history and current), alcohol problems (frequent drinking and alcohol abuse), hopelessness, agitation, impulsivity, impaired reality testing, and command hallucinations. Protective factors included responsibility to family, social support, moral objections to suicide, religiosity, motivation to get treatment, ability to cope with stress, and a healthy lifestyle. A final score was assigned based on the sum of the risk and protective factor scores. @*Conclusion@#We believe that the development of this checklist will help mental health clinicians to better assess those at risk for suicidal behavior. Further studies are necessary to validate the checklist.

Impending Cardiac Tamponade and Hemorrhagic Pleural Effusion as Initial Presentations of Incomplete Kawasaki Disease: A Case Report

Kawasaki disease (KD) is an acute febrile illness that is characterized by systemic inflammation usually involving medium-sized arteries and multiple organs during the acute febrile phase, leading to associated clinical findings. The diagnosis is based on the principal clinical findings including fever, extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy. However, KD diagnosis is sometimes overlooked or delayed because other systemic organ manifestations may predominate in acute phase of KD. As a cardiovascular manifestation, an acute pericarditis usually shows a small pericardial effusion, but large pericardial effusion showing clinical signs of cardiac tamponade is very rare. Here, we described a case of incomplete KD presenting with impending cardiac tamponade, and recurrent fever and pleural effusion.

Radiofrequency catheter ablation of ventricular tachycardia in pediatric patients

Background@#Radiofrequency catheter ablation (RFCA) has been accepted as an efficient therapy for tachycardia, and substantial improvement in the outcomes of RFCA in pediatric patients has been seen. However, there is not enough data on the clinical outcomes of RFCA for ventricular tachycardia (VT) in pediatric patients. The objective of this study was to elucidate the efficacy and safety of RFCA for VT in pediatric patients. @*Methods@#We performed a retrospective study involving 35 consecutive pediatric VT ablation procedures in 28 patients at a single institution. @*Results@#The median age at ablation was 14.0 years (range 6.9–19.2 years). There were 24 patients with a structurally normal heart and four patients with congenital heart disease (CHD). The left ventricular posteroseptal area was the most common site of VT origin (22/28, 78.6%). However, there was an unusual case of VT which involved a papillary muscle as its origin. Acute success was achieved in 30 (85.7%) of 35 procedures. The recurrence rate after successful RFCA was 14.2% (5/35) at a median follow-up of 6.7 years (range 1.0–16.7 years). There were five procedural failures due to the inability to induce VT for complete mapping. Ultimately, long-term success was achieved in 27 patients (96.4%) after repeated procedures and no major complications occurred. Long-term success was associated with VT inducibility (p = < 0.001). @*Conclusions@#Difficulty in inducing VT for precise mapping was a significant obstacle to successful RFCA. RFCA was identified as safe and effective therapy to eliminate VT in the selected pediatric VT patients.

Radiofrequency catheter ablation of ventricular tachycardia in pediatric patients

Background@#Radiofrequency catheter ablation (RFCA) has been accepted as an efficient therapy for tachycardia, and substantial improvement in the outcomes of RFCA in pediatric patients has been seen. However, there is not enough data on the clinical outcomes of RFCA for ventricular tachycardia (VT) in pediatric patients. The objective of this study was to elucidate the efficacy and safety of RFCA for VT in pediatric patients. @*Methods@#We performed a retrospective study involving 35 consecutive pediatric VT ablation procedures in 28 patients at a single institution. @*Results@#The median age at ablation was 14.0 years (range 6.9–19.2 years). There were 24 patients with a structurally normal heart and four patients with congenital heart disease (CHD). The left ventricular posteroseptal area was the most common site of VT origin (22/28, 78.6%). However, there was an unusual case of VT which involved a papillary muscle as its origin. Acute success was achieved in 30 (85.7%) of 35 procedures. The recurrence rate after successful RFCA was 14.2% (5/35) at a median follow-up of 6.7 years (range 1.0–16.7 years). There were five procedural failures due to the inability to induce VT for complete mapping. Ultimately, long-term success was achieved in 27 patients (96.4%) after repeated procedures and no major complications occurred. Long-term success was associated with VT inducibility (p = < 0.001). @*Conclusions@#Difficulty in inducing VT for precise mapping was a significant obstacle to successful RFCA. RFCA was identified as safe and effective therapy to eliminate VT in the selected pediatric VT patients.

Causes of Patient Mortality in Community Mental Health and Welfare Centers and Addiction Management Centers / 생물치료정신의학

OBJECTIVES: Serious mental illnesses and substance use disorder have a high level of early mortality. This study aimed to identify the causes of their deaths among patients who had been under the care of community mental health and welfare centers and addiction management centers.METHODS: We collected information on deceased individuals, whose mortality was attributable to various causes of death, from 10 Community Mental Health Centers and Addiction Centers in Gwangju Metropolitan City. The primary variables collected included psychiatric diagnosis, cause of death, smoking habits, admission history, and several socio-demographic factors.RESULTS: A total of 214 deaths among service users were studies. In Community Mental Health Centers, 109 deaths were identified, with causes that may be itemized as follows : 27 suicides(24.8%), 56 physical illnesses( 51.4%), 14 accidents(12.8%), and 12 unknown causes(11.0%). Among the physical illnesses reported, cardiovascular illness and cancer were the most common causes of death. A history of frequent admission was common among those that had died by suicide(88.9%), compared with that observed among general service users(62.0%). In Addiction Centers, 105 deaths were identified, with causes that may be itemized as follows : 7 suicides(6.7%), 71 physical illnesses(68.3%), 7 accidents(6.7%), and 20 unknown causes(19.0%). Among the physical illnesses reported, sudden death, hepatic disorder, cancer, and cardiovascular disorder were the most common causes of death.CONCLUSION: Case managers should give due consideration to and carefully manage the physical health of individuals accessing mental health services via community mental health centers and addiction centers.

Physical Health Literacy and Health-related Behaviors in Patients with Psychosis

OBJECTIVE: This study compared the levels of knowledge of physical illnesses and patterns of health behaviors between patients with psychosis and the general population. METHODS: A total of 712 participants were included in the study; 292 patients with a schizophrenia spectrum disorder and 420 healthy controls matched for age and gender. Questionnaires were administered to study participants to determine the level of knowledge of chronic physical illnesses such as cancer, hypertension, and diabetes mellitus and health-related behavior. Results from the two study groups were compared to identify differences in knowledge of physical illness and health-related behaviors. RESULTS: Compared with healthy controls, patients with psychosis were less likely to undergo regular medical check-ups and engage in exercise. Patients with psychosis had poorer knowledge of physical illnesses, and were more likely to smoke, be overweight, or have diabetes. Patients with psychosis were significantly less likely to acknowledge the importance of early detection of cancer and controlling hypertension and diabetes, independent of education and type of medical insurance. Patients who smoked were significantly less likely to agree with the statement on the relationship between smoking and physical illnesses. Patients not undergoing regular medical check-ups were significantly less likely to agree with statements concerning the need for cancer screening. CONCLUSION: Patients with psychosis demonstrated lower levels of knowledge of physical illnesses and a lack of understanding of preventive behaviors. Low levels of knowledge were associated with poor health-related behaviors. Education of physical health should be provided to patients with psychosis.

Factors Influencing Quality of Life of Alcoholics Anonymous Members in Korea

PURPOSE: The purpose of this study was to determine quality of life (QOL) related factors in Alcoholics Anonymous (AA) members based on PRECEDE Model. METHODS: A cross sectional survey was conducted with participants (N =203) from AA meeting in 11 alcohol counsel centers all over South Korea. Data were collected using a specially designed questionnaire based on the PRECEDE model and including QOL, epidemiological factors (including depression and perceived health status), behavioral factors (continuous abstinence and physical health status and practice), predisposing factors (abstinence self-efficacy and self-esteem), reinforcing factors (social capital and family functioning), and enabling factors. Data were analyzed using t-test, one way ANOVA, Tukey HSD test and hierarchical multiple regression analysis with SPSS (ver. 21.0). RESULTS: Of the educational diagnostic variables, self-esteem (β=.23), family functioning (β=.12), abstinence self-efficacy (β=.12) and social capital (β=.11) were strong influential factors in AA members' QOL. In addition, epidemiological diagnostic variables such as depression (β= - .44) and perceived health status (β=.35) were the main factors in QOL. Also, physical health status and practice (β=.106), one of behavioral diagnostic variables was a beneficial factor in QOL. Hierarchical multiple regression analysis showed the determinant variables accounted for 44.0% of the variation in QOL (F=25.76, p <.001). CONCLUSION: The finding of the study can be used as a framework for planning interventions in order to promote the quality of life of AA members. It is necessary to develop nursing intervention strategies for strengthening educational and epidemiological diagnostic variables in order to improve AA members' QOL.

Bispectral Index Monitoring during Anesthesiologist-Directed Propofol and Remifentanil Sedation for Endoscopic Submucosal Dissection: A Prospective Randomized Controlled Trial

PURPOSE: Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications. MATERIALS AND METHODS: A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded. RESULTS: The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications. CONCLUSION: BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.

Ankle-brachial blood pressure differences before and during anesthesia

BACKGROUND: In surgeries involving the upper extremities and breast, the blood pressure is frequently measured at the ankles. As the blood pressure is used as a pain indicator in the full surgical anesthesia, the ankle blood pressure higher than the brachial blood pressure may be misinterpreted by the anesthesiologist, in determining the depth of the anesthesia. This paper investigated whether the ankle blood pressure is significantly higher than the brachial blood pressure before the anesthesia induction, during induction, and after tracheal intubation. METHODS: Two hundred seventeen patients requiring general anesthesia for elective surgery were included in this study. Ankle and brachial blood pressure were simultaneously measured before the anesthesia induction, during induction, and after tracheal intubation. RESULTS: The ankle blood pressure was higher than the brachial blood pressure before induction, during induction, and after tracheal intubation. Ankle-brachial blood pressure differences were significantly higher before induction and after intubation as compared to that during induction. The correlation coefficient between the systolic ankle-brachial blood pressure difference before induction and that after tracheal intubation was 0.623. In 33 child patients with an ankle-brachial blood pressure index > or =1 before induction, there were no significant differences in the ankle-brachial blood pressure during induction. The brachial systolic blood pressure could be predicted by simple and multiple regression equations (R2 = 0.349-0.828). CONCLUSIONS: The results of the study suggest that the anesthesiologists need to consider the ankle-brachial blood pressure differences in monitoring the anesthesia, in cases where the brachial blood pressure cannot be measured during surgery.

Use of the On-Q system for pain management after robot - assisted endoscopic transaxillary thyroidectomy

BACKGROUND: The robot-assisted transaxillary approach to thyroid surgery is a novel method that has recently been used to improve patient safety and cosmetic outcomes. We evaluated post-operative pain, following robot-assisted endoscopic transaxillary thyroid surgery, and pain relief using a continuous wound perfusion system with local anesthetics. METHODS: In a control group of 25 female patients who underwent robot-assisted endoscopic transaxillary thyroidectomy, the post-operative pain scores and characteristics as well as analgesic use were monitored. Fifty female patients undergoing robot-assisted endoscopic transaxillary thyroidectomy were given the On-Q system. They were then randomly assigned to receive one of two different local anesthetic doses: Group I (0.25% Ropivacaine, n = 25); and Group II (0.375% Ropivacaine, n = 25). The pain score, pain site, analgesic requirements and side effects of each group were recorded during the 48 hour period post-surgery. RESULTS: Post-operative pain scores and analgesic demand were lower in the On-Q groups than in the control group. No difference was found between Group I and Group II. Until 6-12 hours after surgery, pain was mainly located in the axilla, while after 6-12 hours, the primary location of pain had a tendency to move to the neck. Pain scores gradually decreased in time for all patients. CONCLUSIONS: Patients who underwent robot-assisted endoscopic transaxillary thyroidectomy with an On-Q system injecting 0.25% ropivacaine had lower pain scores, showing the effectiveness of the system. As a potential pain blocker, continuous wound perfusion with the On-Q system attenuates side effects. This could lead to shortened hospital stays after robot-assisted endoscopic transaxillary thyroidectomy.

Use of the On-Q system for pain management after robot - assisted endoscopic transaxillary thyroidectomy

BACKGROUND: The robot-assisted transaxillary approach to thyroid surgery is a novel method that has recently been used to improve patient safety and cosmetic outcomes. We evaluated post-operative pain, following robot-assisted endoscopic transaxillary thyroid surgery, and pain relief using a continuous wound perfusion system with local anesthetics. METHODS: In a control group of 25 female patients who underwent robot-assisted endoscopic transaxillary thyroidectomy, the post-operative pain scores and characteristics as well as analgesic use were monitored. Fifty female patients undergoing robot-assisted endoscopic transaxillary thyroidectomy were given the On-Q system. They were then randomly assigned to receive one of two different local anesthetic doses: Group I (0.25% Ropivacaine, n = 25); and Group II (0.375% Ropivacaine, n = 25). The pain score, pain site, analgesic requirements and side effects of each group were recorded during the 48 hour period post-surgery. RESULTS: Post-operative pain scores and analgesic demand were lower in the On-Q groups than in the control group. No difference was found between Group I and Group II. Until 6-12 hours after surgery, pain was mainly located in the axilla, while after 6-12 hours, the primary location of pain had a tendency to move to the neck. Pain scores gradually decreased in time for all patients. CONCLUSIONS: Patients who underwent robot-assisted endoscopic transaxillary thyroidectomy with an On-Q system injecting 0.25% ropivacaine had lower pain scores, showing the effectiveness of the system. As a potential pain blocker, continuous wound perfusion with the On-Q system attenuates side effects. This could lead to shortened hospital stays after robot-assisted endoscopic transaxillary thyroidectomy.

Cardiac arrest in the elderly with silent myocardial ischemia during general anesthesia / 대한마취과학회지

No abstract available.

Back pain with erectile dysfunction: A case report

A 42-year-old male was referred to our pain clinic with back pain. Four years ago, he was treated for back pain caused by falling down injury. He also complained of erectile dysfunction, which was regarded as having psychologic origin at other departments. He had grade IV leg weakness and left lower thoracic paravertebral tenderness. Thoracic CT, plane X-ray and whole body bone scan revealed normal findings. After diagnostic medial branch block at lower thoracic vertebra, pain was subsided partially, but erectile dysfunction persisted. Due to persistent symptoms, we ordered MRI, and the extramedullary mass at T9 level was found. He had undergone neurosurgical operation for tumor removal, and pathologic finding was Schwannoma. After the operation his symptoms improved completely. Although erectile dysfunctions are presumed to have psychologic origin frequently, we report a patient whose symptoms were from the spinal cord tumor.

A Case of Ampullary Perforation Treated with a Temporally Covered Metal Stent

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is classified into three or four types based on anatomical location and the mechanism of injury. Although ampullary injury, among them, may be managed nonsurgically, surgical management is required in cases of perforation with retroperitoneal fluid collection and severe condition. Here, a patient with ERCP-related severe ampullary perforation with retroperitoneal fluid collection that was treated nonsurgically with a covered stent is presented.

Thoracic epidural anesthesia for modified radical mastectomy in a patient with diffuse systemic sclerosis: A case report

Systemic sclerosis is a systemic autoimmune disease. It is characterized by deposition of collagen in skin, blood vessels and internal organs. Systemic sclerosis can cause skin, cardiovascular, pulmonary, gastrointestinal, renal and other complication. A 42 year old woman with systemic sclerosis and breast cancer was scheduled for modified radical mastectomy under thoracic epidural anesthesia because of exertional dypnea, decreased diffusion lung capacity and Raynaud's phenomenon. There was no dyspnea or significant hemodynamic change during operation under epidural anesthesia. She discharged 12 days after operation without complications.

Delayed detection of subcutaneous emphysema following routine endotracheal intubation -A case report- / 대한마취과학회지

A tracheal intubation-related tracheobronchial rupture is a relatively rare complication. We report a case of tracheobronchial rupture after single lumen endotracheal intubation. Twenty four hours after extubation of an endotracheal tube, subcutaneous emphysema developed on the patient's neck. A pneumomediastinum was also detected by computerized tomography (CT). The patient recovered uneventfully after conservative management.

The Risk Factors and Outcome of Acute Kidney Injury in the Intensive Care Units

BACKGROUND/AIMS: Acute kidney injury (AKI) is a common and serious complication in critically ill patients, especially in the intensive care unit (ICU). The present study was performed to evaluate the occurrence rate of AKI using the RIFLE (increasing severity classes risk, injury, and failure, and the two outcome classes loss and end-stage kidney disease) classification, to define factors associated with AKI and hospital mortality. METHODS: We performed a retrospective study of all ICU patients over a 6-month period at Keimyung University Dongsan Hospital, Daegu, Korea. AKI was evaluated according to the RIFLE classification. RESULTS: AKI occurred in 156 of the 378 patients (41.3%) during their ICU stay, with maximum RIFLE-R, I, and F in 13.8%, 12.4%, and 15.1%, respectively. In univariate analysis, the proportion of medical admission and maximum Sequential Organ Failure Assessment (SOFA) score (SOFAmax) were significantly higher in patients with AKI than in those without. However, these factors did not remain significant in a multivariate analysis. The overall mortality rate of ICU patients was 25.7%. In multivariate analysis, mean age, occurrence of AKI, SOFAmax score, pulmonary disease, and malignancy were independent risk factors for hospital mortality. CONCLUSIONS: In these ICU patients, AKI is associated with increased hospital mortality. The RIFLE classification is a simple and useful clinical tool to detect and stratify the severity of AKI, and may aid in the prediction of outcome.

Small lymphocytic lymphoma that developed in a patient with long-standing cold agglutinin disease / 대한내과학회지

Cold agglutinin disease (CAD) is an autoimmune hemolytic anemia (AIHA) induced by cold antibodies. CAD constitutes 16~32% of AIHA cases and the causative cold autoantibodies are commonly specific against blood group I or i antigens. CAD is closely related to lymphoid neoplasia and infections such as Mycoplasma and Epstein-Barr virus (EBV). Primary CAD has a tendency to develop into malignant lymphoma over its course. We experienced a case of small lymphocytic lymphoma during the treatment of primary CAD over 11 years. The patient was a 67-year-old man who complained of a neck mass. Node biopsy revealed diffuse neoplastic proliferation of small monotonous lymphoid cells with polygonal or oval nuclei;these cells were CD20- and CD5-positive. Follow-up chest and neck computed tomography after treatment with chlorambucil and prednisolone showed partial resolution and stable disease status for over 2 years. We report a case of small lymphocytic lymphoma that developed in a patient with long-standing cold agglutinin disease for 11 years and review the literature.

Folate, Vitamin B12, and Homocysteine as Risk Factors for Cognitive Decline in the Elderly

OBJECTIVE: Cross-sectional studies have shown that the dysregulation of one-carbon metabolism is associated with cognitive impairment. However, the findings of longitudinal studies investigating this association have been inconsistent. This study investigated the prospective associations between cognitive decline and the levels of folate, vitamin B12 and homocysteine both at baseline and over course of the study period. METHODS: A total of 607 (83%) elderly individuals were selected from a group of 732 elderly individuals without dementia at baseline and followed over a 2.4-year study period. The Mini-Mental State Examination (MMSE) was administered to the subjects, and the serum levels of folate, vitamin B12 and homocysteine were assayed both at baseline and at follow-up examinations. Covariates included demographic data, disability, depression, alcohol consumption, physical activity, vascular risk factors, serum creatinine level, vitamin intake, and apolipoprotein E genotype. RESULTS: Cognitive decline was associated with decreasing quintiles of folate at baseline, a relative decline in folate and an increase in homocysteine across the two examinations after adjustment for relevant covariates. CONCLUSION: These results suggest that folate and homocysteine are involved in the etiology of cognitive decline in the elderly.

A retrospective analysis of prolonged propofol-remifentanil anesthesia in the neurosurgical patients

BACKGROUND: A rare, but fatal, propofol infusion syndrome has been reported in critically ill patients after prolonged use of propofol (more than 24-48 hours). But there are few reports on the clinical characteristics of prolonged anesthesia (more than 10 hours) using propofol, especially in the neurosurgical patients. METHODS: A retrospective study was conducted to find intra-and post-anesthetic characteristics (up to 7 postoperative days) and long-term outcomes (more than 1 and half years) in the neurosurgical patients who needed prolonged propofol-remifentanil anesthesia. Data were collected via medical records and descriptive analysis was conducted. RESULTS: Thirty one neurosurgical patients underwent 34 operations using propofol-remifentanil anesthesia for more than 10 hours from November 2005 to January 2007. Mean duration of anesthesia and surgery was 936 +/- 279 and 805 +/- 283 min, respectively. Propofol and remifentanil were administered with a mean infusion rate of 7.2 +/- 1.8 mg/kg/h and 8.6 +/- 2.4microg/kg/h, respectively. Vasopressors were used in six cases during anesthetic management. Intraoperative hypotension occurred in two patients. Even though hepatic, cardiac, and renal enzymes elevated transiently in some patients during postanesthetic course, any significant lactic acidosis did not occur in them. Two patients died of sepsis and GI bleeding thereafter. Median days of hospital admission and stay at neurosurgical care unit were 36.5 days and 8 days. CONCLUSIONS: A retrospective analysis of the prolonged propofol and remifentanil anesthesia for 34 neurosurgical cases did not show any morbidities and mortalities related to intravenous anesthetics.