The Role of Blind Protected Specimen Brushing (PSB) in Intubated Patients / 결핵

BACKGROUND: In intubated patients, cultures of endotracheal aspirates (EA) are apt to contamination throughout the endotracheal tube. Therefore, the identification of etiologic agents via conventional EA cultures is not always reliable. In order to differentiate a pulmonary infection from a non-infectious disease, and to identify the true etiologic agent of acute pulmonary infection, blinded protected specimen brushing (PSB) was used, and its efficacy evaluated. METHODS: In 51 intubated patients, with suspected pneumonia, blind PSB were performed, and the results compared with blood and EA cultures. A protected specimen brush was introduced through the endotracheal tube, and settled at the affected large bronchus. A specimen brush was introduced to the expected region using the blind method. The tip of the brush was introduced with an aseptic technique after vigorously mixed for 1 minute in 1cm3 of Ringer's lactate solution. The specimens were submitted for quantitative culture within 15 minutes, with a culture being regarded as positive if the colony forming units were above 103/ml. RESULTS: Of the 51 patients, 15 (29.4%) had community-acquired pneumonia (CAP), 27 (52.9%) hospital-acquired pneumonia (HAP) and 9 (17.6%) non-infectious diseases. The sensitivity and specificity of the quantitative PSB culture for the diagnosis of pneumonia were 52.4 and 88.9%, respectively. The sensitivity and specificity of EA were 78.6 and 77.8%, respectively. The blind PSB was superior to the EA for the identification of true etiologic agents. Of 53 episodes of 27 HAP patients, MRSA (Methicillin-resistant staphylococcus aureus) (41.5%) was the most common causative agent followed by Pseudomonas aeruginosa (15.1%), Klebsiella sp. (7.5%) and Acinetobacter sp. (7.5%). CONCLUSIONS: As a simple, non-invasive diagnostic modality, the blind PSB is a useful method for the differentiation of a pulmonary infection from non-infectious diseases and to identify the etiologic agents in intubated patients. A blind PSB can be performed without bronchoscopy, so is safer, more convenient and cost-effectiveness for patients where bronchoscopy can not be performed.

Prevalence and Clinical Impact of a Subclinical Intrapulmonary Right to Left Shunt Diagnosed by Contrast Echocardiography in Patients with End Stage Hepatic Disease

BACKGROUND AND OBJECTIVES: The clinical impact of an intrapulmonary right to left shunt, without hypoxia (subclinical IPS), has not been sufficiently evaluated. We investigated the prevalence and clinical impact of a subclinical IPS in patients with end stage hepatic disease. SUBJECTS AND METHODS: Contrast echocardiography, with hand-agitated saline, was performed in 72 consecutive candidates for a liver transplantation between April 2001 and November 2001. A positive contrast echocardiography indicated an intrapulmonary right to left shunt, and was defined as the delayed appearance of microbubbles in the left side of the heart (3 to 6 beats after the initial appearance in the contrast in the right side of the heart). We compared the clinical events of the patients both with and without a shunt, i.e. death, spontaneous bacterial peritonitis, sepsis, hepatic encephalopathy or variceal bleeding. RESULTS: A subclinical IPS was detected in 19 of the 72 candidates for a liver transplantation (26.3%). All these candidates were Child class C liver cirrhosis. There were no differences in the baseline characteristics between the patients and those without a shunt in the Child class C (n=57). The mean PaO2 value of the patients with at least a 3+ left ventricular opacification (3 to 4+, n=6) was significantly lower than those with a 1+ to 2+ left ventricular opacification (n=13) (76+/-10 mmHg vs. 103+/-13 mmHg, p< 0.05). The mortality was not significantly difference between the patients with (5%, 1/19) or without (21%, 8/38, p=0.24) a shunt. Also, there were no significant differences in the clinical events during the mean follow-up period of 7+/-3 months (68.4% vs. 83.5% p=0.12). CONCLUSION: Subclinical IPS's are not uncommon in patients with end stage hepatic disease. The extent of shunting correlates with the level of arterial oxygenation. However, a subclinical IPS is not associated with the mortality or clinical events of the patient selected.

Predictive Value of C-Reactive Protein for Cardiac Events after Coronary Stenting

BACKGROUND AND OBJECTIVES: Recent studies have implicated inflammation in the pathogenesis of coronary artery disease. The aim of this study was to determine whether C-reactive protein (CRP) levels are predictive of major adverse cardiac events (MACE) following stenting. SUBJECTS AND METHODS: The study comprised 193 patients (90 men, 152 unstable angina, mean age 63 years) between October 1999 and March 2001. The patients were classified into 2 groups according to their MACE, [group A; MACE (+), n=46 and group B; MACE (-), n=147]. RESULTS: During clinical follow-up at a mean duration of 15 months, there was 1death, 7 myocardial infarctions, 25 cases of revascularization therapy, and 13 recurrent anginas. At 24 hours after stenting, the CRP levels were significantly higher in group A compared to group B (5.4, 0.6-15.2 vs. 3.1, 0.1-9.8 mg/L, respectively, p8.0 mg/L) occurring more commonly in group A than group B (24% vs. 9%, p<0.05). The differences in the CRP levels between the baseline and 24 hours following stenting (CRP 24h-base ) were also significantly higher in group A than in group B. After adjustment for age, sex, and cardiovascular risk factor, multi-variate analysis using logistic regression revealed the CRP levels 24 hours after stenting were predictive of MACE, with an odd ratio of 1.6 (95% CI 1.1-2.2, p=0.01). CONCLUSION: CRP levels, 24 hours following intervention, are powerful predictor of cardiac events in patients with stable or unstable angina undergoing coronary stenting. These results suggest that the inflammatory responsiveness to coronary intervention can plays an important role in predicting cardiac events.

Transcatheter Coil Embolization of Coronary Arteriovenous Fistula in Patient with Turner Phenotype with 46,XX

The coronary arteriovenous fistula (CAVF) is a rare congenital anomaly but constitutes the most common hemodynamically significant coronary artery anomaly. Transcatheter embolization is as an effective alternative to surgery even though procedure may be complicated by migration of the coil into peripheral vessels or pulmonary arteries. To our knowledge, the association of CAVF with Turner syndrome was not reported. We report a case of successful coil embolization of CAVF using a complex, helical-fibered platinum coil in patient with Turner phenotype with 46,XX.

Valvular Regurgitation in Patients with Graves' Disease

The high cardiac output state and an increased incidence of atrial fibrillation are well-known cardiovascular complications of Graves' disease, whereas the valvular complications are less well recognized. With 2D color Doppler echocardiography, the cardiac and valvular function of 39 patients with Graves' disease were evaluated and our data were compared with previous Kage's study. The incidences of mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with Graves' disease were 54% and 51%, respectively. There was no correlation between the incidence of MR and ventricular dilatation. In patients with congestive heart failure (CHF), the incidences of severe TR and atrial fibrillation were significantly higher than in patients without CHF. The incidences of TR and MR in patients with Graves' disease were not different by thyroid function status (hyperthyroid vs. euthyroid). We suggest that the examination for TR and MR in patients with Graves' disease is important not only their high prevalence but also their clinical significance as a risk factor for CHF.

A Case of Primary Gastric T-cell Lymphoma with Helicobacter pylori Infection / 대한소화기내시경학회지

The primary T-cell lymphoma of the stomach is a extremely rare disease, only about 33 cases were described in the literature since 1986. Recent studies have proved a strong relation between Helicobacter pylori infection and several gastric diseases such as peptic ulcer, chronic gastritis, gastric cancer, and lymphoma. We report a case of primary gastric T-cell lymphoma with H. pylori infection in a 63-year-old male who had a history of epigastric fullness for 2 years. Gastroscopy showed a round ulcer of 1cm in size on anterior side of gastric angle. The gastroscopic biopsy revealed diffuse large cell malignant non-Hodgkin' s lymphoma on light microscopic examination, and T-cell immunophenotype with immunohistochemical study. The result of CLOtest was positive. No lymphadeno-pathy was found with chest roentgenogram and computed omography of abdomen and pelvis. Bone marrow examination showed normal finding.

Reflux Esophagitis after Cure of Helicobacter pylori Infection: Report of two cases / 대한소화기내시경학회지

Helicobacter pylori infection causes chronic gastritis and its well documented con- sequences are peptic ulcer disease and gastric neoplasia. As duodenal ulcer is often associated with gastroesophageal reflux disease and antral gastritis is a frequent finding in patients with reflux disease, H. pylori infection may be a common cause of both conditions. Recent studies reveal that H. pylori has no role in the pathogenesis of reflux esophagitis. Furthermore, there are some arguments on whether H. pylori infection may have a protective role in reflux esophagitis. We have experienced two cases of reflux esophagitis after cure of H. pylori infection. H. pylori eradication therapy was performed in two patients who have gastric and/or duodenal ulcer with omeprazole and two anti-biotics (clarithromycin and amoxicillin). After cure of H. pylori infection, reflux esophagitis was demonstrated in these patients by endoscopy.

Salt Consumption as a risk factor of Gastric Cancer and Helicobacter pylori Infection / 대한내과학회지

OBJECTIVES: Gastric cancer is one of the most important malignancy of the gastrointestinal tract. High salt intake has been suggested as a risk factor of gastric cancer and promoting Helicobacter pylori infection. Few studies have been addressed about the relation between excessive salt intake and gastric cancer. This study was performed to investigate the relation of high salt intake to H. pylori infection and gastric cancer. METHODS: Between May 1996 and July 1997, hospitalized patients with epigastric pain or dyspepsia were prospectively recruited. Patients with underlying diseases which could reduce kidney function were excluded. Salt consumption was estimated by the urine sodium to creatinine ratio(U-Na/Cr) on fresh single urine sample. Gastric cancer was diagnosed by endoscopic biopsies. H. pylori infection was evaluated by CLOtest. Gastric cancer was classified histologically by Lauren classification. RESULTS: Ninety seven patients, 52 patients with gastric cancer and 45 patients with chronic gastritis were enrolled. There was no statistically significant difference in the sodium to creatinine ratio between gastric cancer group (173.60+/-123, range; 21-665.2) and chronic gastritis group (164.02+/-138, range; 20.4-482.7) (p=0.361). In gastric cancer, the sodium to creatinine ratio was not different between CLOtest positive and negative group (p=0.201), and among intestinal, diffuse and mixed type (p=0.419), either. CONCLUSION: This study does not support the causal relation of high salt diet on gastric carcinogenesis. There is no significant difference in H. pylori infection rate between CLOtest positive group and negative group.

Two cases of Ticlopidine-induced neutropenia in patients with cardiovascular disease

Ticlopidine is an antiplatelet agent used as a drug to prevent the recurrence of cerebral infarction or ischemic heart disease. Close attention has recently been paid to the superiority of this drug to aspirin in the prevention of stroke. Its mechanism of action differs from aspirin, dipyridamole, and sulfinpyrazone. Inhibition of the adenosine diphosphate induced pathway of platelet aggregation, along with the activation of adenylate cyclase and suppression of platelet-activating factor and thromboxane A2, are the postulated mechanisms of action of ticlopidine. Because ticlopidine causes neutropenia and agranulocytosis in roughly 1% of treated patients, usually within the first 3 months of treatment, this drug has been reserved for patients intolerant to aspirin therapy. We reported two cases of ticlopidine-induced neutropenia and one patient hospitalized with severe neutropenia and pneumonia.

Two cases of Ticlopidine-induced neutropenia in patients with cardiovascular disease

Ticlopidine is an antiplatelet agent used as a drug to prevent the recurrence of cerebral infarction or ischemic heart disease. Close attention has recently been paid to the superiority of this drug to aspirin in the prevention of stroke. Its mechanism of action differs from aspirin, dipyridamole, and sulfinpyrazone. Inhibition of the adenosine diphosphate induced pathway of platelet aggregation, along with the activation of adenylate cyclase and suppression of platelet-activating factor and thromboxane A2, are the postulated mechanisms of action of ticlopidine. Because ticlopidine causes neutropenia and agranulocytosis in roughly 1% of treated patients, usually within the first 3 months of treatment, this drug has been reserved for patients intolerant to aspirin therapy. We reported two cases of ticlopidine-induced neutropenia and one patient hospitalized with severe neutropenia and pneumonia.