Effect of neuromuscular blockade reversal by pyridostigmine on spectral entropy values during recovery from desflurane anesthesia: a prospective, randomized, double-blind, controlled trial / 대한마취과학회지

BACKGROUND: According to several studies investigating the relationship between muscle activity and electroencephalogram results, reversal of neuromuscular blockade (NMB) may affect depth of anesthesia indices. Therefore, we investigated the effect of pyridostigmine on these indices via spectral entropy. METHODS: Fifty-six patients scheduled for thyroidectomy or parotidectomy were included in this study and randomized into two groups. At the start of skin suturing, the desflurane concentration was adjusted to 4.2 vol% in both groups. Following this, the pyridostigmine group (group P, n = 28) was administered pyridostigmine 0.2 mg/kg mixed with glycopyrrolate 0.04 mg/kg, while the control group (group C, n = 28) received normal saline. Entropy values (response entropy [RE] and state entropy [SE]), train of four (TOF) ratio, and end-tidal desflurane concentration were recorded from point of drug administration to 15 minutes post-drug administration. RESULTS: Mean RE values at 15 minutes, when the maximum effect of pyridostigmine was anticipated, showed a statistically significant difference between groups (53.8 ± 10.5 in group P and 48.0 ± 8.8 in group C; P = 0.030). However, mean SE at 15 minutes showed no significant difference between the two groups (P = 0.066). At 15 minutes, there were significant differences in the TOF ratio between the two groups (P < 0.001). CONCLUSIONS: NMB reversal by pyridostigmine significantly increased RE values but not SE values. This finding suggests that spectral entropy may be a useful alternative tool for monitoring anesthetic depth during recovery from anesthesia in the presence of electromyogram activity.

A Case of Invasion of Muscularis Propria of Gastric Inflammatory Fibroid Polyp

Inflammatory fibroid polyp (IFP) is an uncommon benign tumor and a proliferative disease localized to the submucosal area of the gastrointestinal tract. IFP has been detected more frequently with the increasing use of endoscopy. Histologically, gastric IFP is mostly limited to the submucosa, rarely invading the muscle layer. However, we experienced a case of gastric IFP invading the proper muscle layer. A 62-year-old man was referred for evaluation of epigastric pain. Contrast enhanced computed tomography of the abdomen and endoscopic examination revealed a stomach mass. IFP was histologically confirmed by surgical resection, and the patient was discharged without complication. IFP originating in the stomach that invades the muscularis propria is rare compared to that originating in the large or small intestine. The incidence of gastric IFP is relatively low. Invasion of the muscularis propria by IFP depends not only on the location but also the size of the IFP. There have been no published reports on the outcomes of gastric IFP invading the muscularis propria, therefore close follow-up of the present patient is important.

Comparison of Epidural Anesthesia with 0.5% Levobupivacaine and 0.5% Ropivacaine for Cesarean Section / 대한마취과학회지

BACKGROUND: Ropivacaine and levobupivacaine, both single S-enantiomers, show less toxicity on the central nervous and cardiovascular system than racemic bupivacaine. Earlier studies have shown that levobupivacaine and bupivacaine are almost equipotent while ropivaciane was 60% less potent than bupivacaine. The aim of this prospective, double blinded study was to compare the clinical efficacy and safety of epidural anesthesia produced by 0.5% levobupivacaine and 0.5% ropivacaine for a cesarean section. METHODS: Sixty-two parturients undergoing an elective cesarean section were randomized to receive either epidural levobupivacaine 0.5% 20 ml (n = 31) or epidural ropivacaine 0.5% 20 ml (n = 31). Surgery was commenced when the sensory block had reached the dermatome level, T6. The onset, duration, quality of the sensory and motor block and abdominal muscle relaxation were evaluated. The blood pressure and heart rate of the mother and neonatal outcome, as assessed by the Apgar score and umbilical pH, were also recorded. RESULTS: There was no difference in the onset time, the segmental spread of sensory block and analgesic supplement between the two groups. However, levobupivacaine produced a longer duration of sensory block than ropivacaine (levobupivacaine 224.1 +/- 66.6 min, ropivacaine 176.5 +/- 32.8 min, P < 0.05). The onset time (except Bromage scale 2), intensity and duration of the motor block and muscle relaxation were similar in both groups. There was no difference in the maternal and neonatal outcomes between the two groups. CONCLUSIONS: 0.5% levobupivacaine and 0.5% ropivacaine produced equivalent efficacy and safety in epidural anesthesia for a cesarean section, but levobupivacaine resulted in a longer duration of sensory block.

The Effect of Remifentanil with Sevoflurane in Subtotal Gastrectomy Patients with Patient Controlled Epidural Analgesia / 대한마취과학회지

BACKGROUND: Remifentanil is an ultra-short acting opioid, and its use has been known to be related to acute opioid withdrawal or tolerance. This study was performed to compare the hemodynamic response, recovery characteristics, and postoperative pain response after sevoflurane-remifentanil or sevoflurane anesthesia in subtotal gastrectomy patients. METHODS: Sixty patients scheduled for gastrectomy were randomly allocated into two groups. Thoracic epidural catheterization was performed before anesthesia. Anesthesia was maintained with sevoflurane-remifentanil (SR group) or sevoflurane (SN group). We compared hemodynamic variables during surgery and recovery, the pain and sedation score during recovery, and the pain score and analgesic requirements during the postoperative period. RESULTS: Intraoperative blood pressure and heart rates in the SR group were lower than in the SN group. There was no significant difference in extubation time and recovery time between patients in the two groups. The patients in the SN group showed more prompt recovery at 15 minutes after extubation. The VAS scores and analgesic demand of the SR group were greater than in the SN group. CONCLUSIONS: Intraoperative use of remifentanil with sevoflurane may be related to increased postoperative pain.

The Effects of Midazolam or Propofol Combined with Remifentanil Infusion for Central Venous Catheterization in Children / 대한마취과학회지

BACKGROUND: Midazolam or propofol has been used for the procedural sedation in children. However, the combined use of remifentanil have not been widely investigated. The purpose of this study was to evaluate the effectiveness and safety of remifentanil infusion with intravenous anesthetics during the central venous catheterization in children. METHODS: After institutional review board approval and written informed consent from patients' parent, 20 children planned central venous catheterization for chemotherapy were randomly assigned into two groups. All patients were infused with remifentanil 0.1microng/kg/min. In M group, 0.3 mg/kg of midazolam bolus was injected and 0.1 mg/kg bolus were injected intermittently if the sedation was inadequate. In P group, 1.0 mg/kg of propofol bolus and 150microng/kg/min were infused. 0.5 mg/kg of propofol was given intermittently if the sedation was inadequate. Hemodynamic variables, end-tidal CO2 (EtCO2), bispectral index score (BIS) were monitored throughout the procedure. RESULTS: There were no significant differences in hemodynamic variables, sedation and recovery times. Oxygen saturation (SpO2) in P group was significantly lower than that of M group at 15 min after the start of infusion. EtCO2 in P group was significantly higher than that of M group at 10 min after the start of infusion. Hypoxemia (SpO2< 90%) were occurred in three patients of P group. There was no significant difference in BIS among the groups. CONCLUSIONS: The combined infusion of remifentanil 0.1microng/kg/min with midazolam provided successful sedation without airway assistance during the central venous catheterization in children.

The Correlation between Genetic Polymorphism of OPRM1 (A118G) and MDR1 (C3435T) with Analgesia and the Adverse Effects by Epidural Morphine / 대한마취과학회지

BACKGROUND: The effect of a single nucleotide polymorphism (SNP) of the micro-opioid receptor gene at nucleotide position 118 (OPRM1:118A > G) and the MDR1 gene (exon 26: C3435T) have an influence on the interindividual variability of clinical opioid pain therapy. This study aims to evaluate the correlation among pain control and side effects of epidural morphine and these pharmacogenetic modulators. METHODS: 194 patients who were undergoing abdominal surgery were included in the study. Patients received a morphine 2 mg bolus and 2 mg/day via epidural route. The VAS score and opioid side effects were checked at postoperative 6, 24 and 48 hr. Patients were genotyped for the known SNPs of the OPRM1 and MDR1. RESULTS: For the SNP of OPRM1, the mutated genotype frequency (homo-wild, heterozygous, and homo-mutants) were 36.8, 47.9 and 15.3%, respectively, and the mutated genotype frequencies for the MDR1 SNP were 46.7, 40.2 and 13.1%, respectively. There were no significant differences in the VAS scores and side effects among the three groups of OPRM1 and MDR1. Yet carriers of the mutated allele 3435 TT, CT of the MDR1 gene showed marginally greater significant sedation effects than did non-carriers (CC) (P = 0.065, the OR was 1.78, 95% CI 0.98-3.24, P = 0.059) and also a lower incidence of analgesic usage (P =0.058). CONCLUSIONS: In our data there was a large difference in OPRM1 SNP allele frequency for the Korean population compared to other populations. The SNP of OPRM1 and MDR1 genes did not have significant altered clinical morphine analgesia and side effects via the epidural route. But the SNP of MDR1 gene is more sensitive genetic predictor of the clinical side effects (especially for sedation) and analgesic effects by opioid.

A Case of Bart's Syndrome

Bart's syndrome was initially described as a genodermatosis characterized by congenital localized absence of the skin with blistering and nail deformities 1-3. However, it is considered as any type of epidermolysis bullosa(EB) with localized congenital absence of the skin on the extremities. A 33-day-old fbmale baby was presented with congenital absence of the skin over the left shin and dorsa of both feet which were covered with the thin, translucent, and brown-red glistening membranes. Blistering of the right calf and left great toe nail deformity were also noted. She was diagnosed as a recessive dystrophic EB by the histopathological, ultra- structural and immunomapping studies.

Treatment for Pseudocyst of the Auricle with Intralesional Injection of Minocycline: A Report of One Case / 대한피부과학회지

Pseudocyst of the auricle is a disease of degenerative cartilage associated with asymptomatic swelling of the external ear caused by an intracartilaginous accumulation of serous fluid. Histological examination shows an intracartilaginous cavity without an epithelial lining. This disease is characterized by frequent relapses despite various therapeutic approaches. In this report we describe one patient with pseudocyst of the auricle who was successfully treated with intralesional injection of 1 mg/mL of minocycline hydrochloride.

Study of Bacterial Distribution on the Skin of Psoriasis by Tape Method / 대한피부과학회지

BACKGROUND: Psoriasis is one of the relatively common chronic relapsing cutaneous disorders. The etiology and pathogenesis of the psoriatic skin lesion are still unknown. A colonization of microbacterial organisms especially Staphylococcus aureus (S. aureus) have been considered as a factor for development and exacerbation of psoriatic skin lesion. OBJECTIVES: The purpose of this study was to observe the bacteria on the skin of the patients with psoriasis and healthy normal persons, and evaluate the relations between bacterial density, S. aureus colonization, and severity of psoriatic skin lesions. MATERIALS & METHODS: Twenty two psoriasis patients and 25 healthy normal persons were involved for this study. Psoriasis patients were classified according to a severity estimated by PASI (Psoriasis Area and Severity Index) and activity of psoriatic skin lesions. Microbial sampling by tape method (3M, 5x5 cm) were performed on the psoriatic skin lesion and uninvolved skin in the patients of psoriasis, and on the inner forearm of the normal healthy person. Microbial sampling by a swab were also carried out from nasal mucosa. The tapes were gently contacted on the blood agar plate, and cultured in aerobic condition(30 degrees C) during 2-5 days and the numbers of colony forming unit (CFU) were estimated. RESULTS: The results were as follows; Total numbers of CFU in the lesion and uninvolved skin of psoriasis patients were significantly higher than those of the healthy controls (p0.05). The activity of psoriasis was relatively correlated with PASI score and total number of CFU (p0.05). There was a significant correlation between the numbers of S. aureus on the lesional and uninvolved skin and that on the nasal mucosa. (p<0.05). CONCLUSION: This study demonstrates that bacterial density is significantly higher on the psoriatic skin lesions, which suggests that bacterial colonization on the skin has a role in the development and exacerbation of the psoriatic lesion.

A Case of Adult T-cell leukemia / lymphoma / 대한피부과학회지

Adult T-cell leukemia/lymphoma (ATLL) is an often aggressive and fatal malignancy of mature CD4+ T lymphocytes, characterized by leukemia, lymphadenopathy, hypercalcemia and lytic bone lesions. Diagnosis of ATLL is based cm abnormal T lymphocytes in the peripheral blood and histologically and cytologically proven lymphoid malignancy with T cell surface antigens. Anti-HTLV-I serum antibodies and demonstration of clonality to HTLV-I proviral DNA are included. We report a case of ATLL in a 64-year-old man who had a painful nodule on the right cheek and multiple scattered papules and nodules on the trunk for 2 months. He had multiple cervical and axillary lymph node enlargements and hepatosplenomegaly. On laboratory finding peripheral leukocytes count was 33,400/mm3 with 63% atypical lymphocytes. Clover-shaped lyrnphocytes with multilobulated nuclei were found in peripheral blood and bone marrow. Histologic findings showed dense bandlike infiltrations of atypical lymphocytes in the dermis with angiocentricity. The surface phenotype of these abnormal cells were CD2+, CD3+, CD4+, CD30+ and HLA-DR+ and HTLV-I specific antibodies were found.

A Case of Solar Urticaria / 대한피부과학회지

Solar urticaria can be defined as an idiopathic photodermatosis characterized by the occurrence of itchy erythematous or urticarial lesions that are provoked only by sunlight and disappear nearly within 24 hours after avoidance of sun exposure. A 25-year-old male patient was presented with a 7-year history of recurrent wheals and itching, which developed after sunlight exposure. Cutaneous lesions and itching completely subside within 2 hours after avoidance of sunlight. Phototesting for UVB, UVA and visible light were all negative. But provocative test with natural sunlight showed positive result. Histopathologically, edema of papillary dermis and mild perivascular inflammatory infiltrations were seen.

Two Cases of Herpetic Syringitis / 대한피부과학회지

The histology of herpes virus infection of the skin is characterized as an intraepidermal vesicle formed as the result of acantholysis and ballooning degeneration of kerationocytes. Dermal changes is limited to polymorphous inflammatory cells infiltrate, leukocytoclastic vasculitis, and herpetic folliculitis. Involvement of eccrine epithelium is very rare finding. We report two cases of herpes zoster with prominent viral infection of the eccrine sweat glands.

A Case of Rowell's Syndrome / 대한피부과학회지

Rowell's syndrome is described as erythema multiforme(EM)-like lesions in the presence of lupus erythematosus(LE) associated with immunoserological characteristics of speckled antinuclear antibodies and positive tests for anti-Ro/La antibodies and rheumatoid factor. We report a case of Rowell's syndrome in a 28-year-old woman with systemic lupus erythematosus for 13 years, who presented with targetoid eruptions on the right arm and with positive immunoserologic findings as above.

Radial Artery Approach for Transcatheter Arterial Chemoembolization in Patients with Hepatocellular Carcinoma

PURPOSE: To evaluate the feasibility and usefulness of the transradial approach for intra-arterial chemoembolization therapy in patients with hepatocellular carcinomas. MATERIALS AND METHODS: Twenty-nine patients with hepatocellular carcinoma who underwent intra-arterial chemoembolization via the radial artery approach were involved in this study. All underwent Allen's test to check ulnar arterial patency. In all cases, we used the radial approach hepatic artery (RHA) catheter designed by ourselves, evaluating the selection ability of the hepatic artery using an RHA cathter, the number of punctures, the procedure time, and compression time at the puncture site as well as complications occurring during and after the procedure. RESULTS: Except for three in which puncture failure, brachial artery variation or hepatic artery variation occurred, all procedures were successful. The mean number of punctures was 3.5, and the average duration of the whole procedure was one and half hours. This gradually decreased as the number of procedures increased. The average duration at a compression of puncture site was 12 minutes. There were no major complications. Minor complications included minimal intimal dissection of the radial artery (3.8%), reversible vasospasm of the radial artery (7.7%), hematoma at a puncture site (7.7%) and transient neurologic deficit (3.8%). CONCLUSION: The transradial approach using an RHA catheter for intra-arterial chemoembolization therapy in patients with hepatocellular carcinomas was technically feasible, with acceptable levels of safety. It may be a good alternative to absolute bed rest with a sand bag after the femoral approach.

Development of the Single Nodular VX-2 Carcinoma Model in Rabbit Liver: Tissue Chip Implantation under Ultrasonographic Guidance

PURPOSE: To implant tissue chips in New Zealand rabbits, and thus redurce the frequency with which scattered VX2 carcinoma nodules and early metastasis develop in these animals. MATERIALS AND METHODS: VX2-carcinoma tissue chips of two different sizes were implanted under ultrasonographic guidance. In each of 12 New Zealand rabbits (group 1), there 1-mm tissue chips were implanted in the liver using an 18-gauge needle, and in the same way, one 3-mm chip with an added gelfoam pellet was implanted in the proximal lumen of the liver of each of ten other New Zealand rabbits (group 2). Three weeks after implantation, the animals underwent dvalphase CT scanning and were sacrificed, and the Number and size of tumor nodules, and metastasis were evaluated either macro-or microscopically. RESULTS: In ten rabbits in group I, a total of 21 nodules (16 in the liver, 5 in the peritoneal wall) were observed, which in nine rabbits in group 2, a total of ten nodules-all in the liver-were present. CT scans depicted tumor nodules in 50% of group-I rabbits, and in 29% those in group 2. Mean tumor diameter was 12 +/-9 mm in group 1 and 6.4 +/-3 mm in group 2. Histologic examination indicated the presence of nodular VX2 carcinoma, with varying degrees of central necrosis, a feature more prominent in group 2. CONCLUSION: To provide a well-localized tumor nodule in rabbit liver, tissue chip implantation of VX2 carcinoma, especially with added gelfoam, is a good alternative to intraparenchymal injection of tumor suspension.

Expression of Antigen Presenting Function-Associated Surface Molecules on Interferon gamma-Treated Gingival Fibroblasts and Periodontal Ligament Fibroblasts / 대한치주과학회지

It is becoming increasingly clear that human gingival fibroblasts(HGF) may play a role in regulating immune responsiveness in inflammatory periodontal lesions. Stimulation of HGF with locally-secreted T cell cytokine IFNgamma induces human leukocyte antigen class II(HLA II) expression on HGF, which is one of the characteristic feature of professional antigen presenting cells(pAPC). However, IFNgamma-treated HGF and other nonprofessional antigen presenting cells(npAPC) are known to be ineffective or less effective antigen presenter to resting T cells. This study, therefore, was undertaken in an effort to elucidate the differences in expression of cell surface molecules between npAPC in periodontal tissues, such as HGF and periodontal ligament fibroblasts(PDLF), and pAPC such as monocytes/macrophages. Using flow cytometry, the levels of cell surface expression of HLA-D, ICAM-1, LFA-3, and B7-1, which are involved in antigen presentation, were determined in HGF, PDLF and human myelomonocytic cell line THP-1. IFNgamma clearly induced HLA-D expression on both of fibroblasts and monocytes dose dependently. However, expression level on monocytes were 4 to 5 times higher than that on fibroblasts, and induction rate was faster in monocytes than in fibroblasts. The levels of ICAM-1 expression on fibroblasts and monocytes were enhanced by IFNgamma in a dose dependent manner. On the other hand, the expression of LFA-3 molecule, which could be detected in fibroblasts and monocytes without cytokine stimulation, was no more enhanced by addition of IFNgamma. B7-1, important costimulatory molecule in T cell activation and proliferation, was not detected on both of fibroblasts and monocytes even when stimulated with IFNgamma, except on monocytes fully differentiated by pretreatment of PMA and treated by IFNgamma. These results suggest that delayed expression of HLA-D and absence of B7-1 on IFNgamma -treated fibroblasts may at least in part be involved in the ineffectiveness of fibroblasts as primary APC. And it is postulated that although periodontal fibroblasts may not serve as primary APC in normal periodontium, sustained expression of HLA II on ubiquitous fibroblasts in inflammatory lesions may perpetuate immune responses and produce chronic inflammation and tissue injury.