Application of Advance Directives for Patients with End Stage Renal Disease / 대한신장학회지

PURPOSE: In other countries, government guidelines related to chronic illness are being used to enhance supportive care of renal patients. In Korea, the number of old ages and hemodialysis patients with many complications has been increased. But we don't have any guidelines for palliative care of end stage renal disease. This paper reports a study exploring decisions about end-of-life treatment (e.g. cardiopulmonary resuscitation, renal replacement therapy) via routine use of advance directives in people with end stage renal disease undergoing hemodialysis. METHODS: 1) We revised advance directives in Seoul Medical Center. 2) We recommended the routine use of advance directives to patients who were treated in hemodialysis room of Seoul Medical Center from Jan, 2007 to Jun, 2007. So 35 patients were enrolled. 3) They had been interviewed about end- of-life treatment plans and filled up advance directives. RESULTS: 23 males and 12 females in total were enrolled. The advance directives include 18 questions about patient preferences for treatment of end-of-life. The majority of hemodialysis patients replied "I will follow doctor's decisions including cardiopulmonary resuscitation and renal replacement therapy" 8 females (67%), 15 diabetes (53%) and 11 geriatric patients above 60yrs old (52%), however, were against cardiopulmonary resuscitation. CONCLUSION: Routine use of advance directives will provide basic sources for end-of-life decisions in the care of end stage renal patients. And they would like to keep the high quality of life with the help of prepared therapeutic plan of care and well-dying presented advance directives.

Two Cases of Successful Clipping Closure of Iatrogenic Duodenal Perforation Occurred during Endoscopic Procedure / 대한소화기내시경학회지

The risk of complications associated with endoscopic procedures, including bleeding and perforation, tends to increase due to the magnification of the therapeutic endoscopic spectrum. In cases of duodenal perforation, surgical closure is the treatment of choice; however, there have been some cases in which the nonsurgical treatment of an iatrogenic duodenal perforation during an endoscopic procedure was effected via endoscopic clipping closure. Here, we report two cases of successful endoscopic clipping closure of an iatrogenic duodenal perforation occur ring during a duodenoscopy insertion for ERCP and endoscopic mucosal resection for the treatment of duodenal adenoma.

A Case of Isolated ACTH Deficiency Manifestated by Atrial Fibrillation and Hypoglycemia / 대한내분비학회지

Isolated ACTH deficiency is a rare cause of secondary adrenocortical insufficiency caused by the defect of synthesis or release of ACTH in pituitary gland. The clinical presentation can be simiilar to that of primary adrenal insufficiency, but there is a greater tendency for hypoglycemia and absence of hyperpigmentation. The patient, 80 year-old female, was admitted in chief complaint of deteriorated mental states. On admission, serum sodium was 127mEq/L, potassium 4.4mEq/L, blood glucose 27mg/dL and on routine E.C.G. was atrial fibrillation was revealed. The basal morning serum cortisol level was 9.97 pg/dL it dosent respond to insulin-induced hypoglycemia enoughly, but other pituitary functions were intact in pituitary cocktail stimulation test. In CRH stimulation test, there was no remarkable response in serum ACTH and cortisol level. Brain MRI failed to reveal any anatomic abnormalities of the sellar or suprasellar area consistent with the defect of pituitary ACTH secretion. This case was a isolated ACTH deficiency, So, we conclude that associated with atrail fibrillation and hypoglycemia.