TWNK Gene Associated Perrault Syndrome Patient with Neurological Features

Perrault syndrome 5 is a rare autosomal recessive disorder that is characterized by the association of sensorineural hearing loss and ovarian dysgenesis in females with diversity of neurologic deficits due to variants of twinkle mtDNA helicase (TWNK) gene. Since neurologic deficits develop gradually, patient is often misdiagnosed with other neurological disease during early age. Herein, we report a case of genetically diagnosed Perrault syndrome 5.

Risk and protective factors affecting sensory recovery after breast reconstruction

Background@#Although loss of sensation in patients with breast cancer after mastectomy followed by breast reconstruction is an important factor affecting patients’ quality of life, the mechanism of sensory recovery is still unclear. Our study aimed to identify variables that affect sensory recovery, especially pain, in reconstructed breasts. @*Methods@#All patients with breast cancer who underwent mastectomy followed by immediate breast reconstruction, including nipple reconstruction or areolar tattooing, were included in this study. Sensation was evaluated in the nipple as an endpoint of sensation recovery of the whole breast. Patients rated pain severity using a 3-point verbal rating scale (VRS): grade 0, no pain; grade 1, mild to moderate pain; and grade 2, severe pain. The VRS was assessed by a single experienced plastic surgeon. @*Results@#In the univariate analysis, the odds ratio (OR) for sensation recovery was 0.951 for age (P=0.014), 0.803 for body mass index (P=0.001), 0.996 for breast volume before surgery (P=0.001), 0.998 for specimen weight after mastectomy (P=0.040), and 1.066 for the period between mastectomy and sensory assessment (P=0.003). In the multivariate analysis, the variables that showed a significant effect were age (OR, 0.953; P=0.034), the period between mastectomy and sensory assessment (OR, 1.071; P=0.006), and reconstruction using abdominal tissue instead of prosthetic reconstruction (OR, 0.270; P=0.004). @*Conclusions@#Based on our results, it can be inferred that aging has a negative impact on the recovery of sensation, breast sensation improves with time after surgery, and the recovery of sensation is better in prosthetic reconstruction.

Treatment strategy for skin and soft tissue infections caused by nontuberculous mycobacteria following various procedures

Background@#The early diagnosis and treatment of skin and soft tissue infections caused by nontuberculous mycobacteria (NTM) are important, especially as infections with rapidly growing mycobacteria (RGM) are rare and difficult to diagnose and treat. Recently, we identified 22 cases of NTM infections; in this study, we suggest treatment strategies by analyzing the demographic characteristics and treatment progress of these patients. @*Methods@#A retrospective study of patients with NTM infections from 2009 to 2019 was conducted. To identify NTM infections, acid-fast bacillus (AFB) staining, Gram staining, polymerase chain reaction (PCR), and cultures of mycobacteria were performed. Empirical treatment with a combination of antibiotics or surgery was performed; species identification and drug susceptibility tests were performed by the Korean National Tuberculosis Association. The final regimen was determined after obtaining the test results. @*Results@#The mean incubation time of NTM was 4.32±2.88 weeks. RGM were detected in mycobacterial cultures in 21 of the 22 NTM patients. The results of AFB staining were negative in all patients, although PCR was positive for NTM in one patient. Fourteen patients were hospitalized for treatment with intravenous antibiotics and surgery. Treatment with a combined regimen of oral antibiotics was maintained for a mean of 5.41±1.85 months. @*Conclusions@#The unusual clinical manifestations of skin and soft tissue infections caused by NTM make them difficult to diagnose. Suspicion of NTM based on clinical presentation and a detailed examination should be followed by proper treatment involving multiple antibiotics and surgery in these patients.

Correction of Eyes and Lip Canting after Bimaxillary Orthognathic Surgery

Patients who have a lower facial asymmetry with compensatory head posture (developmental facial asymmetry) may have minor temporomandibular (T-M) joint problems and tend to mask their asymmetry by tilting the head for camouflage of their chin deviation. However, this compensatory head posture can give the impression of orbital dystopia and c spine deviation. When these patients undergo bimaxillary orthognathic surgery, orbital canting and head tilting improves gradually without the need for camouflage, and bleary eyes become clearer. We evaluated 13 patients who underwent LeFort I osteotomy combined with bilateral sagittal split osteotomy of the mandible for developmental facial asymmetry to quantitatively observe whole facial postural changes after surgery. Pre-operative and post-operative 1:1 full-face photographs of the patients were analyzed to compare the degrees of head tilting and orbital canting and the sizes of the eye opening. After bimaxillary orthognathic surgery, eye canting decreased from 2.6° to 1.5°, eye and lip lines came closer to parallel, and the degree of head tilting decreased from 3.4° to 1.3°. The eyes also appeared to open wider. Correction of lower facial skeletal asymmetry through bimaxillary orthognathic surgery improved head tilting and orbital canting gradually by eliminating the need of compensatory head posture. Facial expressions also changed as the size of the eyes increased due to the reduction of facial muscle tension caused by T-M joint dysfunction.

Effects of magnesium sulfate on remifentanil requirements for achieving hemodynamic stability during laparoscopy assisted distal gastrectomy

BACKGROUND: Magnesium is known to reduce the requirement of analgesic agents by blocking calcium channels that exist at the neuronal and neuromuscular junctions. However, former studies have shown inconsistent results regarding this concept. Therefore, we investigated the effects of magnesium on remifentanil requirements for achieving hemodynamic stabilization in patients undergoing laparoscopic gastrectomy. METHODS: Laparoscopic gastrectomy patients (n = 30) were randomly divided into two groups. Group M received 50 mg/kg of magnesium sulfate for 15 minutes prior to the induction of anesthesia. Then, 20 mg/kg/h of magnesium was administered during the operation time. Group N was administered the same amount of saline. Anesthesia was maintained with intravenous propofol and remifentanil injection. Vecuronium (0.1 mg/kg) was administered before intubation, and an additional 0.02 mg/kg was administered if a T1 twitch response was observed during surgery. Anesthetic time was standardized to provide an appropriate comparison of all patients. During 100 minutes, total anesthetic requirements and anesthetic requirements at every 10 minutes were analyzed. Postoperative pain was controlled with a patient controlled analgesia device. RESULTS: The remifentanil and vecuronium requirements during 100 minutes were significantly lower in Group M. There was no significant difference in propofol requirements between the two groups. No significant difference was observed in mean arterial pressure and heart rate. Postoperative VAS, PONV, or shivering also did not show any difference between the two groups. CONCLUSIONS: Magnesium reduced remifentanil and vecuronium requirements but not propofol requirements. Magnesium seems to have antinociceptic properties and reduces remifentanil requirements.

Accidental avulsion of the cuff after one-lung ventilation by using the Coopdech bronchial blocker: A case report

A variety of anesthetic equipment has been introduced for one-lung ventilation (OLV) during video-assisted thoracoscopic surgeries. A double-lumen endobronchial tube or bronchial blockers are the most common techniques used for achieving OLV. We herein describe a case of general anesthesia requiring both the OLV and two-lung ventilation with a Coopdech bronchial blocker and a single-lumen endotracheal tube. A 43-year-old woman is being scheduled to undertake mediastinal mass removal and tonsillectomy. After performing tonsillectomy by using an endotracheal tube, a Coopdech bronchial blocker is being inserted into her right bronchus for video-assisted thoracoscopic surgery. After her surgery, we have encountered resistance while carefully trying to remove the bronchial blocker. When using fiberoptic bronchoscopy, we have observed that the cuff was being avulsed, which could be removed without difficulty. We thus describe a case in which the balloon cuff was detached and retained in the right bronchus.

The synergistic effect of gentamicin and clindamycin on rocuronium-induced neuromuscular blockade / 대한마취과학회지

BACKGROUND: Gentamicin reduces acetylcholine release and clindamycin causes end-plate ion channel blockade. Because of these reasons, two drugs show muscular relaxant effect and potentiate the action of nondepolarizing neuromuscular agents. This study was intended to evaluate the effect of gentamicin and clindamycin on rocuronium-induced neuromuscular blockade and the interaction between these drugs. METHODS: Male Sprague-Dawley rats' phrenic nerves and diaphragms were installed in a bath containing Krebs solution. They were divided into three study groups. The first group was pre-treated with 0.1 (n = 3), 0.2 (n = 4) or 0.5 (n = 3) mM gentamicin and the tension was measured as the concentration of rocuronium was increased. The second group was experimented by increasing gentamicin on 0.25 (n = 5), 0.5 (n = 6) or 1.0 (n = 6) mM clindamycin. The final group was pre-treated with various combinations of gentamicin and clindamycin. The drug concentration was gradually increased until single twitch tension decreased by around 80%. Effective concentration was calculated using a probit model and interaction indices derived the Loewe additivity. RESULTS: The administration of gentamicin and the combination of gentamicin and clindamycin enhanced rocuronium-induced neuromuscular blockade. At 0.2 and 0.5 mM gentamicin, synergistic interactions with rocuronium were observed. Likewise, at 0.5 and 1.0 mM clindamycin, synergistic interactions with gentamicin appeared. When all three drugs were combined, in the tetanic fade, all the groups except for those administered with 0.01 mM gentamicin and 0.25 mM clindamycin showed synergistic interactions. CONCLUSIONS: This study demonstrate that gentamicin and clindamycin potentiated rocuronium induced neuromuscular blockade. Moreover, it was found that these drugs interacted synergistically.

The safety and efficacy of minimal-flow desflurane anesthesia during prolonged laparoscopic surgery / 대한마취과학회지

BACKGROUND: Minimal-flow anesthesia can meet the demands of a modern society that is more sensitive to environmental protection and economic burdens. This study compared the safety and efficacy of minimal-flow desflurane anesthesia with conventional high-flow desflurane anesthesia for prolonged laparoscopic surgery. METHODS: Forty-six male patients (ASA physical status II or III) undergoing laparoscopic urologic surgery for more than 6 hours were randomly divided into two groups: the high-flow (HF) group and the minimal-flow (MF) group. The HF group was continuously administered a fresh gas flow of 4 L/min. In the MF group, a fresh gas flow of 4 L/min was administered for the first 20 minutes and was thereafter lowered to 0.5 L/min. Inspiratory and expiratory desflurane concentrations, respiratory variables, and hemodynamic variables were continuously monitored during administration of anesthesia. Measurements of carboxyhemoglobin (COHb) concentration and arterial blood gas analysis were performed every 2 hours during anesthesia. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), blood urea nitrogen (BUN) and creatinine were measured on the first and second day after the surgery. RESULTS: Demographic data and duration of anesthesia were not different between the two groups. Significant differences were not observed between the two groups in terms of hemodynamic variables, respiratory variables, and inspiratory and expiratory desflurane concentrations. Inspiratory O2 concentration was maintained lower in the MF group than in the HF group (43-53% vs. 53-59%; P < 0.05). Compared with the HF group, COHb concentrations was higher (P < 0.05), but not increased from the baseline value in the MF group. Serum AST, ALT, BUN, and creatinine were not significantly different between the two groups. CONCLUSIONS: In prolonged laparoscopic surgery, no significant differences were found in safety and efficacy between minimal-flow and high-flow desflurane anesthesia.

Application of Periareolar Approach to Diverse Mammoplasty

Augmentation mammoplasty can be performed through various ways such as transaxillary, inframammary, periareolar and transumbilical approaches according to the patient's breast contour, body shape, and patient's and physician's preference. Each approach has unique pros and cons. From March, 2000 to October, 2002, we have applied periareolar approaches for augmentation mammoplasties in 69 patients, 134 breasts. Periareolar approach has several advantages. It is easy to access to the subpectoral space technically because of shorter distance and direct visualization. It requires smaller incision and leaves inconspicuous scar. Using endoscope, precise dissection of subpectoral space and hemostasis during operation could be achieved. We have kept fill-tube attached to the saline implant even after the surgery in selective cases. On the following day after the surgery, patients could check her breast contour, size, and symmetry by themselves in front of the mirror. Additional adjustment of implant volume was possible in the range of 10 to 15 per cent and it would decrease patient's complaint about the final result. We have introduced endoscope in periareolar augmentation mammoplasty in some cases. It allows us direct visualization of the subpectoral space and the origin of the pectoralis major muscle, and more accurate manipulation and hemostasis were possible. We have applied periareolar approach to various situations such as primary procedures in hypoplastic breasts, asymmetric breasts and secondary procedures in capsular contracture, rupture of mammary implant and combined operation with breast cancer or inverted nipple. Periareolar approach can be applied for diverse cases of mammoplasty, whether it is primary or secondary procedure, successfully because of its easiness, convenience, safety, economical efficacy and positive effect for doctor-patient relationship.

Effects of Aesthetic Plastic Surgery on Anxiety, Depression and Social Discomfort

While studies spanning four decades have reported that most people undergoing cosmetic interventions are satisfied with the results, what has been less studied is the outcome in psychosocial terms. Authors have attempted to evaluate whether improvement in psychosocial wellbeing following cosmetic enhancement can be objectively evaluated. From August, 2002 to June, 2003, forty patients who have received cosmetic surgery such as blepharoplasty, rhinoplasty, facial scar revision, mammoplasty were investigated on anxiety, depression and social discomfort by answering questionnaires repeatedly at preoperative, immediately postoperative and 3 months postoperative visits. The results were analyzed and statistically processed using psychological methods including Spielberger's State-Trait Anxiety Inventory (STAI), Beck's Depression Inventory(BDI), Social Avoidance & Distress Scale(SAD), Sheehan's Disability Scale. The study observed that there happens anxiety and depression, social discomfort at work and home, and various social activities have decreased in the patients after cosmetic surgeries. But satisfactory feeling in general lives of the patients has not been improved after cosmetic surgeries. In our study, cosmetic surgeries gave the patients enhancement in several psychosocial problems, but long term improvement about the satisfaction of general life needs other changes in wide range of life.