Getting patient blood management Pillar 1 right in the Asia-Pacific: a call for action

Preoperative anaemia is common in the Asia-Pacific. Iron deficiency anaemia (IDA) is a risk factor that can be addressed under patient blood management (PBM) Pillar 1, leading to reduced morbidity and mortality. We examined PBM implementation under four different healthcare systems, identified challenges and proposed several measures: (a) Test for anaemia once patients are scheduled for surgery. (b) Inform patients about risks of preoperative anaemia and benefits of treatment. (c) Treat IDA and replenish iron stores before surgery, using intravenous iron when oral treatment is ineffective, not tolerated or when rapid iron replenishment is needed; transfusion should not be the default management. (d) Harness support from multiple medical disciplines and relevant bodies to promote PBM implementation. (e) Demonstrate better outcomes and cost savings from reduced mortality and morbidity. Although PBM implementation may seem complex and daunting, it is feasible to start small. Implementing PBM Pillar 1, particularly in preoperative patients, is a sensible first step regardless of the healthcare setting.

Gender affirmative care of transgender people: a single center's experience in Korea

OBJECTIVE: To investigate the clinical characteristics and medical management of transgender people in South Korea. METHODS: The electronic medical records of 54 transgender persons who had visited Soonchunhyang University Hospital from January 2016 to December 2017 for medical care were retrospectively reviewed. We identified patient demographics and gender identity-related characteristics. Moreover, we compared our hospital protocol with official guidelines. RESULTS: At the time of the medical record search, the average age of these 52 transgender persons was 27 years, and 46 (88.5%) were Korean. Ten (19.2%) persons had a mental disorder other than gender dysphoria. Gonadotropin-releasing hormone agonist, estrogen, antiandrogen agents, and testosterone were used according to the guidelines issued by the World Professional Association for Transgender Health and the Endocrine Society. Ten (19.2%) transgender persons, including 6 (22.2%) male-to-females (MTFs) and 4 (16.0%) female-to-males (FTMs), had a mental disorder other than gender dysphoria. Among persons who were administered testosterone, 3 had high triglyceride and lipoprotein cholesterol levels. Nine patients, including 6 (66.7%) MTFs and 3 (33.3%) FTMs, underwent both gonadectomy and gender affirmative surgery. Seven (43.8%) persons, including 1 (14.3%) MTF and 6 (85.7%) FTMs, underwent only gonadectomy. There was a significant difference (P=0.040) between MTFs and FTMs. CONCLUSION: Medical providers should have adequate knowledge of and experience in managing transgender persons and be familiar with the relevant guidelines and literature. Long-term follow-up examinations should also be performed.

Development of a Transfusion-Indication Data-Entry Program and Analysis of Transfusion Indications at a University Hospital in Korea / 대한수혈학회지

BACKGROUND: Transfusion guidelines are not only essential for the optimal use of blood products, but also help reduce transfusion-related adverse reactions and improve patients' outcomes. In this hospital, a transfusion-indication data-entry program based on the national transfusion guidelines was developed and applied to the electronic medical record system in 2016. All transfusion orders, except for emergencies, have been performed using this program since then. This study analyzed the reasons for the transfusion to monitor the blood product usage and provide feedback to clinicians.

Blood Management Protocol without Transfusion in Orthopedic Surgery / 대한수혈학회지

We developed a new blood management protocol that allows patients to not undergo transfusion during major orthopaedic surgery. Here, we report the safety of or our protocol. The preoperative pharmacological protocol consisted of the administration of 40 µg of recombinant erythropoietin subcutaneously and 100 mg of iron supplements intravenously. During the operation, reinfusion of drainage blood using a cell saver and plasma expander was used. The cell saver device passed the collected blood through a filter, which washed the blood, removing the hemolyzed cells and other impurities. Intravenous tranexamic acid 1 g is given just before the operation, except high-risk patients for venous thromboembolism. Postoperatively, recombinant erythropoietin and iron supplements were administered in the same manner with the preoperative protocol and continued until a hemoglobin level reached 10 g/dL.

Comparison of Morphological Characteristics of the Subaxial Cervical Spine between Athetoid Cerebral Palsy and Normal Control

OBJECTIVE: To compare the morphometry of subaxial cervical spine between cerebral palsy (CP) and normal control. METHODS: We retrospectively analyzed 72 patients with CP, as well as 72 patients from normal population. The two groups were matched for age, sex, and body mass index. Pedicle, lateral mass (LM), and vertebral foramen were evaluated using computed tomography (CT) imaging. Pedicle diameter, LM height, thickness, width and vertebral foramen asymmetry (VFA) were measured and compared between the two groups. Cervical dynamic motion, disc and facet joint degeneration were investigated. Additionally, we compared the morphology of LM between convex side and concave side with cervical scoliotic CP patients. RESULTS: LM height was smaller in CP group. LM thickness and width were larger in CP group at mid-cervical level. In 40 CP patients with cervical scoliosis, there were no height and width differences between convex and concave side. Pedicle outer diameter was not statistically different between two groups. Pedicle inner diameter was significantly smaller in CP group. Pedicle sclerosis was more frequent in CP patients. VFA was larger in CP group at C3, C4, and C5. Disc/facet degeneration grade was higher in the CP group. Cervical motion of CP group was smaller than those of the control group. CONCLUSION: LM morphology of CP patients was different from normal population. Sclerotic pedicles and vertebral foramen asymmetry were more commonly identified in CP patients. CP patients were more likely to demonstrate progressive disc/facet degeneration. This data may provide useful information on cervical posterior instrumentation in CP patients.

Comparison of Morphological Characteristics of the Subaxial Cervical Spine between Athetoid Cerebral Palsy and Normal Control

OBJECTIVE: To compare the morphometry of subaxial cervical spine between cerebral palsy (CP) and normal control.METHODS: We retrospectively analyzed 72 patients with CP, as well as 72 patients from normal population. The two groups were matched for age, sex, and body mass index. Pedicle, lateral mass (LM), and vertebral foramen were evaluated using computed tomography (CT) imaging. Pedicle diameter, LM height, thickness, width and vertebral foramen asymmetry (VFA) were measured and compared between the two groups. Cervical dynamic motion, disc and facet joint degeneration were investigated. Additionally, we compared the morphology of LM between convex side and concave side with cervical scoliotic CP patients.RESULTS: LM height was smaller in CP group. LM thickness and width were larger in CP group at mid-cervical level. In 40 CP patients with cervical scoliosis, there were no height and width differences between convex and concave side. Pedicle outer diameter was not statistically different between two groups. Pedicle inner diameter was significantly smaller in CP group. Pedicle sclerosis was more frequent in CP patients. VFA was larger in CP group at C3, C4, and C5. Disc/facet degeneration grade was higher in the CP group. Cervical motion of CP group was smaller than those of the control group.CONCLUSION: LM morphology of CP patients was different from normal population. Sclerotic pedicles and vertebral foramen asymmetry were more commonly identified in CP patients. CP patients were more likely to demonstrate progressive disc/facet degeneration. This data may provide useful information on cervical posterior instrumentation in CP patients.

Efficacy and safety of drospirenone 2 mg/17β-estradiol 1 mg hormone therapy in Korean postmenopausal women

This regulatory post-marketing surveillance study aimed to evaluate the therapeutic efficacy and safety of drospirenone (DRSP) 2 mg/estradiol (E₂) 1 mg tablet in Korean postmenopausal women. A total of 4,149 patients were enrolled and the study was conducted at 207 clinical research centers. The patients' source data was collected between November 2006 and November 2012. More than 85% of patients experienced improvement of menopausal symptoms. The most frequently reported adverse events were vaginal bleeding and breast pain; most of the women suffering from these symptoms fully recovered. The incidence of adverse event was higher in patients of younger age (20 to 39 years), in patients with concomitant diseases, previous hormone replacement therapy in medical history, those treated with DRSP 2 mg/E₂ 1 mg for shorter duration (3 years or less) and in patients using concomitant medication. In conclusion, the results from this large post-marketing surveillance study confirm the efficacy and safety of DRSP 2 mg/E₂ 1 mg tablet in Korean postmenopausal women.

Tamoxifen-associated polypoid endometriosis mimicking an ovarian neoplasm

Tamoxifen has been widely used for adjuvant treatment of breast cancer, but several gynecological side effects have been noted, including endometrial hyperplasia, polyp and carcinoma. Polypoid endometriosis is one of the extremely rare benign complications associated with tamoxifen therapy. A 66-year-old postmenopausal woman, who had received left partial mastectomy due to breast cancer (about 4 years ago) and was taking tamoxifen treatment, had an ovarian cyst on ultrasonography. Pelvic magnetic resonance imaging suggested tamoxifen-associated endometrial and ovarian changes, especially a 4.1x3.4-cm-sized, well-defined, multicystic mass in the right ovary. She received hysterectomy with bilateral salpingo-oophorectomy. Microscopically, the right paratubal mass showed endometrial glands and stroma, and immunohistochemical staining for CD10 confirmed the endometrial nature of the stroma. Three cases of polypoid endometriosis have been reported in the Korean literature, but in none of the cases, polypoid endometriosis was associated with tamoxifen use. Herein, we report the first case of polypoid endometriosis associated with tamoxifen treatment in Korea.

A survey on the sexual behavior of adolescents in South Korea: The third survey in 2007 / 대한산부인과학회지

OBJECTIVE: The survey was conducted to improve the health of Korean adolescents and to prepare adequate teaching programs by investigating their sexual behavior. METHODS: The participants of the survey was 80,000 middle and high school students aged 13 to 18. The survey was conducted from September 1st, 2007 to September 22nd, 2007. RESULTS: 78,834 students were surveyed and 74,698 (94.8%) students responded the survey. 35,232 (47.2%) of respondents were male students and 39,466 (52.8%) of respondents were female students. 38,820 (52.0%) of respondents were middle school students, 25,051 (33.5%) of respondents were high school students and 10,827 (14.5%) of respondents were technical high school students. 5.2% of respondents experienced sexual intercourse. The average age of the first sexual intercourse was 14.2 years old. 1.0% of respondents had a sexual intercourse before they enter the middle school. The pregnancy rate was 0.3%. Among respondents who experienced sexual intercourse, the rate of the use of contraceptive methods was 38.2%. The rate of using inappropriate contraceptive methods was 21.6%. The average age of a first wet dream for boys was 13.2 years old. The average age of menarche for girls was 12.4 year old. The rate of respondents who had a sex education was 72.2%. CONCLUSION: The average age of the first wet dream and menarche had been decreased. The average age of the first sex experience among adolescents had been decreased. The rate of adolescents who experienced a sexual intercourse was increased. However, the rate of using reliable contraceptive methods was very low. Therefore, adequate sex educations including effective contraceptive methods needs to be conducted to prevent unwanted pregnancy of adolescents.

Sclerosing stromal tumors of the ovary occurred in various ages / 대한산부인과학회지

Sclerosing stromal tumor (SST) of the ovary is a rare, benign tumor. The most common clinical symptom is menstrual irregularity. Diagnosis of SST is often made by postoperative pathologic examination. The important differential diagnoses are other sex cord stromal tumors including fibroma, thecoma and etc. We present four cases of SST of the ovary during 10 years with a brief review of the literature.

A case of pelvic desmoplastic small round cell tumor in a old aged woman / 대한산부인과학회지

Peritoneal desmoplastic small round cell tumor is a very rare and highly aggressive neoplasm that predominantly strikes male children and young adults. It frequently presents as a large abdominal mass with widespread peritoneal involvement at diagnosis. We report one case of desmoplastic small round cell tumors in the pelvis in a old aged woman with a brief review of literature.

A survey of sexual behavior of teenagers in South Korea: 2006 / 대한산부인과학회지

OBJECTIVE: This research was performed to improve the health of Korean adolescents and to prepare adequate teaching programs by investigating their sexual cognition and behavior and preparing for adequate programs. METHODS: We conducted a survey of eighty thousand middle and high school students whose ages range from 13 to 18, during the period of September 1st, 2006 to October 30th, 2006. RESULTS: 78,593 people are polled and 71,404 people responded. Accordingly, the response rate was 90.0%: 52.1% (37,204) of the respondents were boys and 47.9% (34,200) were girls; 52.4% (37,420) of respondents were middle school students, 32.9% (23,500) of them were high school students, and 14.7% (10,479) of them were technical high school students. The rate of respondents who had experienced sexual relationship was 5.1%. The average age of starting sexual relationship was 14.2 year old. The rate of respondents who had experienced sexual relationship before they go to the middle school was 1.0%. The rate of pregnancy experience was 0.5%. The rate of respondents who were using a contraceptive method was 38.1%. The average boys age of having the first wet dream was 13.1 years old and girls of starting menstruation was 12.5 year old. The rate of using inappropriate contraception was 24.3%. The rate of having a sex education per a year was 62.0%. CONCLUSION: This research shows that the rate of adolescents who are experiencing sexual relationship is increasing. Besides, the age of adolescents starting sexual relationship is decreasing as their age of starting wet dream and menstruation decreases. As a result, it is strongly asserted that adequate sex education programs are indispensable to adolescents.

One case of adenomatoid tumor of uterus / 대한산부인과학회지

Adenomatoid tumor of uterus is described by Golden and Ash as a tumor that similar to adenoma but found obscured histogenesis. Adenomatoid tumor is a rare benign disease that originated from mesothelium and mostly occurred in male and rarely in female, and can be treated by simple excision of tumor because there is no recurrence or malignant change. We describe the clinical and histologic findings with references to other reported cases. We herein report a case of adenomatoid tumor of the uterus that gets an operation under clinical impression of myoma uteri.

A spontaneous pregnancy and Cesarean delivery in a Turner mosaic with previous recurrent miscarriages / 대한산부인과학회지

Ovarian failure and infertility are typical features in Turner syndrome. Conception without ovum donation is very rare. We experienced one case of pregnancy and Cesarean delivery in a Turner mosaic with previous recurrent miscarriages.

Torsion of the paratubal cyst in an adolescent female: A case report / 대한산부인과학회지

Torsion of the paratubal cyst is a rare but significant cause of acute or recurrent lower abdominal pain in adolescent females that is difficult to recognize preoperatively. Early diagnosis is very important in adolescent because of the risk of decreased fertility if it is not treated at an early stage. We report a case of torsion of the paratubal cyst that has resulted in hemorrhagic infarction of the paratubal cyst and fallopian tube in an adolescent female with brief review of literatures.

Two cases of cesarean section after laparoscopic radiofrequency myolysis / 대한산부인과학회지

Radiofrequency myolysis is a method for preserving uterus and fecundity, and due to its more non-invasive and simpler operation, it is now carried out to cure the uterine myomas. However, not long time has passed since this operation started, and little studies were conducted on this complications and side effects. Therefore, since the authors experienced the pregnancy after radiofrequency myolysis of uterine myoma, we hereby report the cases.

Acute Sheehan's syndrome with hyponatremia and hypoglycemia / 대한산부인과학회지

We report two cases of acute Sheehan's syndrome with a brief review of literature: A 28-year-old woman who had been performed cesarean section delivery complicated by hemorrhage due to uterine atony. And a 29-year-old woman who had vaginal birth after cesarean section (VBAC) complicated by hemorrhage due to birth canal laceration. On 8th day after delivery, both patient visited emergency room in critical condition with nausea, vomiting and general weakness. Although clinically significant Sheehan's syndrome is an uncommon consequence of obstetric hemorrhage, Sheehan's syndrome should be considered in the differential diagnosis of hyponatremia and suggestive hypoglycemia in early postpartum period women with history of massive obstetric hemorrhage.

Antenatal Cognitive-behavioral Therapy for Prevention of Postpartum Depression: A Pilot Study

PURPOSE: To examine the efficacy of cognitive-behavioral therapy (CBT) for the prevention of postpartum depression (PPD) in "at risk" women. MATERIALS and METHODS: We recruited 927 pregnant women in 6 obstetric and gynecology clinics and screened them using Beck Depression Inventory (BDI). Ninety-nine of the screened women who had significantly high scores in BDI (a score above 16) were selected for the study. They were contacted through by telephone, and 27 who had consented to participate in the study were interviewed via SCID-IV-I. Twenty-seven eligible women were randomly assigned to the CBT intervention (n = 15) and control condition (n = 12). All participants were required to complete written questionnaires, assessing demographic characteristics, depressive symptoms, negative thoughts, dyadic communication satisfaction, and global marital satisfaction prior to treatment and approximately 1 month postpartum. The 15 women in the CBT condition received 9 bi-weekly 1-hour individual CBT sessions, targeting and modifying negative patterns of thinking and behaviors occurring in the context of the dyadic relationship. RESULTS: The analysis of covariance (ANCOVA) showed that there were significant differences in all postpartum measures between the 2 groups, indicating that our antenatal intervention with CBT was effective in reducing depressive symptoms and improving marital satisfaction, which lasted until the postpartum period. CONCLUSION: Our pilot study has provided preliminary empirical evidence that antenatal CBT intervention can be an effective preventive treatment for PPD. Further study in this direction was suggested.

Clinical analysis of non-blood transfusion treatment in patients who refused a blood transfusion for obstetrical part / 대한산부인과학회지

OBJECTIVE: The goal of this study is to analyze the clinical manifestation of obstetrical patients who refused transfusion of any blood component. Through this analysis, we could define the guideline of non-blood transfusion treatment during the obstetrical procedure. METHODS: 127 patients who visited our non-blood transfusion treatment center and had obstetrical procedures from 1 Jan. 2000 to 31 March 2006 participated in this study. They were retrospectively analyzed according to the following indexes; the reason of refusing blood transfusion, age, ratio of vaginal delivery to Cesarean section, comparison of hemoglobin level, volume of blood loss, presence of bloodless treatment, days of hospitalization, presence of blood transfusion, consequence of patient (including complications and deaths). Bloodless treatment at the hospital are medical method (recombinant human erythropoietin, Aprotinin, Hemocoagulase, Tranexamine acid, Venoferrum), Autotransfusion and Electrocauterization. RESULTS: Among 126 patients (except for 1 patient who was delivered at the other hospital), the vaginal delivery group consisted of 57, and the Cesarean operation group was 69. The most common cause of primary caesarean section was arrest disorder of cephalo-pelvic disproportion. Among 26 patients qualified for indication of transfusion, uterine atony had the highest number of patients at 16. Among the indication of transfusion, low hemoglobin level (< or =8.0 g/dL) after operation had the highest number of patients at 20. Patients qualified indication of transfusion had twice more blood loss (464.6+/-34.2 ml vs 920.5+/-214.2 ml) and two more days of hospitalization (7.6+/-0.5 day vs 9.7+/-0.6 day) compared with those of non-qualified for indication of transfusion. Nobody received direct transfusion of blood component. There were no death but acute renal failure in one patient, and DIC (disseminated intravascular coagulation) in another patient as complications. CONCLUSIONS: This study analyzed the clinical manifestations of patients who refused a blood transfusion in obstetrics. Especially, when the non-blood transfusion treatment was performed, which had been an issue in recent times, more active treatment showed less reduction of hemoglobin level than no treatment. This study also confirmed that bleeding patients can be treated by selective non-blood transfusion treatment.

The effects of cervical conization on sexual function / 대한산부인과학회지

OBJECTIVE: This study is aimed to evaluate the effects of cervical conization on sexual function in patients with non-malignant conditions. METHODS: We choose thirthy-one patients who were operated by cervical conization. They were interviewed retrospectically that effects on sexual desire or interest, sexual activity or frequency, pleasure, communication and satisfaction with sexual relationship. RESULTS: After cervical conization, there was no statistically significant change (p>.05) in sexual desire or interest, sexual activity or frequency, pleasure, communication and satisfaction with sexual relationship. CONCLUSION: Cervical conization was not found to have any adverse effects on sexual function in our study. In this respects, conization is a suitable conservative method when treating patients with non-malignant conditions.