Intradialytic exercise improves physical function and reduces intradialytic hypotension and depression in hemodialysis patients

BACKGROUND/AIMS@#As numbers of maintenance hemodialysis patients are growing, debilitating conditions of muscle wasting and atrophy are becoming some of the greatest concerns in end-stage renal disease patients. Exercise training has various potential benefits in terms of prevention of a sustained decline in functional status. This study aimed to evaluate the physical, psychological, laboratory, and dialysis-related effects of intradialytic exercise.@*METHODS@#We enrolled 22 patients from a hemodialysis center for a 6-month non-randomized prospective trial. Combination of aerobic exercise with bicycle ergometer and anaerobic exercise with elastic bands was conducted during hemodialysis. Data including physical fitness test results, dialysis-related measurements, and biochemical laboratory results were collected at baseline, 3, and 6 months. Depression and quality of life were assessed using Beck Depression Inventory and Short Form-36 health survey.@*RESULTS@#After exercise completion, there were significant improvements in back muscle power, forward and backward trunk flexibility, vertical jump, elbow flexion, sit to stand test, and 6-minute walk test (p < 0.05). No significant changes were observed in dry weight, blood pressure, Kt/V, and biochemical variables, except for intradialytic hypotension (p < 0.05). For depression, Beck Depression Inventory showed statistically significant enhancement (p < 0.05). Scores of Short Form-36 health survey did not show significant increase in each domain, except for bodily pain (p < 0.05).@*CONCLUSIONS@#Combined aerobic and anaerobic exercise training during dialysis was found to be effective on physical health status, intradialytic hypotension, and depression in terms of mental health. Therefore, the findings of the current study may provide an appropriate guidance for encouraging exercise by nephrologists.

Treatment of Chronic Osteomyelitis on Medial Malleouls after Electrical Burn Injury by Propeller Flap: A Case Study

It is known that cases of osteomyelitis are less common than 5% in deep burn cases. This research presents a case of chronic osteomyelitis, presented 7 years after initial electrical burn injury. A 43-year-old male patient was admitted to the Department of Plastic Surgery, suffering from an 22900-voltage electrical burn on right medial malleolus in 2010. There was no postoperative complication for five years observation. In November 2016, he was admitted to the Plastic Surgery department, suffering from the skin and soft tissue defect on right medial malleolus without trauma history. The osteomyelitis on the right medial malleolus was found in bone scintigraphy. The medial malleolus was covered with a local flap two days after admission. Dehiscence was found after surgery and exudate was emerged continuously from the flap site. We decided to cover the raw surface with a perforator based propeller flap 22 days after admission considering reconstructive ladder. The flap survived successfully, and partial epidermal sloughing was healed completely by daily dressing at 51 days after the surgery. It is advisable to establish and access the prudent plan before surgery through many kinds of radiological tests and physical examinations considering vascular stability and delayed wound healing.

Reconstruction of Large Orbital Floor Defect Caused by Maxillary Sinus Mucocele

Maxillary sinus mucocele can occur due to many medical factors such as chronic infection, allergic sinonasal disease, trauma, and previous surgery. However, it occurs mainly after Caldwell-Luc operation, usually more than 10 years after surgery. There are a few cases of maxillary sinus mucocele with ocular symptoms. Also, a case causing ocular symptoms because of invasion to the orbital floor is rare. Therefore, we report a case of a 55-year-old male patient who underwent Caldwell-Luc operation about 30 years ago. Then, symptoms such as exophthalmos, diplopia, and visual disturbance developed suddenly 3 months prior to admission. Computed tomography showed a cyst invading the orbital floor which resulted in eyeball deviation. The orbital floor defect measured approximately 2.5×3.3 cm. Maxillary sinus mucocele was removed through an endoscopic approach. After this, we reconstructed the orbital floor through a subciliary incision. Observation was carried out after three years, and ocular symptoms such as diplopia and exophthalmos did not recur.

Dual Perforator Flap for Reconstruction of Large Sacral Defects: Superior Gluteal Artery Perforator Super-Flap with Parasacral Perforator

The superior gluteal artery perforator flap technique has increasingly been used for soft tissue defects in the sacral area following its introduction nearly 25 years ago. Advantages in covering sacral defects include muscle sparing, versatility in design, and low donor side morbidity. The bilateral superior gluteal artery perforator flap procedure is planned in cases of large sacral defects that cannot be covered with the unilateral superior gluteal artery perforator flap. Here, we report two cases of large sacral defects in which patient factors of poor general health, such as old age, pneumonia, and previous operation scar, led to use of a large unilateral superior gluteal artery perforator super-flap with parasacral perforator. The approach was utilized to reduce the operation time and prevent unpredictable flap failure due to the large flap size. Even though the parasacral perforator was included, the versatility of the large superior gluteal artery perforator flap was preserved because sufficient perforator length was acquired after adequate dissection.

Severe Case of Low Temperature Contact Burn with Rhabdomyolysis

Although low temperature contact burn doesn't have clear definition, it is used to describe the burn occurred by long time exposure under 50℃ temperature. 4(th) degree burn can be occurred by low temperature contact burn because of low pain, especially in patients who are insensitive to stimulation by various reasons. The under-floor heating system such as Ondol or electronic heating pad is popular in Korea because of the cultural influence. Although the upper limit surface temperature of electronic heating pad is 50℃, severe burn injury can happen by long time exposure. So we report a low temperature contact burn case of 4(th) degree involving gluteus maximus muscle of the buttock caused by electric heating pad, which led to Rhabdomyolysis.

Clinical Consideration about Characteristics and Treatment of Scalding Burn Caused by Instant Noodle

PURPOSE: Instant noodle is one of the most popular noodle and its consumption is increasing annually. So scalding burns caused by Instant noodle are comparatively common. Instant noodle can lead to contact burn caused by noodle as well as scalding burn by soup. Because the depth of the burn can be deeper than general scalding burn, it can cause physical or psychological disability and the medical and social expense is not a few. The purpose of this study was to investigate the epidemiology and clinical features of the scalding burn caused by Instant noodle. METHODS: Retrospective research was conducted 165 patients with scalding burn by Instant noodle among patients admitted to our burn medical center from May 2011 to April 2016. Subjects were classified by age, gender, affected site and degree and treatment method. RESULTS: For 6 years, 165 subjects went through hospital treatment because of the scalding burn by Instant noodle. It consisted of 48 infants, 74 children and adolescence, and 43 adults. The average TBSA (total body surface area, %) was 3.43. The number of patients exceeding 10% were 3. The most common affected site was thigh in 35.5% and there was no big differences between each age group. 8 patients did operations and 6 did dermabrasion. CONCLUSION: From May 2011 to April 2016, about 7% of total scalding burn patients was injured by Instant noodle. Considering the characteristics of scalding burn by Instant noodle, conservative treatment was preferred to surgical treatment. 149 of total 165 patients were done conservative treatment using cultured allogenic keratinocytes.

Periumbilical Dermal Graft as a Good Option for Volume Enhancement in Secondary Cleft Lip Deformity: A Case Report

Volume deficiency and poorly defined cupid's bow of the upper lip are frequently encountered problems in secondary cleft lip deformities. In this report, we present the method of a periumbilical dermal graft for correcting secondary cleft lip deformity. A 17-year-old male patient presented with a poorly defined notching cupid's bow and volume deficiency of the upper lip. He had undergone cleft lip surgery when he was 2 years old. We planned to perform a periumbilical dermal graft. There were sufficient amount of periumbilical subdermis and fat tissue thickness to obtain abundant volume. The periumbilical contour was similar to the natural contour of the lip. Less scarring was expected. There was no need to change the posture during operation, making it easy to harvest. Postoperative evaluations showed vermilion symmetry. Ideal cupid's bow shape and position were achieved without color mismatch. As a result, we obtained an ideal volume of the upper lip. Therefore a periumbilical dermal graft is a good option for correcting volume deficiency of the lip with good aesthetic outcomes.

Nasal Tip Plasty Using a Batten Graft with Ear Cartilage in East Asians

BACKGROUND: Plastic surgeons have constantly investigated methods of nasal tip plasty and nasal lengthening in rhinoplasty. The septal extension graft has been widely applied as a very useful method for East Asians who have different internal nasal structures and nasal skin from those of Caucasians. In this study, we performed nasal tip plasty with a batten-type septal extension graft using ear cartilage. METHODS: Nasal tip plasty was performed for 48 patients by batten graft with ear cartilages at the Cocoa Plastic Surgery Clinic and in the plastic surgery unit of Hanil General Hospital from January 2009 to January 2015. A batten-type septal extension graft was constructed with cymba of the concha cartilage. An average area of 2.0 cm × 1.4 cm of the cymba and 1.0 cm × 1.0 cm of the cavum from the concha cartilage was harvested. RESULTS: Of the 48 patients who underwent batten-type septal extension graft using ear cartilages, nasal tip plasty and columellar lengthening were successfully achieved in almost all of the patients. The nasal tip's height was well-maintained for the follow-up period ranging from 6 months to 5 years after surgery. CONCLUSIONS: Nasal tip plasty using a septal extension graft is a very useful method for East Asians with a low nasal tip. The septal extension graft with ear cartilage enables the creation of a desirable nasal shape because there is a sufficient amount of ear cartilage to stably support the nasal tip, thus creating a natural and smooth nose shape.

Coverage of a 4(th) Degree Contact Burn of Scalp and Calvarium Using a Fasciocutaneous Transposition Flap: A Case Report

Scalp and calvarium defects are caused by trauma, burn, tumor resection, or congenital diseases. We experienced a few cases of severe electrical burn of scalp and calvarium, but fourth-degree contact burn of scalp and calvarium is a rare case. A 67 years old man was presented with a 25% total body surface area contact burn. A 20 cm×15 cm thick eschar on the patient's scalp was observed. Among various techniques for scalp reconstruction, we planned fasciocutaneous transposition flap with split thickness skin graft for coverage of large defect. Considering aesthetically satisfactory outcome, we designed a fasciocutaneous transposition flap including the hair-bearing areas. We additionally used skin graft for uncovered surrounding areas. There were no flap necrosis, graft loss, or any other surgical complications after the surgical flap and skin graft. At 6-month follow-up, the operation site was stable. The patient satisfied with functional and aesthetical outcomes, so we report this case.

Usefulness of Silicone Net Dressing in Fixation of Skin Grafts

PURPOSE: Skin graft may fail for a number of reasons. Hematoma or seroma formation prevents graft adherence. Traditionally tie-over dressing has been used in skin graft fixation, but skin graft in convex and narrow place like fingers or toes, tie-over dressing is hard to be applied. And Vaseline gauze over graft often adheres to graft by exudate into gauze fibers and hardening, and may cause damage to graft in dressing change. We report successful results of using silicone net dressing in fixation of split thickness skin graft over these place. METHODS: After skin graft, the silicone net, Mepitel(R) (Molnlycke Health Care, Box 13080, SE-402 52 Goteborg, Sweden) was applied over the graft followed saline wet gauze dressing in 25 patients. 13 cases were on finger, 8 cases were on foot or toes, 4 cases were on anterior chest. RESULTS: In 22 cases, there were no hematoma or seroma formation, Mepitel(R) maintained 5 days after skin graft. And then, Mepitel(R) was removed from the graft. In 3 cases, there were hematoma formation, Mepitel(R) was removed at 3 days after skin graft. In all cases, grafts were taken well without maceration or skin eruption. CONCLUSION: The silicone net, Mepitel(R), is dressing material made of silicone gel bound to a pliable polyamide net, and it can provide uniform pressure to the graft, even in convex and narrow place. And net like structure allows the exudates of the wound to pass freely into the secondary absorbent dressing and easier to remove from the grafts than Vaseline gauze. We think that the use of a Mepitel(R) is a efficient tool for securing skin grafts.

A Case of Multiple Hypervascular Hyperplastic Liver Nodules in a Patient with No History of Alcohol Abuse or Chronic Liver Diseases / 대한소화기학회지

Up-to-date imaging modalities such as three-dimensional dynamic contrast-enhanced CT (3D CT) and MRI may contribute to detection of hypervascular nodules in the liver. Nevertheless, distinguishing a malignancy such as hepatocellular carcinoma from benign hypervascular hyperplastic nodules (HHN) based on the radiological findings is sometimes difficult. Multiple incidental liver masses were detected via abdominal ultrasonography (US) in a 65-year-old male patient. He had no history of alcohol intake and no remarkable past medical history or relevant family history, and his physical examination results and laboratory findings were normal. 3D CT and MRI showed numerous enhanced nodules with hypervascularity during the arterial phase. After US guided liver biopsy, the pathological diagnosis was HHN. To date, several cases of HHN have been reported in patients with chronic alcoholic liver disease or cirrhosis. Herein, we report on a case of HHN in a patient with no history of alcoholic liver disease or cirrhosis.

Coverage of Skin Defect in Deep Second Degree Burn by Using Skin Graft After Advancement Flap

PURPOSE: Skin graft is useful treatment in burn wound. The major disadvantage of traditional skin graft is related to recipient site scarring and donor site morbidity. Then we present our successful experience of using skin graft after advancement flap. METHODS: The study is based on 22 patients who has deep 2nd burn wound with eschar and 3rd degree burn wound. We performed split-thickness skin graft in 17 patients, and fullthickness skin graft in 5 patients. After undermining of wound margin about 1.3 cm~4 cm, we performed suture of wound marginal skin and subcutaneous tissue with absorbable suture materials. Then we harvested skin according to reduced wound size, and we applied donor skin in recipient area. RESULTS: The skin graft area of the 17 patients who had split skin-thickness graft showed a decline of 25% compared with that of the initial burn wound. 5 patents who had full-thickness skin graft also showed a decrease of 10% in the skin graft area compared with that of the initial burn wound. All Grafts were well taken in 22 patients without skin loss. By observing the progress 12 to 15 months after the operation, minor hypertrophic scar on the boundary of grafted skin area was observed in the 2 patents and hypertrophic scar or contracture was not seen in all 22 patients. CONCLUSION: Skin graft after advancement flap can be used as a treatment in deep 2nd degree and 3rd degree burn wound. Compared with traditional skin graft, the result seems to be good cosmetically and functionally.

Clinical Consideration of Contact Burn Caused by Hair Straightener

PURPOSE: Hair straightener is a common tool among various household electric appliances used for hair styling. Hair straightener has plate consists of metal or ceramic, which lead to possible burn if contacted. Main users of hair straightener are young women whereas main victims of hair straightener caused-burn are infants. Among patients visiting our burn medical center, the case of attending hospital due to contact burn by hair straightener tends to increase. METHODS: Retrospective research was conducted 72 patients with contact burn by hair straightener among patients admitted to our burn medical center from Jan 2012 to Dec 2014. Subjects were classified by age, gender, affected site and degree and treatment method. RESULTS: 72 subjects consisted of 39 infants, 9 children, adolescence and 24 adults. Affected sites were presented as hands in 31, face in 21, foot in 13, arms in 5 and legs in 2 subjects. Degree of burn was presented as deep second degrees in 67 and third degrees in 5 subjects; 70 subjects were cured through conservative treatment whereas 2 subjects had local flap. CONCLUSION: Contact burn by hair straightener can be ranged from partial to full thickness skin defect. It is important to note this kind of burn develops more frequently in infants and is preventative. Education for young women who use hair straightener is crucial. Training regarding function and design improvement of hair straightener is also essential. Uncovering the heated plate after use through a separate lock device might be great help for prevention of contact burn if developed.

Effective Dressing Considering Adhesion and Absorptance in Treatment of Second Degree Facial Burn

PURPOSE: In second degree burn injuries of face, it is important to solve much discharge of early burn wound and shorten healing time. We introduce methodical and effective dressing in treatment of second degree facial burn at focus to solve much discharge of early burn wound and to shorten healing time. METHODS: From March, 2011 to December 2013, a study was done with 398 patients who had second degree burn wound on face. Initially we performed dressing with hydrofiber agent (Aquacel(R)). After cleansing with saline, Vasaline guaze was layed on face, and hydrofiber agent were layed over it, and Vasaline guaze was layed over there again, then saline wet guaze dressing performed. When we changed dressing daily, we evaluated burn wound degree. In superficial second degree burn wound like pinkish colored wound, we repeated hydrofiber agent and saline wet guaze dressing. In deep second degree burn wound like pale or mottled colored wound, we changed dressing with cultured allogenic keratinocyte (Kaloderm(R)). RESULTS: Number of patients with only superficial second degree burn wound was 272, with superficial second degree and deep second degree burn wound together was 113, with only deep second degree burn wound was 13. In only superficial second degree burn wound, the average healing time was 5.1 days with hydrofiber agent and saline wet dressing. In superficial second degree and deep second degree burn wound together, the average healing time was 7.2 days with hydrofiber agent and saline wet guaze dressing and cultured allogenic keratinocyte. In deep second degree burn wound, average healing time was 11 days with hydrofiber agent and saline wet guaze dressing and cultured allogenic keratinocyte. CONCLUSION: In this strategy, hydrofiber agent is good to be attached on irregular surface of facial burn wound, and we use hydrofiber agent to make wet environment to promotion wound healing, not as absorbable material. We use Saline wet guaze as absorbable material. And after evaluation of degree of burn, we use cultured allogenic keratinocyte to promote wound healing in case of deep second degree burn. We think this strategy using hydrofiber agent and saline wet gauze and cultured allogenic keratinocyte on facial burn wound is very effective dressing method.

Reconstruction of MCP Joint or Web Space Region with Adipofascial Turnover Flap in Electric Burn Injuries

PURPOSE: In many cases, electric burn can affect regional MCP joint or web space of hand, and reconstruction of these area is significant, because it can lead severe functional and aesthetical impairment of hand. Considering many respects like hand anatomy, flap characters, functional and aesthetical results, we applied reverse adipofascial flap and report the effectiveness of this method. METHODS: From June 2010 to January 2014, 21 cases of electric burn at MCP joint or web space area were reconstructed with reverse adipofascial flaps. Within a week after theses injuries, we performed a debridement of the necrotic tissue. After elevation adipofascial flap under the skin, the flap was transferred to defect site and then we performed STSG over the flap. The donor site was closed primarily. RESULTS: Complete flap survival was achieved in 75.5% of total cases. And the partial necrosis was occurred in 7 cases. There were no other complications and satisfaction of patient survey was performed by 'Likert scale, 1~5 points', the average point was 4 that meant significantly good result. CONCLUSION: Like fasciocutaneous flap or free flap, the adipofascial flap can cover soft tissue defect with exposed or injured tendon or bone because it has good vascularity. Also, compared with other flaps, it has suitable for MCP joint or web space area in respect of flap size or bulkiness and it has more aesthetical advantages. In conclusion, adipofacial flap can be considered as appropriate method to reconstruction of electrical injury at regional MCP joint area and web space.

Staged Operation Using Fasciocutaneous Transposition Flap on Reconstruction of Exposed Patella Region in 4th Degree Burn: Case Report

PURPOSE: Soft tissue injuries of the patellar region are difficult problems because of insufficient arterial blood supply and lack of muscle. There have been many methods for reconstructing the soft tissue injuries of the patellar area such as primary closure, skin graft, muscle flap and free tissue transfer. However, each method has some limitations in their application. We used fasciocutaneous transposition flap according to limitations of patient's condition. METHODS: A 67-year-old-man was hospitalized by contact burn with TBSA 15% involving scalp, back, buttock, both legs. We found 20x30 cm2 sized eschar on right knee. We debrided necrotizing patella bone and found insufficient blood supply. In addition, general weakness, low weight (170 cm/42 kg), old age, DM made us to plan 2 staged operation. At first, coverage using medial fascio-cutaneous transposition flap. After 7 days, there were 1/4 necrosis by congestion. we used Vancomycin for systemic antibiotic treatments and betadine irrigation. 2 weeks after, We debrided necrotizing patella bone and coverage using lateral fascio-cutaneous transposition flap. RESULTS: There were no post-operative complications such as infection, hematoma, seroma or flap necrosis. And there was no contracture or contour deformity. CONCLUSION: Due to limitations of patient's condition, we used fasciocutaneous transposition flap instead of musculocutaneous flap or free flap. We gained satisfactory result by using fasciocutaneous flap in patella exposed wound reconstruction.

Axillary Fistula and Scar Contracture due to Uncontrolled Chronic Infection after Trans-Axillary Augmentation Mammaplasty

No abstract available.

Evaluation of Merkel Cell Carcinoma Metastasis Using Positron Emission Topography/CT

Merkel cell carcinoma is rare skin malignancy originated from epidermal mechanoreceptor of neural origin. The tumor usually affects older individuals at sun exposed area such as head, neck and extremity. Subclinical involvement of regional lymph node is reported frequently at the time of initial treatment. Thus even asymptomatic patients who present with clinically localized tumor should undergo evaluation with computed tomography and lymphangiography. Positron emission tomography(PET) scans can imaging the metabolic difference of malignant tumors. Increased glucose uptake of malignant tumor cells are detected by PET scanner. PET scans can provide qualitative and quantitative informations about systemic metastasis of tumors. Although there are no data that define the efficacy of PET scans in the initial diagnostic evaluation of head and neck cancer, they could be considered. Current standards of treatment of Merkel cell carcinoma is wide surgical excision and regional lymphadenectomy if there are suspicious lymph nodes. The author reported a patient with Merkel cell carcinoma of cheek. Wide surgical excision and postoperative PET/CT was done for evaluation of regional lymph node and distant metastasis. There were two hot-uptakes in patient's neck, so they were considered as metastatic node, but finally they were proved to be tuberculosis lymphadenitis after excision.

Two Cases of the Incomplete Upper Median Cleft Lip: New Classification

A median cleft lip has been broadly defined as any congenital vertical cleft through the center of the upper lip. In the Tessier 0 cleft, the location of the median cleft of the upper lip has a spectrum of dysmorphic gradation. This varies from a simple central vermillion notch to a wide cleft accompanied by a bifid nose and hypertelorism. Despite its extreme variability, the median cleft is quite rare and has a reported incidence amongst cleft patients alone of 0.43 to 0.73%. We experienced two cases of incomplete median cleft lip without other craniofacial anomalies. One of them who had reverse V-shaped defect of upper vermilion and fibrous band in her oral mucosa, was corrected with orbicularis oris muscle union and Z-plasty. The other patient had triangular shaped upper lip and deficiency of vermilion. We reviewed the classifications of median cleft lip and devised new classification, so that it helps understanding of median cleft lip.

A Case of Epithelial-myoepithelial Carcinoma of the Parotid Gland

Epithelial-myoepithelial carcinoma (EMC) of the salivary gland is a rare tumor that comprises approximately 1% of all salivary gland tumors. It has a distinctive histological appearance comprising ductal structures with an inner epithelial cell component and an outer layer of myoepithelial cells. We report a case of EMC of the parotid gland in a 41- year-old man. He presented left-sided subauricular swelling developed 3-month earlier. Neck CT scans revealed a well-defined mass in the left superficial parotid gland. He underwent superficial parotidectomy and was diagnosed as EMC. He was taken postoperative radiotherapy. There was no evidence of recurrence during a follow-up period of 12 months.