Ruptured pseudoaneurysm of the internal maxillary artery in zygomaticomaxillary fracture: a case report

Post-traumatic pseudoaneurysms of internal maxillary artery are rare, but may be life-threatening. When arterial damage leads to pseudoaneurysm formation, delayed intractable epistaxis can occur. We report our experience with the diagnosis and management of a ruptured internal maxillary arterial pseudoaneurysm that was discovered preoperatively in a patient with a zygomaticomaxillary complex (ZMC) fracture. He presented to the emergency room with epistaxis, which ceased shortly, and sinus hemorrhage was observed with a fracture of the posterior maxillary wall. The patient was scheduled for open reduction and internal fixation (ORIF) of the ZMC fracture. However, immediately before surgery, uncontrolled epistaxis of unknown origin was observed. Angiography indicated a pseudoaneurysm of the posterior superior alveolar artery. Selective endovascular embolization was performed, and hemostasis was achieved. After radiologic intervention, ORIF was successfully implemented without complications. Our case shows that in patients with a posterior maxillary wall fracture, there is a risk of uncontrolled bleeding in the perioperative period that could be caused by pseudoaneurysms, which should be considered even in the absence of typical symptoms.

The Presence of Urinary Ketones according to Metabolic Status and Obesity

Background@#Recently, new concepts about obesity and normal weight subtypes with metabolic conditions are rising and ketone bodies are emerging as a significant indicator of metabolic health. This study aimed to find a relationship between ketonuria and those subtypes. @*Methods@#The data of 19,036 subjects were analyzed in this cross-sectional study (2013–2017 Korea National Health and Nutrition Examination Survey, KNHANES). Based on body mass index and adult treatment panel III with modification of waist circumference, individuals were categorized into 4 groups: metabolically healthy normal weight (MHNW), metabolically healthy obese (MHO), metabolically unhealthy normal weight (MUNW), and metabolically unhealthy obese (MUO). Individuals were divided into 2 groups, positive and negative ketonuria groups, and the metabolic parameters were compared. @*Results@#The metabolic indicators of the positive ketonuria group showed better results than those of the negative ketonuria group and the MHNW group showed the highest proportion of positive ketonuria. The MHNW group showed higher urinary ketones than the MUO group (odds ratio [OR], 0.391; 95% confidence interval [CI], 0.254–0.601) in men. In women, OR of having ketonuria was 0.698 (95% CI, 0.486–1.002) in the MHO group and 0.467 (95% CI, 0.226–0.966) in the MUNW group compared to the MHNW group, respectively. @*Conclusion@#Compared to the MHNW group, the MUO group showed lower presence of ketonuria in men, and tendency to have less ketonuria in women.

Comparing hemostatic resuscitation management of intraoperative massive bleeding with traumatic massive bleeding: a computer simulation

Background@#Appropriate blood component transfusion might differ between intraoperative massive bleeding and traumatic massive bleeding in the emergency department because trauma patients initially bleed undiluted blood and replacement typically lags behind blood loss. We compared these two blood loss scenarios, intraoperative and traumatic, using a computer simulation. @*Methods@#We modified the multi-compartment dynamic model developed by Hirshberg and implemented it using STELLA 9.0. In this model, blood pressure changes as blood volume fluctuates as bleeding rate and transcapillary refill rate are controlled by blood pressure. Using this simulation, we compared the intraoperative bleeding scenario with the traumatic bleeding scenario. In both scenarios, patients started to bleed at a rate of 50 ml/min. In the intraoperative bleeding scenario, fluid was administered to maintain isovolemic status; however, in the traumatic bleeding scenario, no fluid was supplied for up to 30 min and no blood was supplied for up to 50 min. Each unit of packed red blood cells (PRBC) was given when the hematocrit decreased to 27%, fresh frozen plasma (FFP) was transfused when plasma was diluted to 30%, and platelet concentrate (PC) was transfused when platelet count became 50,000/ml. @*Results@#In both scenarios, the appropriate ratio of PRBC:FFP was 1:0.47 before PC transfusion, and the ratio of PRBC:FFP:platelets was 1:0.35:0.39 after initiation of PC transfusion. @*Conclusion@#The ratio of transfused blood component did not differ between the intraoperative bleeding and traumatic bleeding scenarios.

Leaky Gut Syndrome

Increased intestinal permeability, termed leaky gut syndrome (LGS), plays an important role in health and disease. LGS creates gaps in the intestinal walls that allow harmful bacteria and toxic substances to enter the bloodstream. Several researchers have found significant evidence to support the existence of a leaky gut. Emerging evidence also indicates that leaky gut contributes to a range of health conditions. LGS is closely associated with autoimmune diseases, liver conditions, diabetes, food allergies/hypersensitivity, irritable bowel syndrome, polycystic ovary syndrome, and autism. Therefore, LGS should be considered as a factor in the pathophysiology and differential diagnosis of patients presenting with autoimmune diseases, non-alcoholic fatty liver disease, liver cirrhosis, polycystic ovary syndrome, irritable bowel syndrome, diabetes, autism, food allergies, and food hypersensitivity. However, since there has not yet been a large-scale study regarding the causality between LGS and these diseases, further research is required to determine if LGS plays a pathogenic role in the progression and development of these diseases or whether these diseases lead to LGS. The 5R program, which includes non-absorbing antibiotic use, probiotic supplementation, exercising regularly, and certain dietary and lifestyle changes, may help restore impaired intestinal permeability.

Serum Alanine Aminotransferase Level as a Risk Factor for Coronary Heart Disease Prediction in Koreans: Analysis of the Korea National Health and Nutrition Examination Survey (V-1, 2010 and V-2, 2011) / 가정의학회지

BACKGROUND: The blood level of alanine aminotransferase (ALT) is associated with increased coronary heart disease (CHD) risk. However, its use as an independent factor for CHD risk prediction remains unclear in Asian populations. The purpose of this study was to examine the association between serum ALT levels and CHD risk in Koreans. METHODS: This was a cross-sectional study using data from the Korea National Health and Nutrition Examination Survey (V-1, 2010 and V-2, 2011). The ALT levels of 3,215 individuals were analyzed. The Framingham Risk Score (FRS) modified by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) was used to compute the 10-year CHD risk prediction. RESULTS: Positive correlations were established between log-transformed ALT concentration and FRS (r=0.433, P<0.001). After adjusting for body mass index, low-density lipoprotein cholesterol, the amount of alcohol intake, and gamma-glutamyl transferase, the odds ratio (95% confidence interval) for intermediate or greater risk of 10- year CHD prediction (10-year risk ≥10%) for the lowest quartile of participants was 2.242 (1.405–3.577) for the second quartile, 2.879 (1.772–4.679) for the third quartile, and 3.041 (1.789–5.170) for the highest quartile. CONCLUSION: In Koreans, a higher serum ALT concentration was significantly correlated with 10-year CHD risk prediction according to NCEP ATP III guidelines.

A Randomized Clinical Trial of Synbiotics in Irritable Bowel Syndrome: Dose-Dependent Effects on Gastrointestinal Symptoms and Fatigue / 가정의학회지

BACKGROUND: This double-blind, randomized controlled design study aimed to assess the dose-dependent effects of synbiotics on gastrointestinal symptoms of and fatigue in irritable bowel syndrome (IBS). METHODS: Thirty subjects with IBS were randomly assigned into the following three groups and received 2 capsules a day for 8 weeks: (1) high-dose (2 capsules of synbiotics); (2) low-dose (1 capsule of synbiotics and 1 capsule of placebo); and (3) placebo (2 capsules of placebo). At baseline and 8 weeks, they completed the study questionnaires. RESULTS: Two subjects in the high-dose group were lost to follow-up, leaving a total of 28 patients for the analysis. After 8 weeks, abdominal discomfort, abdominal bloating, frequency of formed stool, fatigue Visual Analog Scale (VAS), and Multidimensional Fatigue Inventory were significantly different among the groups (P=0.002, 0.006, 0.007, 0.028, and 0.041, respectively, by Kruskal-Wallis test). However, only abdominal discomfort, abdominal bloating, frequency of formed stool, and fatigue VAS were significantly improved in the high-dose group compared with those in the placebo group (P=0.002, 0.003, 0.002, and 0.013, respectively) by Mann-Whitney test with Bonferroni correction. No adverse drug reactions were reported. CONCLUSION: High-dose synbiotics were superior to placebo in improving bowel symptoms and fatigue of IBS patients, suggesting that synbiotic dosage plays an important role in the treatment of IBS.

Correlation between Serum Uric Acid and Bone Mineral Content in Healthy Women

BACKGROUND: Osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and skeletal microstructural abnormalities. We investigated the correlation between serum uric acid (SUA) levels and bone mineral content (BMC) values as a surrogate marker of bone health. Additionally, we assessed whether the correlation, if any, was evident even after classifying the study population into two groups based on a diagnosis of obesity in these individuals.METHODS: This study included 936 women who visited the healthcare centers that participated in this study. Fasting blood samples were obtained from all women to measure SUA, BMC of the lumbar spine was measured using dual-energy X-ray absorptiometry. We evaluated the correlation between SUA and BMC in obese and non-obese groups.RESULTS: SUA concentration and BMC were positively correlated (β=0.257, P=0.001); however, this correlation was significant only in the obese group (β=0.203, P=0.001).CONCLUSION: SUA concentration and BMC are positively correlated in women diagnosed obesity.

Effect of palmitoylethanolamide on inflammatory and neuropathic pain in rats / 대한마취과학회지

BACKGROUND: A growing body of evidence suggests that neuroinflammation, which is characterized by infiltration of immune cells, activation of mast cells and glial cells, and production of inflammatory mediators in the peripheral and central nervous systems, plays an important role in the induction and maintenance of chronic pain. Palmitoylethanolamide (PEA), which is a type of N-acylethanolamide and a lipid, has an anti-inflammatory effect. Relative to the anti-inflammatory effect, little is known about its analgesic effect in chronic pain. This study aimed to determine whether PEA relieves chronic inflammatory and neuropathic pain. METHODS: Male Sprague-Dawley rats were injured by transection of the left L5 and L6 spinal nerves to induce neuropathic pain or were injected with monoiodoacetic acid into the synovial cavity of knee joints to induce inflammatory pain. To assess the degree of pain, two kinds of stimuli - pressing von Frey filaments and wetting with acetone - were applied to the plantar surface of the rat to measure mechanical and cold sensitivity, respectively. Pain was measured by assessing behavioral responses, including paw withdrawal response threshold and paw withdrawal frequency upon stimulation. RESULTS: Neuropathic pain caused by spinal nerve transection (SNT) decreased the mechanical threshold and increased the frequency of response to acetone application. But, cold allodynia caused by SNT did not decrease the withdrawal frequency. Mechanical hyperalgesia caused by chronic inflammation was significantly reduced by both intraperitoneal and intra-articular injections of PEA. CONCLUSIONS: These outcomes revealed that PEA might be effective in relieving inflammatory and neuropathic pain, especially pain induced by mechanical hyperalgesia, but not cold allodynia.

Obesity Is Inversely Related to Hydrogen-Producing Small Intestinal Bacterial Overgrowth in Non-Constipation Irritable Bowel Syndrome

There have been inconsistent findings on the association of obesity and non-constipation irritable bowel syndrome (IBS). Small intestinal bacterial overgrowth (SIBO) with hydrogen (H₂) gas forming-microflora causes non-constipation IBS. But, the effect of H₂ producing SIBO on obesity in non-constipation IBS patients has not been studied yet. The aim of this study was to investigate the association between obesity and SIBO in non-constipation IBS patients. We reviewed the charts of patients who showed IBS symptoms along with the documented results of their lactulose hydrogen breath test (LHBT) for SIBO. Multivariate models were used to assess the association between obesity and SIBO. Four-hundred fifty-eight patients were retrospectively included in the study. Of the 485 IBS patients, 158 (30.7%) subjects had positive results for LHBT. Subjects without SIBO showed significantly higher levels of body mass index (24.8 vs. 23.3; P < 0.001) and waist circumference (86.5 vs. 82.7; P < 0.001) as compared to subjects with SIBO. In multivariate analysis, the odds ratios of SIBO were 0.396 (P = 0.018) for obesity and 0.482 (P = 0.021) for abdominal obesity. This is the first human study to demonstrate that obesity is inversely related to SIBO with H2 gas production in non-constipation IBS patients.

Correlation between the 2-Dimensional Extent of Orbital Defects and the 3-Dimensional Volume of Herniated Orbital Content in Patients with Isolated Orbital Wall Fractures

BACKGROUND: The purpose of this study was to assess the correlation between the 2-dimensional (2D) extent of orbital defects and the 3-dimensional (3D) volume of herniated orbital content in patients with an orbital wall fracture. METHODS: This retrospective study was based on the medical records and radiologic data of 60 patients from January 2014 to June 2016 for a unilateral isolated orbital wall fracture. They were classified into 2 groups depending on whether the fracture involved the inferior wall (group I, n=30) or the medial wall (group M, n=30). The 2D area of the orbital defect was calculated using the conventional formula. The 2D extent of the orbital defect and the 3D volume of herniated orbital content were measured with 3D image processing software. Statistical analysis was performed to evaluate the correlations between the 2D and 3D parameters. RESULTS: Varying degrees of positive correlation were found between the 2D extent of the orbital defects and the 3D herniated orbital volume in both groups (Pearson correlation coefficient, 0.568−0.788; R²=32.2%−62.1%). CONCLUSIONS: Both the calculated and measured 2D extent of the orbital defects showed a positive correlation with the 3D herniated orbital volume in orbital wall fractures. However, a relatively large volume of herniation (>0.9 cm³) occurred not infrequently despite the presence of a small orbital defect (<1.9 cm²). Therefore, estimating the 3D volume of the herniated content in addition to the 2D orbital defect would be helpful for determining whether surgery is indicated and ensuring adequate surgical outcomes.

Rare Location of Castleman's Disease in the Temporal Region: A Case Report Involving a Young Korean Woman and Review of the Literature

Castleman's disease (CD) is an uncommon benign lymphoproliferative disorder of unknown etiology. Histopathologically, it is divided into three types: hyaline-vascular, plasma cellular, and multicentric CD. The mass usually presents asymptomatically; however, it can cause non-specific symptoms such as fever and fatigue. Although CD can be found wherever lymph nodes are present, 75% of cases are reported in the mediastinum, and occurrence in the head and neck is rare. Herein, we report a rare case of CD presenting as a superficial mass in the temporal region. To the best of our knowledge, this is the first report of temporal CD in Korea involving a young patient.

Rare Location of Castleman's Disease in the Temporal Region: A Case Report Involving a Young Korean Woman and Review of the Literature

Castleman's disease (CD) is an uncommon benign lymphoproliferative disorder of unknown etiology. Histopathologically, it is divided into three types: hyaline-vascular, plasma cellular, and multicentric CD. The mass usually presents asymptomatically; however, it can cause non-specific symptoms such as fever and fatigue. Although CD can be found wherever lymph nodes are present, 75% of cases are reported in the mediastinum, and occurrence in the head and neck is rare. Herein, we report a rare case of CD presenting as a superficial mass in the temporal region. To the best of our knowledge, this is the first report of temporal CD in Korea involving a young patient.

Successful transfusion-free pancreatectomy in Jehovah's Witness patients

BACKGROUNDS/AIMS: Although perioperative therapies have improved greatly, pancreatectomies still often need blood transfusions. However, the morbidity from blood transfusions, the poor prognosis of blood transfused patients, high cost, and decreasing supply of blood products is accelerating transfusion-free (TF) surgery in the patients who have pacreatectomies. The aim of this study was to assess the feasibility of TF pancreatectomies for patients who are Jehovah's Witness. METHODS: We investigated the possibility of TF pancreatectomies for the Jehovah's Witness patients undergoing pancreatectomies between January 2007 and Februay 2014. There were 4 cases of Whipple's operation, 4 of pylorus-preserving pancreaticoduodenectomy, 2 of radical antegrade modular pancreatosplenectomy and 1 of laparoscopic distal pancreatectomy. All were performed by one surgeon. RESULTS: Most of the TF pancreatecomies patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution (ANH). They received no blood transfusions at any time during their hospitalization, and pre- and intra-operative data and outcomes were acceptably favorable. CONCLUSIONS: To the best of our knowledge, this report is the first successful consecutive pancreatectomy program for Jehovah's Witness not involving blood transfusion. TF pancreatectomy can be performed successfully in selected Jehovah's Witness. Postoperative prognosis and outcomes should be confirmed in follow up studies.

Coronary Calcification Is Reversely Related with Bone and Hair Calcium: The Relationship among Different Calcium Pools in Body

BACKGROUND: With aging, calcium efflux from bone is increased with age-related bone loss, and it can reduce bone mineral density (BMD). On the contrary, age-related calcium adoption into arterial wall progressively stiffens blood vessels. Theses process insinuates shift of calcium among different pools in body. However, their relationships have not been elucidated yet. So we investigated the correlation among calcium contents in different body pools, such as hair, bone, and blood vessels in women. METHODS: We analyzed 50 females retrospectively who measured Agatston coronary artery calcium score (CACS), BMD, and hair calcium concentration at a regular health check-up in a university hospital. CACS was achieved by coronary multidetector computed tomography, BMD was measured by dual energy X-ray absorptiometry in the lumbar spine and femur, and hair calcium level was checked by hair tissue mineral analysis. RESULTS: CACS inversely correlated with BMD (r=-0.280, P=0.049 with lumbar vertebrae 1-4, r=-0.310, P=0.028 with femur neck, r=-0.333, P=0.018 with femur total) and hair calcium concentration (r=-0.352, P=0.012). CONCLUSIONS: CACS has negative correlation with BMD and hair calcium level in women. Different body calcium pools such as bone, hair and blood vessel significantly correlated each other.

Anaphylactic shock caused by intramuscular injection of midazolam during the perioperative period: a case report / 대한마취과학회지

Although anaphylactic shock during the perioperative period is rare, it can be lethal due to severe cardiovascular and respiratory collapse. Midazolam is generally used as premedication for relieving anxiety about the operation, and the danger of anaphylactic shock after intramuscular injection is not widely recognized. We report the first case of anaphylactic shock occurring during the perioperative period after intramuscular injection of midazolam. Since anaphylactic shock after intramuscular injection can be of slow onset, the operation should be delayed if an anaphylactic reaction is suspected, even if the symptoms are limited. In addition, anesthesiologists should be prepared for the occurrence of anaphylaxis at any time in the perioperative period.

Anaphylactic shock caused by an intradermal skin test-negative antibiotic during general anesthesia: A case report

Anaphylaxis during the perioperative period is rare, but it still causes severe cardiovascular and respiratory collapse that can be fatal. In particular, when using antibiotics that have a high risk of hypersensitivity reactions, it is important to establish that intradermal skin tests are negative before using antibiotics. We report a case of anaphylactic shock occurring during general anesthesia after using an intradermal skin test-negative antibiotic. Regrettably, negative results of intradermal skin tests before using antibiotics do not completely eliminate the risk of anaphylaxis. Therefore, anesthesiologists should be prepared for anaphylaxis to occur at any point during the perioperative period.

Reference Intervals for Plasma Amyloid β in Korean Adults Without Cognitive Impairment

Amyloid β (Aβ) peptides are important components of plaques in patients with Alzheimer's disease (AD). Recent studies suggest that a low plasma ratio of Aβ42 to Aβ40 may precede the development of the sporadic form of AD. The aim of this study was to establish reference intervals for plasma Aβ in Korean adults. A total of 370 apparently healthy individuals (181 males and 189 females aged 40-69 yr) without cognitive impairment were enrolled. Plasma concentrations of Aβ40 and Aβ42 were measured by using a human amyloid β assay kit (Immuno-Biological Laboratories, Japan). Reference intervals were established according to the "CLSI guidelines for defining, establishing, and verifying reference intervals in the clinical laboratory". There was no need to partition the data with respect to gender or age group. The 95th percentile reference intervals for Aβ40 and Aβ42 were 127-331 pg/mL and 2.31-19.84 pg/mL, respectively. The reference interval for the Aβ42/Aβ40 ratio was 0.011-0.092. Plasma Aβ concentrations obtained in this study could be used as reference intervals for clinical purposes.

Irritable Bowel Syndrome May Be Associated with Elevated Alanine Aminotransferase and Metabolic Syndrome

PURPOSE: Recent studies have revealed close relationships between hepatic injury, metabolic pathways, and gut microbiota. The microorganisms in the intestine also cause irritable bowel syndrome (IBS). The aim of this study was to examine whether IBS was associated with elevated hepatic enzyme [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)], gamma-glutamyl transferase (gamma-GT) levels, and metabolic syndrome (MS). MATERIALS AND METHODS: This was a retrospective, cross-sectional, case-control study. The case and control groups comprised subjects who visited our health promotion center for general check-ups from June 2010 to December 2010. Of the 1127 initially screened subjects, 83 had IBS according to the Rome III criteria. The control group consisted of 260 age- and sex-matched subjects without IBS who visited our health promotion center during the same period. RESULTS: Compared to control subjects, patients with IBS showed significantly higher values of anthropometric parameters (body mass index, waist circumference), liver enzymes, gamma-GT, and lipid levels. The prevalences of elevated ALT (16.9% vs. 7.7%; p=0.015) and gamma-GT (24.1% vs. 11.5%; p=0.037) levels were significantly higher in patients with IBS than in control subjects. A statistically significant difference was observed in the prevalence of MS between controls and IBS patients (12.7% vs. 32.5%; p<0.001). The relationships between elevated ALT levels, MS, and IBS remained statistically significant after controlling for potential confounding factors. CONCLUSION: On the basis of our study results, IBS may be an important condition in certain patients with elevated ALT levels and MS.

Functional Comparison of Human Embryonic Stem Cells and Induced Pluripotent Stem Cells as Sources of Hepatocyte-Like Cells

Pluripotent stem cells can differentiate into many cell types including mature hepatocytes, and can be used in the development of new drugs, treatment of diseases, and in basic research. In this study, we established a protocol leading to efficient hepatic differentiation, and compared the capacity to differentiate into the hepatocyte lineage of human embryonic stem cells (hESCs) and human induced pluripotent stem cells (hiPSCs). Optimal combinations of cytokines and growth factors were added to embryoid bodies produced by both types of cell. Differentiation of the cells was assessed with optical and electron microscopes, and hepatic-specific transcripts and proteins were detected by quantitative reverse transcription polymerase chain reaction and immunocytochemistry, respectively. Both types of embryoid body produced polygonal hepatocyte-like cells accompanied by time-dependent up regulation of genes for α-fetoprotein, albumin (ALB), asialoglycoprotein1, CK8, CK18, CK19, CYP1A2, and CYP3A4, which are expressed in fetal and adult hepatocytes. Both types of cell displayed functions characteristic of mature hepatocytes such as accumulation of glycogen, secretion of ALB, and uptake of indocyanine green. And these cells are transplanted into mouse model. Our findings indicate that hESCs and hiPSCs have similar abilities to differentiate into hepatocyte in vitro using the protocol developed here, and these cells are transplantable into damaged liver.

Postoperative nausea and vomiting after capsicum plaster at the P6 acupoint after laparoscopic cholecystectomy according to gender

BACKGROUND: Postoperative nausea and vomiting (PONV) has a remarkably high reported incidence (70%) in female patients after anesthesia. This study aims to evaluate the clinical effect of capsicum plaster at the P6 acupoint with respect to gender in preventing PONV after laparoscopic cholecystectomy. METHODS: A prospective, placebo-controlled, double-blind study was conducted with 120 patients undergoing laparoscopic cholecystectomy and who were randomly assigned to four groups (n = 30 each): Group MC = male patients with capsicum plaster at the P6 acupoint; Group MP = male patients with placebo tape at the P6 acupoint; Group FC = female patients with capsicum plaster at the P6 acupoint; Group FP = female patients with placebo tape at the P6 acupoint. The treatment tape was applied before the induction of anesthesia and was removed eight hours after the operation. RESULTS: The incidence of nausea was reduced in both genders with application of capsicum plaster at P6 acupoint. No change in vomiting or use of anti-emetics was observed. Satisfaction scores with PONV control were improved with this intervention. No gender difference was observed which actually the initial objective of this study was. CONCLUSIONS: The application of capsicum plaster at the P6 acupoint is a proven antiemetic method in both gender after laparoscopic cholecystectomy, however there are no intergender differences.