Does acute normovolemic hemodilution affect intraoperative value of serum-creatinine concentration in patients undergoing cardiac surgery

BACKGROUND: The possible impact of hemodilution during acute normovolemic hemodilution (ANH) using hydroxyethyl starch (HES) on intraoperative serum concentration of creatinine (s-Cr) has not been well investigated. METHODS: Patients undergoing cardiac surgery were randomly allocated into Group-ANH (n = 15) or Group-C (control; n = 17). In Group-ANH, 5 ml/kg whole blood was collected, and they were administered 5 ml/kg of HES 130/0.4 after anesthesia induction and before initiating cardiopulmonary bypass (CPB). In both groups, moderate hypothermic CPB was initiated using 1,600–1,800 ml of bloodless priming solution. The changes of s-Cr, blood urea nitrogen, hematocrit (Hct), electrolytes, and osmolality were determined before ANH administration (T1), after administering ANH 5 ml/kg (T2), 30 and 60 s after the initiation of CPB (T3, T4), and at the end of surgery (T5). RESULTS: In Group-ANH, the s-Cr values at T2 (median [IQR25–75%], 0.83 [0.71–1.00] mg/dl) were not significantly different compared to those at T1 (0.84 [0.64–1.00] mg/dl), while those at T3 and T4 (0.68 [0.61–0.80] and 0.76 [0.59–0.92] mg/dl, respectively) were significantly lower than those at T2 (0.83 [0.71–1.00] mg/dl, P < 0.001). Hct at T3, T4 and T5 were significantly lower than those of T1 in both groups, and those at T2 and T4 of Group-ANH were significantly lower than those of Group-C (P < 0.001). There was no significant inter-group difference in all other parameters. CONCLUSIONS: Intraoperative s-Cr was not affected by the administration of ANH 5 ml/kg, although it reduced transiently at the beginning of CPB. Further study is needed to determine the clinical relevancy of our results.

Implantable drug delivery systems with morphine in fibromyalgia: A case report

The fibromyalgia syndrome (FMS) could be approached by various treatments modalities including education, aerobic exercise, cognitive behavioral therapy, tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, pregabalin, and so on. If other treatments fail, opioids including morphine should be considered. In this case report, we describe the case of a 44-year-old woman who was diagnosed with FMS three years ago, and suffered from severe intractable pain, side effects from other drugs, and opioid tolerance. Administration of morphine via an implantable drug delivery system resulted in significant improvement in the patient's pain intensity, fibromyalgia impact questionnaire score, and sleep disturbance. Our case demonstrates that an implantable drug delivery system with morphine can be a potential treatment option for refractory fibromyalgia patients.

High-Grade Mixed Adenoneuroendocrine Carcinoma in the Cecum: A Case Report

Gastrointestinal neoplasms with an exocrine and a neuroendocrine component are rare. Such neoplasms are called “mixed adenoneuroendocrine carcinomas” (MANECs) according to the most recent World Health Organization classification of gastrointestinal tract neoplasms. MANECs have no specific findings that distinguish them from pure adenocarcinomas. In addition, the optimal management strategy of MANECs is largely unknown. We describe the case of a 32-year-old man with dizziness and abdominal bloating. A cecal mass was suspected based on an image study done at a local clinic. We evaluated the cecal mass by using colonoscopy, contrast enhanced computed tomography of the abdomen, positron emission tomography-computed tomography, and laboratory studies. The patient underwent a right hemicolectomy and adjuvant chemotherapy. The final histopathological diagnosis was a high-grade MANEC of the ascending colon, tumor stage T3N2M0.

Transfusion Related Acute Lung Injury after Cesarean Section in a Patient with HELLP Syndrome / 가정의학회지

Transfusion-related acute lung injury (TRALI) is a serious adverse reaction of transfusion, and presents as hypoxemia and non-cardiogenic pulmonary edema within 6 hours of transfusion. A 14-year-old primigravida woman at 34 weeks of gestation presented with upper abdominal pain without dyspnea. Because she showed the syndrome of HELLP (hemolysis, elevated liver enzymes, and low platelet count), an emergency cesarean section delivery was performed, and blood was transfused. In the case of such patients, clinicians should closely observe the patient's condition at least during the 6 hours while the patient receives blood transfusion, and should suspect TRALI if the patient complains of respiratory symptoms such as dyspnea. Furthermore, echocardiography should be performed to distinguish between the different types of transfusion-related adverse reactions.

Rhabdomyolysis after prolonged laparoscopic radical nephrectomy: A case report

Rhabdomyolysis is characterized by the breakdown of skeletal muscle and the subsequent release of intracellular contents into the circulatory system. It is potentially life-threatening because it is sometimes associated with very high creatine kinase levels, myoglobinuria, and acute renal failure. We experienced a case of postoperative rhabdomyolysis after prolonged laparoscopic radical nephrectomy in the semi-lateral decubitus position. It was associated with suspicious gluteal compartment syndrome. Fortunately, the patient's renal function was normal through his hospital course. Rhabdomyolysis is well worth considering at the point of intraoperative positioning and postoperative care after prolonged surgery.

Four Cases of Carbapenem-Resistant Enterobacteriaceae Infection from January to March in 2014 / 가정의학회지

Infection with carbapenem-resistant Enterobacteriaceae (CRE) and other multidrug resistant bacteria has increased rapidly in Korea. The Korea Centers for Disease Control and Prevention reported 1,609 cases of CRE infection in the country in 2013. The risk factors for CRE infection include history of treatment with antibiotics such as cephalosporins or carbapenem, trauma, diabetes, cancer, and history of ventilator support. Herein, we report four cases of CRE infection seen during a 3-month period in our hospital in 2014. CRE infection is associated with a high mortality rate of 30% to 50%, even with combination antibiotic therapy. Prevention of CRE infection in hospital settings is fundamental to controlling its transmission. Key preventive measures include, contact precautions, hand hygiene, education of healthcare personnel, screening for CRE when indicated, and exercising discretion in prescribing carbapenem or cephalosporins.

Regression of a Mucosa-Associated Lymphoid Tissue Lymphoma of the Urinary Bladder After Helicobacter pylori Eradication Therapy in an Elderly Patient

Primary low-grade lymphoma of the mucosa-associated lymphoid tissue (MALT) type lymphoma of the bladder is rare. A relationship between MALT lymphoma of the urinary bladder and chronic cystitis has been proposed by some reports. Additionally a relationship between MALT lymphoma of the urinary bladder and Helicobacter pylori has been reported. Here we present a case of regression of urinary bladder MALT lymphoma after antibiotic therapy, using H. pylori eradication protocol in an elderly patient, who had a high risk of treatment related mortality in curative systemic chemotherapy. The patient is a 74-year-old woman who had a history of chronic cystitis. She was diagnosed with stage IIA primary MALT lymphoma of the urinary bladder and was treated with H. pylori eradication triple therapy for 2 weeks. After 2 months, there was a marked regression of the bladder MALT lymphoma lesion in a computed tomography scan of the abdomen.

Clinical Characteristics and Use of Psychotropic Agents among HIV-Infected/AIDS Patients Referred for Psychiatric Consultation / 정신신체의학

OBJECTIVES: This study aimed to investigate the psychiatric status of HIV-infected/AIDS inpatients in a general hospital over the past 2.5 years. METHODS: A retrospective chart review was conducted of psychiatric consultations performed between January 1, 2011, and July 30, 2013. The records of 97 HIV-infected/AIDS patients were analyzed. These included a total of 282 psychiatric consultations. RESULTS: Of the 97 patients, 91(93.8%) were male, the mean age was 48 years, and mean number of consultations was 2.8. Depressed mood was reported in 102 consultations(23.8%), insomnia in 60(14.0%), and anxiety in 31(7.2%). Psychiatric disorders diagnosed on initial consultation included depressive disorder(37 patients ; 37.0%), cognitive disorder(11 ; 11.0%), and delirium(9 ; 9.0%). Recommended psychotropic medication included Lorazepam(99 ; 17.2%), Escitalopram(90 ; 15.7%), and Quetiapine(84 ; 14.6%). CONCLUSIONS: The main complaints of HIV-infected/AIDS patients were depressed mood, insomnia, and suicidal ideation(including suicide attempts). In total, 85(93.3%) patients of those consulted were diagnosed as meeting the criteria for a psychiatric condition. However, considering that only 16.9% of patients consulted received follow-up treatment, longitudinal research is needed to examine the influence of psychiatric disorders on the transmission of HIV-infection/AIDS, as well as on prognosis and treatment adherence.

A Study of Psychiatric Problems of North Korean Refugees Who Visited a Psychiatric Clinic / 수면정신생리

PURPOSE: According to the statistics announced by the Ministry of Unification, the number of North Korean refugees living in South Korea has increased by 200 on average monthly in 2010. The number of refugees increased only by 300 annually until 2000. The total number of refugees as of February 2012 was 20,956. This study aims to investigate the psychobiology of the North Korean refugees who consulted psychiatric clinics among those living daily life in South Korea. METHODS: The subjects of this study were 85 North Korean refugees that consulted psychiatric clinics from January 1, 2005 to July 2011. This study obtained demographic and psychiatric information in a retrospective approach. RESULTS: Among the 85 North Korean refugees, 75 (88.2%) were females and their average age was 48 years of age. A total of 16 (18.8%) were admitted to a clinic and among the inpatients, 4 were admitted twice and two were admitted three times. As for the claimed symptoms of outpatients, insomnia was shown in 47 (55.3%) patients, headaches in 37 (43.5%), anxiety in 20 (23.5%), depression in 19 (22.4%), etc. The major symptoms represented by inpatients were insomnia in 14 (87.5%) patients, depression in 12 (75%), and headaches in 8 (50%), etc. CONCLUSION: The most frequent psychiatric symptoms of North Korean refugees living in South Korea were insomnia and headaches. It suggests that when performing psychiatric diagnosis and treatment of North Korean refugees, we have to take into consideration the fact that they claimed the physical symptoms more than the emotional ones. Also, from the aspect that most symptoms of North Korean refugees were insomnia, more profound research on sleep is required in the future.

Post-Traumatic Stress Disorder, Depression, and Heart-Rate Variability among North Korean Defectors

OBJECTIVE: This study evaluated the symptoms of post-traumatic stress disorder (PTSD) among North Korean defectors and their level of suicidal ideation and the correlation between these and heart-rate variability (HRV) to explore the possibility of using HRV as an objective neurobiological index of signs of autonomic nervous system disorder. METHODS: A total of 32 North Korean defectors (nine men, 23 women) were selected as subjects, and their HRV was measured after they completed the Minnesota Multiphasic Personality Inventory-PTSD (MMPI-PTSD) scale and the Beck Depression Inventory (BDI). RESULTS: 1) Low-frequency (LF)/high-frequency (HF) ratios in the HRV index and MMPI-PTSD scores were correlated (r=0.419, p<0.05), as were BDI item 9 (suicidal ideation) and MMPI-PTSD scores (r=0.600, p<0.01). 2) A regression analysis of LF/HF ratios and MMPI-PTSD scores revealed an R-value of 13.8% (Adj. R2=0.138, F=4.695, p=0.041), and a regression analysis of BDI item 9 and MMPI-PTSD scores showed an R-value of 32.8% (Adj. R2=0.328, F=11.234, p=0.003). In other words, the LF/HF ratio (beta=0.419) and BDI item 9 (beta=0.600) appear to be risk factors in predicting MMPI-PTSD scores. CONCLUSION: The LF/HF ratio, a standard index of autonomic nervous system activity, can be used as an objective neurobiological index to analyze PTSD among North Korean defectors presenting with various mental and physical symptoms, and the approximate level of suicide -ideation can act as a predicting factor for PTSD.

Inferior Orbital Wall Reconstruction with Vascularized Partial Thickness Calvarial Bone Flap in Three Cases of Maxillary Tumor

PURPOSE: Inevitably, Maxillary structural defect follows maxillary cancer extirpation. Maxillary reconstruction is over every surgeon's head. Every physician tried to overcome limited donor site of craniofacial defect. We considered to suggest optimal method of inferior orbital wall defect in functional point as well as esthetic point. METHODS: We performed wide excision of maxilla and vascularized partial thickness calvarial bone flap to reconstruct the defect from cancer extirpation in three cases. We select ipsilateral superficial temporal artery, vein and outer cortex of parietal bone flap as donor. And we applied bone flap as inferior orbital wall structure. The bony surface was wrapped with fascia to prevent direct contact between orbital contents and rough bony flap surface. Computed tomography image was checked during follolw up period. RESULTS: We can observe these patients for over two years. In all three cases, We can get fair inferior orbital wall structure. Even though they got radiation therapy, there was no limitation of extraocular movements, no diplopia. no enophthalmos. Also there was minimal donor site morbidity. CONCLUSION: We suggest vascularized calvarial bone flap is practically excellent strategy for inferior orbital wall reconstruction

Treatment of Compensatory Hyperhidrosis with Botulinum Toxin A: A case report

Conventional thoracoscopic sympathectomy is an effective method in treating palmar-axillary hyperhidrosis. However, this may result in a postoperatively compensatory hyperhidrosis. Conservative treatments of compensatory hyperhidrosis consist of aluminum chloride, anticholinergics, iontrophoresis, and botulinum toxin A injections. Surgical treatments in compensatory hyperhidrosis include excision of axillary tissue, liposuction, and thoracoscopic sympathectomy. Intradermal injection of botulinum toxin A has used to treat focal axillary or palmar hyperhidrosis. Botulinum toxin A bestows significant benefits with few side-effects and is well-tolerated, with beneficial results lasting from 4-16 months. We report a case illustrating the beneficial use of botulinum toxin A in a 25-year-old healthy male patient with compensatory sweating of the flank after thoracoscopic sympathectomy. Modified Minor's starch iodine test was used to allow accurate assess the impact of hyperhidrosis on the patient. In conclusion, Botulinum toxin type A is a valuable therapy for compensatory sweating after endoscopic thoracic sympathectomy.

Treatment of Steatocystoma Multiplex on Whole Body: A Case Report

PURPOSE: Steatocystoma multiplex is a rare benign disease that occurred multiply on whole body surface. Many physicians have tried managing steatocystoma in variable methods. However it is hard to define the optimal way to cure steatocystoma. We performed both aspiration and excisional method to study the usefulness of both methods. METHODS: A 28-year-old woman has asymptomatic multiple subcutaneous nodules on whole body. Most lesions were aspirated with 26-guage needled 3cc syringe but large and purulent three nodules were excised. RESULTS: We diagnosed the lesion histologically as steatocystoma multiplex. Aspirated wound healed without scar, excised wound remained scar but esthetically acceptable. Axillary lesion contained so clustered type cysts that was difficult to aspirate whole cyst. Thus additional excisional method was needed. CONCLUSION: There are many practical methods to cure steatocystoma. However, there is no appropriate method to cure it. Therefore we should select different therapeutic method according to anatomical location and cyst size. Especially at subcutaneous fat-rich lesion like axilla and abdomen, it is better to excise the clustered cyst than to aspirate.

Anatomical Study of Superficial Peroneal Nerve Accessory Artery and Perforators in the Anterior Intermuscular Septum of Lower Leg Using Cadaveric Dissection

PURPOSE: In the 1990s, skin island flap supplied by the vascular axis of the sensitive superficial nerves had been introduced. For example, neurocutaneous flaps supplied by the vascular axis of the sural nerve and saphenous nerve have been used. But the flap supplied by the vascular axis of superficial peroneal nerve has not been used commonly. Because there have been few anatomical reports about the superficial peroneal nerve accessory artery(SPNAA), we could not apply the neurocutaneous flap supplied by SPNAA. The aim of this study is to investigate the anatomy of SPNAA, number and location of its perforators, and septocutaneous perforators from the anterior tibial artery in anterior intermuscular septum. METHODS: So, we dissected a total of eight cadavers. Measurements were made of the positions of the dissected arteries and perforators from the head of the fibula. RESULTS: In all cadavers the superior lateral peroneal artery was originated from the anterior tibial artery and contributed SPNAA. Arising from the anterior tibial artery an average of 5.63 cm inferior to the fibular head, it varied from 10 cm to 16 cm in length. SPNAA gave off an average of 4.38 perforators to supply lateral aspect. In one case the inferior lateral peroneal artery was present and arose from the anterior tibial artery 18 cm inferior to the fibular head. There were an average of 3.38 direct septocutaneous perforators from the anterior tibial artery. CONCLUSION: Septocutaneous perforators from SPNAA mainly exist from proximal 1/6 to 3/5 of lower leg. In the distal 1/3 of lower leg where the accessory artery was disappeared, exist mainly direct septocutaneous perforators from the anterior tibial artery. Our results can be helpful to applications of the neurocutaneous flap using SPNAA or fasciocutaneous flap based on direct septocutaneous perforators.

Anatomical Study of Superficial Peroneal Nerve Accessory Artery and Perforators in the Anterior Intermuscular Septum of Lower Leg Using Cadaveric Dissection

PURPOSE: In the 1990s, skin island flap supplied by the vascular axis of the sensitive superficial nerves had been introduced. For example, neurocutaneous flaps supplied by the vascular axis of the sural nerve and saphenous nerve have been used. But the flap supplied by the vascular axis of superficial peroneal nerve has not been used commonly. Because there have been few anatomical reports about the superficial peroneal nerve accessory artery(SPNAA), we could not apply the neurocutaneous flap supplied by SPNAA. The aim of this study is to investigate the anatomy of SPNAA, number and location of its perforators, and septocutaneous perforators from the anterior tibial artery in anterior intermuscular septum. METHODS: So, we dissected a total of eight cadavers. Measurements were made of the positions of the dissected arteries and perforators from the head of the fibula. RESULTS: In all cadavers the superior lateral peroneal artery was originated from the anterior tibial artery and contributed SPNAA. Arising from the anterior tibial artery an average of 5.63 cm inferior to the fibular head, it varied from 10 cm to 16 cm in length. SPNAA gave off an average of 4.38 perforators to supply lateral aspect. In one case the inferior lateral peroneal artery was present and arose from the anterior tibial artery 18 cm inferior to the fibular head. There were an average of 3.38 direct septocutaneous perforators from the anterior tibial artery. CONCLUSION: Septocutaneous perforators from SPNAA mainly exist from proximal 1/6 to 3/5 of lower leg. In the distal 1/3 of lower leg where the accessory artery was disappeared, exist mainly direct septocutaneous perforators from the anterior tibial artery. Our results can be helpful to applications of the neurocutaneous flap using SPNAA or fasciocutaneous flap based on direct septocutaneous perforators.

Effects of Respiratory Rate on Cardiovascular Variability under General Anesthesia with Mechanical Ventilation / 대한마취과학회지

BACKGROUND: Although heart rate variability (HRV) and blood pressure variability (BPV) arise from many different influences, probably the most consistent external modulator is respiration. At rest, the heart rate increases on inspiration and decreases on expiration, a phenomenon called respiratory sinus arrhythmia (RSA). Spectral analysis of heart rate offers good and reproducible estimate of RSA and BPV. Many studies have been conducted on the effects of respiration on HRV and BPV during awake subject breathing spontaneously. However, little is known as to whether respiratory rate modulates HRV and BPV during general anesthesia with mechanical ventilation. Here, we studied effects of respiratory rate on HRV and BPV during general anesthesia. METHODS: We studied 40 patients undergoing general anesthesia with mechanical ventilation. Maintaining anesthesia with isoflurane, we recorded R-R interval and systolic blood pressure at respiratory rate of 15, 10 and 6 breaths/minute. Data was analyzed by the power spectral analyses of HRV and BPV, which were divided into low frequency (LF) and high frequency (HF) band. RESULTS: Respiratory rate did not affect RR interval, systolic blood pressure, and total spectral power HRV and BPV. Compared with its value at 15 breaths/minute, HF-HRV was significantly increased at 6 breaths/minute. HF-and LF-BPV at 6 breaths/minute were significantly increased versus 15 breaths/minute. CONCLUSIONS: Respiratory rate modulates HRV and BPV during general anesthesia with mechanical ventilation. We suggest that respiratory rate should be considered and controlled in studies of cardiovascular variability during general anesthesia.

The Mechanism of Antiallodynic Effect of Intrathecal Morphine in Neuropathic Pain Induced by Spinal Nerve Ligation: The Effect of Methysergide and Theophylline / 대한마취과학회지

BACKGROUND: Although the efficacy of morphine in a neuropathic pain state is somewhat controversial, spinally administered morphine reversed the tactile allodynia in a previous animal study. Using a behaviorial test, we examined the involvement of serotonergic and adenosine receptors in the mechanism of the antiallodynic action of the intrathecal morphine by injection of serotonergic and adenosine antagonist in a rat model of neuropathic pain induced by a spinal nerve ligation. METHODS: Male Sprague-Dawley rats were prepared with a tight ligation of the left lumbar 5th and 6th spinal nerve and a chronic lumbar intrathecal catheter implantation. Morphine 1 microgram was administered intrathecally to attenuate the tactile allodynia. Methysergide 10 microgram and 30 microgram, theophylline 20 microgram was administered intrathecally before and after the injection of morphine in order to investigate the reversal of an increased allodynic threshold by morphine. The allodynic thresholds for the left hindpaw withdrawl to von Frey hairs were assessed and converted to %MPE. RESULTS: The tactile allodynic threshold was significantly increased by 1 microgram of intrathecal morphine (P < 0.05). Methysergide 10 microgram and 30 microgram, but not theophylline 20 microgram, reversed significantly the antiallodynic effect of intrathecal morphine in pre- and post-treatment (P < 0.05). CONCLUSIONS: The results suggested that the mechanism of tactile antiallodynia induced by intrathecal morphine appears to be mediated by serotonin receptor system at the spinal level in the rat model of spinal nerve ligation.

Treatment of Degenerative Lumbar Stenosis with Minimal Decompression / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: In the operative treatment of lumbar spinal stenosis, the wide decompression and fusion method has many problems, such as a long operation time, large blood loss and the long time required to achieve solid fusion. As a solution to these problems, a minimal decompression method was been performed, which minimizes the resection of laminae and facet joints. SUMMARY OF LITERATURE REVIEW: In the operative therapy for lumbar spinal stenosis, favorable results can be obtained by simple decompression. MATERIALS AND METHODS: 42 cases of degenerative lumbar stenosis, with neither segmental instability nor spondylolisthesis, underwent a minimal decompressive surgery, without instrumentation. The mean operation time and amount of blood loss were analyzed, and the clinical results evaluated according to Kim's criteria and the postoperative segmental instability by the Dupuis method. The average follow-up period was 70 months. RESULTS: Transfusions were not required in all cases. The mean operative times were 1hour 5minutes and 1hour 46minutes in the one and two segment decompressions, respectively. The clinical results, according to Kim's criteria, were excellent in 24 cases and good in 12. There was no dynamic instability in the radiographs at the last follow-up. CONCLUSIONS: With the degenerative lumbar stenosis, without segmental instability or spondylolisthesis, minimal decompression was an effective surgical method.

Depression tendency between working housewives and non-working housewives in a medium: small city in the suburb of Seoul

INTRODUCTION: In traditional society, the roles of housewives were to do housework, to look after her children and to give her family emotional stability. With rapid social and economic change, the traditional sense of value changes and the concepts of sexual roles, too. However, they are in a transition period yet. These discord and tension followed by role change appeared as the form of psychological instability or social pathological problem in modern family. Thus, this study aimed to avaluate the effect of employment on depression of housewives who play importent roles in family and their commumity. METHODS: From May to July 1996, the questonnaires were distributed to 179 housewives who have university education background(including community college), and have one or more children and live in Bundang-Ku of Sungnam city, making a distinction between working housewives and nonworking housewives. Regarding the subjects of this study, the non-working housewives are restricted to full-time housewives who have no job, and working housewives who have full-time job. As tools of measurement, we used BDI questionnaires consisted of 15 items in Korean. We performed statistical analysis among the data by means of SPSS/PC+. We analyzed statistical data for significance using one-way ANOVA and analyzed categorical data for significance using S-test. RESULTS: The average score on BDI for working housewives was 12.22(standard deviation 7.42) and this is rather higher than that of non-working housewives(10.80, standard deviation : 7.42). But the number of children increased, the BDI score were higher significantly in both groups. And the BDI score was high in working Housewives groups whose husbands had professional job or dommerce job, whose family system is a multi-generation family, and who feel a lot of fatigue after work. In case of non-working housewives, the BDI score was high with age(especially between 50-59), duration of marriage, lower income and Duvalls family life cycle 6, 7. CONCLUSIONS: There is no difference in depression tendency between working housewives and nonworking housewives. But in case of working housewives, some factors have influence on their depression tendency, the number of children, husbands job, family type, degree of fatigue after work. And in case of non-working housewives, the factors are the number of children, age, duration of marriage, income, family life cycle.