Efficacy of preoperative percutaneous cholecystostomy in the management of acute cholecystitis according to severity grades

BACKGROUND/AIMS: The aim of this retrospective study was to assess the efficacy of percutaneous cholecystostomy (PC) for patients with acute cholecystitis (AC) according to severity. METHODS: A total of 325 patients who underwent cholecystectomy between January 2008 and October 2010 were enrolled. Patients were classified into three groups based on severity grade according to the Tokyo guidelines for AC: grade I (mild), grade II (moderate), and grade III (severe). These groups were further classified into two subgroups based on whether or not they underwent preoperative PC. RESULTS: A total of 184 patients were classified into the grade I group (57%), 135 patients were classified into the grade II group (42%), and five patients were classified into the grade III group (1%). In the grade I and II groups, the mean length of hospital stay was significantly shorter in the patients who did not undergo PC than in those who received PC (10.7 ± 4.4 vs. 13.7 ± 5.8, p < 0.001; 11.8 ± 6.5 vs. 16.9 ± 12.5, p = 0.003, respectively). The mean length of preoperative hospital stay was significantly shorter in the patients without PC than in those with PC in the grade I and II groups (5.8 ± 3.3 vs. 8.2 ± 4.6, p = 0.001; 6.0 ± 4.4 vs. 8.8 ± 5.2, p = 0.002). In addition, the operative time was shorter in patients without PC, especially in the grade I group (94.6 ± 36.4 vs. 107.3 ± 33.5, p = 0.034). CONCLUSIONS: Preoperative PC should be reserved for only selected patients with mild or moderate AC. No significant benefit of preoperative PC was identified with respect to clinical outcome or complications.

A Study on the Classification of Nursing Management Competencies and Development of related Behavioral Indicators in Hospitals

PURPOSE: The aim of this study was to classify nursing management competencies and develop behavioral indicators for nurse managers in hospitals. Also, levels of importance and performance based on developed criteria were to be identified and compared. METHODS: Using expert survey we classified nursing management competencies and behavioral indicators with data from 34 nurse managers and professors. Subsequently, data from a survey of 216 nurse managers in 7 cities was used to analyze the importance-performance comparison of the classified nursing management competencies and behavioral indicators. RESULTS: Forty-two nursing management competencies were identified together with 181 behavioral indicators. The mean score for importance of nursing management competency was higher than the mean score for performance. According to the importance-performance analysis, 5 of the 42 nursing management competencies require further development: vision-building, analysis, change management, human resource development, and self-management competency. CONCLUSION: The classification of nursing management competencies and behavioral indicators for nurse managers in hospitals provides basic data for the development and evaluation of programs designed to increase the competency of nurse managers in hospitals

Mucinous Cystic Neoplasm of the Pancreas Presenting with Acute Pancreatitis, Initially Misdiagnosed as a Pseudocyst / 대한내과학회지

Pancreatic cystic lesions include retention cysts (congenital cysts), pseudocysts, and cystic neoplasms. Pancreatic cystic neoplasms have recently been diagnosed more commonly, possibly due to advances in imaging and widespread screening programs. Cystic neoplasms of the pancreas account for 10-20% of pancreatic tumors. Mucinous cystic neoplasms (MCN) and intraductal papillary mucinous neoplasms are regarded as premalignant lesions, whereas serous cystadenoma is not. In the clinical setting of acute pancreatitis, pancreatic cystic lesions are usually diagnosed as pseudocysts. However, cystic neoplasms of the pancreas should be considered in the differential diagnosis of pancreatic cysts, even in patients with a history of pancreatitis. In the Korean literature, MCN combined with acute pancreatitis has rarely been reported. Here, we report a case of MCN presenting with acute pancreatitis in a 22-year-old female, which was initially misdiagnosed as pancreatic pseudocyst.

A Case of Perforated Gastrointestinal Stromal Tumor in the Jejunum as a Rare Cause of Acute Abdomen

Preoperative diagnosis of Gastrointestinal Stromal Tumors (GISTs) in the small intestine is often delayed until complications such as hemorrhage, bowel obstruction or perforation develop. Such GISTs are usually asymptomatic and tumor perforation is an uncommon clinical presentation. In this report, we review the diagnosis, pathology and treatment of a 32-year-old male with a perforated GIST in the jejunum who presented with symptoms of acute abdomen. Abdominal computed tomography (CT) showed a ruptured huge tumor with inhomogeneous density in the small intestine. The patient underwent a complete tumor excision and jejunal segmental resection. A histopathological examination of the tumor confirmed that it was a GIST. Postoperatively, the patient received medical treatment, using oral Imatinib 400 mg daily for 10 months without any signs of disease recurrence. Prognosis is worse in ruptured GISTs and in these cases, complete surgical resection of the tumor must be followed by adjuvant therapy with Imatinib.

A Case of Acute Colonic Diverticulitis as a Complication of Colonoscopy

Colonoscopy is a good diagnostic tool and facilitates treatment of various colonic diseases. Nevertheless, it can induce many serious complications such as perforation and hemorrhage. Diverticulitis has also been reported as a serious complication of colonoscopy, with an incidence ranging from 0.04% to 0.08%. A 44-year-old male with chronic hepatitis B was presented with general weakness, myalgia, and febrile sensation. After admission for evaluation, pneumonia detected in the left upper and lower lobe and treated. We performed colonoscopy for screening and found multiple colonic diverticula in the right side of the colon. After 48 hours, the patient complained of abdominal pain and febrile sensation. Physical examination revealed tenderness in the right side of the abdomen. Abdomen-pelvis computed tomography showed bowel wall thickening of the cecum and ascending colon and multiple inflamed diverticula at the cecum with pericolic fat infiltration and fluid collection. We diagnosed the patient with acute diverticulitis after colonoscopy. Thereafter, he was treated with bowel rest and broad-spectrum intravenous antibiotics, and recovered. With a review of the relevant literature, we report a case of acute colonic diverticulitis as a complication of colonoscopy.

A Clinical Review of the Intussusception in Adult

BACKGROUND/AIMS: Intussusception is uncommon in adults compared with children. The present study aimed to review our experience of adult intussusceptions and discuss the preoperative diagnosis and management. METHODS: A retrospective review was performed for 25 patients, at least 18 years old. These patients were diagnosed as intestinal intussusceptions at Hallym University Sacred Heart Hospital from January 1999 to October 2010. RESULTS: There were 14 male and 11 female with a mean age of 55 years. The most common symptom was abdominal pain. The preoperative diagnostic rate was 92% because of the use of an abdominal computed tomography (CT) and an ultrasound. A total of 9 (36%) patients had enteroenteric intussusception, 8 had ileocolic, 1 had ileocecal and 7 patients had colocolic intussusception. A discrete pathologic process was present in 22 (88%) patients and the remaining 3 (12%) patients were idiopathic. There were 12 small bowel lesions and 10 colonic lesions. Neoplasms were the most common etiology of intussusceptions. Of the cases with a defined colonic cause, 8 (80%) were malignant. Overall, 12 (48%) patients underwent primary resection of the intussusception without prior reduction, 11 (44%) patients had reduction of their intussusception followed by resection. CONCLUSIONS: Adult colonic intussusception is usually associated with malignancy. All patients with obstruction of unknown cause or lead point on CT should consider surgical exploration.

Safety and Efficacy of Deep Sedation with Propofol Alone or Combined with Midazolam Administrated by Nonanesthesiologist for Gastric Endoscopic Submucosal Dissection

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is accepted as a treatment for gastric neoplasms and usually requires deep sedation. The aim of this study was to evaluate the safety and efficacy profiles of deep sedation induced by continuous propofol infusion with or without midazolam during ESD. METHODS: A total of 135 patients scheduled for ESDs between December 2008 and June 2010 were included in this prospective study and were randomly assigned to one of two groups: the propofol group or the combination group (propofol plus midazolam). RESULTS: The propofol group reported only one case of severe hypoxemia with no need of mask ventilation or intubation. Additionally, 18 cases of mild hypotension were observed in the propofol group, and 11 cases were observed in the combination group. The combination group had a lower mean total propofol dose (378 mg vs 466 mg, p<0.012), a longer mean recovery time (10.5 minutes vs 7.9 minutes, p=0.027), and a lower frequency of overall adverse events (32.8% vs 17.6%, p=0.042). CONCLUSIONS: Deep sedation induced by continuous propofol infusion was shown to be safe during ESD. The combination of continuous propofol infusion and intermittent midazolam injection can decrease the total dose and infusion rate of propofol and the overall occurrence of adverse events.

Case of Thyroid Hormone Resistance Syndrome with a Mutation in the Thyroid Hormone Receptor Beta Gene / 대한내과학회지

In thyroid hormone resistance syndrome (THR) TSH levels are normal or elevated despite thyroid hormone levels being elevated. THR is distinguished from TSH-producing pituitary adenoma by TRH stimulation and alpha-subunit tests, thyroid hormone receptor (TR) beta gene analysis, and sellar MRI. A 24-year old man with diffuse goiter visited our hospital complaining of fatigue, heat intolerance, palpitation, and weight loss. He had elevated total T3 and free T4 levels, but normal TSH levels. Serum TSH levels during TRH stimulation tests performed before and after T3 suppression showed normal and non-suppressible responses, respectively. The serum basal alpha-subunit test result was normal. A TR beta gene R438H mutation was identified, and a pituitary mass with cystic change was identified by sellar MRI. We report a case of THR with a mutation (R438H) in the TR beta gene, the first case of its kind in Korea.

Incidence and prognosis of disseminated intravascular coagulation in patients with severe sepsis or septic shock / 대한내과학회지

BACKGROUND/AIMS: We investigated the incidence and prognosis of disseminated intravascular coagulation (DIC) using DIC scoring system in patients with severe sepsis or septic shock. METHODS: Patients admitted to the intensive care unit (ICU) in a tertiary hospital for severe sepsis or septic shock were enrolled from Mar. 2008 to Feb. 2009. Using the International Society on Thrombosis and Haemostasis (ISTH) criteria, we calculated DIC score at three time points (Day 0, Day 1, and Day 2). RESULTS: Among 111 patients with severe sepsis or septic shock, 89 (severe sepsis, 8; septic shock, 81) were enrolled. Mean DIC score at ICU admission was 3.3+/-1.3 and the incidence of overt DIC (DIC score > or = 5) during the first 48 hours was 33.8% (27/89). Sequential Organ Failure Assessment (SOFA) score was well correlated with DIC score and was higher in patients with overt DIC than in those without. The ICU, hospital and 28-day death rates in patients with overt DIC were 63.0%, 66.7%, and 63.0%, respectively, which were significantly higher than in those without overt DIC. In multivariate analysis, Simplified Acute Physiology Score (SAPS) II was significantly associated with hospital death (p=0.002), and the occurrence of overt DIC showed a borderline significance (p=0.053). CONCLUSIONS: Using the ISTH criteria for DIC, the incidence of overt DIC was 33.8% in patients with severe sepsis or septic shock. The occurrence of overt DIC was associated with a higher organ failure score and hospital outcomes.

The Usefulness of Endoscopic Ultrasonoraphy for Discriminating Gastric Mucosal Cancer from Submucosal Invasion / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) has been used to discriminate gastric mucosal cancer (T1m) from submucosal invasion (T1sm). Thus the aims of this study are 1) to determine the accuracy of EUS for diagnosing tumor depth, 2) to compare the accuracy of EUS with the endoscopic impressions of variously experienced endoscopists and 3) to compare the accuracy of performing EUS by one doctor according to the experience. METHODS: The EUS and pathologic reports of early gastric cancer patients were analyzed. The same endoscopic images were reviewed again by 3 endoscopists, who had one-, three- and five-years experience, respectively. The accuracies of EUS and conventional endoscopy were analyzed. RESULTS: 77 patients were included from November 2003 to October 2005. The kappa of the EUS for actual examiner and conventional endoscopy for reviewer 1, reviewer 2 and reviewer 3 were 0.421, 0.134, 0.359 and 0.307, respectively and accuracies were 68.8%, 45.5%, 67.5% and 62.3%, respectively. Of the 52 T1m patients, 23 (44.2%) were overstaged as T1sm with performing EUS. But of 25 T1sm patients, only 1 (4.0%) was understaged as T1m with performing EUS. The accuracy and kappa of the EUS for one doctor during the first-year experience were 60.6% and 0.316, respectively, and they were 75.0% and 0.508, respectively during the second-year experience. CONCLUSIONS: EUS is useful for complementing the conventional endoscopic discrimination of gastric mucosal cancer from submucosal invasion. Yet physician should keep in mind the relatively common overstaging.

The Significance of Connexin 26 Expression in Squamous Cell Lesions of the Larynx / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Gap junctional intercellular communication (GJIC) is a mechanism for direct cell to cell signalling and is mediated by gap junctions, which consist of transmembrane proteins called connexins (Cxs). The authors investigated the role of connexin 26 as a biomarker that helps diagnose laryngeal squamous cell lesions. SUBJECTS AND METHOD: Paraffin-embedded tissue specimens from 50 patients, who were diagnosed with laryngeal invasive squamous cell carcinoma (n=15), carcinoma in situ (n=10), dysplasia (n=15), and non-neoplastic epithelial hyperplasia (n=10) between 1993 and 2005, were immunohistochemically stained for connexin 26 protein. RESULTS: Intracytoplasmic positive expression of connexin 26 was found in 100% of invasive squamous cell carcinoma and in 20% of carcinoma in situ. However, in dysplasia and hyperplasia, there were no positive expressions. Moreover, the majority of intercellular or membranous staining tended to decline in dysplasia, carcinoma in situ, and squamous cell carcinoma. CONCLUSION: These results suggest that aberrant expression of connexin 26 in laryngeal squamous cell lesions can be associated with tumorigenesis and invasion. Further studies are needed to investigate these expressions of connexin 26 and that it may represent more aggressive pathology of the larynx.

A Case of Triple Cancers of the Esophagus, Stomach and Duodenum / 대한소화기내시경학회지

Multiple primary cancer is defined as the multiple occurrence of malignant neoplasm in the same individual. The incidence of multiple primary cancer is 0.26~1.43% in Korea, but this malady is increasing due to development of diagnostic modalities, the treatment of cancer and the recording of accurate cancer statistics. The most common site of multiple primary cancer in Korea is the stomach, colon, breast, cervix, liver and lung. We report here on a case of triple cancer that was located at the middle esophagus, stomach and duodenum in 75 year-old man.

Prevalence and Risk Factors of Gallbladder Polyp in Adults Living in Daegu and Gyeongbuk Provinces / 대한소화기학회지

BACKGROUND/AIMS: Although there are various reports on the prevalence of gallbladder (GB) polyp according to the race or area, there is no report on Daegu and Gyeongbuk provinces. Therefore, we investigated the prevalence and related risk factors of GB polyp in health screening population of Daegu and Gyeongbuk provinces. METHODS: Of 28,911 adult health screening examinees from January 1997 to May 2003, age and gender-matched 8,008 (3,896 men, 4,112 women) were randomly selected to evaluate the prevalence. Independent risk factors were analyzed by comparing various variables between the GB polyp positive and negative groups. RESULTS: The prevalence of GB polyp was 2.2% (175/8,008). Those were 2.7% (104/3,896) among men and 1.7% (71/4,112) among women. Independent risk factors related with GB polyp were male gender (OR 1.434, p<0.001), obesity (OR 1.237, p=0.024), and hepatitis B carrier (OR 1.888, p<0.001) CONCLUSIONS: Prevalence of GB polyp in Daegu and Gyeongbuk provinces is 2.2%. Male, obesity, and hepatitis B carrier may be the risk factors related with GB polyp in this region.

A Case of Inflammatory Myofibroblastic Tumor of the Maxillary Sinus / 대한이비인후과학회지

Inflammatory myofibroblastic tumor (inflammatory pseudotumor) is a term used to describe the space occupying the neoplastic lesion rather than the inflammatory lesion. Its occurrence in the maxillary sinus is rare. The etiology and pathophysiology of the maxillary inflammatory myofibroblastic tumor is unknown. The diagnosis must be based on histological evidence to exclude other disease. We report a case of a 72-year-old patient with maxillary and nasal cavity inflammatory myofibroblastic tumor that simulated an invasive neoplasm in its clinical presentation, Radiologic findings showed near total coagulation necrosis histopathologically.

The Change of Cardiac Function and Morphology after Mitral Valve Repair Surgery in Mitral Valve Prolapse with Mitral Regurgitation

BACKGROUND AND OBJECTIVES: Although it is well known that mitral valve repair provides a better postoperative outcome than valve replacement for mitral valve prolapse with mitral regurgitation, there haven't been much studied the nature of remnant regurgitation and the change of heart function and structure by remnant regurgitation after mitral valve repair surgery. We tried to research for it. METHODS AND RESULTS: Retrospective analysis of echocardiographic data and medical records was done in patients who underwent repair surgery for mitral valve prolapse with significant mitral regurgitation at the Keimyung University Dong-san Medical Center from February 1996 to February 2000. Patients who underwent echocardiography before and after the surgery were selected for the analysis. Of patients who underwent mitral valve repair surgery for mitral valve prolapse with mitral regurgitation during that period, 30 patients (male 15, female 15) were included in this study. The average age of them was 44.30+/-14.30 year old. After surgery, heart chamber size was decreased significantly in all patients (e. g. LVDd 6.25+/-1.06 cm vs. 5.14+/-0.62 cm, LV mass 272.46+/-107.36 gm vs. 197.30+/-75.16 gm). Remnant mitral regurgitation after repair surgery was found in 22 patients (73.3%). Remnant mitral regurgitation above trivial flow was found in 10 patients. Such case as involving ant. leaflet was found in 5 patients (16.7%), as involving post. leaflet, in 2 patients (6.7%), as involving both leaflet, in 3 patients (10%) among 10 ones. Eccentric flow among remnant regurgitation, was observed in 2 patients who underwent repair surgery for ant. leaflet, 1 patient who underwent repair surgery for both leaflet. CONCLUSION: Mitral valve repair surgery reduce the left ventricular chamber size and left ventricular mass. Postoperatively, patients who involve ant. leaflet were much remnant regurgitation above trivial flow more than others.

The Usefulness of Supine Bycycle Stress Echocardiography for Evaluationg Coronary Artery Disease: Comparision with Exercise Electrocardiography

BACKGROUND AND OBJECTIVES: Posttreadmill exercise echocardiography or supine bicycle exercise echocardiography are widely used for evaluating coronary artery disease. In comparison with posttreadmill exercise echocardiography, supine bicycle stress echocardiography (SBSE) has the advantage of imaging during stress and at peak exercise and ischemic wall motion abnormalities at the time of imaging are more frequent and more extensive. Therefore, SBSE is a valuable tool for evaluation of coronary artery disease. This study was designed to provide the hemodynamic changes during exercise and compare the sensitivity, specificity and predictive values of the wall motion abnormalities of supine bicycle stress echocardiography during peak exercise with those of 12-lead electrocardiography (ECG) during exercise for evaluating coronary artery disease. MATERIALS AND METHODS: One hundred patients for evaluation of possible coronary artery disease performed supine bicycle stress echocardiography. This study consisted of 51 patients who underwent coronary arteriography. Significant coronary artery disease was defined as the presence of 50% or 75% diameter reduction determined by magnified electronic caliper measurements, compairing the accuracy of supine bicycle stress echocardiography to that of 12-lead exercise ECG. RESULTS: 1) Fifty-one patients (31 men, 20 women) underwent both supine bicycle stress echocardiography and coronary arteriography, the results were age (54.5+/-9.8 years), heart rates(68+/-12 vs 12422 beats/min), systolic blood pressure (130+/-23 vs 175+/-32 mmHg), diastolic blood pressure (76+/-13 vs 96+/-25mmHg) in resting vs during peak exercise and % predicted maximal heart rate (72+/-10%). 2) At coronary artery disease was defined as the presence of 50% diameter reduction, 26 of 51 patients were included(19 with single-vessel, 6 with double-vessel and 1 with triple-vessel disease). SBSE was 69.2% sensitivity, 64% specificity, 66.7% positive predictive value and 66.7% negative predictive value compared with 33.3% sensitivity, 70.8% specificity of ECG during exercise. 3) At coronary artery disease was defined as the presence of 75% diameter reduction, 19 of 51 patients were included(16 with single-vessel and 3 with double-vessel disease). SBSE was 84.2% sensitivity, 65.6% specificity, 59.3% positive predictive value and 45.8% negative predictive value compared with 31.6% sensitivity, 68.7% specificity of 12-lead ECG during exercise. 4) There were no serious complications like that ventricular tachycardia or fibrillation, severe hypotension or hypertension, acute myocardial infarction and death during exercise test. CONCLUSIONS: The sensitivity of supine bicycle stress echocardiography during peak exercise was higher than 12-lead ECG during exercise for evaluation of coronary artery disease because wall motion abnormality of echocardiography was more early detected than ECG changes during exercise at same amounts of workload. Therefore, supine bicycle stress echocardiography is a useful tool for evaluating coronary artery disease.

Clinical Evaluation of The Retinal Injuries following Perforating Ocular Traumas

We reviewed the records of 152 patients with retinal injuries following perforating ocular traumas who had visited at the Department of Ophthalmology, Yeungnam University Hospital from March 1983 to December 1993. Young men predominated, and the most common cause of injury was metallic particle(63.3%). The ocular perforation site was found in sclera(38.2%), cornea(36.2%) and corneosclera(25.6%). The associated disorders with retinal injuries revealed retinal tear alone in 45 eyes, retinal detachment in 46 eyes, marked vitreous hemorrhage in 66 eyes, and endophthalmitis in 15 eyes. The site and length of perforating ocular injuries, traumatic cataract, traumatic hyphema, intraocular foreign body and endophthalmitis did not affect visual prognosis significantly. Significant predictors of good visual outcome were good initial visual acuity, absence of vitreous hemorrhage or retinal detachment, and early vitrectomy.

Surgical Management of Scleral Necrosis

Scleral necrosis is a focal thinning of the sclera, and causes an exposure of underlying uveal tissue, endophthalmitis, and eyeball perforation. The authors experienced 16 cases of scleral necrosis after pterygium excision and performed combined lamellar scleral grafting and conjunctival flap for 13 cases, and simple conjunctival flap for 3 cases. After 12 months of follow-up period, all of the scleral grafts healed well except one case of graft melting. Six cases associated with endophthalmitis showed three lines of mean visual acuity improvement with Snellen chart after postoperative healing of inflammation. Postoperative complications included temporary corneal erosion(6 cases), conjunctival cyst formation(2 cases), scleral graft melting(1 case), and partial absorption of conjuctival flap(1 case).

Analysis of the Causes of Ptosis

The authors reviewed the patient's charts of 300 patients with ptosis(401 eyes). The patients were classified into congenital and acquired and analyzed patients according to causes and their incidences. Of all patients, 261(86%) were congenital ptosis and the remaining 39 were acquired. The most common type of convenital ptosis was simple one(85%). On the other hand, acquired ptosis composed of mechanical(35.9%) and traumatic (23.1 %) in their incidence. In regarding severity of ptosis, severe form were 72% and 45% in congenital and acquired, respectively. When compared with reports from other countries on their incidence, congenital ptosis was much higher than that of incidence.