Efficacy of Inhaled Iloprost in Cor Pulmonale and Severe Pulmonary Hypertension Associated with Tuberculous Destroyed Lung

Chronic obstructive pulmonary disease (COPD) is one of the causes of cor pulmonale. Cor pulmonale patients with pulmonary hypertension have a significant lower survival rate than patients without. However, there is no conclusive treatment options in cor pulmonale and pulmonary hypertension associated with COPD until now. We report a patient with cor pulmonale and pulmonary hypertension associated with severe form of COPD and tuberculous destroyed lung who achieved marked clinical, functional and echocardiographic hemodynamic improvements with inhaled iloprost for six months.

Functional Class and Targeted Therapy Are Related to the Survival in Patients with Pulmonary Arterial Hypertension

PURPOSE: Pulmonary arterial hypertension (PAH) is an orphan disease showing poor prognosis. The purpose of study was to evaluate clinical factors influencing outcomes in PAH. MATERIALS AND METHODS: Patients who were diagnosed with PAH at a single center were reviewed retrospectively. Forty patients (34.9+/-14.5 years, 80% of female) were enrolled. RESULTS: Causes were congenital heart disease in 24 (60%), connective tissue disease in 8 (20%) and idiopathic PAH in 6 (15%). Sixteen patients (40%) were WHO functional class III or IV at the time of diagnosis. Twenty seven patients (67.5%) received molecular targeted therapy. During follow-up (53.6+/-45.5 months), 10 patients (25%) died and 1-, 2-, and 8 year survival rates were 91.3%, 78.7%, and 66.8%, respectively. As expected, median survival of patients with functional class I or II were significantly longer than patients with III or IV (p=0.041). Interestingly, patients with molecular targeted therapy showed longer survival than conventional therapy (p=0.021). CONCLUSION: WHO functional class at the time of diagnosis was the strong predictor of survival, and molecular targeted therapy could significantly improve the survival. Therefore, early screening and intensive management would be crucial to improve the prognosis in the patient with PAH.

Vasorelaxant mechanisms of ketamine in rabbit renal artery / 대한마취과학회지

BACKGROUND: Ketamine is a non-barbiturate anesthetic agent which has various effects on the cardiovascular system. Among them, ketamine is known for its hypotensive properties. The hypotension is thought to be mediated by a direct effect on vascular smooth muscles. This study is designed to examine the effects of ketamine on KCl- and histamine-induced contraction in isolated rabbit renal arteries. METHODS: Endothelium-intact or -denuded smooth muscle rings were prepared and mounted in myographs for isometric tension measurements. The inhibitory effect of ketamine were investigated in smooth muscle rings precontracted with either 50 mM KCl- or 10 microM histamine. RESULTS: Ketamine (0.1-100 microg/ml) produced similar concentration-dependent inhibition of contractile responses induced by either 50 mM KCl or 10 microM histamine. The respective IC50 values measured for ketamine following precontractions by 50 mM KCl and 10 microM histamine were 28.9 microg/ml (105.5 microM) and 26.7 microg/ml (97.5 microM). The inhibitory effect of 30 microg/ml ketamine were similarly observed after removal of endothelium or pretreatment with NG-Nitroarginine Methyl Ester (0.1 mM). The inhibitory effect of 30 microg/ml ketamine on histamine-evoked contraction was reduced by either tetraethylammonium (10 mM) or iberiotoxin, a large conductance Ca2+-activated K+ channel blocker. However, depletion of intracellular Ca2+ stores by ryanodine (10 microM) or thapsigargin (10 microM) showed no significant effect on 30 microg/ml ketamine-induced relaxation. Pre-incubation with 30 microg/ml ketamine significantly inhibited CaCl2-induced contraction at almost all ranges of concentration. CONCLUSIONS: Ketamine-induced relaxation of rabbit renal arteries is mediated by both the activation of large conductance Ca2+-activated K+ channel and the inhibition of Ca2+ influx.

An Alternative Approach to Needle Placement in Cervicothoracic Epidural Injections

The use of fluoroscopy guidance together with the loss of resistance technique during epidural injections has been advocated lately; moreover, epidural injections in the absence of fluoroscopic guidance have a high rate of inaccurate needle-tip placement during the injections. However, the approach to the lower cervical and upper thoracic epidural space may be challenging due to its obscure lateral fluoroscopic views from overlying normal tissue structures. In this case, we report an alternative oblique C-arm fluoroscopy guided view approach to supplement the standard anterior-posterior and lateral fluoroscopic views to facilitate successful needle placement and precise anatomical localization of the epidural space.

The effect of pneumoperitoneum and Trendelenburg position on respiratory mechanics during pelviscopic surgery / 대한마취과학회지

BACKGROUND: Conventional pelviscopic surgery requires pneumoperitoneum with CO2 gas insufflation and lithotomy-Trendelenburg position. Pneumoperitoneum and Trendelenburg position may influence intraoperative respiratory mechanics in anesthetic management. This study was conducted to investigate the influence of pneumoperitoneum and Trendelenburg position on respiratory compliance and ventilation pressure. METHODS: Twenty-five patients scheduled for elective gynecologic laparoscopy were evaluated. The patients had no preexisting lung or heart disease or pathologic lung function. Conventional general anesthesia with thiopental sodium, lidocaine, rocuronium, and sevoflurane was administered. The peak inspiratory pressure, plateau pressure, and end-tidal CO2 were measured before and after creation of pneumoperitoneum with an intraabdominal pressure of 12 mmHg, then after 10 minutes and 30 minutes in the 20degrees Trendelenburg position, and after deflation of pneumoperitoneum. The dynamic lung compliance was then calculated. RESULTS: Following creation of pneumoperitoneum, there was a significant increase in peak inspiratory pressure (6 cmH2O), plateau pressure (7 cmH2O), and end-tidal CO2 (5 mmHg), while dynamic lung compliance decreased by 12 ml/cmH2O. Overall, the Trendelenburg position induced no significant hemodynamic or pulmonary changes. CONCLUSIONS: The effects of pneumoperitoneum significantly reduced dynamic lung compliance and increased peak inspiratory and plateau pressures. The Tredelenburg position did not change these parameters.

Pemetrexed versus Gefitinib versus Erlotinib in Previously Treated Patients with Non-Small Cell Lung Cancer

BACKGROUND/AIMS: The efficacy and safety of pemetrexed, gefitinib, and erlotinib administration in previously treated patients with non-small cell lung cancer (NSCLC) were compared. METHODS: The study patients met the following criteria: histologically confirmed, previously treated advanced (stage IIIB or IV) or recurrent NSCLC; a measurable lesion; > or = 18 years of age; Eastern Cooperative Oncology Group Performance status 0 to 2; and no prior exposure to the three study drugs. Patients received 500 mg/m2 of pemetrexed intravenously every 3 weeks with vitamin supplementation, gefitinib (250 mg/day per os), or erlotinib (150 mg/day per os). RESULTS: Of 57 patients (pemetrexed, 20; gefitinib, 20; and erlotinib, 17), 55 were evaluated for a response. The numbers of males, smokers, and squamous histology were increased in the pemetrexed group compared to the other groups. The objective response rates were 5.3%, 25.0%, and 12.5% (p = 0.22), and the disease control rates (DCR) were 5.3%, 40.0%, and 50.0%, respectively (p < 0.01). The median progression-free survival (PFS) was 1.7, 3.5, and 4.4 months (p < 0.01) and the median overall survival (OS) was 5.6, 21.8, and 21.5 months (p = 0.04), respectively. In subgroup analyses, patients with non-squamous histology, males, and a smoking history had a higher DCR and longer PFS with gefitinib and erlotinib than with pemetrexed. All three chemotherapeutic agents had manageable toxicities. CONCLUSIONS: Both oral epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKIs) had comparable efficacy and safety. The superior PFS and OS of EGFR TKIs with more favorable baseline clinical characteristics than those of pemetrexed suggest the impact of baseline clinicopathological factors.

Clinical characteristics of lung cancer diagnosed from 2006 to 2008: Data from Gachon University Gil Hospital / 대한내과학회지

BACKGROUND/AIMS: This study examined the clinical characteristics of patients with lung cancer who were diagnosed at the Gachon University of Medicine and Science Gil Hospital from January 2006 to December 2008. METHODS: The lung cancer data were downloaded from the hospital medical information system using cancer registration information. The patient clinical characteristics were analyzed retrospectively. RESULTS: A total of 713 patients were diagnosed with lung cancer. Their median age was 69 years, 78.1% were over 60 years old, and 73.1% and 58.2% were men and smokers, respectively. Adenocarcinoma (32.7%) was the most common histologic type, followed by squamous carcinoma (25.9%), unclassifiable non-small-cell lung cancer (NSCLC) (17.3%), and small-cell carcinoma (SCLC) (15.0%). In the NSCLC group, the stage at diagnosis was IA (1.5%), IB (5.6%), IIA (1.3%), IIB (4.3%), IIIA (5.4%), IIIB (23.1%), IV (47.7%), and unknown (11.1%). In the SCLC group, 20.6% of the patients were in the limited stage, 76.6% were in the extensive stage, and 2.8% were unknown. The patients were treated by surgery (9.8%), concurrent chemoradiotherapy (6.7%), radiotherapy only (5.9%), chemotherapy (32.4%), or best supportive care only (29.7%). The median overall survival was 15.3 months (95% CI, 11.5~19.1). The median survival based on histology was adenocarcinoma (35.0 months), squamous (13.5 months), NSCLC (14.2 months), and SCLC (11.8 months) (p=0.0445). CONCLUSIONS: Adenocarcinoma was the most common histologic type at our institute. Most patients were over 60 years of age (78.1%) and had stage III/IV (76.3%) cancer. The survival of patients with adenocarcinoma was longer than that for the other histological types.

Simultaneous Occurrence of Chromophobe Renal Cell Carcinoma and Urothelial Carcinoma in the Same Kidney

The simultaneous occurrence of a renal cell carcinoma and a urothelial carcinoma in the same kidney is uncommon. Here we report the case of a 79-year-old woman with ipsilateral synchronous renal cell carcinoma and urothelial carcinoma. She was referred to our hospital for gross hematuria and right flank pain. A computed tomography scan showed a 15x20 mm enhanced lesion on the upper calyx and a 12x15 mm mass on the lateral aspect of the right kidney. We thus suspected a renal pelvis tumor and performed right hand assisted laparoscopic nephroureterectomy with bladder cuff excision (HALSNU). Gross findings were multiple, pale yellowish papillary masses on the upper and lower major calices, of which the largest one measured 16x20 mm. A separated solid mass measuring 12x16 mm was also noted on the anterior midportion of the kidney. The former was a urothelial carcinoma and the latter was a chromophobe renal cell carcinoma. We present a rare case of a chromophobe renal cell carcinoma and a urothelial carcinoma in the same kidney.

Renal Intracystic Massive Hemorrhage after Blunt Trauma / 대한비뇨기과학회지

Spontaneous and post-traumatic renal intracystic hemorrhages are extremely rare, but are a potential danger to patients with cystic kidney disease. We report two cases of post-traumatic intracystic massive hemorrhage in renal cysts. One patient was a 27-year-old male who presented with left flank pain and gross hematuria after slipping on the stairs 2 days previously. The other patient was a 58-year-old male who presented with back pain due to an accident. The circulatory states of the two patients were deteriorated and renal intracystic hemorrhages were detected on computed tomography. One patient underwent a simple nephrectomy and the other patient was treated with arterial embolization. We present two cases of renal intracystic hemorrhage, emphasizing early diagnosis and the treatment of choice.

Pain Evaluation with Surface Electromyography in Temporomandibular Myofascial Pain Dysfunction Syndrome

OBJECTIVE: To investigate usefulness of surface electromyography (sEMG) for the pain evaluation in the patients with temporomandibular myofascial pain dysfunction syndrome (TM-MPDS). METHOD: Twenty unilateral TM-MPDS patients (10 males, 10 females, duration of disease 6.6+/-5.6 months, age 28.5+/-3.0 years) and twenty healthy controls (10 males, 10 females, age 30.1+/-6.2 years) were recruited for this study. The patients were treated with trigger point injection therapy and cryotherapy once a week, and ultrasound thermotherapy four times a week for 2 weeks. Active electrodes were attached on temporalis and masseter muscles with reference electrode on chin and ground electrode on forehead. All of subjects were instructed to clench teeth for 5 seconds after full relaxation. For temporalis and masseter muscles, the amplitudes of clenching-EMG activities were obtained and the mean value of five biting cycles was calculated on both sides. sEMG, visual analog scale (VAS) and asymmetry index (AI) were assessed before and 2 weeks after treatment. RESULTS: For temporalis and masseter muscles, the amplitudes of affected side-EMG activity significantly decreased, and the AI of the patient group significantly increased compared with those of the control group (p<0.05, p< 0.05). The AI of the patient group significantly decreased after treatment (p<0.05, p<0.05). Higher AI in masseter muscle before treatment was significantly correlated with lower VAS after treatment (r=-0.487, p<0.05). CONCLUSION: It is suggested that sEMG would be useful for diagnosing and evaluating the pain in TM-MPDS.

The Effect of Thermo-undulation Therapy on the Patients with Chronic Low Back Pain

OBJECTIVE: To verify the effect of thermo-undulation therapy on the patients with chronic low back pain. METHOD: 115 patients with back pain (mean age: 51.2 year-old; male, female: 46, 69) were recruited. Experimental group (n=85) was subjected to thermo-undulation therapy for 30 minutes, once a day, five days a week during eight weeks and control group (n=30) was administered with sham procedure. Before and after the therapy, range of motion (ROM) the spine and flexibility of lower extremity muscles were evaluated with goniometry. The functional status was measured by Roland Morris disability questionnaire and quality of life was measured by the SF-36 (36-Item Short Form Health Survey Instrument) and SF-12 scales. The STAI-6 (Spielberger State-Trait Anxiety Inventory) was used for anxiety. We checked the intensity of pain by visual analog scale (VAS) and evaluated the effect of far-infrared ray with Digital Infrared Thermographic Imaging (DITI) technique. RESULTS: After therapy, the scores of muscle flexibility, spine ROM, VAS, Roland Morris disability questionnaire, SF-36, SF-12 and STAI-6 showed a tendency to improve in experimental group (p0.05). Only the temperature differences of experimental group by DITI were significantly lower than those of control group (p<0.05). CONCLUSION: Thermo-undulation therapy may be an adjuvant therapy for chronic low back pain.

Therapeutic Experience in a Patient with Complex Regional Pain Syndrome Related to Brachial Plexitis: A case report

We report our therapeutic experience in a patient with complex regional pain syndrome (CRPS) related to brachial plexitis. A 16-year-old female suffered from excruciating burning pain and allodynia abruptly developed on left shoulder. Cervical MRI was normal. Electrodiagnostic findings were compatible with acute brachial plexopathy. Hand swelling, dystrophic color change, desquamation, and anhidrosis were displayed. Three-phase bone scan revealed increased radio-uptake on left upper extremity. The course of the disease was slowly progressive with wax and wane pattern. Pain became gradually intractable to all therapeutic modalities and medications. She gradually improved with long-term multimodal pain management. After 2 years of disease-free period, CRPS recurred and the extent was more severe than the first attack. We tried oral mexiletine, risedronate, high dose multi-vitamin, and leukotriene modulator which were effective in reducing pain and allodynia. Hand swelling gradually subsided and functional regain was obtained.

Adult-onset Still's Disease with Dysphagia: Case report

We experienced a case of adult-onset Still's disease with dysphagia of soft tissue origin. A 38-year-old woman was admitted for intermittent high spiking fever, diffuse pain and swelling on anterior neck with dysphagia. Physical examination revealed a thin woman with trismus, board-like hardness of anterior neck, hepatomegaly, and erythematous evanescent rash on leg. Neck CT displayed bilateral cervical lymphadenopathy with soft tissue swelling, and tonsilitis. Chest and abdomen CT showed the inflammatory changes of multiple organs. Laboratory evaluation revealed neutrophilic leukocytosis, slightly increased alanine transaminase, negative antinuclear antibody and rheumatoid factor, and increased inflammatory markers. Skin, liver, colon, and pleural biopsy demonstrated the chronic inflammation. Videofluoroscopic swallowing study revealed laryngeal penetration with large amount residue in vallecular space and pyriform sinus, and incomplete cricopharyngeal relaxation. Gradual improvement in anterior neck pain and pulmonary edema and the decrease of effortful and multiple swallowing were observed with high dose steroid therapy.

The Cross Effects of Needle Electrical Stimulation according to Electrode Placements on the Analgesia in Arthritic Rat Model

OBJECTIVE: To investigate the analgesic effect of needle electrical stimulation (NES) according to the electrode placement in acute arthritic rat model. METHOD: Male Sprague-Dawley rats (120 rats, 250+/-50 g) were injected with a mixture of 3% carrageenan and 3% kaolin into the right knee joint. Rats were randomly assigned into one of four groups: Group I, control group (n=30); Group II, arthritic limb-induced control group (n=30); Group III, NES application group on the ipsilateral arthritic limb (n=30); Group IV, NES application group on the contralateral arthritic limb (n=30). We applied the NES (2 Hz, 200micro s, 20 min) to group III and IV. We assessedthe change of paw withdrawal latency (PWL) and the immunoreactivity of c-fos by immunohistochemistry at baseline, 4, 8, 12 and 24 hours after induction of arthritis. RESULTS: NES was more effective in Group III and IV than group II 8 hours after the induction of arthritis (p < 0.001) based on the results of PWLs and c-fos immunoreactivity. The analgesic effects of Group III were greater than those of group IV (p < 0.001). CONCLUSION: Contralateral NES on arthritic limb reduced pain in arthritic rat model as effectively as ipsilateral NES.

Clinical Features of Central Neuropathic Pain after Contusive Spinal Cord Injury in Rats

OBJECTIVE: To investigate the characteristics of the central neuropathic pain (CNP) after contusive spinal cord injury in rats. METHOD: Twenty Sprague-Dawley rats (300+/-50 g, male) undergone the free-drop contusion injury from the drop-height of 2.5 cm at T10 cord (n=20) and ten rats undergone sham operation (n=10) were subjected to the neurobehavioral analyses by the Basso Beattie Bresnahan (BBB) locomotor rating scales, Touch test(TM) sensory evaluator (TTSE, North Coast Medical Inc., Canada) and Plantar test(R)(Ugo Basile, Italy) after contusion at the 1(st), 3(rd), 5(th), 7(th), 14(th), 21(st) and 28(th) day. RESULTS: The scores of BBB scales were the lowest at the 1st day and then slowly increased to spontaneous recovery state, but they were significantly lower than those of control group (p<0.05). The thresholds of mechanical allodynia were significantly increased just after cord contusion, but progressed to decline, and significantly decreased after the 21(st) day (p<0.05). The latencies of thermal hyperalgesia were delayed just after cord contusion, but significantly shorter than those of the control group after the 7(th) day (p<0.05). CONCLUSION: These results would be helpful for the study of the CNP after contusive spinal cord injury in rats.

Lipopolysaccharide-induced Synthesis of IL-1beta, IL-6, TNF-alpha and TGF-beta by Peripheral Blood Mononuclear Cells / 결핵

BACKGROUND: Endotoxin (LPS lipopolysaccharide), a potent activator of immune system, can induce acute and chronic inflammation through the production of cytokincs by a variety of cells, such as monocytes, endothelial cells, lymphocytes, eosinophils, neutrophils and fibroblasts. LPS stimulate the mononucelar cells by two different pathway, the CD14 dependent and independent way, of which the former has been well documented, but not the latter. LPS binds to the LPS-binding protein (LBP), in serum, to make the LPS-LBP complex which interacts with 0D14 molecules on the mononuclear cell surface in peripheral blood or is transported to the Ussues. In case of high concentration of LPS, LPS can stimulate directly the macrophages without LBP. We investigated to detect, the generation of proinflammatory cytokines such as interleukin 1 (IL-1), IL-6 and TNF-alpha, and fibrogenic cytokine, TGF-beta, by peripheral blood mononuclear cells (PBMC) after LB'S stimulation under serum-free conditions, which lacks LBPs. METHODS: PBMC were obtained by centrifugation on Ficoll Hypaque solution of peripheral venous bloods from healthy normal subjects, then stimulated in the presence of LPS (0.1 microgram/mL to 100 microgram/mL). The activities of IL-1, IL-6, TNF, and TGF-betawere measured by bioassaies using cytokines - dependent proliferating or inhibiting cell lines. The cellular sources producing the cytokines was investigated by immunohistochemical stains and in situ hybridization. RESULTS: PBMC started to produce IL-6, TNF-alpha and TGF-beta in 1 hr, 4 hrs and 8hrs, respectively, after LPS stimulation The production of IL-6, TNF-alpha and TGF-beta continuously increased 96 His after stimulation of LPS. The amount of production was 19.8 ng/ml of IL-6 by 105 PEMC, 4.1 ng/mL of TNF by 106 PBMC and 344 pg/mL of TGF-betaby 2 x 106 PBMC. The immunoreactivity to IL-6, TNF-alpha and TGF-betawere detected on monocytes in LPS-stimulated PBMC. Some of lymphocytes showed positive immunoreactivity to TGF-beta. Double immunohistochemical stain showed that IL-1beta, IL-6, TNF-alpha expression was not associated with CD14 postivity on monocytes. IL-1beta, IL-6, TNF-alpha and TGF-/betamRNA expression worn same as observed in immunoreactivity for each cytokines. CONCLUISON: When monocytes are stimulted with LPS under serum-free conditions, IL-6 and TNF-alphaare secreted in early stage of inflammation. In contrast, the secretion of TGF-beta arise in the late stages and that N maintained after 96 his. The main cells releasing lL-1beta, IL-6, INF-alpha and TGF-beta are monocytes, but also lymphocytes can secret TGF-beta.

Diffuse Alveolar Damage Associated with Polymyositis / 결핵

Interstitial pneumonitis may be the presenting manifestation of polymyositis-dermatomyositis (PM-DM), or may occur later in the evolution of disease. The clinical picture is characterized by non-productive cough, dyspnea and hypoxemia. The chest radiograph demonstrates interstitial infiltrates with predilection for the lung bases, often with an alveolar pattern in addition. We experienced a case of polymyositis associated with diffuse alveolar damage(DAD) that was proven in open lung biopsy. The patient was a 52 year-old woman who was presented with 6 months' duration of generalized ache, edema on ankle and wrist, non-productive cough and mild dyspnea. She had typical symptoms and physical findings of interstitial pneuminitis, and elevated muscle enzyme levels in serum with characteristic histologic findings of myositis on muscle biopsy. She also had typical interstitial lung disease pattern on high resolution CT and restrictive pattern on pulmonary function tests. The findings of open lung biopsy was compatible with diffuse alveolar damage(DAD). She failed to respond to the therapeutic trials with corticosteroid and cyclophosphamide, and finally expired due to acute respiratory distress syndrome.