Continuous infusion versus intermittent bolus injection of propofol during endoscopic retrograde cholangiopancreatography

Background/Aims@#It is unclear whether continuous infusion or intermittent bolus injection of propofol is better for achieving adequate sedation in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to compare the efficacy and safety of continuous infusion and intermittent bolus injection of propofol during therapeutic ERCP. @*Methods@#In this prospective study, we randomly assigned 232 patients undergoing therapeutic ERCP to either continuous infusion (CI group, n = 113) or intermittent bolus injection (BI group, n = 119) of propofol. The primary outcome was the quality of sedation as assessed by the endoscopist. Other sedation-related parameters included sedation induction time, total dose of propofol, recovery time, involuntary patient movement, and adverse events. @*Results@#Overall satisfaction with sedation by the endoscopist and monitoring nurse were significantly higher in the CI group than the BI group (mean satisfaction score, 9.66 vs. 8.0 and 9.47 vs. 7.96, respectively, p < 0.01 for both). However, patients in the CI group had a significantly longer sedation induction time (5.28 minutes vs. 4.34 minutes, p < 0.01) and received a higher dose of propofol than patients in the BI group (4.22 mg/kg vs. 2.08 mg/kg, p < 0.01). There was no significant difference in adverse events between the two groups. @*Conclusions@#Continuous infusion of propofol during therapeutic ERCP had the advantage over intermittent bolus injection of maintaining a constant level of sedation without increasing adverse events. However, it was associated with an increased total dose of propofol and prolonged sedation induction time.

Risk of Clostridium difficile Infection with the Use of a Proton Pump Inhibitor for Stress Ulcer Prophylaxis in Critically Ill Patients

BACKGROUND/AIMS: Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are commonly prescribed for stress ulcer prophylaxis (SUP) in critically ill patients. Several studies have suggested that the use of PPIs is a potential risk factor for Clostridium difficile infection (CDI). We compared the incidences of CDI in the PPI group and H2RA group for SUP in critically ill patients. METHODS: From August 2005 to July 2012, the incidences of CDI were retrospectively analyzed in patients who were admitted directly to intensive care units and stayed for more than 3 days. SUP-related CDI was defined as a CDI diagnosed during the SUP period. Patient clinical data were analyzed to identify potential risk factors for SUP-related CDI. RESULTS: Of the 1,005 patients enrolled (444 patients received PPI and 561 received H2RA), 38 (3.8%) were diagnosed with SUP-related CDI. The incidence of SUP-related CDI was considerably higher in patients who received PPI than in those who received H2RA (6.7% vs 1.8%). PPI use for SUP (odds ratio [OR], 3.3; confidence interval [CI], 1.5 to 7.1; p=0.003) and diabetes mellitus (OR, 2.3; CI, 1.2 to 4.7; p=0.019) were independent risk factors for SUP-related CDI. CONCLUSIONS: PPI therapy is associated with a higher risk of SUP-related CDI than H2RA therapy in critically ill patients.

A case of chronic myeloid leukemia with features of essential thrombocythemia in peripheral blood and bone marrow

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by overproduction of myeloid white blood cells. Philadelphia chromosome is an essential finding for CML diagnosis. Generally, a clinical diagnosis of essential thrombocythemia (ET) can be established from isolated marked thrombocytosis in peripheral blood. However, Philadelphia chromosome-positivity or bcr/abl rearrangement with isolated thrombocytosis should be diagnosed as CML, not ET, according to World Health Organization diagnostic criteria. Therefore, CML should not be excluded before confirming the presence of the Philadelphia chromosome or bcr/abl rearrangement in cases of isolated thrombocytosis in peripheral blood. We report a case of CML with clinical features of ET in a patient successfully treated with imatinib.

Psychological Stress in Chronic Intestinal Diseases / 한양의대학술지

Psychological stress induces alterations in the function of the hypothalamic-pituitary-adrenal axis via corticotorphin releasing factor and alterations in the enteric nervous system via actions of the autonomic nervous system. Mucosal mast cells and adrenal glands release several inflammatory cytokines and cortisol, causing increased intestinal permeability. Increased intestinal permeability as well as increased inflammatory cytokines and hormones cause changes in bacterial-mucosal interactions, leading to the aggravation of disease activity and gastrointestinal symptoms in inflammatory bowel syndrome (IBD) and irritable bowel syndrome (IBS). Several studies have demonstrated that stress has an important roles in the pathogenesis of IBD and IBS. Personal traits, health beliefs and personal stress-coping mechanisms can also have adverse effects on the disease course of IBD and IBS. Stress reduction therapies have been adapted for treatment of IBD and IBS. Antidepressants and psychological therapies such as cognitive-behavior therapy, hypnotherapy, and multi-component psychological therapy have been used for control of disease activity and symptoms in IBD and IBS patients. The efficacy of such treatments is controversial, because there has not been an adequate standardization in treatment protocol, and studies suffer from the difficulties involved in selection of appropriate control groups, questions related to a high placebo effect, as well as differences in interpretation. Well-designed prospective controlled studies evaluating the role of stress in the pathogenesis of IBD and IBS and the role of stress reduction therapies are warranted for improvement of clinical treatments and outcomes.

A Case of Transient Hypertension after Blunt Abdominal Trauma / 대한내과학회지

Arterial hypertension following blunt abdominal trauma is a rare complication that can be induced by compression of the renal parenchyma due to a perirenal or subcapsular hematoma or adrenal hemorrhage. A 63-year-old woman was admitted after blunt abdominal trauma. Abdominal computed tomography (CT) revealed a right renal subcapsular hematoma and right adrenal gland hematoma. The patient developed hypertension during conservative treatment. Pheochromocytoma, renovascular hypertension, adrenal adenoma, thyroid disease, and other causes of secondary hypertension were excluded. On following the patient, her blood pressure normalized spontaneously without prescribing any antihypertensive medications. The renal subcapsular hematoma and adrenal hemorrhage regressed progressively as the blood pressure normalized. We report this case to make physicians aware that transient hypertension can develop in patients with blunt abdominal trauma, and to prevent the use of unnecessary antihypertensive medications.

Amyotrophic Lateral Sclerosis Identified by Failure to Wean From Mechanical Ventilation

In most cases of amyotrophic lateral sclerosis (ALS), respiratory muscle involvement is a late complication. Only 2.7% of ALS patients presenting with their first clinical symptoms in the extremities also experience respiratory symptoms. We report a case of an 81-year-old man with ALS, diagnosed by an unexplained failure to wean from mechanical ventilation. The patient was presented with acute respiratory failure, tachypnea and respiratory acidosis. Computed tomography of the chest showed large amounts of sputum in the trachea. An endotracheal tube was inserted, and the patient was placed on volume-controlled ventilation. However, in the course of recovery, he could not be weaned from mechanical ventilation, despite the absence of cardiopulmonary impairment. Having considered other causes of respiratory failure, wediagnosed ALS after a physical and neurologic examination and electrodiagnostic testing.

A Case of Intestinal Behcet's Disease Complicated Enterocutanous Fistula with a Good Response to Adalimumab

Behcet's disease (BD) is a multisystemic disorder, which is characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesion. Although intestinal involvement is an uncommon manifestation of the BD, it leads to a poor prognosis, as a result of a high complication, such as intestinal perforation, fistula formation, and massive hemorrhage. Intestinal BD has the tendency for the resistance to conventional medical treatment, and it often requires a surgical intervention because of severe complication. Although the causes of intestinal BD are unknown, some studies show that tumor necrosis factor Alpha (TNF-alpha) plays a key role in the pathogenesis of BD. Therefore, anti-TNF-alpha monoclonal antibody, such as adalimumab, is one of the useful treatment for refractory and relapsed intestinal BD. We describe a patient who had intestinal BD complicated enterocutanous fistula with a good response to adalimumab.