Assessment of Treatment Response in Patients With Severe Asthma Using Visual and Quantitative Analysis of Chest CT

Objective@#To evaluate the role of visual and quantitative chest CT parameters in assessing treatment response in patients with severe asthma. @*Materials and Methods@#Korean participants enrolled in a prospective multicenter study, named the Precision Medicine Intervention in Severe Asthma study, from May 2020 to August 2021, underwent baseline and follow-up chest CT scans (inspiration/expiration) 10–12 months apart, before and after biologic treatment. Two radiologists scored bronchiectasis severity and mucus plugging extent. Quantitative parameters were obtained from each CT scan as follows: normal lung area (normal), air trapping without emphysema (AT without emph), air trapping with emphysema (AT with emph), and airway (total branch count, Pi10). Clinical parameters, including pulmonary function tests (forced expiratory volume in 1 s [FEV1] and FEV1/ forced vital capacity [FVC]), sputum and blood eosinophil count, were assessed at initial and follow-up stages. Changes in CT parameters were correlated with changes in clinical parameters using Pearson or Spearman correlation. @*Results@#Thirty-four participants (female:male, 20:14; median age, 50.5 years) diagnosed with severe asthma from three centers were included. Changes in the bronchiectasis and mucus plugging extent scores were negatively correlated with changes in FEV1 and FEV1/FVC (ρ = from -0.544 to -0.368, all P 0.05). @*Conclusion@#Visual and quantitative CT parameters of normal, AT without emph, and total branch count may be effective for evaluating treatment response in patients with severe asthma.

Soluble ACE2 and TMPRSS2 Levels in the Serum of Asthmatic Patients

Background@#Angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine subtype 2 (TMPRSS2) are key proteins mediating viral entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although gene expressions of ACE2 and TMPRSS2 have been analyzed in various organs and diseases, their soluble forms have been less studied, particularly in asthma. Therefore, we aimed to measure circulating ACE2 and TMPRSS2 in the serum of asthmatics and examine their relationship with clinical characteristics. @*Methods@#Clinical data and serum samples of 400 participants were obtained from an asthma cohort. The soluble ACE2 (sACE2) and soluble TMPRSS2 (sTMPRSS2) level was measured by enzyme-linked immunosorbent assay, and the values underwent a natural log transformation. Associations between sACE2 and TMPRSS2 levels and various clinical variables were analyzed. @*Results@#The patients younger than 70 years old, those with eosinophilic asthma (eosinophils ≥ 200 cells/µL), and inhaled corticosteroids (ICS) non-users were associated with higher levels of sACE2. Blood eosinophils and fractionated exhaled nitric oxide levels were positively correlated with serum ACE2. In contrast, lower levels of sTMPRSS2 were noted in patients below 70 years and those with eosinophilic asthma, while no association was noted between ICS use and sTMPRSS2. The level of sTMPRSS2 also differed according to sex, smoking history, coexisting hypertension, and forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio. The proportion of sputum neutrophils was positively correlated with sTMPRSS2, while the FEV1/FVC ratio reported a negative correlation with sTMPRSS2. @*Conclusion@#The levels of ACE2 and TMPRSS2 were differently expressed according to age, ICS use, and several inflammatory markers. These findings suggest variable susceptibility and prognosis of SARS-CoV-2 infection among asthmatic patients.

Korean Clinical Practice Guidelines for Adverse Reactions to Intravenous Iodinate and MRI-Gadolinium Contrast Agents: Revised Clinical Consensus and Recommendations (3rd Edition, 2022)

The Korean Society of Radiology and Medical Guidelines Committee amended the existing 2016 guidelines to publish the “Korean Clinical Practice Guidelines for Adverse Reactions to Iodide Contrast for Injection and Gadolinium Contrast for MRI: The Revised Clinical Consensus and Recommendations (2022 Third Edition).” Expert members recommended and approved by the Korean Society of Radiology, the Korean Academy of Asthma, Allergy and Clinical Immunology, and the Korean Nephrology Society participated together. According to the expert consensus or systematic literature review, the description of the autoinjector and connection line for the infection control while using contrast medium, the acute adverse reaction, and renal toxicity to iodized contrast medium were modified and added. We would like to introduce the revised contents.

Adverse Reactions Following the First Dose of ChAdOx1 nCoV-19 Vaccine and BNT162b2 Vaccine for Healthcare Workers in South Korea

Background@#We performed a prospective survey on the adverse reactions following the first dose of two types of vaccines against coronavirus disease 2019 (COVID-19) in healthcare workers (HCWs) in South Korea. @*Methods@#HCWs at a tertiary referral hospital in Seoul, South Korea, received a chimpanzee adenovirus-vectored vaccine (ChAdOx1 nCoV-19) or an mRNA-based vaccine (BNT162b2) between March 5 and March 26, 2021. The HCWs were asked to report adverse reactions through a mobile self-report questionnaire for three days after vaccination. @*Results@#A total of 7,625 HCWs received the first dose of ChAdOx1 or BNT162b2 vaccine during the study period. Of them, 5,866 (76.9%) HCWs (ChAdOx1, n = 5,589 [95.3%];BNT162b2, n = 277 [4.7%]) participated at least once in the survey, of whom 77% were female and 86% were younger than 50 years. The overall adverse reaction rate was 93% in the ChAdOx1 group and 80% in the BNT162b2 group (P < 0.001). Both local and systemic reactions were more commonly reported in the ChAdOx1 group, and the difference was larger in systemic reactions such as fever and fatigue. In the ChAdOx1 group, the incidence of adverse reactions was significantly higher in females and those in the younger age groups, while the BNT162b2 group showed such difference according to age. @*Conclusion@#In our prospective survey, vaccine-associated adverse reactions were more commonly reported in the ChAdOx1 group than in the BNT162b2 group. Females and younger age groups experienced vaccine-associated adverse reactions more frequently.

Adverse Reactions of the Second Dose of the BNT162b2 mRNA COVID-19Vaccine in Healthcare Workers in Korea

We conducted a prospective, mobile-based survey on the self-reported adverse reactions in healthcare workers (HCWs) who received both doses of the BNT162b2 mRNA vaccine. Of the 342 HCWs who completed the two-dose vaccination, 265 (77.5%) responded to the survey at least once. Overall, the rates of adverse reactions were higher after the second dose compared with the first dose (89.1% vs. 80.1%, P = 0.006). The most common systemic reactions were muscle ache (69.1%), fatigue (65.7%), headache (48.7%), chills (44.2%), and fever (32.1%), and were notably more common after the second dose vaccine as well. We also noted a sex difference in which the frequency of adverse reactions after the second dose of the vaccine was significantly higher in females, which was not observed after the first dose. The rates of adverse reactions were lower in older age groups, and the rates and severities of the adverse reactions decreased during the 3-day period following vaccination.

Adverse Reactions Following the First Dose of ChAdOx1 nCoV-19 Vaccine and BNT162b2 Vaccine for Healthcare Workers in South Korea

Background@#We performed a prospective survey on the adverse reactions following the first dose of two types of vaccines against coronavirus disease 2019 (COVID-19) in healthcare workers (HCWs) in South Korea. @*Methods@#HCWs at a tertiary referral hospital in Seoul, South Korea, received a chimpanzee adenovirus-vectored vaccine (ChAdOx1 nCoV-19) or an mRNA-based vaccine (BNT162b2) between March 5 and March 26, 2021. The HCWs were asked to report adverse reactions through a mobile self-report questionnaire for three days after vaccination. @*Results@#A total of 7,625 HCWs received the first dose of ChAdOx1 or BNT162b2 vaccine during the study period. Of them, 5,866 (76.9%) HCWs (ChAdOx1, n = 5,589 [95.3%];BNT162b2, n = 277 [4.7%]) participated at least once in the survey, of whom 77% were female and 86% were younger than 50 years. The overall adverse reaction rate was 93% in the ChAdOx1 group and 80% in the BNT162b2 group (P < 0.001). Both local and systemic reactions were more commonly reported in the ChAdOx1 group, and the difference was larger in systemic reactions such as fever and fatigue. In the ChAdOx1 group, the incidence of adverse reactions was significantly higher in females and those in the younger age groups, while the BNT162b2 group showed such difference according to age. @*Conclusion@#In our prospective survey, vaccine-associated adverse reactions were more commonly reported in the ChAdOx1 group than in the BNT162b2 group. Females and younger age groups experienced vaccine-associated adverse reactions more frequently.

Adverse Reactions of the Second Dose of the BNT162b2 mRNA COVID-19Vaccine in Healthcare Workers in Korea

We conducted a prospective, mobile-based survey on the self-reported adverse reactions in healthcare workers (HCWs) who received both doses of the BNT162b2 mRNA vaccine. Of the 342 HCWs who completed the two-dose vaccination, 265 (77.5%) responded to the survey at least once. Overall, the rates of adverse reactions were higher after the second dose compared with the first dose (89.1% vs. 80.1%, P = 0.006). The most common systemic reactions were muscle ache (69.1%), fatigue (65.7%), headache (48.7%), chills (44.2%), and fever (32.1%), and were notably more common after the second dose vaccine as well. We also noted a sex difference in which the frequency of adverse reactions after the second dose of the vaccine was significantly higher in females, which was not observed after the first dose. The rates of adverse reactions were lower in older age groups, and the rates and severities of the adverse reactions decreased during the 3-day period following vaccination.

Evaluation of Drug-Induced Liver Injury Developed During Hospitalization Using Electronic Health Record (EHR)-Based Algorithm

PURPOSE: The incidence of drug-induced liver injury (DILI) has been increasing; however, few algorithms are available to identify DILI in electronic health records (EHRs). We aimed to identify and evaluate DILI with an appropriate screening algorithm.METHODS: We collected data from 3 university hospitals between June 2015 and May 2016 using our newly developed algorithm for identifying DILI. Among patients with alanine transferase (ALT) ≤ 120 IU/L and total bilirubin (TB) ≤ 2.4 mg/dL in blood test results within 48 hours of admission, those who either had 1) ALT > 120 IU/L and TB > 2.4 mg/dL or 2) ALT > 200 IU/L at least once during hospitalization were identified. After excluding patients with liver disease-related diagnosis at discharge, medical records were retrospectively reviewed to evaluate epidemiological characteristics of DILI.RESULTS: The total number of inpatients was 256,598, of whom 1,100 (0.43%) were selected by the algorithm as suspected DILI. Subsequently, 365 cases (0.14% of total inpatients, 95% confidence interval, 0.13–0.16) were identified as DILI, yielding a positive predictive value of 33.1%. Antibiotics (n = 214, 47.2%) were the major class of causative drug followed by chemotherapeutic agents (n = 87, 19.2%). The most common causative drug was piperacillin-tazobactam (n = 38, 8.4%); the incidence of DILI by individual agent was highest for methotrexate (19.4 cases/1,000 patients administered the drug). Common reasons for excluding suspected DILI cases were ischemic hepatitis and postoperative liver dysfunction.CONCLUSIONS: Using our EHR-based algorithm, we identified that approximately 0.14% of patients developed DILI during hospitalization. Further studies are needed to modify criteria for more accurate identification of DILI.

Cough-Related Laryngeal Sensations and Triggers in Adults With Chronic Cough: Symptom Profile and Impact

PURPOSE: Recent evidence suggests that cough hypersensitivity may be a common feature of chronic cough in adults. However, the clinical relevance remains unclear. This study evaluated the cough-related symptom profile and the clinical relevance and impact of cough hypersensitivity in adults with chronic cough. METHODS: This cross-sectional multi-center study compared cough-related laryngeal sensations and cough triggers in patients with unexplained chronic cough following investigations and in unselected patients newly referred for chronic cough. A structured questionnaire was used to assess abnormal laryngeal sensations and cough triggers. Patients with unexplained cough were also evaluated using the Leicester Cough Questionnaire (LCQ) and a cough visual analogue scale (VAS), and these scores were assessed for correlations with the number of triggers and laryngeal sensations. RESULTS: This study recruited 478 patients, including 62 with unexplained chronic cough and 416 with chronic cough. Most participants reported abnormal laryngeal sensations and cough triggers. Laryngeal sensations (4.4 ± 1.5 vs. 3.9 ± 1.9; P = 0.049) and cough triggers (6.9 ± 2.6 vs. 5.0 ± 2.8; P < 0.001) were more frequent in patients with unexplained chronic cough than in those with chronic cough. The number of triggers and laryngeal sensations score significantly correlated with LCQ (r = −0.51, P < 0.001) and cough VAS score (r = 0.53, P < 0.001) in patients with unexplained chronic cough. CONCLUSIONS: Cough hypersensitivity may be a common feature in adult patients with chronic cough, especially those with unexplained chronic cough. Cough-related health status and cough severity were inversely associated with the number of triggers and laryngeal sensations, suggesting potential relevance of assessing cough hypersensitivity in chronic cough patients.

Inhaled Corticosteroids and Placebo Treatment Effects in Adult Patients With Cough: A Systematic Review and Meta-analysis

PURPOSE: Inhaled corticosteroids (ICSs) are often considered an empirical therapy in the management of patients with cough. However, ICS responsiveness is difficult to interpret in daily clinical practice, as the improvements may include placebo effects or self-remission. We aimed to evaluate ICS and placebo treatment effects in adult patients with cough. METHODS: Electronic databases were searched for studies published until June 2018, without language restriction. Randomized controlled trials reporting the effects of ICSs compared with placebo in adult patients with cough were included. Random effects meta-analyses were conducted to estimate the treatment effects. Therapeutic gain was calculated by subtracting the percentage change from baseline in the cough score in the ICS treatment group from that in the placebo treatment group. RESULTS: A total of 9 studies were identified and 8 studies measuring cough severity outcomes were included for meta-analyses. Therapeutic gain from ICSs ranged from −5.0% to +94.6% across the studies included; however, it did not exceed +22%, except for an outlier reporting very high therapeutic gains (+45.6% to +94.6%, depending on outcomes). Overall ICS treatment effects in cough severity outcomes were small-to-moderate (standardized mean difference [SMD], −0.38; 95% confidence interval [CI], −0.54, −0.23), which were comparable between subacute and chronic coughs. However, pooled placebo treatment effects were very large in subacute cough (SMD, −2.58; 95% CI, −3.03, −2.1), and modest but significant in chronic cough (SMD, −0.46; 95% CI, −0.72, −0.21). CONCLUSIONS: Overall therapeutic gain from ICSs is small-to-moderate. However, placebo treatment effects of ICS are large in subacute cough, and modest but still significant in chronic cough. These findings indicate the need for careful interpretation of ICS responsiveness in the management of cough patients in the clinic, and also for rigorous patient selection to identify ICS-responders.

Future Risks in Patients With Severe Asthma

A major burden of severe asthma is the future risk of adverse health outcomes. Patients with severe asthma are prone to serious exacerbation and deterioration of lung function and may experience side effects of medications such as oral corticosteroids (OCSs). However, such future risk is not easily measurable in daily clinical practice. In particular, currently available tools to measure asthma control and asthma-related quality of life incompletely predict the future risk of medication-related morbidity. This is a significant issue in asthma management. This review summarizes the current evidence of future risk in patients with severe asthma. As future risk is poorly perceived by controlled asthmatics, our review focuses on the risk in patients with ‘controlled’ severe asthma. Of note, it is likely that long-term OCS therapy may not prevent future asthma progression, including lung function decline. In addition, the risk of drug side effects increases even during low-dose OCS therapy. Thus, novel treatments are highly desirable for reducing future risks without any loss of asthma control.

Comparison of oxycodone and fentanyl for postoperative patient-controlled analgesia after orthopedic surgery

BACKGROUND: Oxycodone is widely used as bolus or patient-controlled analgesia (PCA) for control of postoperative pain. The aim of this study was to assess the efficacy and side effects of oxycodone for somatic pain by comparing oxycodone and fentanyl intravenous PCA after orthopedic surgery. METHODS: Seventy-three patients undergoing orthopedic surgery were randomly assigned to receive fentanyl or oxycodone using intravenous PCA (potency ratio 1:60). Pain severity at rest and with movement and adverse effects were assessed at 1, 6, 24, and 48 hours after surgery. The PCA dose and patient satisfaction scores were measured at 48 hours after surgery. RESULTS: The resting visual analogue scale (VAS) and moving VAS scores of the oxycodone group were significantly higher than those of the fentanyl group at 6 hours (P = 0.001, P = 0.021), but at 48 hours, the resting and moving VAS of the oxycodone group were significantly lower than those of the fentanyl group (P = 0.014, P = 0.037). There were no significant differences in adverse effects, satisfaction scores, dose of patient-controlled mode, or total cumulative PCA dose. CONCLUSIONS: With a 1:60 ratio of oxycodone to fentanyl when using PCA for pain control after orthopedic surgery, the use of larger doses of oxycodone for 6 hours is effective in controlling early postoperative pain.

Use of laryngeal mask after repeated endotracheal intubation failure in a patient with tracheobronchopathia osteochondroplastica: case report / 고신대학교의과대학학술지

We report a case of difficult endotracheal intubation in a patient with tracheobronchopathia osteochondroplastica. A 65-year-old man was scheduled to undergo ulnar nerve decompression and ganglion excisional biopsy under general anesthesia. During induction of general anesthesia, an endotracheal tube could not be advanced through the vocal cords due to resistance. A large number of nodules were identified below the vocal cords using a Glidescope® video-laryngoscopy, and fiberoptic bronchoscopy revealed irregular nodules on the surface of the entire trachea and the main bronchus below the vocal cords. Use of a small endotracheal tube was attempted and failed. a laryngeal mask airway (LMA Supreme ™) rather than further intubation was successfully used to maintain the airway.

Palonosetron-Induced Anaphylaxis During General Anesthesia: A Case Report

Palonosetron is a 5-hydroxytryptamine-3 (5-HT-3) receptor antagonist used for preventing postoperative nausea and vomiting. Compared with ondansetron and granisetron, it is a better drug because of prolonged action and minimal side effects. Some adverse effects of palonosetron have been reported. In this report, we describe a 37-year-old male who developed severe hypersensitivity reactions to palonosetron during surgery for kidney donation. His medical history was unremarkable, except for inguinal hernia with herniorrhaphy 8 years ago. The surgery was uneventful until 2 hours 20 minutes. After palonosetron injection, his blood pressure dropped to 80/50 mm Hg, and facial edema, rash, conjunctival swelling, and wheezing developed. The patient was resuscitated by administration of ephedrine, hydrocortisone, and peniramine. Following the surgery, the patient was monitored for 3 days, and there were no subsequent anaphylactic reactions or other complications. The skin test on postoperative day 54 was positive for hypersensitivity to palonosetron. Although palonosetron is known for its safety, other hypersensitivity events have been reported. Ondansetron is another widely used 5-HT-3 antagonist, which has been reported to cause anaphylaxis. Therefore, clinicians should be aware of the possibility of patients experiencing severe adverse reactions to palonosetron.

Budd-Chiari syndrome with antiphospholipid syndrome and systemic lupus erythematosus in a patient with Klinefelter's syndrome / 영남의대학술지

Klinefelter's syndrome is the most common congenital abnormality that causes primary hypogonadism. It is associated with diseases that predominantly affect women, such as systemic lupus erythematosus (SLE), and it can sometimes cause veno-occlusive disease. We experienced a case of Budd-Chiari syndrome (BCS) in a 33-year-old man with Klinefelter's syndrome presented with hematemesis and edema in both lower extremities. The clinical and laboratory findings were compatible with SLE, antiphospholipid syndrome, and BCS. To the best of our knowledge, this is the first case report to describe a simultaneous presentation of these four clinical syndromes in a single patient.

Propacetamol as an alternative of ketorolac for postoperative pain management using patient-controlled analgesia

BACKGROUND: The objective of this study was to examine effect of propacetamol in comparison with ketorolac in intravenous patient-controlled analgesia after gynecologic surgeries. METHODS: Patients aged 18 to 70 years and undergoing laparoscopic gynecologic surgeries were selected. They were randomly allocated to either group K (180 mg of ketorolac with fentanyl and ramosetron) or group P (10 g of propacetamol with fentanyl and ramosetron). Their vital signs and visual analogue scale (VAS) were examined six times (0 min, 15 min, 30 min, 60 min, 12 h, and 24 h) and laboratory workup was done 48 hours after PCA application. Development of side effects was examined 15 minutes after the PCA application. Data from 111 patients were used for the final analysis. RESULTS: There were no significant differences in changes of systolic and diastolic blood pressures, heart rate, body temperature, and VAS between the groups (P = 0.325, 0.835, 0.346, 0.524, and 0.382, respectively). There were significant differences in the levels of hemoglobin, hematocrit, blood urea nitrogen, and international normalized ratio but it was not clinically meaningful. The development of vomiting, dizziness, and headache were not significantly different between the groups and no patient developed pruritus. Although the overall number of patients with nausea was higher in group P with statistical significance (P = 0.002), there were no significant differences between the groups when examined at each detection time. CONCLUSIONS: The present study suggested propacetamol as a possible alternative of ketorolac in postoperative care after laparoscopic gynecologic surgeries.

Propacetamol as an alternative of ketorolac for postoperative pain management using patient-controlled analgesia

BACKGROUND: The objective of this study was to examine effect of propacetamol in comparison with ketorolac in intravenous patient-controlled analgesia after gynecologic surgeries. METHODS: Patients aged 18 to 70 years and undergoing laparoscopic gynecologic surgeries were selected. They were randomly allocated to either group K (180 mg of ketorolac with fentanyl and ramosetron) or group P (10 g of propacetamol with fentanyl and ramosetron). Their vital signs and visual analogue scale (VAS) were examined six times (0 min, 15 min, 30 min, 60 min, 12 h, and 24 h) and laboratory workup was done 48 hours after PCA application. Development of side effects was examined 15 minutes after the PCA application. Data from 111 patients were used for the final analysis. RESULTS: There were no significant differences in changes of systolic and diastolic blood pressures, heart rate, body temperature, and VAS between the groups (P = 0.325, 0.835, 0.346, 0.524, and 0.382, respectively). There were significant differences in the levels of hemoglobin, hematocrit, blood urea nitrogen, and international normalized ratio but it was not clinically meaningful. The development of vomiting, dizziness, and headache were not significantly different between the groups and no patient developed pruritus. Although the overall number of patients with nausea was higher in group P with statistical significance (P = 0.002), there were no significant differences between the groups when examined at each detection time. CONCLUSIONS: The present study suggested propacetamol as a possible alternative of ketorolac in postoperative care after laparoscopic gynecologic surgeries.

Current clinical application of dexmedetomidine for sedation and anesthesia

Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.

Current clinical application of dexmedetomidine for sedation and anesthesia

Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.

Budd-Chiari syndrome with antiphospholipid syndrome and systemic lupus erythematosus in a patient with Klinefelter's syndrome / 영남의대학술지

Klinefelter's syndrome is the most common congenital abnormality that causes primary hypogonadism. It is associated with diseases that predominantly affect women, such as systemic lupus erythematosus (SLE), and it can sometimes cause veno-occlusive disease. We experienced a case of Budd-Chiari syndrome (BCS) in a 33-year-old man with Klinefelter's syndrome presented with hematemesis and edema in both lower extremities. The clinical and laboratory findings were compatible with SLE, antiphospholipid syndrome, and BCS. To the best of our knowledge, this is the first case report to describe a simultaneous presentation of these four clinical syndromes in a single patient.