Liver transplantation of a patient with extreme thrombocytopenia - A case report -

Background@#Patients with chronic liver disease (CLD) planned for liver transplantation (LT) often show severe thrombocytopenia, but there is a lack of evidence in deciding the threshold for prophylactic platelet transfusion.Case: A 47-year-old women with acute liver failure was referred for LT. Despite daily transfusion of platelets, platelet counts remained under 10,000/µl. During LT, 2 units of single donor platelets (SDP) were transfused. Although platelet counts remained extremely low (3,000–4,000/µl) no diffuse oozing was observed and the blood loss was 860 ml. Postoperatively, there was no sign of active bleeding or oozing, and the patient received only 1 unit SDP transfusion. @*Conclusions@#CLD patients may have severe thrombocytopenia. However, primary hemostasis may not be significantly hindered due to the existence of rebalanced hemostasis. Prophylactic platelet transfusion in these patients should not be decided based on platelet counts only, but also take other coagulation tests and clinical signs into consideration.

Changes in the allocation policy for deceased donor livers in Korea: perspectives from anesthesiologists

Background@# The allocation policy for deceased donor livers in Korea was changed in June 2016 from Child-Turcotte-Pugh (CTP) scoring system-based to Model for End-stage Liver Disease (MELD) scoring system-based. Thus, it is necessary to review the effect of allocation policy changes on anesthetic management. @*Methods@# Medical records of deceased donor liver transplantation (DDLT) from December 2014 to May 2017 were reviewed. We compared the perioperative parameters before and after the change in allocation policy. @*Results@# Thirty-seven patients underwent DDLT from December 2014 to May 2016 (CTP group), and 42 patients underwent DDLT from June 2016 to May 2017 (MELD group). The MELD score was significantly higher in the MELD group than in the CTP group (36.5 ± 4.6 vs. 26.5 ± 9.4, P < 0.001). The incidence of hepatorenal syndrome (HRS) was higher in the MELD group than in the CTP group (26 vs. 7, P < 0.001). Packed red blood cell transfusion occurred more frequently in the MELD group than in the CTP group (5.0 ± 3.6 units vs. 3.4 ± 2.2 units, P = 0.025). However, intraoperative bleeding, vasopressor support, and postoperative outcomes were not different between the two groups. @*Conclusions@# Even though the patient’s objective condition deteriorated, perioperative parameters did not change significantly.

Immune landscape and biomarkers for immuno-oncology in colorectal cancers

Recent advances in immuno-oncology have increased understanding of the tumor immune microenvironment (TIME), and clinical trials for immune checkpoint inhibitor treatment have shown remission and/or durable response in certain proportions of patients stratified by predictive biomarkers. The TIME in colorectal cancer (CRC) was initially evaluated several decades ago. The prognostic value of the immune response to tumors, including tumor-infiltrating lymphocytes, peritumoral lymphoid reaction, and Crohn’s-like lymphoid reaction, has been well demonstrated. In this review, we describe the chronology of TIME research and review the up-to-date high-dimensional TIME landscape of CRC. We also summarize the clinical relevance of several biomarkers associated with immunotherapy in CRC, such as microsatellite instability, tumor mutational burden, POLE/POLD mutation, consensus molecular subtype, and programmed death-ligand 1 expression.

CpG Island Methylation in Sessile Serrated Adenoma/Polyp of the Colorectum: Implications for Differential Diagnosis of Molecularly High-Risk Lesions among Non-dysplastic Sessile Serrated Adenomas/Polyps

BACKGROUND: Although colorectal sessile serrated adenomas/polyps (SSA/Ps) with morphologic dysplasia are regarded as definite high-risk premalignant lesions, no reliable grading or risk-stratifying system exists for non-dysplastic SSA/Ps. The accumulation of CpG island methylation is a molecular hallmark of progression of SSA/Ps. Thus, we decided to classify non-dysplastic SSA/Ps into risk subgroups based on the extent of CpG island methylation. METHODS: The CpG island methylator phenotype (CIMP) status of 132 non-dysplastic SSA/Ps was determined using eight CIMP-specific promoter markers. SSA/Ps with CIMP-high and/or MLH1 promoter methylation were regarded as a high-risk subgroup. RESULTS: Based on the CIMP analysis results, methylation frequency of each CIMP marker suggested a sequential pattern of CpG island methylation during progression of SSA/P, indicating MLH1 as a late-methylated marker. Among the 132 non-dysplastic SSA/Ps, 34 (26%) were determined to be high-risk lesions (33 CIMP-high and 8 MLH1-methylated cases; seven cases overlapped). All 34 high-risk SSA/Ps were located exclusively in the proximal colon (100%, p = .001) and were significantly associated with older age (≥ 50 years, 100%; p = .003) and a larger histologically measured lesion size (> 5 mm, 100%; p = .004). In addition, the high-risk SSA/Ps were characterized by a relatively higher number of typical base-dilated serrated crypts. CONCLUSIONS: Both CIMP-high and MLH1 methylation are late-step molecular events during progression of SSA/Ps and rarely occur in SSA/Ps of young patients. Comprehensive consideration of age (≥ 50), location (proximal colon), and histologic size (> 5 mm) may be important for the prediction of high-risk lesions among non-dysplastic SSA/Ps.

Clinicopathological Characterization and Prognostic Implication of SMAD4 Expression in Colorectal Carcinoma

BACKGROUND: SMAD family member 4 (SMAD4) has gained attention as a promising prognostic factor of colorectal cancer (CRC) as well as a key molecule to understand the tumorigenesis and progression of CRC. METHODS: We retrospectively analyzed 1,281 CRC cases immunohistochemically for their expression status of SMAD4, and correlated this status with clinicopathologic and molecular features of CRCs. RESULTS: A loss of nuclear SMAD4 was significantly associated with frequent lymphovascular and perineural invasion, tumor budding, fewer tumor-infiltrating lymphocytes, higher pT and pN category, and frequent distant metastasis. In contrast, tumors overexpressing SMAD4 showed a significant association with sporadic microsatellite instability. After adjustment for TNM stage, tumor differentiation, adjuvant chemotherapy, and lymphovascular invasion, the loss of SMAD4 was found to be an independent prognostic factor for worse 5-year progression-free survival (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.01 to 1.60; p=.042) and 7-year cancer-specific survival (HR, 1.45; 95% CI, 1.06 to 1.99; p=.022). CONCLUSIONS: We confirmed the value of determining the loss of SMAD4 immunohistochemically as an independent prognostic factor for CRC in general. In addition, we identified some histologic and molecular features that might be clues to elucidate the role of SMAD4 in colorectal tumorigenesis and progression.

Neuregulin-1 Protects Neuronal Cells Against Damage due to CoCl2-Induced Hypoxia by Suppressing Hypoxia-Inducible Factor-1α and P53 in SH-SY5Y Cells / 대한배뇨장애요실금학회지

PURPOSE@#Hypoxia-mediated neurotoxicity contributes to various neurodegenerative disorders, including Alzheimer disease. Neuregulin-1 (NRG1) plays an important role in the development and plasticity of the brain. The aim of the present study was to investigate the neuroprotective effect and the regulating hypoxic inducible factor of NRG1 in cobalt chloride (CoCl₂) induced hypoxia.@*METHODS@#Hypoxia was induced in SH-SY5Y cells by CoCl₂ treatment. SH-SY5Y cells were pretreated with NRG1 and then treated with CoCl₂. Western blotting, immunocytochemistry, and lactate dehydrogenase (LDH) release assays were performed to examine neuroprotective properties of NRG1 in SH-SY5Y cells.@*RESULTS@#Our data showed that CoCl₂ induced cytotoxicity and changes of hypoxia-inducible factor-1α (HIF-1α) and p53 expression in SH-SY5Y cells. However, pretreatment with NRG1 inhibited CoCl₂-induced accumulation of HIF-1α and p53 stability. In addition, NRG1 significantly attenuated cell death of SH-SY5Y induced by CoCl₂.@*CONCLUSIONS@#NRG1 can regulate HIF-1α and p53 to protect neurons against hypoxic damage.

Neuregulin 1/ErbB4 signaling attenuates neuronal cell damage under oxygen-glucose deprivation in primary hippocampal neurons / 대한해부학회지

The Influence of Emotional Labor and Mental Health on Care Performance of Certified Caregivers for Elders with Dementia / 의료커뮤니케이션

BACKGROUND: The purpose of this study is to identify the degree of emotional labor, mental health care, care performance of certified caregivers for elder with dementia, and the factors that affect care performance.METHODS: In order to collect data, structured questionnaire was used for 197 caregivers who worked at 3 dementia specialized facilities located in D city. Data were analyzed by t-test, ANOVA, correlation and multiple regression using SPSS/WIN 20.0.RESULTS: Care performance had negative relationship with emotional labor(r=−.320, p < .000) and mental health(r=−.240, p < =001). Emotional labor had positive relationship with mental health(r=.208, p=.003) And the prediction factors influencing care performance were health status(β=.363, p < .001), emotional labor(β=−.242, p < .001), mental health(β=−.223, p=.001). The total variance was 38.9% by predictors(F=25.978, p < .001).CONCLUSION: Based on the results of this study, in order to improve the care performance mental health program should be provided and good health management is needed to improve health status. And also it is necessary to develop and apply new strategies to reduce emotional labor of the dementia facility caregivers.

The Influence of Focusing Manner and Emotional Labor on Nursing Performance of Clinical Nurses / 임상간호연구

PURPOSE: Focusing manner is very powerful mind-body self-help and self-awareness competence. So focusing manner may affect nurses' emotional labor and nursing performance, but few are known about it to date. The purpose of this study was to identify the degree of focusing manner, emotional labor, nursing performance of clinical nurses, and the factors that affect nursing performance. METHODS: In order to collect data, structured questionnaires were administered to 212 nurses who worked at 2 university hospitals located in D city. Data were analyzed by t-test, ANOVA, correlation and multiple regression using SPSS/WIN 20.0. RESULTS: Nursing performance had positive relationship with focusing manner (r=.45, p<.001), and negative relationship with emotional labor (r=−.25, p<.001). And the most prediction factor influencing nursing performance was focusing manner (β=.41, p<.001) and the other factors were age (β=.30, p=.002), and emotional labor (β=.14, p=.012). The total variance was 37.1% by those predictors (F=25.87, p<.001). CONCLUSION: Based on the results of this study, it is necessary to develop and educational program on focusing manner-oriented psychotherapy in order to improve the nursing performance. Also, the management system for controlling emotional labor needs to be set up for nurses in clinical settings.

The pain caused by a 2% propofol target-controlled infusion during anesthesia induction in adults / 대한마취과학회지

BACKGROUND: An increasing number of cases of target-controlled infusion (TCI) of propofol have substituted 2% propofol for 1% due to the concerns about lipid deposition and the practical convenience. However, 2% propofol may possess a higher proportion of free aqueous propofol because of the relatively decreased lipid-solvent ratio as compared to that for 1% propofol. We performed a prospective, randomized, double-blind trial to evaluate the pain of 1% and 2% propofol TCI. The efficacy of lidocaine pretreatment to abolish the pain was also tested for each concentration of propofol. METHODS: Two hundred adult patients were randomly allocated to 4 groups according to the pretreatment drugs and propofol concentrations; placebo (normal saline) and 1% propofol group (group 1), placebo and 2% propofol group (group 2), lidocaine and 1% propofol group (group 1L), and lidocaine and 2% propofol group (group 2L). Administration of pretreatment drug was followed by TCI with using each concentration of propofol. Pain was assessed using a four-point scale during propofol infusion. RESULTS: Propofol pain was more frequent (82% vs. 63%, respectively, P = 0.026), and severe (P = 0.002) for the group 2 than for group 1. Pain was significantly reduced by lidocaine pretreatment in the group 2L (48%) and group 1L (19%), as compared with group 2 (82%) and group 1 (63%), respectively (P < 0.001, both). However, group 2L still showed considerable pain that was similar to the pain of group 1. CONCLUSIONS: TCI of 2% propofol caused more frequent and severe pain despite of lidocaine pretreatment.

A Large Subcutaneous Hematoma during Internal Jugular Vein Catheterization: A case report / 대한마취과학회지

We report a patient who developed a large subcutaneous hematoma during internal jugular vein catheterization.We usually find the internal jugular vein by advancing the needle along the medial border of the lateral head of the sternocleidomastoid muscle. The external jugular vein should be identified to avoid puncture.But the external jugular vein is known to exhibit variations in its formation and course. During internal jugular catheterization especially for advanced venous access, identifying the external jugular vein by sono probe may be important.

Spinal Cord Stimulation in Management of Intractable Chronic Pain: A 5-Year Experience / 대한마취과학회지

BACKGROUND: We investigated the effect of spinal cord stimulation on intractable chronic pain retrospectively and report our 5-year experience. METHODS: 49 patients with the medical history of trial spinal cord stimulation have been retrospectively analyzed. They consist of 34 men and 15 women, ranging in age from 22 to 89 years. Causes of intractable chronic pain included postherpetic neuralgia, failed back surgery syndrome, complex regional pain syndrome, chronic back and leg pain, cauda equina syndrome, perineal pain, diabetic polyneuropathy, and spinal cord injury. RESULTS: The pain due to failed back surgery syndrome, complex regional pain syndrome, chronic low back and leg pain, and spinal cord injury was well controlled by using spinal cord stimulation system. After a trial period of stimulation, 20 patients had permanent stimulators implanted. Most of them reported satisfactory pain relief for maximum 60 months and minimum 9 months. Noticeable complications included electrode displacement and hemorrhage. CONCLUSIONS: We may suggest that spinal cord stimulation is an effective and safe therapy for chronic intractable pain.

Survey of Central Venous Catheter Depth Using the Carina as a Radiologic Landmark in ICU Patients / 대한마취과학회지

BACKGROUND: There is no unique guideline as to how to determine the depth of a central venous catheter (CVC). In this study, we inspected the current practice of CVC placement and evaluated insertion depth using the carina as a radiologic landmark in intensive care unit (ICU) patients. METHODS: In 138 ICU patients with a CVC in the right subclavian (SCV group) or internal jugular vein (IJV group), a chest X ray was taken, and the radiographic vertical distance between the catheter tip and the carina level (D-CC) was measured in Picture Archiving and Communication System (PACS) view. The distance between the skin puncture site and the carina level (D-SC) was calculated by adding/subtracting D-CC to/from the actual CVC insertion length. In addition, we surveyed physicians using a questionnaire about the methods they used to determine CVC depth. RESULTS: Mean D-SC was 13.80 +/- 1.69 cm in the SCV group, 14.42 +/- 1.34 cm in the IJV group, but no correlation was found with any measured physical dimension. In males, D-SC was greater, but this difference was not statistically significant. Physicians determined required insertion depths using many different methods (e.g., height, sex......). CONCLUSIONS: Patient height, weight, body mass index (BMI), and sex were not found to be reliable for predicting a safe CVC length. We recommend that after CVC insertion, a chest X ray should be taken and the catheter tip repositioned if necessary to reduce catheter related fatal complications (e.g., cardiac tamponade).

Novel Self-inflating Resuscitators Maintaining High FiO2 with High Minute Ventilation / 대한마취과학회지

BACKGROUND: Self inflating resuscitators are widely used for the patients who need positive pressure ventilation during transport. During self inflating resuscitator ventilation, the FiO2 may decreases even with the use of the oxygen reservoir. Such phenomenon may increase the difficulty and risk of transport of the critically ill patients. Twin self inflating resuscitator was assembled by being modified from two conventional ones to achieve more stable FiO2. METHODS: The twin self inflating resuscitator and one conventional adult self inflating resuscitator were tested on a test lung. In the twin resuscitator, two adult self inflating resuscitators were connected serially without distal unidirectional valve plate. The resuscitators were compressed at variable tidal volumes, respiratory rates and oxygen flow rates, guided by the monitor. RESULTS: With conventional self inflating resuscitator ventilation, the FiO2 was maintained over 95% until minute ventilation of 7,500, 1,4000, 17,500 ml at respectively 5, 10, 15 L/min oxygen flow rate. With serial type, the FiO2 started to decrease with the minute ventilation over 12,500, 24,000, 28,000 ml at 5, 10, 15 L/min oxygen flow rate. CONCLUSIONS: By simple connection of two self inflating resuscitators, the FiO2 during self inflating resuscitator ventilation could be maintained during almost two times of minute ventilation compared to conventional ones.