Nutritional Impact of Percutaneous Endoscopic Gastrostomy: A Retrospective Single-center Study / 대한소화기학회지

Background/Aims@#Several conditions may cause difficulties with oral feeding. Percutaneous endoscopic gastrostomy (PEG) is commonly performed on patients who require enteral feeding for >2-3 weeks. This study examined the nutritional state of patients who required enteral feeding and underwent PEG to quantify the benefits of the procedure. @*Methods@#This retrospective study included patients who underwent PEG at the Chungnam National University Hospital between January 2013 and December 2018. A gastroenterologist performed all PEG procedures using the pull technique, and all patients were followed up for >3 weeks postoperatively. The BMI and lymphocyte count, along with the levels of hemoglobin, total protein, albumin, total cholesterol, BUN, and creatinine pre-PEG and between 3 weeks and 6 months post-PEG were evaluated. @*Results@#Overall, 151 patients (116 males; mean age 64.92 years) were evaluated. Of these patients, 112 (74.2%), 34 (22.5%), and five (3.3%) underwent PEG tube insertion because of neurological diseases, malignancy, and other conditions, respectively. The BMI and the hemoglobin, total protein, albumin, and total cholesterol levels were significantly higher post-PEG than pre-PEG. @*Conclusions@#These findings highlight the usefulness of PEG in the management of nutritionally poor patients with difficulties in feeding orally.

Intestinal Perforation as a Paradoxical Reaction to Antitubercular Therapy: A Case Report

Paradoxical reactions to tuberculosis (TB) treatment are characterized by an initial improvement of the clinical symptoms followed by clinical or radiological deterioration of existing tuberculous lesions, or by development of new lesions. Intestinal perforation in gastrointestinal TB can occur as a paradoxical reaction to antitubercular therapy. A 55-year-old man visited the outpatient department with lower abdominal pain and weight loss. He was diagnosed with intestinal TB and started antitubercular therapy. After 3 months of antitubercular therapy, a colonoscopy revealed improvement of the disease. Three days after the colonoscopy, the patient visited the emergency room complaining of abdominal pain. Abdominal computed tomography revealed extraluminal air-filled spaces in the pelvic cavity. We diagnosed a small bowel perforation and performed an emergency laparotomy and a right hemicolectomy with small bowel resection. This report describes the case of intestinal perforation presenting as a paradoxical reaction to antitubercular and provides a brief literature review.

Intestinal Perforation as a Paradoxical Reaction to Antitubercular Therapy: A Case Report

Paradoxical reactions to tuberculosis (TB) treatment are characterized by an initial improvement of the clinical symptoms followed by clinical or radiological deterioration of existing tuberculous lesions, or by development of new lesions. Intestinal perforation in gastrointestinal TB can occur as a paradoxical reaction to antitubercular therapy. A 55-year-old man visited the outpatient department with lower abdominal pain and weight loss. He was diagnosed with intestinal TB and started antitubercular therapy. After 3 months of antitubercular therapy, a colonoscopy revealed improvement of the disease. Three days after the colonoscopy, the patient visited the emergency room complaining of abdominal pain. Abdominal computed tomography revealed extraluminal air-filled spaces in the pelvic cavity. We diagnosed a small bowel perforation and performed an emergency laparotomy and a right hemicolectomy with small bowel resection. This report describes the case of intestinal perforation presenting as a paradoxical reaction to antitubercular and provides a brief literature review.

Low-level viremia and cirrhotic complications in patients with chronic hepatitis B according to adherence to entecavir

Background/Aims@#Low-level viremia (LLV) after nucleos(t)ide analog treatment was presented as a possible cause of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). However, detailed information on patients’ adherence in the real world was lacking. This study aimed to evaluate the effects of LLV on HCC development, mortality, and cirrhotic complications among patients according to their adherence to entecavir (ETV) treatment. @*Methods@#We performed a retrospective observational analysis of data from 894 consecutive adult patients with treatment-naïve CHB undergoing ETV treatment. LLV was defined according to either persistent or intermittent episodes of <2,000 IU/mL detectable hepatitis B virus DNA during the follow-up period. Good adherence to medication was defined as a cumulative adherence ≥90% per study period. @*Results@#Without considering adherence in the entire cohort (n=894), multivariate analysis of the HCC incidence showed that LLV was an independent prognostic factor in addition to other traditional risk factors in the entire cohort (P=0.031). Good adherence group comprised 617 patients (69.0%). No significant difference was found between maintained virologic response and LLV groups in terms of the incidence of liver-related death or transplantation, HCC, and hepatic decompensation in good adherence group, according to multivariate analyses. @*Conclusions@#In patients with treatment-naïve CHB and good adherence to ETV treatment in the real world, LLV during treatment is not a predictive factor for HCC and cirrhotic complications. It may be unnecessary to adjust their antiviral agent for patients with good adherence who experience LLV during ETV treatment.

Free fatty acid-induced histone acetyltransferase activity accelerates lipid accumulation in HepG2 cells

BACKGROUND/OBJECTIVES: Non-alcoholic fatty liver disease (NAFLD) is a common metabolic disease triggered by epigenetic alterations, including lysine acetylation at histone or non-histone proteins, affecting the stability or transcription of lipogenic genes. Although various natural dietary compounds have anti-lipogenic effects, their effects on the acetylation status and lipid metabolism in the liver have not been thoroughly investigated. MATERIALS/METHODS: Following oleic-palmitic acid (OPA)-induced lipid accumulation in HepG2 cells, the acetylation status of histone and non-histone proteins, HAT activity, and mRNA expression of representative lipogenic genes, including PPARγ, SREBP-1c, ACLY, and FASN, were evaluated. Furthermore, correlations between lipid accumulation and HAT activity for 22 representative natural food extracts (NExs) were evaluated. RESULTS: Non-histone protein acetylation increased following OPA treatment and the acetylation of histones H3K9, H4K8, and H4K16 was accelerated, accompanied by an increase in HAT activity. OPA-induced increases in the mRNA expression of lipogenic genes were down-regulated by C-646, a p300/CBP-specific inhibitor. Finally, we detected a positive correlation between HAT activity and lipid accumulation (Pearson's correlation coefficient = 0.604) using 22 NExs. CONCLUSIONS: Our results suggest that NExs have novel applications as nutraceutical agents with HAT inhibitor activity for the prevention and treatment of NAFLD.

Restoration of bilateral distal extension removable partial denture using a fixed implant prosthesis in unilateral partial edentulous patient: A case report / 대한치과보철학회지

Traditional removable partial denture is a successful treatment for partial edentulous patients. When the abutment is formed with unilateral minority teeth, satisfaction with the use of removable partial denture may be lowered due to patient's discomfort and damage of the abutment. Recently, it has been reported that the unilateral posterior extension partial denture is used as a bilateral posterior extension partial denture using implant fixed prostheses as abutments. In this case, by using implant surveyed crown prostheses, bilateral posterior extension partial denture is fabricated in site that is predicted to have a poor prognosis. This resulted in improved support, maintenance, and stabilization of the removable partial denture, which were economically beneficial to patient and satisfied with use.

Management Outcomes of Colonoscopic Perforations Are Affected by the General Condition of the Patients

PURPOSE: The management of a colonoscopic perforation (CP) varies from conservative to surgical. The objective of this study was to evaluate the outcomes between surgical and conservative treatment of patients with a CP. METHODS: From 2003 to 2016, the medical records of patients with CP were retrospectively reviewed. Patients were divided into 2 groups depending on whether they initially received conservative or surgical treatment. RESULTS: During the study period, a total of 48 patients with a CP were treated. Among them, 5 patients had underlying colorectal cancer and underwent emergency radical cancer surgery; these patients were excluded. The mean age of the remaining 43 patients was 64.5 years old, and the most common perforation site was the sigmoid colon (15 patients). The initial conservative care group included 16 patients, and the surgery group included 27 patients. In the conservative group, 5 patients required conversion to surgery (failure rate: 5 of 16 [31.3%]). Of the surgery group, laparoscopic surgery was performed on 19 patients and open surgery on 8 patients, including 2 conversion cases. Major postoperative complications developed in 11 patients (34.4%), and postoperative mortality developed in 4 patients (12.5%). The only predictor for poor prognosis after surgery was a high American Society of Anesthesiologists physical status classification. CONCLUSION: In this study, conservative treatment for patients with a CP had a relatively high failure rate. Furthermore, surgical treatment showed significant rates of complications and mortality, which depended on the general status of the patients.

Percutaneous Endoscopic Gastrostomy Tube Insertion-induced Superior Mesenteric Artery Injury Treated with Angiography / 대한소화기학회지

Percutaneous endoscopic gastrostomy (PEG) is widely used to provide nutritional support for patients with dysphagia and/or disturbed consciousness preventing oral ingestion, and PEG tube placement is a relatively safe and convenient non-surgical procedure performed under local anesthesia. However, the prevention of PEG-insertion-related complications is important. A 64-year-old man with recurrent pneumonia underwent tracheostomy and nasogastric tube placement for nutritional support and opted for PEG tube insertion for long-term nutrition. However, during the insertion procedure, needle puncture had to be attempted twice before successful PEG tube placement was achieved, and a day after the procedure his hemoglobin had fallen and he developed hypotension. Abdominal computed tomography revealed injury to a pancreatic branch of the superior mesenteric artery (SMA) associated with bleeding, hemoperitoneum, and pancreatitis. Transarterial embolization was performed using a microcatheter to treat hemorrhage from the injured branch of the SMA, and the acute pancreatitis was treated using antibiotics and supportive care. The patient was discharged after an uneventful recovery. Clinicians should be mindful of possible pancreatic injury and bleeding after PEG tube insertion. Possible complications, such as visceral injuries or bleeding, should be considered in patients requiring multiple puncture attempts during a PEG procedure.

Cytomegalovirus colitis in immunocompetent patients

No abstract available.

The effects of adjuvant intrathecal fentanyl on postoperative pain and rebound pain for anorectal surgery under saddle anesthesia / 대한마취과학회지

BACKGROUND: Intrathecal opioid has been known to enhance the quality and prolong the duration of spinal anesthesia, as well as to reduce postoperative pain. The purpose of this study was to evaluate postoperative analgesic characteristics of intrathecal fentanyl for the first 48 hours after anorectal surgery under saddle anesthesia. METHODS: Eighty patients were recruited in our study. Forty patients were randomly allocated to group B that received 0.5% bupivacaine 5 mg with 0.3 ml normal saline. The other 40 patients were assigned to group BF which was given 0.5% bupivacaine 5 mg with fentanyl 15 μg. The primary outcome variable was a numeric rating scale (NRS) at six hours postoperatively. Secondary outcomes included changes in the NRS score between one and 48 hours postoperatively, consumption of rescue analgesics, and the frequency of rebound pain. RESULTS: Group BF exhibited a lower mean NRS score at postoperative six hours compared to group B (P < 0.001). However, the mean NRS score was not different after postoperative six hours between the two groups. The median consumption of rescue analgesics in group BF was less than that of group B (P = 0.028) and the frequency of rebound pain decreased in group BF when compared to group B (P = 0.021). The levels of sensory block were S1 dermatome and motor block scores were 0 for both groups. There was no significant difference in adverse effects between the groups. CONCLUSIONS: Intrathecal fentanyl 15 μg for anorectal surgery under saddle anesthesia led to an improved pain score for the first six hours after surgery and decreased postoperative analgesic use. Rebound pain diminished with intrathecal fentanyl and adverse effects did not increase.

Clinical application of mandibular removable partial denture using implant-supported surveyed crown: A case report / 대한치과보철학회지

When making conventional removable partial denture for the remaining teeth where the remaining teeth are only on one side, rotation of the denture occurs -in function- on the axis of the connected remaining teeth. If the edentulous portion is long, it becomes harder to obtain retention and stability for the abutment as the importance of the mucous membrane support is elevated. Such movements of denture decrease denture retention and stability, put excessive stress on the abutment, and give bad influence on periodontal health. Therefore, additional implant placement can be of a good choice in gaining additional retention and stability for partial denture. Thus hereby we report this clinical case as successful results were obtained by placing implants symmetrical to the remaining teeth and putting implant-supported surveyed crowns on the implants, allowing the partial denture to be designed to accept varying components and to have suitable path of insertion.

Ethanol extract of Allium fistulosum inhibits development of non-alcoholic fatty liver disease

BACKGROUND/OBJECTIVES: Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease and is closely associated with metabolic syndrome. In the present study, we observed the effect of ethanol extract of Allium fistulosum (EAF) on NAFLD and have suggested the possibility of using EAF as a natural product for application in the development of a treatment for NAFLD. MATERIALS/METHODS: The preventive effect on hepatic lipid accumulation was estimated by using an oleic acid (OA)-induced NAFLD model in vitro and a Western diet (high-fat high-sucrose; WD)-induced obese mouse model. Animals were divided into three groups (n = 7): normal diet group (ND), WD group, and WD plus 1% EAF group. RESULTS: EAF reduced OA-stimulated lipid accumulation in HepG2 cells in the absence of cellular cytotoxicity and significantly blocked transcriptional activation of sterol regulatory element-binding protein 1 and fatty acid synthase genes. Subsequently, we investigated these effects in vivo in mice fed either ND or WD in the presence or absence of EAF supplementation. In comparison to the ND controls, the WD-fed mice exhibited increases in body weight, liver weight, epididymal fat weight, and accumulation of fat in hepatocytes, and these effects were significantly attenuated by EAF supplementation. CONCLUSIONS: Allium fistulosum attenuates the development of NAFLD, and EAF elicits anti-lipogenic activity in liver. Therefore, EAF represents a promising candidate for use in the development of novel therapeutic drugs or drug combinations for the prevention and treatment of NAFLD.

Comparison of Aquatic Treadmill and Anti-Gravity Treadmill Gait Training to Improve Balance and Gait Abilities in Stroke Patients

PURPOSE: The purpose of this study was to compare to aquatic treadmill and anti-gravity treadmill gait training to improve balance and gait abilities in stroke patients. METHODS: All subjects were randomly divided into three groups where nine subjects were in the aquatic treadmill group, eight subjects in the anti-gravity treadmill group, and ten subjects in the control group. Subjects in the aquatic treadmill group and the anti-gravity treadmill group received gait training during 30 minutes, with 3 sessions per week for 4 weeks, and subjects in all groups received conventional physical therapy during 30 minutes, with 5 sessions per week for 4 weeks. All subjects were assessed with the Berg balance scale (BBS), timed up and go test (TUG) and 10-meter walk test (10MWT) pre and post intervention. RESULTS: Results showed that BBS, TUG and 10MWT scores significantly improved post-intervention (p < 0.05), and the control group also had significantly improved in all areas pre-post intervention (p < 0.05). In addition, it has been confirmed that aquatic treadmill group and anti-gravity treadmill group had significantly improved in BBS, TUG and 10MWT scores compared with the control group (p < 0.05). However, no significant difference was found in the comparison between the aquatic treadmill and the anti-gravity treadmill group. CONCLUSION: Finding of this study suggested that aquatic treadmill and anti-gravity treadmill improves balance and gait abilities in stroke patients.

Iatrogenic Development of Cerebrospinal Fluid Leakage in Diagnosing Spontaneous Intracranial Hypotension / 가정의학회지

A 34-year-old woman came to the emergency room complaining of a severe orthostatic headache. Results of a cerebrospinal fluid tap and brain computed tomography were normal. Based on her history and symptoms, she was found to have spontaneous intracranial hypotension. She was hospitalized and her symptoms improved with conservative treatment. On the next day, her headache suddenly worsened. Cisternography was performed to confirm the diagnosis and determine the spinal level of her cerebrospinal fluid leak. It revealed multiple cerebrospinal fluid leaks in the lumbar and upper thoracic regions. It was strongly believed that she had an iatrogenic cerebrospinal fluid leak in the lumbar region. An epidural blood patch was performed level by level on the lumbar and upper thoracic regions. Her symptoms resolved after the epidural blood patch and she was later discharged without any complications. In this case, an iatrogenic cerebrospinal fluid leak was caused by a dural puncture made while diagnosing spontaneous intracranial hypotension, which is always a risk and hampers the patient's progress. Therefore, in cases of spontaneous intracranial hypotension, an effort to minimize dural punctures is needed and a non-invasive test such as magnetic resonance imaging should be considered first.

A Comparison of Underwater Gait Training with Additional Weight Application and Over-ground Gait Training to Improve Balance and Lower Extremity Strength in Persons with Stroke

PURPOSE: This purpose of this study was to compare additionally applied weight underwater gait training and over-ground gait training to improve balance and lower extremity strength in stroke patients. METHODS: Subjects were randomly allocated into two groups. Underwater gait training group (n=10) and Over-ground gait training group (n=9). The groups performed their respective programs as well as conventional physical therapy 3 times/week for 6 weeks. All subjects were assessed with the Berg balance scale test, the timed up and go test, and the medical research council test pre and post in-tervention. A paired t test was applied to compare the differences before and after the intervention, and an independent t test was used to compare the differences between the groups. The level of statistical significance was set at p<0.05. RESULTS: The results showed that subjects in the underwater gait training group had a significantly increased Berg balance scale, timed up and go, and medical research council scores (p<0.05), and over-ground gait training group showed a significantly increased medical research council score (p<0.05) after intervention. The underwater gait training group showed a more significant improvement in medical research council, Berg balance scale and the timed up and go test scores compared to the over-ground gait training group (p<0.05). CONCLUSION: Findings of this study suggest that applying additional weight during underwater gait training improves lower extremity strength and balance in stroke patients. It' findings can contribute to the development of more efficient rehabilitation for stroke patients.

Stress distribution of implants with external and internal connection design: a 3-D finite element analysis

PURPOSE: This study aims to analyze the stress distribution of mandibular molar restoration supported by the implants with external hex and internal taper abutment connection design. MATERIALS AND METHODS: Models of external connection (EXHEX) and internal connection (INCON) implants, corresponding abutment/crowns, and screws were developed. Supporting edentulous mandibular bony structures were designed. All the components were assembled and a finite element analysis was performed to predict the magnitude and pattern of stresses generated by occlusal loading. A total of 120 N static force was applied both by axial (L1) and oblique (L2) direction. RESULTS: Peak von Mises stresses produced in the implants by L2 load produced 6 – 15 times greater than those by L1 load. The INCON model showed 2.2 times greater total amount of crown cusp deflection than the EXHEX model. Fastening screw in EXHEX model and upside margin of implant fixture in INCON model generated the peak von Mises stresses by oblique occlusal force. EXHEX model and INCON model showed the similar opening gap between abutment and fixture, but intimate sealing inside the contact interface was maintained in INCON model. CONCLUSION: Oblique force produced grater magnitudes of deflection and stress than those by axial force. The maximum stress area at the implant was different between the INCON and EXHEX models.

Quadriplegia as a position-related complication after parotidectomy: the need for cooperation between anesthesiologists and surgeons when positioning patients: A case report

During surgery, the patient is positioned optimally according to the type of operation. Careful attention is required because damage associated with patient positioning may occur during the course of the surgery. Here, we present a case of hyperextension neck injury observed following parotidectomy. A 68-year-old man who was diagnosed with a parotid tumor underwent an elective right partial superficial parotidectomy. After surgery, the patient was not able to move his upper and lower extremities and experienced voiding difficulty. Cervical magnetic resonance imaging showed spinal cord injury at the C3-4 and C5-6 levels. High-dose steroid treatment was started, and emergency laminoplasty C4-5 to C5-6 was performed. Following laminoplasty, motor function was almost fully recovered, but proprioception was weak, and voiding difficulty remained a problem. The patient received rehabilitation treatment in the hospital for about 3 months, demonstrating improvement. He was discharged and continued treatment in the outpatient department.

Quadriplegia as a position-related complication after parotidectomy: the need for cooperation between anesthesiologists and surgeons when positioning patients: A case report

During surgery, the patient is positioned optimally according to the type of operation. Careful attention is required because damage associated with patient positioning may occur during the course of the surgery. Here, we present a case of hyperextension neck injury observed following parotidectomy. A 68-year-old man who was diagnosed with a parotid tumor underwent an elective right partial superficial parotidectomy. After surgery, the patient was not able to move his upper and lower extremities and experienced voiding difficulty. Cervical magnetic resonance imaging showed spinal cord injury at the C3-4 and C5-6 levels. High-dose steroid treatment was started, and emergency laminoplasty C4-5 to C5-6 was performed. Following laminoplasty, motor function was almost fully recovered, but proprioception was weak, and voiding difficulty remained a problem. The patient received rehabilitation treatment in the hospital for about 3 months, demonstrating improvement. He was discharged and continued treatment in the outpatient department.

Airway obstruction by dissection of the inner layer of a reinforced endotracheal tube in a patient with Ludwig's angina: A case report

Intraoperative airway obstruction is perplexing to anesthesiologists because the patient may fall into danger rapidly. A 74-year-old woman underwent an emergency incision and drainage for a deep neck infection of dental origin. She was orally intubated with a 6. 0 mm internal diameter reinforced endotracheal tube by video laryngoscope using volatile induction and maintenance anesthesia (VIMA) with sevoflurane, fentanyl (100 µg), and succinylcholine (75 mg). During surgery, peak inspiratory pressure increased from 22 to 38 cmH₂O and plateau pressure increased from 20 to 28 cmH₂O. We maintained anesthesia because we were unable to access the airway, which was covered with surgical drapes, and tidal volume was delivered. At the end of surgery, we found a longitudinal fold inside the tube with a fiberoptic bronchoscope. The patient was reintubated with another tube and ventilation immediately improved. We recognized that the tube was obstructed due to dissection of the inner layer.

Esthetic prosthesis for a patient with the maxillary diastema: a case report

In the treatment of esthetically important areas such as maxillary anterior teeth, they should be corresponded with surrounding tissues, and shape of the smile line, soft tissue, and hard tissue, also the anatomical shape and proportion of the teeth should be considered as well. Esthetic analysis includes facial analysis which evaluates the proper parallelism between the occlusal plane and the horizontal reference line, dentolabial analysis which assesses the position of the incisal edge and the coherence between the occlusal plane and the commissural line, tooth analysis which evaluates not only esthetics but also morphology and appearance for proper function, and gingival analysis which forms ideal outline of gingival margins. A maxillary anterior diastema can be esthetically restored through the systematic diagnostic approach and treatment planning, and orthodontic, prosthetic, and conservative treatment can be applied for the treatment.