Association of Pre- and Post-Donation Renal Function with Midterm Estimated Glomerular Filtration Rate in Living Kidney Donors: A Retrospective Study

Purpose@#The estimated glomerular filtration rate (eGFR) at 6 months after donation (eGFR 6m) is strongly associated with the risk of end-stage renal disease in living kidney donors. This study aimed to investigate the incidence of eGFR 6m <60 mL/min/1.73 m 2 eGFR 6m <60) and identify the risk factors that can predict the occurrence of eGFR 6m <60 in living kidney donors. @*Materials and Methods@#Living kidney donors who underwent nephrectomy at Severance Hospital between January 2009 and December 2019 were identified. We excluded 94 of 1233 donors whose creatinine values at 6 months after donation were missing. The risk factors for eGFR 6m <60 were assessed using multivariate regression analysis. The optimal cutoff points for candidate risk factors for predicting eGFR 6m <60 occurrence were determined using the Youden index. @*Results@#The eGFR 6m <60 occurred in 17.3% of the participants. Older age (≥44 years), history of hypertension, lower preoperative eGFR (<101 mL/min/1.73 m 2 ), and degree of increase in creatinine levels on postoperative day 2 compared to those before surgery (ΔCr2_pre) (≥0.39 mg/dL) increased the risk of eGFR 6m <60. The addition of ΔCr2_pre to preoperative eGFR yielded a higher predictive accuracy for predicting eGFR 6m <60 than that with preoperative eGFR alone {area under the receiver operating characteristic curve=0.886 [95% confidence interval (CI), 0.863–0.908] vs. 0.862 (95% CI, 0.838–0.887), p<0.001}. @*Conclusion@#The incidence of eGFR 6m <60 was 17.3%. Older age, lower preoperative eGFR, history of hypertension, and greater ΔCr2_pre were associated with the occurrence of eGFR 6m <60 after living donor nephrectomy. The combination of preoperative eGFR and ΔCr2_pre showed the highest predictive power for eGFR 6m <60.

Benzydamine inhibits osteoclast differentiation and bone resorption down-regulation of interleukin-1 expression

Bone diseases such as osteoporosis and periodontitis are induced by excessive osteoclastic activity, which is closely associated with inflammation. Benzydamine (BA) has been used as a cytokine-suppressive or non-steroidal anti-inflammatory drug that inhibits the production of pro-inflammatory cytokines or prostaglandins. However, its role in osteoclast differentiation and function remains unknown. Here, we explored the role of BA in regulating osteoclast differentiation and elucidated the underlying mechanism. BA inhibited osteoclast differentiation and strongly suppressed interleukin-1 (IL-1) production. BA inhibited osteoclast formation and bone resorption when added to bone marrow-derived macrophages and differentiated osteoclasts, and the inhibitory effect was reversed by IL-1 treatment. The reporter assay and the inhibitor study of IL-1 transcription suggested that BA inhibited nuclear factor-B and activator protein-1 by regulating IB kinase, extracellular signal regulated kinase and P38, resulting in the down-regulation of IL-1 expression. BA also promoted osteoblast differentiation. Furthermore, BA protected lipopolysaccharide- and ovariectomy-induced bone loss in mice, suggesting therapeutic potential against inflammation-induced bone diseases and postmenopausal osteoporosis.

Efficacy of Palonosetron vs. Ramosetron for the Prevention of Postoperative Nausea and Vomiting: A Meta-Analysis of Randomized Controlled Trials

PURPOSE: This study was designed as a meta-analysis of randomized controlled trials (RCTs) that included the comparison of palonosetron and ramosetron for postoperative nausea and vomiting (PONV) prophylaxis. MATERIALS AND METHODS: A systematic search was conducted for the PubMed, EMBASE, Web of Science, CENTRAL, KoreaMed, and Google Scholar databases (PROSPERO protocol number CRD42015026009). Primary outcomes were the incidences of postoperative nausea (PON) and postoperative vomiting (POV) during the first 48 hrs after surgery. The total 48-hr period was further analyzed in time epochs of 0–6 hrs (early), 6–24 hrs (late), and 24–48 hrs (delayed). Subgroup analyses according to number of risk factors, sex, and type of surgery were also performed. RESULTS: Eleven studies including 1373 patients were analyzed. There was no difference in PON or POV between the two drugs for the total 48-hr period after surgery. However, palonosetron was more effective in preventing POV during the delayed period overall [relative risk (RR), 0.59; 95% confidence interval (CI), 0.39 to 0.89; p=0.013], as well as after subgroup analyses for females and laparoscopies (RR, 0.56; 95% CI, 0.36 to 0.86; p=0.009 and RR, 0.46; 95% CI, 0.23 to 0.94; p=0.033). Subgroup analysis for spine surgery showed that ramosetron was more effective in reducing POV during the total 48-hr (RR, 3.34; 95% CI, 1.46 to 7.63; p=0.004) and early periods (RR, 8.47; 95% CI, 1.57 to 45.72; p=0.013). CONCLUSION: This meta-analysis discovered no definite difference in PONV prevention between the two drugs. The significant findings that were seen in different time epochs and subgroup analyses should be confirmed in future RCTs.

Standard versus Rotation Technique for Insertion of Supraglottic Airway Devices: Systematic Review and Meta-Analysis

PURPOSE: Supraglottic airway devices have been widely utilized as an alternative to tracheal intubation in various clinical situations. The rotation technique has been proposed to improve the insertion success rate of supraglottic airways. However, the clinical efficacy of this technique remains uncertain as previous results have been inconsistent, depending on the variable evaluated. MATERIALS AND METHODS: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in April 2015 for randomized controlled trials that compared the rotation and standard techniques for inserting supraglottic airways. RESULTS: Thirteen randomized controlled trials (1505 patients, 753 with the rotation technique) were included. The success rate at the first attempt was significantly higher with the rotation technique than with the standard technique [relative risk (RR): 1.13; 95% confidence interval (CI): 1.05 to 1.23; p=0.002]. The rotation technique provided significantly higher overall success rates (RR: 1.06; 95% CI: 1.04 to 1.09; p<0.001). Device insertion was completed faster with the rotation technique (mean difference: -4.6 seconds; 95% CI: -7.37 to -1.74; p=0.002). The incidence of blood staining on the removed device (RR: 0.36; 95% CI: 0.27 to 0.47; p<0.001) was significantly lower with the rotation technique. CONCLUSION: The rotation technique provided higher first-attempt and overall success rates, faster insertion, and a lower incidence of blood on the removed device, reflecting less mucosal trauma. Thus, it may be considered as an alternative to the standard technique when predicting or encountering difficulty in inserting supraglottic airways.

Evaluation of Informed Consent for Withholding and Withdrawal of Life Support in Korean Intensive Care Units / 대한구급학회지

BACKGROUND: The goal of this study was to analyze the process and characteristics of withholding or withdrawal of life support (WLS) in Korean intensive care units (ICUs). METHODS: This was a single-centered retrospective analysis of patients who died in the ICUs of a tertiary hospital in Korea from January to December 2012. WLS informed consents and clinical data were analyzed. RESULTS: Of 285 deaths during the study period, informed consents for WLS were obtained from 228 patients (80.0%). All WLS decisions were made by family members after the patient's loss of decision-making capacity. Decisions were made most frequently by the patient's son (50.6%). Patients in the WLS group were older than those in the non-WLS group, and older age was associated with the WLS decision. Thirty-seven patients (16.2%) died within one hour of WLS approval, and 182 patients (79.8%) died on the day of WLS approval. The most frequently withheld life support modality was chest compression (100%), followed by defibrillation (95.9%) and pacemaker insertion (63.3%). CONCLUSIONS: Aggressive and invasive life support measures were those most frequently withheld or withdrawn by decision-makers in Korean ICUs. The most common proxy was the son, rather than the spouse.

Evaluation of Informed Consent for Withholding and Withdrawal of Life Support in Korean Intensive Care Units / 대한중환자의학회지

BACKGROUND: The goal of this study was to analyze the process and characteristics of withholding or withdrawal of life support (WLS) in Korean intensive care units (ICUs). METHODS: This was a single-centered retrospective analysis of patients who died in the ICUs of a tertiary hospital in Korea from January to December 2012. WLS informed consents and clinical data were analyzed. RESULTS: Of 285 deaths during the study period, informed consents for WLS were obtained from 228 patients (80.0%). All WLS decisions were made by family members after the patient's loss of decision-making capacity. Decisions were made most frequently by the patient's son (50.6%). Patients in the WLS group were older than those in the non-WLS group, and older age was associated with the WLS decision. Thirty-seven patients (16.2%) died within one hour of WLS approval, and 182 patients (79.8%) died on the day of WLS approval. The most frequently withheld life support modality was chest compression (100%), followed by defibrillation (95.9%) and pacemaker insertion (63.3%). CONCLUSIONS: Aggressive and invasive life support measures were those most frequently withheld or withdrawn by decision-makers in Korean ICUs. The most common proxy was the son, rather than the spouse.

Predicting Delayed Ventilator Weaning after Lung Transplantation: The Role of Body Mass Index / 대한구급학회지

BACKGROUND: Weaning from mechanical ventilation is difficult in the intensive care unit (ICU). Many controversial questions remain unanswered concerning the predictors of weaning failure. This study investigates patient characteristics and delayed weaning after lung transplantation. METHODS: This study retrospectively reviewed the medical records of 17 lung transplantation patients from October 2012 to December 2013. Patients able to be weaned from mechanical ventilation within 8 days after surgery were assigned to an early group (n = 9), and the rest of the patients were assigned to the delayed group (n=8). Patients' intraoperative and postoperative characteristics were collected and analyzed, and conventional weaning predictors, including rapid shallow breathing index (RSBI), were also assessed. RESULTS: The results of the early group showed a significantly shorter ICU stay in addition to a shorter hospitalization overall. Notably, the early group had a higher body mass index (BMI) than the delayed group (20.7 vs. 16.9, p = 0.004). In addition, reopening occurred more frequently in the delayed group (1/9 vs. 5/8, p = 0.05). During spontaneous breathing trials, tidal volume (TV) and arterial oxygen tension were significantly higher in the early group compared to the delayed weaning group, but differences in RSBI and respiratory rate (RR) between groups were not statistically significant. CONCLUSIONS: Low BMI might be associated with delayed ventilator weaning in lung transplantation patients. In addition, instead of the traditional weaning predictors of RSBI and RR, TV might be a better predictor for ventilator weaning after lung transplantation.

Efficacy of Intrathecal Morphine Combined with Intravenous Analgesia versus Thoracic Epidural Analgesia after Gastrectomy

PURPOSE: Epidural analgesia has been the preferred analgesic technique after major abdominal surgery. On the other hand, the combined use of intrathecal morphine (ITM) and intravenous patient controlled analgesia (IVPCA) has been shown to be a viable alternative approach for analgesia. We hypothesized that ITM combined with IVPCA is as effective as patient controlled thoracic epidural analgesia (PCTEA) with respect to postoperative pain control after conventional open gastrectomy. MATERIALS AND METHODS: Sixty-four patients undergoing conventional open gastrectomy due to gastric cancer were randomly allocated into the intrathecal morphine combined with intravenous patient-controlled analgesia (IT) group or patient-controlled thoracic epidural analgesia (EP) group. The IT group received preoperative 0.3 mg of ITM, followed by postoperative IVPCA. The EP group preoperatively underwent epidural catheterization, followed by postoperative PCTEA. Visual analog scale (VAS) scores were assessed until 48 hrs after surgery. Adverse effects related to analgesia, profiles associated with recovery from surgery, and postoperative complications within 30 days after surgery were also evaluated. RESULTS: This study failed to demonstrate the non-inferiority of ITM-IVPCA (n=29) to PCTEA (n=30) with respect to VAS 24 hrs after surgery. Furthermore, the IT group consumed more fentanyl than the EP group did (1247.2+/-263.7 microg vs. 1048.9+/-71.7 microg, p<0.001). The IT group took a longer time to ambulate than the EP group (p=0.021) and had higher incidences of postoperative ileus (p=0.012) and pulmonary complications (p=0.05) compared with the EP group. CONCLUSION: ITM-IVPCA is not as effective as PCTEA in patients undergoing gastrectomy, with respect to pain control, ambulation, postoperative ileus and pulmonary complications.

Predicting Delayed Ventilator Weaning after Lung Transplantation: The Role of Body Mass Index / 대한중환자의학회지

BACKGROUND: Weaning from mechanical ventilation is difficult in the intensive care unit (ICU). Many controversial questions remain unanswered concerning the predictors of weaning failure. This study investigates patient characteristics and delayed weaning after lung transplantation. METHODS: This study retrospectively reviewed the medical records of 17 lung transplantation patients from October 2012 to December 2013. Patients able to be weaned from mechanical ventilation within 8 days after surgery were assigned to an early group (n = 9), and the rest of the patients were assigned to the delayed group (n=8). Patients' intraoperative and postoperative characteristics were collected and analyzed, and conventional weaning predictors, including rapid shallow breathing index (RSBI), were also assessed. RESULTS: The results of the early group showed a significantly shorter ICU stay in addition to a shorter hospitalization overall. Notably, the early group had a higher body mass index (BMI) than the delayed group (20.7 vs. 16.9, p = 0.004). In addition, reopening occurred more frequently in the delayed group (1/9 vs. 5/8, p = 0.05). During spontaneous breathing trials, tidal volume (TV) and arterial oxygen tension were significantly higher in the early group compared to the delayed weaning group, but differences in RSBI and respiratory rate (RR) between groups were not statistically significant. CONCLUSIONS: Low BMI might be associated with delayed ventilator weaning in lung transplantation patients. In addition, instead of the traditional weaning predictors of RSBI and RR, TV might be a better predictor for ventilator weaning after lung transplantation.

Effect of sevoflurane on grafted kidney function in renal transplantation / 대한마취과학회지

BACKGROUND: The objective of this retrospective study was to determine if there are any differences in grafted kidney function in recipients of kidney transplantation (KT) when donors and recipients were anesthetized with sevoflurane compared to desflurane. METHODS: Seventy-three pairs of donors-recipients were anesthetized with sevoflurane (Sevo group) and 71 pairs were anesthetized with desflurane (Des group). We retrospectively investigated the blood urea nitrogen (BUN) levels, creatinine (Cr) levels, and estimated glomerular filtration rates (eGFR) of the recipients in both groups for 1 year postoperatively. We tested non-inferiority for serum creatinine at discharge and 1 year after KT. Short-term (1 year) outcomes of KT were assessed by the incidence of delayed graft function (DGF), acute rejection episodes (ARE), and graft failure. RESULTS: There were no differences in BUN, Cr, eGFR, or outcomes of KT at 1 year postoperatively. Specifically, the 95% confidence interval for the difference in creatinine levels between the Sevo and Des groups was less than the margin of equivalence at the time of discharge and 1 year after surgery. The occurrences of DGF, ARE, and graft failure were comparable between the groups. CONCLUSIONS: Compared to desflurane, sevoflurane had no adverse effects on grafted renal function or on the short-term outcome of renal transplantation.

Effect of sevoflurane on grafted kidney function in renal transplantation / 대한마취과학회지

BACKGROUND: The objective of this retrospective study was to determine if there are any differences in grafted kidney function in recipients of kidney transplantation (KT) when donors and recipients were anesthetized with sevoflurane compared to desflurane. METHODS: Seventy-three pairs of donors-recipients were anesthetized with sevoflurane (Sevo group) and 71 pairs were anesthetized with desflurane (Des group). We retrospectively investigated the blood urea nitrogen (BUN) levels, creatinine (Cr) levels, and estimated glomerular filtration rates (eGFR) of the recipients in both groups for 1 year postoperatively. We tested non-inferiority for serum creatinine at discharge and 1 year after KT. Short-term (1 year) outcomes of KT were assessed by the incidence of delayed graft function (DGF), acute rejection episodes (ARE), and graft failure. RESULTS: There were no differences in BUN, Cr, eGFR, or outcomes of KT at 1 year postoperatively. Specifically, the 95% confidence interval for the difference in creatinine levels between the Sevo and Des groups was less than the margin of equivalence at the time of discharge and 1 year after surgery. The occurrences of DGF, ARE, and graft failure were comparable between the groups. CONCLUSIONS: Compared to desflurane, sevoflurane had no adverse effects on grafted renal function or on the short-term outcome of renal transplantation.

The Benefit of Braille for Successful Weaning off Mechanical Ventilation in Congenital Blindness and Hearing Impairment: A Case Report / 대한구급학회지

To achieve adequate depth of sedation and assess the severity of pain in mechanically ventilated patients in the intensive care unit, appropriate communication with the patients is necessary. Communication is also important for successful weaning from the mechanical ventilator as well as weaning predictors, such as respiratory muscle capacity. Here, we present a case report of a 39-year-old man with congenial blindness and hearing impairment who successfully weaned off ventilator support using Braille to communicate under an optimal level of sedation and analgesia after septic shock management.

Association between Primary Care Quality and Health Behaviors in Patients with Essential Hypertension Who Visit a Family Physician as a Usual Source of Care / 가정의학회지

BACKGROUND: Management of hypertension has been performed mainly in primary care institutions, but hypertension control in population is still unsatisfactory. This study was aimed at finding a strategy to improve health promotion activities in patients with hypertension by exploring the association between health behaviors and quality of primary care. METHODS: April to June in 2007, a questionnaire survey of the patients who has a family physician as a usual source of care was conducted for the development of the Korean Primary Care Assessment Tool (KPCAT). In this study, a usual source of care was defined as a physician of the persons who had visited their primary care clinic on six or more occasions over a period of more than 6 months. Of the data collected from 9 private clinics (3 in Seoul and 6 at small cities), cases of the patients who marked on having hypertension were selected. The associations between levels of quality of primary care and socio-demographic characteristics or health behaviors were analysed by Student t-test and chi-square test. Controlling socio-demographic variables, the association between quality of primary care and health behaviors was examined by multiple logistic regression analysis. RESULTS: Among the patients (n = 602) of 9 private clinics who has a family physician as a usual source of care, those who marked on having hypertension were 134. Among 5 domains of the KPCAT, the highest domain in score was personalized care (71.7/100), and the lowest domain in score was coordination function (49.7/100). In patients who gave total average (69.2/100) or more in total primary care score, after adjustment with age, sex, income, education, and duration, odds ratio to have a normal BMI (<25 kg/m2) was 2.53 (P = 0.02), and odds ratio to have a habit drinking an adequate amount of alcohol was 4.32 (P = 0.02). CONCLUSION: The fact that high-quality primary care was associated with good health behaviors in this study suggests that improving quality of primary care by health care reform can make health behaviors more desirable in patients with essential hypertension.

Patient Assessment of Primary Care of Health Cooperative Clinics in South Korea / 가정의학회지

BACKGROUND: In South Korea, major health care problems have been occurred under the structural background that medical services are mainly provided by private medical institutions. Primary health care, which is very crucial in public health, has been overlooked, and is disorganized and fragmented. In the mean time, health cooperative movement was initiated by local residents and medical doctors to overcome health care problems in 1987. We conducted this study to evaluate the role of health cooperative clinics and obtain lessons for the future primary care policy. METHODS: During April to June in 2007, survey was performed by a trained interviewer at the waiting rooms of 3 health cooperative clinics, in the process of development of the Korean Primary Care Assessment Tool (KPCAT). The KPCAT consists of 5 domains (21 items): first contact (5), coordination function (3), comprehensiveness (4), family/community orientation (4), and personalized care (5). Subjects were patients (or guardians) who had visited their health cooperative clinics on six or more occasions over a period of more than 6 months. We compared primary care scores of each domain between members and non-members of health cooperative clinics by student t-test. Effect of having a membership on each primary care domains was examined by multiple regression analysis. RESULTS: Among the participants (N = 100), members of health cooperatives were 48, and non-members 52. Total average scores of 5 primary care domains of the KPCAT were 78.0 +/- 13.5 on 100 point scale. (82.0 +/- 13.1 in members, and 74.3 +/- 13.0 in nonmembers; P = 0.004) Among primary care domains, personalized care was the highest (91.4 +/- 11.0), and coordination function the lowest (61.0 +/- 33.1) in score. Significant differences between members and nonmembers were noted in coordination function (68.9 vs. 53.7, P = 0.021) and comprehensiveness (78.4 vs. 67.2, P = 0.008). These differences were continued after adjusting by multiple regression analysis for socio-demographic variables including age, sex, income, education, number of disease, and duration since the first visit. CONCLUSION: In the health cooperative clinics whose primary care performance has been considered exemplary in the context of health care in South Korea, primary care scores assessed by members were higher than those by non-members. The significant differences of scores in coordination function and comprehensiveness between members and nonmembers suggest that the future primary care policy should be focused to strengthen these two domains of primary care.