Utility of combining PIVKA-II and AFP in the surveillance and monitoring of hepatocellular carcinoma in the Asia-Pacific region

Even though the combined use of ultrasound (US) and alpha-fetoprotein (AFP) is recommended for the surveillance of hepatocellular carcinoma (HCC), the utilization of AFP has its challenges, including accuracy dependent on its cut-off levels, degree of liver necroinflammation, and etiology of liver disease. Though various studies have demonstrated the utility of protein induced by vitamin K absence II (PIVKA-II) in surveillance, treatment monitoring, and predicting recurrence, it is still not recommended as a routine biomarker test. A panel of 17 experts from Asia-Pacific, gathered to discuss and reach a consensus on the clinical usefulness and value of PIVKA-II for the surveillance and treatment monitoring of HCC, based on six predetermined statements. The experts agreed that PIVKA-II was valuable in the detection of HCC in AFP-negative patients, and could potentially benefit detection of early HCC in combination with AFP. PIVKA-II is clinically useful for monitoring curative and intra-arterial locoregional treatments, outcomes, and recurrence, and could potentially predict microvascular invasion risk and facilitate patient selection for liver transplant. However, combining PIVKA-II with US and AFP for HCC surveillance, including small HCC, still requires more evidence, whilst its role in detecting AFP-negative HCC will potentially increase as more patients are treated for hepatitis-related HCC. PIVKA-II in combination with AFP and US has a clinical role in the Asia-Pacific region for surveillance. However, implementation of PIVKA-II in the region will have some challenges, such as requiring standardization of cut-off values, its cost-effectiveness and improving awareness among healthcare providers.

The Neuromuscular Pharmacodynamics for Rocuronium at the Adductor Pollicis and the Flexor Hallucis Brevis Muscle / 대한마취과학회지

BACKGROUND: Neuromuscular block is commonly monitored using the adductor pollicis (AP) because of its easy access. However, the hand may not always be accessible for neuromuscular monitoring during surgery. In that situation, monitoring of the flexor hallucis brevis (FHB) secondary to stimulation of the tibial nerve at the ankle joint may be used as an alternative. METHODS: During propofol and remifentanil anesthesia, acceleromyography of the thumb and big toe were recorded. Single twitch responses were measured simultaneously after cumulative administration of rocuronium from 80 to 200microgram/kg at intervals of 40microgram/kg. Furthermore, the amount of rocuronium required for 50% and 95% twitch height depression were calculated. Rocuronium was infused continuously to maintain 5% to 15% twitch responses. We also obtained the onset, duration of action, and antagonism effect of neostigmine from both muscles via neostigmine (20microgram/kg) administration. RESULTS: ED50 and ED95 were significantly lower in the AP than in the FHB. The highest twitch response at peak and neostigmine antagonism were significantly higher in the FHB than in the AP. However, there was no significant difference in the onset time or duration of neostigmine between AP and FHB. CONCLUSIONS: Due to its resistance to rocuronium, the onset of FHB is not a good indicator of optimal conditions for tracheal intubation. Also, because of its higher antagonism effect, there is potential risk of overlooking a residual block. Sufficient recovery of the block should be readjusted to estimate recovery in the FHB with the use of other reliable clinical tests.

Wound Infiltration in Patients with Chronic Pain after Forehead Lift Surgery: A case report / 대한통증학회지

Local infiltration in surgical wounds can reduce postoperative pain with very few side effects. We experienced two cases of chronic pain after forehead lift surgery. A 41-year-old male patient was suffering from a headache at the crown of the head and pain from the posterior neck. A 54-year-old female patient had pain around the forehead, worsened by psychological stress. They underwent forehead lift surgery 10 years and 8 months ago, respectively. Conservative treatments such as medication and physical therapy were not effective. After wound infiltration with 1% lidocaine more than ten times, pain significantly resolved in both patients.

Comparative Study on Frameless Stereotactic Hematoma Aspiration versus Frame-Based Stereotactic Hematoma Aspiration in Deep Seated Intracerebral Hemorrhage: A Clinical Article / 대한뇌혈관외과학회지

OBJECTIVE: We compare the frameless stereotactic hematoma aspiration (FSA) with frame-based stereotactic hematoma aspiration (FBSA) in intracerebral hemorrhage (ICH) about operative advantage and result. MATERIAL AND METHODS: Between January 2002 and December 2002, we surgically treated 30 patients presenting with spontaneous ICH at our hospital. 15 patients underwent FBSA via Codman-Roberts-Wells system and catheter placement with urokinase infusion and drainage, and 15 patients underwent FSA and catheter placement via neuronavigator with urokinase infusion and drainage. RESULTS: The amount of remaining hematoma and removal rate were from 1 to 26 and 76% in FSA and from 2 to 55 and 60.4% in FBSA. The entry point was selected within 2.03+/-0.85 cm in a frontal direction from Kocher's point and 2.86+/-0.57 cm in lateral direction from Kocher's point and the trajectory was selected toward the distal margin of hematoma along the long axis of hematoma in FSA but the entry point was restricted within Kocher's point and the trajectory was selected toward the center of the maximum axial section of hematoma in FBSA. The mean time of operative preparation was mean 61 minutes in FSA and 78 minutes in FBSA. The number of patients not required with infusion of urokinase was 10 in FSA and 7 in FBSA. The mean duration of urokinase infusion was 3.6 day in FSA and 4.1 day in FBSA. CONCLUSION: FSA is fast, simple and effective procedure. In comparison with FBSA, FSA has advantage in selecting the entry point and the trajectory for hematoma aspiration and catheter placement, and in a less time-consuming procedure.

The Relationship of the Anthropometric Variables to the Infusion Rate of Rocuronium in the Elderly

We have determined the infusion rates of rocuronium in the elderly and young adult patients during sevoflurane and nitrous oxide anesthesia. The correlation of some anthropometric predictors with infusion rate of rocuronium was also investigated for both elderly and young adult. Participating patients were assigned to one of two groups: 1) young adult patients aged 20 to 50 years (n = 30) ; 2) elderly patients aged over 65 years (n = 30). The anthropometric variables such as height, weight, ratio of weight to body surface area, subscapularis and suprailiac skin folds, body surface area, body mass index and % ideal body weight were evaluated as predictors for infusion rate. The infusion rate in elderly patients was significantly less compared with that in young adult patients (p < 0.05). In elderly patients, no anthropometric predictor was related to the infusion rate of rocuronium. This suggests that the infusion rate of rocuronium for an elderly patient needs to be individualized by monitoring neuromuscular transmission to avoid excessive dose.

Delayed Hemorrhagic Manifestation of Blunt Carotid Artery Injury

Blunt carotid artery injury is uncommon, yet not rare. However, it is often underdiagnosed because of inconsistent early symptoms or masking by the presence of coexisting brain and spinal injuries. The delay between the accident and the onset of cerebral ischemic symptoms is variable and has been reported to range from minutes to ten years. However, to our knowledge, there has been no report on a case presented with delayed intracerebral hemorrhage 25months after blunt carotid artery injury. We report on a case with discussion of supporting evidence and possible mechanisms.

Determination of the Pterional Approach Side According to the Direction of the Aneurysm and the Configuration of the H-complex in Anterior Communicating Artery Aneurysms

OBJECTIVE: We proposed to study factors influencing the determination of operative side for easier and more successful clipping in the pterional approach to anterior communicating artery aneurysms and to determine the highest priority of factors in relation to the direction of the aneurysm. METHODS: The present study was conducted retrospectively in 91 patients with anterior communicating artery aneurysm who were operated on between January 1996 and December 2002. A1 dominancy, the size and the direction of aneurysms, the configuration of the H-complex especially the relative locations of both A2 segments in the coronal plane and the presence or absence of accompanying aneurysms were determined by angiogram. The degree of operative difficulty and factors influencing difficulty were reviewed with operative records and videos. RESULTS: In antero-inferior projecting aneurysms, when approached from the side of A1 dominancy, safe and easy clipping resulted(45/46cases). In superior projecting aneurysms, approaches from the side of the ipsilateral proximal A2 posterior to the contralateral A2 yielded favorable results(25/25cases), although the side was A1 non-dominant side. In some cases with posterior projecting aneurysms, approaches from the side of the posteriorly located A2 segment were inappropriate. CONCLUSION: In anterior communicating artery aneurysmal surgery, the A1 dominant side for antero-inferior projecting aneurysms and the side of the ipsilateral proximal A2 posterior to the contralateral A2 for superior projecting aneurysms should be considered prior to other factors. In posterior projecting aneurysms, angiographic analysis for the side where operator can observe the aneurysmal neck directly is required.

Evaluation of Cobas Integra 700 and Distribution of High Sensitivity C-reactive Protein Levels in Koreans / 대한진단검사의학회지

BACKGROUND: Prospective studies suggest that C-reactive protein (CRP) is a novel and indepen-dent risk factor of coronary heart disease. High-sensitivity methods for CRP (hs-CRP) measurement are needed for this purpose. In this study, we evaluated the performance of Cobas Integra 700 (Roche Diagnostics, Basel, Switzerland) and aimed to establish the distribution of serum CRP concentrations in healthy Koreans with the hs-CRP method. METHODS: The subjects of this study were 853 males (age; 45.9 +/- 9.8 years) and 546 females (age; 45.7 +/- 10.8 years) who visited the Health Promotion Center of the Asan Medical Center for routine health checks. Hs-CRP was measured with the Cobas Integra 700. The within-day precision, the between-day precision, the degree of correlation, the linearity, and the detection limit of hs-CRP were also analyzed with the Cobas Integra 700. RESULTS: The within-day coefficients of variation (CVs) were 0% and 1.3%. The between-day CVs were 4.0% and 3.0%. The percentage of relative nonlinearity was 0.78%. The correlation coefficient of the Cobas Integra 700 with the Behring Nephelometer was 0.994. The lower detection limit was 0.064 mg/L and the functional detection limit was 0.472 mg/L. The geometric mean concentration of CRP in Koreans was 0.69 mg/L. The mean CRP of the male population was 0.79 mg/L, which was higher than that of Korean females (0.54 mg/L) (P<0.0001). There was a significant trend to higher CRP values with increasing age (P<0.05). CONCLUSIONS: The linearity, the precision, the correlation, the detection limit of the Cobas Integra 700 were satisfactory. The age and sex-specific guidelines for hs-CRP would make the early intervention for coronary heart disease possible.

Fiberoptic Nasotracheal Intubation in Pediatric Patients with Difficult Mouth Opening: A case report / 대한마취과학회지

We present two pediatric patients, one with Pierre Robin syndrome and one with temporomandibular joint ankylosis with limited mouth opening. They had historical and physical evidence of airway obstruction, difficult feeding, and sleep disturbance. They were scheduled for oromaxillofacial surgery. In each case, two different-sized fiberoptic bronchoscopes were used for nasotracheal intubation. After loss of consciousness following an IV injection of ketamine or inhalation of sevoflurane while maintaining spontaneous respiration, 10% lidocaine was sprayed into one nostril. Following insertion of a 60 cm Olympus LF-2 fiberoptic bronchoscope (OD: 3.8 mm) through the same nostril without tube placement, the vocal cords were visualized and topical anesthesia of the larynx was achieved by spraying 2% lidocaine through the biopsy channel. Thirty seconds later, the bronchoscope was passed into the trachea and 2% lidocaine was sprayed intratracheally. Then, the bronchoscope was withdrawn. An endotracheal tube was advanced through the same nostril and positioned in the nasopharynx and the ultrathin fiberoptic bronchoscope (OD: 2.2 mm) was threaded through the tube. There was neither a cough nor laryngeal spasm during advancement of the tube into the trachea. Extubation was performed without compromise in the operating room. The patients were discharged uneventfully.

Identification and Clinical Significance of Kluyvera species / 대한임상병리학회지

BACKGROUND: Kluyvera, a new genus in the family Enterobacteriaceae, has been rarely isolated from clinical specimens and regarded as an opportunistic pathogen. Although there were several case reports in Korea, most of them were reported at a genus level except a case of K. cyrocrescens. We isolated Kluyvera species from seven patients from July 1996 to January 1999. We identified them to species level and investigated their clinical significance. METHODS: The medical records of seven patients were reviewed for demographical findings, underlying diseases, diagnoses, the association of Kluyvera isolates with disease, antibiotic treatments, and clinical outcomes. Eight strains were identified and tested for the antimicrobial susceptibilities by MicroScan Neg Combo type 14 and 21 Panel(Dade Behring, USA). Five of the eight strains had been stored at -70degrees C and were tested for ascorbate fermentation, the ability to grow and ferment glucose at 5degrees C, and the zone of inhibition around carbenicillin and cephalothin. RESULTS: Kluyvera isolates were regarded as true pathogens in six of seven cases including Hickman-catheter associated sepsis(HCAS), empyema, peritonitis, necrotizing cholecystitis, sepsis, and liver abscess although the latter four cases yielded mixed cultures. While three of the six patients had underlying diseases, malignant lymphoma, hepatocellular carcinoma and stomach cancer, other three were previousely healthy. Most of them were improved with an empirical therapy, but Kluyvera species was repeatedly isolated from the HCAS case in spite of the antibiotic treatment; it was cured bacteriologically after the removal of the catheter. The five isolates were all confirmed to be K. ascorbata by positive ascorbate test, and failure to grow at 5degrees C. CONCLUSIONS: Six of the seven cases including three with no underlying diseases, isolates of Kluyvera species were found clinically significant, suggesting that Kluyvera species is potentially pathogenic in healthy individuals as well as compromized hosts. MicroScan system is capable of identifying Kluyvera species at the genus level, but not at the species level. The ascorbate test is simple and useful for differ entiation of K. ascorbata from K. cryocrescens.

Lymphoid Aggregates in Remissioned Marrow of Childhood Acute Lymphoblastic Leuksemia / 대한혈액학회지

BACKGROUND: Lymphocytes seen during the chemotherapy of childhood ALL are not fully understood regarding their clinical significance. The lymphoid aggregates found during the complete remission period are more confusing. We investigated the characteristics of lymphoid aggregates and the clinial course of children with these in the marrow during the chemotherapy of childhood ALL. This is the first study about this subject. METHODS: From January 1996 to April 1998, 210 bone marrow specimens were diagnosed as complete remission status of ALL and among them, ten patients (4.8%) showed lymphoid aggreagates on the marrow clot sections at the time of complete remission. We reviewed bone marrow specimens, performed immunohistochemical stains for CD3, CD 10 and CD79a and investigated the clinical course. RESULTS: The ten cases were composed of nine ALL, L1 and one ALL, L2. All of them were treated under guidance of the CCG (children's cancer group) protocol. Fourteen lymphoid aggregates from ten cases were found. They showed mean number of 1.4 per clot section, mean diameter of 132 micrometer, regular (36%) or irregular (64%) margin and composition of mature lymphocytes (21%), immature lymphocytes (29%) or mixed pattern (50%). The mean interval between the diagnosis and the emergence of lymphoid agregates was 29 months (2~55 months). One patient in the course of consolidation chemotherapy expired due to upper gastrointestinal bleeding and other nine cases are still in the continuous complete remission state. The lymphoid cells consisting of lymphoid aggregates showed positive reaction only for CD79a and negative reactions for CD3 and CD10. CONCLUSION: Lymphpoid aggregates found at the time of complete remission are collections of regenerating B-lymphocytes and they are not residual leukemic blasts, and show no effect on the complete remission state.

Analysis of Factors Associated with Platelet Refractoriness / 대한수혈학회지

BACKGROUND: Platelet refractoriness is associated with immune and nonimmune factors. It has been shown that the incidence of platelet refractoriness caused by HLA alloimmunization is decreased by using of leukocyte-depleted blood components. The purpose of this study was to determine the incidence of platelet refractoriness in relation to the use of leukocyte removal filter and the relative importance of immune and nonimmune factors. METHODS: One hundred and eighty-five patients with thrombocytopenia, treated with multiple transfusion were classified into three groups according to use of leukocyte removal filters (group I: no filter, II: Asahi filter, III: Pall filter). Patients were considered to be refractory when the 20-hour posttransfusion corrected count increment (CCI) was less than 4.5 x 109/L on three subsequent platelet transfusions. Nonimmune factors analyzed were fever, sepsis, disseminated intravascular coagulation, splenomegaly, bone marrow transplantation, and administration of amphotericin-B. RESLUTS: The overall incidence of platelet refractoriness was 45% in group I, 44% in group II, and 47% in group III. In more than 90%, platelet refractoriness was associated with the presence of nonimmune factors. The incidence of platelet refractoriness presumably caused by alloimmunization was less than 5% and is much higher in aplastic anemia than in leukemia. Patients with pregnancy history developed platelet refractoriness with an increased incidence compared to patients without pregnancy history. CONCLUSION: This study revealed that nonimmune factors were predominant causes of platelet refractoriness regardless of transfusion of leukocyte-depleted blood components.