Prediction of nonresponsiveness to medium-dose intravenous immunoglobulin (1 g/kg) treatment: an effective and safe schedule of acute treatment for Kawasaki disease / 소아과

PURPOSE: Medium-dose (1 g/kg) intravenous immunoglobulin (IVIG) is effective in the majority of patients with Kawasaki disease (KD) but some patients who do not respond to medium-dose IVIG are at high risk for the development of coronary artery lesions (CALs). The purpose of this study was to identify the clinical predictors associated with unresponsiveness to medium-dose IVIG and the development of CALs. METHODS: A retrospective study was performed in 91 children with KD who were treated with medium-dose IVIG at our institution from January 2004 to December 2013. We classified the patients into responders (group 1; n=68) and nonresponders (group 2; n=23). We compared demographic, laboratory, and echocardiographic data between the 2 groups. RESULTS: Multivariate logistic regression analysis identified 6 variables as predictors for resistance to medium-dose IVIG. We generated a predictive scoring system assigning 1 point each for percentage of neutrophils ≥65%, C-reactive protein≥100 mg/L, aspartate aminotransferase≥100 IU/L, and alanine aminotransferase≥100 IU/L, as well as 2 points for less than 5 days of illness, and serum sodium level≤136 mmol/L. Using a cutoff point of ≥4 with this scoring system, we could predict nonresponsiveness to medium-dose IVIG with 74% sensitivity and 71% specificity. CONCLUSION: If a patient has a low-risk score in this system, medium-dose IVIG can be recommended as the initial treatment. Through this process, we can minimize the adverse effects of high-dose IVIG and incidence of CALs.

Usefulness of anterior uveitis as an additional tool for diagnosing incomplete Kawasaki disease / 소아과

PURPOSE: There are no specific tests for diagnosing Kawasaki disease (KD). Additional diagnostic criteria are needed to prevent the delayed diagnosis of incomplete Kawasaki disease (IKD). This study compared the frequency of coronary artery lesions (CALs) in IKD patients with and without anterior uveitis (AU) and elucidated whether the finding of AU supported the diagnosis of IKD. METHODS: This study enrolled patients diagnosed with IKD at The Catholic University of Korea, Uijeongbu St. Mary's Hospital from January 2010 to December 2014. The patients were divided into 2 groups: group 1 included patients with IKD having AU; and group 2 included patients with IKD without AU. We analyzed the demographic and clinical data (age, gender, duration of fever, and the number of diagnostic criteria), laboratory results, and echocardiographic findings. RESULTS: Of 111 patients with IKD, 41 had uveitis (36.98%, group 1) and 70 did not (63.02%, group 2). Patients in group 1 had received a diagnosis and treatment earlier, and had fewer CALs (3 of 41, 1.7%) than those in group 2 (20 of 70, 28.5%) (P=0.008). All 3 patients with CALs in group 1 had coronary dilatation, while patients with CALs in group 2 had CALs ranging from coronary dilatation to giant aneurysm. CONCLUSION: The diagnosis of IKD is challenging but can be supported by the presence of features such as AU. Group 1 had a lower risk of coronary artery disease than group 2. Therefore, the presence of AU is helpful in the early diagnosis and treatment of IKD and can be used as an additional diagnostic tool.

Relationships of physical fitness and obesity with metabolic risk factors in children and adolescents: Chungju city cohort study

PURPOSE: The purpose of this study was to investigate the relationships of physical fitness and obesity with metabolic risk factors in children and adolescents. METHODS: This cohort study was conducted in Chungju city, South Korea. Total 843 subjects were enrolled, including 193 elementary school 4th grade male (E4M), 189 elementary school 4th grade female (E4F) and 461 male-middle school students (M1M). The subjects were also classified into 2 groups by body mass index; normal weight (NW) group and overweight included obesity (OW/OB) group. Physical fitness was measured by shuttle run (cardiorespiratory fitness, CRF), sit and reach (flexibility), handgrip strength (muscular strength) and stand long jump (agility). RESULTS: The prevalence of OW/OB was respectively 33.7% (65 of 193) among E4M, 28.6% (54 of 189) among E4F, and 28.0% (129 of 461) among M1M. Hematocrit, white blood cell, triglyceride, low-density lipoprotein, insulin, homeostasis model assessment of insulin resistance, systolic and diastolic blood pressure were higher, while high-density lipoprotein were lower in the OW/OB group than in the NW group. The OW/OB group presented significantly lower CRF (P<0.01) and lower agility, but higher muscular strength compared with NW group. CRF was negatively correlated with obesity indices and metabolic risk factors. After adjustments for potential confounders, odds ratios for 4th-5th grade CRF of OW/OB compared NW in the E4M, E4F, M1M, were 7.38 (95 % CI, 3.24-16.83), 4.10 (95% CI, 1.83-9.18), 16.06 (95% CI, 8.23-31.00) (P<0.01). CONCLUSION: Our study has shown that CRF has negative correlation with OW/OB in children and adolescents of Chungju city. We suggest that improvement of CRF through regular physical activity would be an important method for reducing the metabolic risks of childhood obesity.

Biomechanical Evaluation of the Capsular Stiffness and Clinical Features in Adhesive Capsulitis of Shoulders

OBJECTIVE: To evaluate the capsular stiffness of the glenohumeral joint by measuring the slope of pressure-volume curves generated during intra-articular hydraulic distension (IHD) and analyze its correlation with clinical variables and outcomes in terms of limitation of range of motion (LOM) and severity of pain. METHOD: IHD with real-time intra-articular pressure monitoring was performed for 53 patients with adhesive capsulitis and the capsular stiffness was measured from pressure-volume curves by calculating the slope of elastic deformation region. LOM, measured by LOM score and sum of ROMs (range of motion), and degree of pain, measured by visual analog scale (VAS), were evaluated before and after IHD: three days (3D) and one month (1M) after IHD. RESULTS: In patients with stiffer capsules, LOM and pain were severe before IHD (Pearson's correlation coefficient (r)= 0.291, -0.348, 0.381 and p=0.065, 0.026, 0.014 for LOM score, sum of ROMs and VAS, respectively. By this order, henceforth). On 3D follow up, the correlation between the stiffness and LOM or pain was maintained (r=0.291, -0.348, 0.381 and p=0.065, 0.026, 0.014). The improvement of LOM score on 3D follow up was less as the capsules were stiffer (r=-0.368, p=0.023). On 1M follow up, LOM remained severer in stiffer capsules whereas pain did not (r=0.372, -0.402, 0.183 and p=0.039, 0.025, 0.342). CONCLUSION: The stiffness of the glenohumeral joint capsule, measured from the slope of pressure-volume curves during IHD, showed significant correlation with the severity of LOM and pain in patients with adhesive capsulitis of shoulder.

Stimulation Intensity of Functional Electrical Stimulation on Hemiplegic Upper Extremity

OBJECTIVE: This study aimed to assess optimal stimulation intensity and to investigate other variables on functional electrical stimulation (FES) for hemiplegic upper limb. METHOD: We divided hemiplegic subjects into two groups, acute (n=28) and chronic (n=18), and control subjects into old (n=26) and young (n=27). Electrical stimulation was performed on the forearm of both sides in hemiplegic patients and of the nondominant side in normal controls. The stimulation site that aimed at open hand motion was targeted to the extensor digitorum and extensor pollicis brevis muscles. We measured the peak to peak amount of current and skin impedance while making hand extension. RESULTS: The acute and chronic hemiplegic groups required a greater current than the control groups (p<0.01).The hemiplegic side required a greater current than the non- hemiplegic side (p<0.001). There was no significant difference of current amount between the acute and chronic hemiplegic groups. The current amount was significantly correlated with subject's age (p=0.001). No difference of skin impedance was found among any of the groups. CONCLUSION: Irrespective of disease duration on hemiplegia, a greater current is required in the hemiplegic upper limb than in the normal upper limb. Age was an important factor in determining stimulation intensity.

An Experimental Study on the Immune Responses to Regenerating Allografts in the Rat / 대한이식학회지

Partial liver transplantation from a living donor or by splitting the liver was developed to expand the donor pool. Sometimes the small-for-size liver is transplanted into larger recipient and it regenerates shortly to ideal volume for the recipient. The relationship between regeneration and rejection-intensity has not defined clearly yet. In this study the 30% partial liver of DA (Dark-Agauti) rats were transplanted heterotopically to Lewis rats by microsurgical technique. End-to-side cavocaval and end-to-end portoportal (or portomesenteric) anastomoses were performed but the artery and the bile duct were not reconstructed. In regenerating group (R), total portal blood of the recipient was diverted to the graft. In non-regenerating group (N), the superior mesenteric vein below the confluence of the splenic vein was anstomosed to the portal vein of the recipient. Both groups were treated with tacrolimus (FK-506 2 mg/kg/d) and compared with non-treated groups. Transplantations were successful with minimal operative mortality. The animals could survive for the studying period in both groups. When compared on day 3, day 5, and day 7, histologic examination revealed no significant differences of cellular infiltration between two groups. In tacrolimus-treated groups, the cellular infiltration was markedly decreased and there were no significant differences in cellular infiltration between regenerating group treated with tarcrolimus (R-F) and non-regenerating group treated with tarcrolimus (N-F). These findings suggest that immune responses to the allograft are not significantly influenced by the hepatic regeneration process in small-for-size graft. Further immunologic and molecular biologic investigation may be needed.

An Experimental Study on the Immune Responses to Regenerating Allografts in the Rat / 대한이식학회지

Partial liver transplantation from a living donor or by splitting the liver was developed to expand the donor pool. Sometimes the small-for-size liver is transplanted into larger recipient and it regenerates shortly to ideal volume for the recipient. The relationship between regeneration and rejection-intensity has not defined clearly yet. In this study the 30% partial liver of DA (Dark-Agauti) rats were transplanted heterotopically to Lewis rats by microsurgical technique. End-to-side cavocaval and end-to-end portoportal (or portomesenteric) anastomoses were performed but the artery and the bile duct were not reconstructed. In regenerating group (R), total portal blood of the recipient was diverted to the graft. In non-regenerating group (N), the superior mesenteric vein below the confluence of the splenic vein was anstomosed to the portal vein of the recipient. Both groups were treated with tacrolimus (FK-506 2 mg/kg/d) and compared with non-treated groups. Transplantations were successful with minimal operative mortality. The animals could survive for the studying period in both groups. When compared on day 3, day 5, and day 7, histologic examination revealed no significant differences of cellular infiltration between two groups. In tacrolimus-treated groups, the cellular infiltration was markedly decreased and there were no significant differences in cellular infiltration between regenerating group treated with tarcrolimus (R-F) and non-regenerating group treated with tarcrolimus (N-F). These findings suggest that immune responses to the allograft are not significantly influenced by the hepatic regeneration process in small-for-size graft. Further immunologic and molecular biologic investigation may be needed.

Surgical Experiences Involving Benign Pancreatic Diseases

Nineteen patients with benign pancreatic disease were managed with surgical treatment in Pusan Medical Center during three years from September 1993 to September 1995 and the results were reviewed retrospectively. The results were as follows; 1) This report includes five cases of severe(hemorrhagic in one case and necrotizing in four cases) acute pancreatitis,eight cases of pancreatic inury,three cases of pancreatic pseudocyst and three cases of chronic pancreatitis. 2)The most common etiology of benign pancreatic disease, excluding pancreatic injury, was alcohol ingestion. 3)Five cases of severe acute pancreatitis were represented with more than 4 of Ranson's prognostic factors and the surgical methods refered were external drainage with debridment or necrosectomy. All were effectively managed surgically except one case of death which had more than 6 of Ranson's prognostic factors. 4)The etiology of pancreatic injury was blunt abdominal trauma in seven cases and surgical complications in one case. The sites of injury were head in three cases,body in three cases and tail in one case. The operative methods used were drainage(all cases),distal pancreatectomy(3 cases),triple ostomy(1 case) and pancreaticoduodenectomy(1 case). 5)The sites of pancreatic pseudocysts were the body in two cases, head in one case. The operative method used was as follows; excision in one case, external drainage in one case and cystojejunostomy in one case. 6)Three cases of the chronic pancreatitis were diagnosed by intraoperative findings. 7)In conclusion, the most reliable treatment for benign pancreatic disease is early surgical intervention, in order to reduce the mortality rate and complications induced by pancreatic inflammation.

Pneumothorax and Pneumoperitoneum due to Occlusion of the Scavenging System during General Endotracheal Anesthesia with Drager Anesthesia Machine / 대한마취과학회지

Pulmonary barotrauma is defined as an extra-alveolar gas from lung damage secondary to changes in intrathoracic pressure. Pneumothorax, pneumoperitoneum, pneumomediastinum and subcutaneous emphysema developed due to complete occlusion of the expiratory tube of the scavenging system. During controlled endotracheal ventilation of the lungs of a 22 year old woman undergoing thyroidectomy increased airway pressure about 50 mbar on the airway pressure gauge approximately 8 minutes after starting ventilator was detected. Vital signs were stable. Subcutaneous emphysema around the neck, face and both shoulders were observed. The expiratory tubing was found to be trapped and competely obstructed between the upper and lower parts of the ventilator. The operation was cancelled and chest x-ray was taken in the operating room, which showed about 15% pneumothorax on the right chest, subcutaneous emphysema and pneumomediastinum. The follow up chest x-ray was taken in postanesthesia care unit and pneumoperitoneum was also detected on the right upper side of the abdomen. The signs of rupture of the abdominal viscus were not noted. She recovered uneventfully with insufflation of 100% oxygen and discharged 3 days later with complete spontaneous resorption of the pneumothorax.

Most Painful Experiences of Patients in Intensive Care Unit / 대한마취과학회지

Intensive care unit (ICU) is an area which promotes feeling of high anxiety. And patients in ICU suffered from physical and psychological discomforts. These physical and psychological discomforts are varied according to patients themselves, age, character, illness and environment such as ICU structure, staff, operating system. Physical and psychological discomforts can affect treatment and prognosis of disease. Several reports have appeared of adverse psychological and psychiatric effects of intensive therapy. On the other hand, some patients may be reassuered by continuous surveillance and exhibit emotional reactions and increased cathecholamine production on returning to a general ward". It may be possible to have considerable influence on these effects by improving the environmental factors. We evaluated the recall of 300 patients after ICU discharge, and 609o of the patients had unpleasant experiences in ICU admission. The most frequently reported unpleasant experiences were pain(18.6%), family worries(15.6%), tracheal suction(5.0%), blood sampling(5.0%), sleep deprivation(4.6%), noise(3.3%), limit of motion and posture (3.0%), unkindness(2.6%) and others(1.0%). We asked about fear for dying in their ICU stay, and 106(35.3%) of 300 patients responded yes. There was no difference in APACHEII score between fear for death and not. Therefore we must try to reduce patient's various painful stimli by more careful and kind treatments. Medical staff should remember that their trivial behavior could stimulate patients and should try to control their patients by heartful experiencing about the prognosis.

Plasma inorganic fluoride concentrations following sevoflurane anesthesia / 대한마취과학회지

Plasma inorganic fluoride concentrations were measured in adult patients without hepatic or renal disease following sevoflurane-N2O anesthesia (n=7) or enflurane-N2O anesthesia (n=6). The anesthetic dosage of sevoflurane and enflurane was 6.48+/-2,15%-hour and 6.57+/-2.05%-hour, respectively. The mean peak plasma inorganic fluoride concentration in the sevoflurane group was 19.5+/-13.4 umol/L 1hour after anesthesia, which decreased to preanesthetic levels 24 hours after anesthesia. In the enflurane group the values were 13.2+/-5.8 umol/L at the end of anesthesia and decreased, but remained, still twice as high as the preanesthetic level 24 hours after anesthesia. The relationship of plasma inorganic fluoride concentration and anesthetic dosage was more pronounced in the sevoflurane group (r=0.68, slope=4.2) than in the enflurane group (r=0.39, slope=1.2). In conclusian, sevoflurane-N2O anesthesia results in similar subnephrotoxic levels of plasma inorganic fluoride as enflurane-N2O. anesthesia, and although the fluoride concentration had a better correlation to anesthetic dosage in the sevoflurane group than in the enflurane group, its excretion was faster in the sevoflurane group than in the enflurane group.