Fatal airway obstruction due to the presence of blood clot occurs in a variety of clinical settings. Initial efforts to remove an airway clot, if warranted, involve suctioning, lavage, and forceps extraction through a flexible bronchoscope. If unsuccessful, further management options include rigid bronchoscopy, balloon-tip embolectomy catheter dislodgement, and the application of topical thrombolytic agents. We report a case of complete airway obstruction that developed after the aspiration of a blood clot during emergency operative vessel ligation in a 86-year-old female patient with gastric ulcer bleeding. Initial conventional suctioning was unsuccessful, in this case, due to a large firmly adherent clot. Therefore we peformed the alternative suctioning technique using suction attached directly to the existing tracheal tube in situ, with the cuff deflated. However, repeated direct tracheal suctioning alone failed to prevent cardiac arrest. Thereafter, simultaneously with several CPR chest compressions, large cylindrical clots were sucked up by direct tracheal suctioning. Presumably simultaneous chest compression has the potential advantage of creating higher airway pressures that provide effective kinetic energy to obstructing object.
Aged, 80 and over ; Airway Obstruction ; Bronchoscopes ; Bronchoscopy ; Cardiopulmonary Resuscitation ; Catheters ; Embolectomy ; Emergencies ; Female ; Fibrinolytic Agents ; Heart Arrest* ; Hemorrhage* ; Humans ; Ligation ; Resuscitation ; Stomach Ulcer ; Suction ; Surgical Instruments ; Therapeutic Irrigation ; Thorax ; Trachea

OBJECTIVE: Left ventricular ejection fraction is an important clinical variable with respect to diagnosis, treatment and prognosis in various cardiovascular diseases. Measurement of left ventricular ejection fraction is performed by three commonly used methods, M-mode and two dimensional echocardiography, radionuclide angiography and contrast cineangiography. We compared echocardiographic and contrast cinean-giographic ejection fraction by correlation coefficiency to determine the accuracy of echocardiography determined ejection fraction at our institution and to assess the agreement of left ventricular ejection fraction between two methods. METHODS: We measured left ventricular ejection fraction by M-mode, two-dimensional echocardiography and contrast cineangiography in 144 cases of normal and cardiovascular heart disease patients from September 1993 to April 1995 in the cardiology division of Ewha Womans University hospital. The echocar-diography and contraat cineangiography were performed within 7 days of each other. RESULTS: M-mode echocardiographic ejection fraction correlated with contrast cineangiographic ejection fraction (r=0.7841). M-mode echocardiographic ejection fraction corrected with two-dimensional echocardiography in the presence of regional wall motion abnormality correlated with contrast cineangiographic ejection fraction (r=0.8149). By agreement analysis, the difference of mean of ejection fraction measured by M-mode echocardiography and contrast cineangiography was within 95% confidence limits. The mean was 4.08% and the standard deviation was 8.29%. The difference of mean of ejection fraction corrected by two-dimensional echocardiography and contrast cineangiography was within 95% confidence limits. The mean was -3.19% and the standard deviation was 7.74% CONCLUSION: The values of left ventricular ejection fraction by echocardiography showed good correlation with those of contrast cineangiographic ejection fraction, Therefore, echocardiography would be a useful tool as contrast cineangiography in evaluating the left ventricular function.
Cardiology ; Cardiovascular Diseases ; Cineangiography* ; Diagnosis ; Echocardiography* ; Female ; Heart Diseases ; Humans ; Prognosis ; Radionuclide Angiography ; Stroke Volume* ; Ventricular Function, Left

We report of a successfully treated case of fatal bronchospasm, which developed after N-acetylcysteine bolus intratracheal instillation in a 49-year-old female patient with bronchial asthma undergoing laparoscopic cholecystectomy. N-acetylcysteine has been widely used as a potent mucolytic agent since 1963, with few reported adverse reactions. Its mucolytic action is due to the breakage of disulfide bonds in mucus mucoproteins. Most adverse reactions to N-acetylcysteine are usually mild and respond to the termination of the medication and symptomatic treatment with antihistamine. However, several cases of fatal bronchospasm have been reported in asthmatic patients after inhaled or intravenous N-acetylcysteine. N-acetylcysteine induced bronchospasm could be avoided in most asthmatic patients if its concentration is not allowed to exceed 10%, and concomitant beta2-selective bronchodilators are utilized. Nevertheless, asthma is still a potent risk factor and requires special precautions, including careful risk-versus-benefit assessment, close observation and the immediate availability of resuscitation equipment and staff in the event of life-threatening bronchospasm.
Acetylcysteine* ; Asthma* ; Bronchial Spasm* ; Bronchodilator Agents ; Cholecystectomy, Laparoscopic ; Female ; Humans ; Middle Aged ; Mucoproteins ; Mucus ; Resuscitation ; Risk Factors

Severe fever with thrombocytopenia syndrome (SFTS) caused by the SFTS virus (SFTSV), a novel Phlebovirus, is endemic to South Korea, central and northeastern China, and western Japan. SFTS poses a threat to public health because of its high mortality and secondary transmission. Ticks and domestic animals are hosts for SFTSV in endemic areas. There is no specific treatment for SFTS, and avoiding tick bites is the best way to prevent infection. Early therapeutic plasma exchange (TPE) is a rescue therapy in patients with rapidly progressive SFTS. Here, we present a patient with SFTS who was improving on TPE but died suddenly due to acute lung injury after TPE.

Background/Aims: Long-term use of acid suppressants such as proton pump inhibitors (PPIs) and histamine 2 receptor antagonist (H2RA) has been associated with the risk of osteoporotic fracture. Acid suppressants and muco-protective agents (MPAs) are often used together as anti-ulcer agents. We evaluated the association between the risk of osteoporotic fracture and the combined use of these anti-peptic agents. Methods: A population-based case-control study was conducted by analyzing the Korean National Health Insurance Data from 2014 to 2020. Patients who had been prescribed anti-peptic agents, such as PPI, H2RA, or MPA, were included. Considering the incidence of osteoporotic fractures, the case group (n = 14,704) and control group (n = 58,816) were classified by 1:4 matching based on age and sex. Results: The use of all types of anti-peptic agents was associated with an increased risk of osteoporotic fractures (PPI: hazard osteoratio [HR], 1.31; H2RA: HR, 1.44; and MPA: HR, 1.33; all p < 0.001). Compared to PPI alone, the combined use of “PPI and H2RA” (HR, 1.58; p = 0.010) as well as “PPI, H2RA, and MPA” (HR, 1.71; p = 0.001) was associated with an increased risk of osteoporotic fracture. However, compared with PPI alone, “MPA and PPI or H2RA” was not associated with an increased risk of osteoporotic fracture. Conclusions This study found that the combined use of “PPI and H2RA” was associated with a higher risk of osteoporotic fractures. In cases where deemed necessary, the physicians may initially consider prescribing the combination use of MPA.

Atonic seizures exhibits loss of postural tone, resulting in head drops or falling. When this event is extremely brief, It has been known as a drop attack. Atonic seizure are firmly placed under the category of generalized seizures. However, a various phenomena satisfying the above description has been recognized in patients with partial seizures. A 13-year-old girl had brief episodes of drop attacks. She complained of weakness of both legs in the absence of consciousness loss. These episodes occurred at a frequency of 4 or 5 time per day for 1 year. Her developmental and physical examinations were normal. Also, the brain MRI was normal. However, her Interictal EEG showed the repetitive spike and wave complexes on C(z) electrode. She was controlled completedly by antiepileptic drungs. We report a patient who suffered from focal atonic seizures characterized by drop attack.
Adolescent ; Brain ; Consciousness ; Electrodes ; Electroencephalography ; Female ; Head ; Humans ; Leg ; Magnetic Resonance Imaging ; Physical Examination ; Seizures* ; Syncope*

PURPOSE: To determine which contrast media are both efficient and safe for the imaging of airways. MATERIALS AND METHODS: We evaluated five contrast media (barium, gastrografin, iotrolan, ioxaglate, iopentol) in terms of image quality and their effects on the lungs of 25 white rabbits. For bronchography 0.5ml of contrast media was used. In each contrast group, HRCT scans were obtained immediately (n=5), 12 hours (n=4), 1 day (n=3), 2 days (n=2), and 1 week (n=1) after bronchography. Histopathologic specimens were obtained immediately, 12 hours, 1 day, 2 days, and 1 week later. Bronchograms were evaluated for image quality by three radiologists working independently, and were scored as 1(poor), 2(moderate), or 3(good) in terms of contrast quality and bronchial coating. HRCT was evaluated by two radiologists who reached a concensus; they determined the presence of contrast media, and then the pattern and extent of pulmonary opacity, and any related changes. Histopatholgic specimens were evaluated by two pathologists who sought consensus as to the extent of inflammation, pulmonary edema, and hemorrhage, and any changes in these aspects. RESULTS: Bronchography indicated that the sum of scores for contrast quality was 45 for barium, 33 for gastrografin, 28 for iotrolan, 30 for ioxaglate, and 28 for iopentol, while for each of these media, the sum of scores for bronchial coating was 39, 19, 25, 23, and 21, respectively. Barium showed the best image quality. In all rabbits, HRCT demonstrated the variable extent of groundglass attenuation and/or consolidation. Lesions were most extensive at 1-2 days and then regressed at 1 week; these HRCT findings correlated well with histologic findings. In histologic studies of all five contrast media groups, variable severe inflammatory reactions were observed, with or without necrosis, congestion, edema, and hemorrhage. It was noted that ioxaglate appeared to cause least tissue reaction. CONCLUSIONS: The imaging results of this experimental study indicate that for bronchography, barium is the best available contrast media, On the basis of the histologic and HRCT results, however, ioxaglate is the best.
Barium ; Bronchography* ; Consensus ; Contrast Media* ; Diatrizoate Meglumine ; Edema ; Estrogens, Conjugated (USP) ; Hemorrhage ; Ioxaglic Acid ; Lung ; Necrosis ; Pneumonia ; Rabbits

OBJECTIVES: The presence of chronic low oxygen delivery to the tissues (blood flow X Hb concentration X arterovenous oxygen content difference) in patients with chronic lung disease (CLD) leads to a aggravated dyspnea. Therefore, total oxygen delivery to the tissues is a reverse correlation with severity of dyspnea. So far, the treatment of patients with CLD has been limited to only the increase of ventilation and perfusion capacity. However, this study focused on the capacity of oxygen delivery to the tissues in patients with CLD. We measured blood oxygen parameters as one of the extended approaches. METHOD: Simultaneous arterial and venous blood samples from 15 patients with CLD at rest were evaluated for 2.3-DPG, CO-Hb (Carboxy-monohe-moglobin), Met-Hb (methomoglobin), ABGA (Arterial blood gas analysis), VBGA (Venous blood gas analysis) and Hb (Hemoglobin). Smokers and patients with other disease were excluded from the study in order to avoid the factors (2.3-DPG, CO-Hb etc.) which can shift the oxygen dissociation curve. There were 12 men and 3 women, ranging in age from 40 to 75 years. The disease onset varied from 3 years to more than 30 years. RESULTS: 1) As total oxygen delivery to the tissues decreased, Ao2(Arterial oxygen partial pressure) and A-VCb (Arteriovenous oxygen content difference) decreased, while 2.3-DPG increased. Total oxygen delivary to the tissues showed a significant correlation with more A-V and 2.3-DPG than AO2. 2) AO2 had a correlation with A-VO2 but AO2 did not clearly reflect A-VO2. 3) 2.3-DPG activity depended on more A-VO2 than AO2. 4) As A-VO2 decreased, there was more significant relationship among 2.3-DPG, A-VO2 and tissue oxygen delivery. 5) A-VO2 showed a significant reverse correlation with 2.3-DPG as well as Met-Hb % + CO-Hb %. 6) ACO2 (arterial carbon dioxide partial pressure) showed a correlation with 2.3-DPG as well as A-VO2. 7) Arterial PH did not correlate with 2.3-DPG as well as A-V. CONCLUSION: 1) AO2 in patient with CLD correlated with A-VO2 but AO2 did not clearly reflect A-V. 2) Total oxygen delivery (severity of dyspnea) showed a significant correlation with more A-VO2 and 2.3-DPG than AO2. 3) 2.3-DPG activity depended on more A-VO2 than AO2. 4) 2.3-DPG activity had a reverse correlation with A-V in spite that 2.3-DPG shifts the oxygen dissociation curve to the right, because 2.3-DPG shift is secondary change associated with the low oxygen delivery to the tissues, More extensive k prospective investigations are needed to clearly define correlation among A-VO2, 2.3-DPG and prognosis of patients with CLD.
Carbon Dioxide ; Dyspnea ; Female ; Humans ; Hydrogen-Ion Concentration ; Lung Diseases* ; Lung* ; Male ; Oxygen* ; Perfusion ; Prognosis ; Ventilation

PURPOSE: The purpose of this study was to compare the findings on high-resolution CT (HRCT) of the chest with those on video-assisted thoracoscopy for the detection of bullae in patients who had undergone an operation for spontaneous pneumothorax, and we also wished to evaluate the relationship between the characteristics of bullae on HRCT and development of spontaneous pneumothorax. MATERIALS AND METHODS: Fifty patients with spontaneous pneumothorax who had undergone both HRCT of the chest and video-assisted thoracoscopic surgery were included in the study. Spontaneous pneumothoraces were classified as either primary or secondary pneumothorax, and as initial or recurrent pneumothorax. The HRCT scans were obtained with 1 mm slice thickness and a 5 mm scan interval. Two radiologists retrospectively compared the HRCT findings of the chest with those findings on video-assisted thoracoscopy for the detection of bullae, and they evaluated the value of HRCT for diagnosing bullae. In addition, we assessed the size and number of bullae in these patients, and we also evaluated the relationship between those findings of bullae and the development of spontaneous pneumothorax. RESULTS: Bullae were detected in 40 patients by using video-assisted thoracoscopy, and HRCT showed bullae in 38 of these patients. Bullae were not identified with video-assisted thoracoscopy in the remaining ten patients, and among these ten patients, bullae were not demonstrated by HRCT in eight of them. Therefore, the sensitivity and specificity of HRCT for the detection of bullae were 95% (38/40) and 80% (8/10), respectively. The average size of the bullae of the affected hemithorax and the contralateral un-affected hemithorax was 1.97 cm+/-2.30 and 1.24 cm+/-1.46, respectively. Pneumothorax was more frequently observed in the hemithorax with larger bullae (p<0.05). The average numerical grade of the bullae (3.38+/-1.60) was higher in the affected hemithorax than in the contralateral un-affected hemithorax (2.96+/-1.86), but there was no statistically significant difference between both groups of hemithoraces (p>0.05). The average size of bullae in patients with secondary pneumothorax and those bullae of patients with primary pneumothorax was 4.44 cm+/-4.06 and 1.42 cm+/-1.26, respectively. The bullae were significantly larger in the patients with secondary pneumothorax than in those patients with primary pneumothorax (p<0.05). Although the average numerical grade of bullae was higher in the patients with secondary pneumothorax (4.00+/-1.58) than in those patients with primary pneumothorax (3.24+/-1.61), the difference between two groups was not statistically significant (p>0.05). CONCLUSION:HRCT of the chest would be a useful modality for detecting the bullae of those patients with spontaneous pneumothorax. The development of spontaneous pneumothorax is associated with the size of bullae rather than the number of bullae.
Humans ; Pneumothorax* ; Retrospective Studies ; Sensitivity and Specificity ; Thoracic Surgery, Video-Assisted ; Thoracoscopy* ; Thorax

OBJECTIVES: Balloon cells and dysplastic neurons are histopathological hallmarks of the cortical tubers of tuberous sclerosis complex (TSC) and focal cortical dysplasia (FCD) of the Taylor type. They are believed to be the epileptogenic substrate and cause therapeutic drug resistant epilepsy in man. P-glycoprotein (P-gp) is the product of multidrug resistance gene (MDR1), and it maintains intracellular drug concentration at a relatively low level. The authors investigated expression of P-gp in balloon cells and dysplastic neurons of cortical tubers in patients with TSC. METHODS: An immunohistochemical study using the primary antibody for P-gp, as an indicative of drug resistance, was performed in the cortical tuber tissues in two patients of surgical resection for epilepsy and six autopsy cases. RESULTS: Balloon cells of each lesion showed different intensity and number in P-gp immunopositivity. P-gp immunopositivity in balloon cells were 28.2%, and dysplastic neurons were 22.7%. These immunoreactivities were more prominent in balloon cells distributed in the subpial region than deeper region of the cortical tubers. Capillary endothelial cells within the cortical tubers also showed P-gp immunopositivity. CONCLUSION: In this study, the drug resistance protein P-glycoprotein in balloon cells and dysplastic neurons might explain medically refractory epilepsy in TSC.
Autopsy ; Drug Resistance* ; Drug Resistance, Multiple ; Endothelial Cells ; Epilepsy ; Genes, MDR ; Humans ; Malformations of Cortical Development ; Neurons ; P-Glycoprotein ; Tuberous Sclerosis* ; Up-Regulation*