Epidural anesthesia is a reliable technique of conduction anesthesia that is not temporally limited and provides profound relaxation. Epidural anesthesia, even in skilled hands, has a failure rate as high as 8%. Technical difficulties may result from abnormalities of the vertebral column and bands or sheaths within the epidural space. Furthermore, kinking, knots, and misplaced epidural catheters may cause incomplete or absent anesthesia. A flexible cannula passed into the epidural space cannot be relied upon to travel for any distance according to the direction of the bevel of the Tuohy needle. Only about one in four cannulas pursues a straight upward course within the epidural space. We describe accidental pass out of epidural space through an intervertebral foramen. A 72-years old man was scheduled for open prostatectomy under epidural anesthesia. The epidural catheter was placed in standard fashion without difficulty or indication of catheter rnalposition but epidural anesthesia was failed. Operation was taken under general anesthesia. At the end of the operation epidurography of the lumbar spine was taken. The epidurography showed that the catheter passed out of epidural space through an intervetebral foramen.
Aged ; Anesthesia ; Anesthesia, Conduction ; Anesthesia, Epidural ; Anesthesia, General ; Catheters* ; Epidural Space ; Hand ; Humans ; Needles ; Prostatectomy ; Relaxation ; Spine

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. The diagnostic criteria for EoE have changed with our growing knowledge over the past two decades. Esophageal eosinophilia, which responds histologically to a proton pump inhibitor (PPI) is not a distinct disease but a subset of EoE. An endoscopic scoring system that relies on the assessment of exudates, rings, edema, furrows, and strictures is a useful tool for assessing endoscopic severity. PPIs are regarded as safe and effective first-line treatments for EoE. Oral topical corticosteroids or dietary therapy are also options for first-line treatment. Endoscopic dilation is effective for relieving the dysphagia symptoms of a patient with an esophageal stricture.

Clostridium septicum is a toxin producing anaerobic, motile, spore-forming, spindle shaped Gram positive rod that may cause devastating systemic illness in patients with neutropenia and underlying hematologic or gastrointestinal malignancy. Clostridium septicum sepsis usually have fulminating clinical courses, and unless the appropriate antibiotics are administered soon after admission, the outcome is fatal. We experienced a case of sepsis due to Clostridium septicum, in a 65-year-old woman with peripheral T-cell lymphoma and diabetes mellitus. She was admitted due to abdominal pain, fever, chilling, nausea, vomiting and watery diarrhea, followed by rapidly progressive course. This patient was not improved by intensive care and continuous antibiotic therapy, expired at the 4th hospital day. Clostridium septicum grew from premortem blood cultures.
Abdominal Pain ; Aged ; Anti-Bacterial Agents ; Clostridium septicum* ; Clostridium* ; Diabetes Mellitus ; Diarrhea ; Female ; Fever ; Humans ; Critical Care ; Lymphoma, T-Cell, Peripheral ; Nausea ; Neutropenia ; Sepsis* ; Vomiting

BACKGROUND: Community-acquired pneumonia (CAP) is more frequent in the elderly and results in higher morbidity and mortality. Korea is undergoing extraordinary demographic change. Elderly patients constitute an even-increasing proportion of the population but there have been few studies on the epidemiological investigation of the CAP in the elderly. The purpose of this study was to characterize the background, etiology, clinical course and outcome of CAP in elderly compared with younger patients. METHODS: During the study period (from 1st January to 31th December 1997), 214 patients with CAP were reviewed with regard to epidemiological, clinical, laboratory and microbiological data. 119 elderly patients (> or =65 years-old of age) were compared with 95 younger patients (<65 years-old of age). The both groups were compared with each others in terms of variables related to CAP. RESULTS: Comparison of epidemiological data between older and younger patients revealed a high prevalence of alcoholics (40% vs 56%), current smoker (33% vs 56%), malignancy (8% vs 24%) in the elderly. In terms of complication and clinical manifestation, shock (1% vs 6%), intubation (6% vs 20%), mechanical ventilation apply (5% vs 18%), respiratory failure (2% vs 12%), dyspnea (26% vs 56%), altered consciousness (0% vs 13%), extrapulmonary symptom (11% vs 18%) and bilateral infiltration (8% vs 20%) showed higher incidence in the elderly than in the younger patients. Causative organisms are identified in 47% (56/119) of elderly patients: those identified most frequently were S. pneumoniae (25%), K. pneumoniae (20%), S. aureus (16%), other Gram-negative bacilli (13%) and H. influenzae (11%). The overall mortality were significantly higher in the elderly patients (24%) than younger patients (5%). Two independent risk factors, those were related to the mortality of the elderly:higher APACHE II score (RR:3.43, 95% CI=1.43~7.21) and requirement of endotracheal tube (RR:4.73; 95% CI=1.72~16.5). CONCLUSION: CAP in the elderly shows more serious clinical and abnormal laboratory features than younger patients. In elderly, S. pneumoniae was the most common causative organism for CAP but other agents, particularly K. pneumoniae was isolated frequently. The severity of illness at initial presentation such as high APACHE II score and requirement of endotracheal tube were the major variables affecting the outcome.
Aged* ; Alcoholics ; APACHE ; Consciousness ; Dyspnea ; Humans ; Incidence ; Influenza, Human ; Intubation ; Korea ; Mortality ; Pneumonia* ; Prevalence ; Respiration, Artificial ; Respiratory Insufficiency ; Risk Factors ; Shock

BACKGROUND: In elective intervention, the implantation of an intracoronary stent is an established treatment modality to reduce restenosis in comparison with balloon angioplasty. However, stenting was empirically thought to be contraindicated for acute myocardial infarction because of the propensity for thrombosis, althought the percutaneous transluminal coronary balloon angioplasty(PTCA) on infarct-related artery is associated with a high incidence of restenosis. To knowlege, there is no report comparing the longterm efficacy of coronary stenting with PTCA in patients with acute myocardial infarction. Accordingly, we investigated the effect of stent implantation on restenosis of infarct-related artery in acute myocardial infarction, comparing with conventional balloon angioplasty. METHOD: From January 1994 to December 1995, 97 patients (stenting in 45 patients : PTCA in 52 patients) underwent intracoronary stenting or PTCA on infarct-related artery successfully at 7-10 days after onset of infarction. The coronary stents were Palmaz-Schatz stent in 35 patients and Cordis stent in 10 patients. Follow-up coronary angiography was performed in all patients 6 months later after intervention. RESULTS: No death, emergency coronary artery bypass surgery or reinfarction occurred during hospitalization in 97 patients. In 45 patients with stent implantation, no stent thrombosisoccurred. The 6-months angiographic restenosis rate was 13 percent in patients assigne to stent implantation and 52 percent in patients assigned to PTCA(p<0.05). CONCLUSION: We conclude that the intracoronary stent implantation on infarct-related artery at 7-10 days after acute myocardial infarction is safe, feasible and significantly reduces the restenosis rate.
Angioplasty, Balloon ; Arteries ; Coronary Angiography ; Coronary Artery Bypass ; Emergencies ; Follow-Up Studies ; Hospitalization ; Humans ; Incidence ; Infarction ; Myocardial Infarction* ; Stents* ; Thrombosis

PURPOSE: The purpose of this study was to assess the clinician satisfaction of a newly introduced around-the-clock radiology coverage system for the emergency department. MATERIALS AND METHODS: Seventeen emergency physicians (8 board certified physicians, 9 residents) were invited to fill out a survey pertaining to the newly introduced radiology coverage system for the emergency department. The questionnaire included 10 questions covering three major topics. The first topic related to the around-the-clock radiology coverage by two full-time radiology residents. The second topic focused on the preliminary interpretations of radiology residents. The last topic included the interpretation assistance system by board-certified radiologists. The answers to each question were assessed using a scoring system of 1 to 5. RESULTS: The mean satisfaction score of the around-the-clock radiology coverage system by the two full-time radiology residents was 4.6 (range 3-5). The mean score for the preliminary interpretation system by the radiology residents was 4.8 (range 4-5). The score for the reliability of the preliminary versus the final interpretations was 4.1 (range 4-5). Lastly, the mean score for the interpretation assistance system by board-certified radiologists was 4.9 (range 4-5). CONCLUSION: The results of this study indicate a high satisfaction rating among clinicians' of the new around-the-clock radiology coverage system for the emergency department.
Emergencies ; Emergency Service, Hospital ; Surveys and Questionnaires

BACKGROUND: Epidural analgesia, via either a thoracic or lumbar route, is commonly used to provide postoperative analgesia following thoracotomy for pulmonary resection, but little data indicate which location is better in terms of postoperative analgesia, side effects, or associated complications. METHODS: 54 patients, who undergo a lateral thoracotomy, were randomized to receive a mixture of fentanyl and 0.15% bupivacaine at 0.5microgram/kg/hr of fentanyl via either a thoracic (Group T) or a lumbar (Group L) catheter. Postoperative pain was assessed 6hrs after the operation and everyday for 5 days on a visual analog scale (VAS). Postoperative side effects and patients satisfaction of epidural analgesia were assessed by 4 grades system. RESULTS: The VAS scores during coughing were higher than those of resting state without intergroup differences. The incidences and severity of side effects (nausea, vomiting, pruritus, sedation) were not different between group T and group L, but the incidence of urinary retention attributable to use of the lumbar epidural route was significantly higher than with the thoracic route (p<0.05). CONCLUSIONS: The authors conclude that there is no clinical advantage of thoracic over lumbar epidural fentanyl in the thoracotomy patients with respect to analgesia and incidences of most side effects except urinary retention.
Analgesia ; Analgesia, Epidural* ; Bupivacaine ; Catheters ; Cough ; Fentanyl* ; Humans ; Incidence ; Pain, Postoperative ; Pruritus ; Thoracotomy* ; Urinary Retention ; Visual Analog Scale ; Vomiting

BACKGROUND: The clinical use of intracoronary stents is impeded by the risk of subacute stent thrombosis and complications associated with the anticoagulant regimen. The use of high pressure balloon dilatations and confirmation of adequate stent expansion by intravascular ultrasound provide assurance that anticoagulation therapy can be safely omitted. Therefore, we evaluated the effect of anticoagulation of subacute thrombosis sfter stenting retrospectively on a consecutive series of patients who received palmaz-Schatz coronary stents with high pressure balloon dilatation. METHOD: From March 1995 to August 1995, 62 patients underwent Palmaz-Schatz coronary stent implantation. After deploying stents successfully, high pressure overdilatation of the stents was performed in all patients. According to post-stent anticoagulation, 32 patients received aspirin 200 mg/day, ticlopidine 500 mg/day and warfarin for two months, 30 patients received aspirin and ticlopidine. RESULTS: The clinical or angiographic variables were not significantly different between the two groups. There was no acute or subacute thrombosis in the two groups. The hospital stay after stenting was significantly shorter in the patients without antcoagulation than in patients with anticoagulation. CONCLUSION: The Palmaz-Schatz stent can be safely implanted without anticoagulation provided that stent expansion is daequate by the use high pressure balloon dilatation This technique significantly reduces hospital time and vascular complications and has a low stent thrombosis rate.
Aspirin ; Dilatation* ; Humans ; Length of Stay ; Retrospective Studies ; Stents* ; Thrombosis ; Ticlopidine ; Ultrasonography ; Warfarin

BACKGROUND: Restenosis remains as the major limitation of percutaneous translumainal coronary balloon angioplasty (PTCA). Although its mechanism remains incompletely understood, proliferative action of arterial smooth muscle cells has been found to play an important role on restenosis by neointimal formation after PTCA. Glycosaminoglycan-containing compounds, including Sulodexide (Vessel Due , ALFA, Wasserman, S.p.A, Italy), inhibit the proliferation and maigration of vascular smooth muscle cells in vitro. OBJECTIVES: This study was performed to assess the efficacy of Sulodexide, a glycosaminoglycan compound with antithrombotic and antiproliferative properties, in preventing restenosis after PTCA. METHOD: Two hundred eighty-four patients with ischemic heart disease were randomized to receive either the standard PTCA without Sulodexide in 144 patients (control group, M : F = 99 : 45, Age = 58 +9 or -9), 160 lesions or the standard PTCA with Sulodexide in 140 patients (treated group, M : F = 89 : 51, age = 58 +10 or -10), 158 lesions. Successful angioplasties were performed in 258 atheromatous coronary lesions in 224 patients for whom follow-up angiographic data were obtained 6 month later. Quantitative coronary angiographic analysis (QCA) was performed before , immediate after PTCA and 6-month later. Angiographic restenosis (>50% diameter stenosis at follow-up) was the primary end point : miniamal luminal diameter at follow-up angiogram was the secondary end point. RESULT: Successful PTCA was 97.6% and 97.5% in the standard PTCA with Sulodexide and the standard PTCA without Sulodexide, respectively. Although reference vessel size and minimal luminal diamater after PTCA were larger in the control group than in the Sulodexide group(2.94+0.11 or-0.11 vs 2.83+0.13 or -0.13 mm and 2.26+0.12 or -0.12 vs 2.18+0.08 or -0.08 mm, respectively, p=NS), there was a increased tendency of minimal lumen diameter at 6 months angiogram in the Sulidexide group than in the control group (1.12+0.50 or -0.50 vs 1.07 + 0.53 or -0.53 mm, respectively, p=NS). Angiographic restenosis occured in 42% of lesions in the Sulodexide group and 52% of the control group (p=NS). CONCLUSIONS: Sulodexide treatment had a tendency to reduce restenosis rate in 6 months after coronary angioplasty. However, further study is necessary to verify the antiproliferative effect of Sulodexide with much larger number of patients.
Angioplasty ; Angioplasty, Balloon, Coronary* ; Constriction, Pathologic ; Follow-Up Studies ; Humans ; Muscle, Smooth, Vascular ; Myocardial Ischemia ; Myocytes, Smooth Muscle ; Phenobarbital ; Prospective Studies*

Telomerase activity has been detected in many human immortal cell lines and tumor tissues. We studied telomerase activity in a series of human musculoskeletal tumors. Twenty-eleven tumors from 27 patients were studied using a sensitive PCR (polymerase chain reaction)-based technique, the TRAP(telomeric repeat amplication protocol) assay. Telomerase activity was present in seven tumors(25.9%). Telomerase activity was present in six of 18 malignant tumors(33.3%), while telomerase was active in one of 9 benign tumors(11.1%). Telomerase was active in 40% for osteosarcomas, 25% for soft tissue sarcomas, 16.7% for giant cell tumors of bone, and none for benign tumors. These results are a remarkablely low positive rate of telomerase activity in comparing with other types of carcinoma. In conclusion, it suggests that the musculoskeletal tumors, arisen from mesenchymal cells, follow different pathways of neoplastic progression or it is due to tile specific characteristics stick of sarcomas-abundant extracellular matrix and lack of tumor cells-differed tumor those of carcinomas.
Cell Line ; Extracellular Matrix ; Giant Cell Tumors ; Humans ; Osteosarcoma ; Polymerase Chain Reaction ; Sarcoma ; Telomerase*