PURPOSE: Because of the complexity and un-expectation of the courses and clinical features for the complex anal fistula, the management of it presents a difficult surgical challenge. Various techniques have been used, such as seton placement, advancement flap closure, muscle filling procedure, and fibrin glue injection. The classic lay-open and seton placement may distort the anal anatomy and result in poor functional outcomes, such as incontinence. Also, advancement flap techniques are associated with relatively high recurrence rates. This study assesses the results of surgery for a complex anal fistula, as performed in Hangun Hospital, Busan. Operative procedures were comprised of two or more separate procedures, including 1) a total fistulectomy, 2) muscle reconstruction, sometimes muscle transposition, 3) direct closure of the primary opening without making a mucosal advancement flap, and 4) a drainage procedure and/or other minor procedure. METHODS: Surgical procedures were performed on 22 patients (18 males) with a complex anal fistula between July 2004 and December 2004. The clinical and the manometric results were analyzed with respect to postoperative recurrence, delayed wound healing, and postoperative fecal incontinence. RESULTS: Nineteen of the 22 patients were completely healed without any sequelae. Treatment failure was encountered in one patient two months postoperatively, when an additional fistulotomy was performed to achieve a cure. There were two patients displaying delayed healing, who were successfully treated by curettage. No patient complained of postoperative fecal incontinence in either the clinical examination on the manometric study (mean resting pressure, 75.5+/-3.5 mmHg; maximal squeeze pressure, 175.7+/-10.3 mmHg). CONCLUSIONS: This short- term study suggests that a direct closure of the internal opening after a total fistulectomy can be an alternative surgical option for the treatment of a complex anal fistula.
Curettage ; Drainage ; Fecal Incontinence ; Fibrin Tissue Adhesive ; Humans ; Muscles ; Rectal Fistula ; Recurrence ; Surgical Procedures, Operative ; Treatment Failure ; Wound Healing

PURPOSE: The purpose of this study was to review the resilience of elderly patients of gastric cancer, their self-efficacy, family support, spiritual well-being and depression. METHODS: The subjects were 100 patients who were 65 years old or older who had been admitted to the surgical department at K University Hospital in B City. Data were collected from August 10 to September 2, 2016. RESULTS: Resilience of patients showed significant correlations with the degree of self-efficacy r=.51 (p<.001), the degree of family support r=.47 (p<.001), the degree of spiritual well-being r=.59 (p<.001), the degree of depression r=.34 (p<.001). The factor that affected resilience most was spiritual well-being (β=.35), followed by self-efficacy (β=.21), monthly average income (β=.20), family support (β=.18), and experienced symptoms (β=.15). The overall explanatory power was 47.4%. CONCLUSION: The degree of resilience in elderly patients of gastric cancer was higher when self-efficacy, family support and spiritual well-being were higher. To improve the resilience of elderly patients of gastric cancer, the development and application of a nursing intervention program that take these variables into account is needed.
Aged* ; Depression ; Humans ; Nursing ; Spirituality ; Stomach Neoplasms*

An ipsilateral supraclavicular lymph node recurrence of breast cancer after surgery has been considered a predecessor to distant metastases. There still is a debate as to whether breast carcinoma patients with the isolated supraclavicular lymph node recurrence should be considered to have disseminated disease or if aggressive treatment, with curative intent, is justified. We report two cases of an isolated ipsilateral supraclavicular lymph node recurrence following modified radical mastectomy, and multimodality treatments with modified radical neck dissection, systemic chemotherapy and involved field radiotherapy. These patients have lived without locoregional recurrence or distant metastases for 3 and 2 years, respectively. Conclusively, we recommend aggressive combined multimodality treatments, including surgery, such as modified radical neck dissection or complete excision of the involved lymph nodes, systemic chemotherapy, and involved field radiotherapy, in patients with isolated supraclavicular lymph node recurrence, but with no other evidence of distant metastases.
Breast Neoplasms ; Drug Therapy ; Humans ; Lymph Nodes ; Mastectomy, Modified Radical ; Neck Dissection ; Neoplasm Metastasis ; Radiotherapy ; Recurrence

Patent foramen ovale (PFO) is growing in clinical interest because of a renewed focus on embolic stroke of undetermined source (ESUS), the PFO attributable fraction (the 10-point Risk of Paradoxical Embolism score), technical advances in PFO diagnosis, and the emergence of endovascular device closure as a treatment option. However, recent randomized controlled trials of the management of patients with ESUS and PFO failed to demonstrate the superiority of closure over medical treatment. The mechanisms of stroke other than paradoxical embolism may be important in patients with ESUS and PFO. This paper reviews the current understanding of the pathophysiology of stroke and therapeutic options in patients with PFO and ESUS.
Diagnosis ; Embolism, Paradoxical ; Foramen Ovale, Patent* ; Humans ; Stroke

PURPOSE: Proper preoperative staging is important in planning optimal therapy for individual patients and improving outcome. There is no ideal imaging methods for accurate colorectal cancer staging. The purpose of our study was to determine the usefulness of fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT) for the status of regional lymph node metastasis in colorectal cancer. METHODS: Two hundred forty six surgically resected colorectal cancers were retrospectively reviewed from Jan 2007 to Jul 2009. All patients underwent abdominal CT and FDG-PET/CT preoperatively. RESULTS: There were 129 males (52.4%) and the mean age was 62 (range: 25~88 years). Tumor location was the colon in 148 (59.7%) patients, and the rectum in 98 (40.3%) patients. Pathological stages were I: 43 (17.5%), II: 78 (31.7%), III: 81 (32.9%), IV: 44 (17.9%). Regional lymph node metastasis by pathological examination was 118 (48%) patients. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of regional lymph node staging were 66.4%, 66.7%, 64.8%, 68.3%, and 67%, respectively, with the FDG-PET/CT, and 57.1%, 71.3%, 64.8%, 64.3%, and 65%, respectively, with whole abdominal CT. The difference in the accuracy of nodal staging between the two modalities was not significant. CONCLUSION: The diagnostic accuracy of FDG-PET/CT for the assessment of regional lymph node metastasis in colorectal cancer was relatively low, and similar to that of abdominal CT. Therefore, further study will be needed to determine the clinical usefulness of preoperative FDG-PET/CT in colorectal cancer.
Colon ; Colorectal Neoplasms ; Humans ; Lymph Nodes ; Male ; Neoplasm Metastasis ; Positron-Emission Tomography ; Rectum ; Retrospective Studies ; Sensitivity and Specificity

BACKGROUND: Dabigatran etexilate, a new oral anticoagulant, was recently approved as an efficacious alternative to warfarin for the prevention of first and recurrent stroke in patients with nonvalvular atrial fibrillation. Limited data are available for dabigatran use in patients with a creatinine clearance rate (CrCL) of 15-30 mL/min. Furthermore, current guidelines do not recommend frequent blood monitoring after dabigatran use. We report herein a patient with severe renal dysfunction who exhibited profound coagulopathy after 2 days of dabigatran use. CASE REPORT: An 87-year-old woman was admitted for altered mental status and left-side weakness. She was diagnosed with right middle cerebral artery infarction. The baseline assessment revealed a serum creatinine concentration of 1.29 mg/dL and a CrCL of 27.2 mL/min. Dabigatran therapy was started 5 weeks after admission at a dosage of 110 mg twice daily. After 2 days of dabigatran use, the patient developed multiple bruises and evidence of upper-gastrointestinal bleeding. Laboratory tests demonstrated a severe coagulopathy, with a prothrombin time of 85.9 sec, an international normalized ratio of 11.36, an activated partial thromboplastin time of 119.2 sec, and a thrombin time of 230.8 sec. Serial assessment of the patient's renal function revealed substantial fluctuation of the CrCL (range, 17.9-26.5 mL/min). CONCLUSIONS: The present case emphasizes the need for frequent checking of renal function and assessment using coagulation assays after commencing dabigatran therapy in patients with moderate-to-severe renal impairment.
Aged, 80 and over ; Anticoagulants* ; Atrial Fibrillation ; Contusions ; Creatinine ; Dabigatran ; Female ; Hemorrhage ; Humans ; Infarction, Middle Cerebral Artery ; International Normalized Ratio ; Partial Thromboplastin Time ; Prothrombin Time ; Stroke ; Thrombin Time ; Warfarin

OBJECTIVE: This study is aimed to evaluate the efficacy and safety of intravenous iron therapy (iron III hydroxide sucrose complex) in ptatients with postoperative anemia following obstetric and gynecologic operations. METHODS: We reviewed the data of 69 patients with postoperative anemia who had undergone obstetric and gynecologic surgery from September 2003 to September 2004, who refused transfusion for correction of post-operative anemia and agreed on treatment with intravenous iron therapy. Iron III hydroxide sucrose complex 200 mg diluted in 100 mL of 0.9% sodium chloride was administrated over 2 hours on postoperative day 1st, 3rd and 5th days. Hemoglobin levels checked and side effects were reviewed. RESULTS: After treatment of intravenous iron therapy, the hemoglobin levels increased rapidly. The lowest hemoglobin levels were observed on postoperative 3rd day but rapid increase of homoglobin levels were observed continously. After 2 weeks from operation, the hemoglobin levels have increased by 0.6+/-1.3 g/dL in the patients with cesarean section and 2.1+/-1.2 g/dL in the patients with gynecology operation. Major side effects such as anaphylaxis and allergic reaction were not observed, and minor side effects were observed in three patients (4%). Emesis, pain on the injection site and skin rash was observed in each patients. CONCLUSION: Intravenous iron sucrose therapy was safe and effective in anemia following obstetric and gynecologic surgery.
Anaphylaxis ; Anemia* ; Cesarean Section ; Exanthema ; Female ; Gynecologic Surgical Procedures* ; Gynecology ; Humans ; Hypersensitivity ; Iron* ; Pregnancy ; Sodium Chloride ; Sucrose ; Vomiting

BACKGROUND AND PURPOSE: The National Institutes of Health Stroke Scale (NIHSS) score is known to be effective in predicting the likelihood of recovery after stroke. However, the baseline NIHSS score predicts long-term outcomes rather crudely because early changes in stroke scores may influence the stroke outcomes. Therefore, a precise prognostic algorithm or a cutoff point for predicting long-term outcomes based on data from serial NIHSS scores is needed. METHODS: We serially assessed 437 patients with acute symptomatic ischemic stroke within the middle cerebral artery territory who presented with nonlacunar stroke and were followed-up for at least 6 months after symptom onset. The NIHSS score was serially checked at 0, 1, 3, 7, and 14 days after admission. In all patients, the Barthel index (BI) and the modified Rankin Scale (mRS) score were checked, with a poor outcome defined as any of the following endpoints: death, modified mRS score of >3, or BI of <60. RESULTS: A marked neurological improvement or worsening (i.e., a change in the NIHSS score of at least 4) was seen in 13.5% or 5.5% of the patients, respectively, during the first 7 days after admission. About 25% of the 437 patients had poor long-term outcomes. Analysis of receiver operating characteristic curves showed that the NIHSS score at day 7 after admission was better for predicting poor long-term outcomes than was the baseline score (P=0.003). In addition, we analyzed the cutoff point of the 7th-day NIHSS score for predicting a poor outcome at 6 months after symptom onset. An NIHSS score of at least 6 at day 7 after admission predicted poor long-term outcomes with a sensitivity of 84% [95% confidence interval (CI), 76-90%], a specificity of 92% (95% CI, 88-94%), and positive and negative predictive values of 77% and 95%, respectively. A logistic regression analysis revealed that age, diffusion-weighted imaging lesion volume, stroke history, and 7th-day NIHSS score were independently associated with poor outcome. However, no score used in addition to the 7th-day NIHSS score improved the prediction of a poor outcome. CONCLUSIONS: An NIHSS score of at least 6 on day 7 after admission accurately forecasts a poor long-term outcome after stroke. Our data may be helpful in predicting the long-term prognosis as well as in making decisions regarding novel therapeutic applications in subacute-stroke trials.
Humans ; Logistic Models ; Middle Cerebral Artery* ; National Institutes of Health (U.S.) ; Prognosis ; ROC Curve ; Sensitivity and Specificity ; Stroke Volume ; Stroke*

PURPOSE: The purpose of this study was to examine the effects of simulation-based learning on the knowledge about and performance confidence in the nursing care of children with asthma. METHODS: A one-group pre- and post- study design was used. A total of 70 nursing students participated in the study. In groups of five, the participants experienced simulation-based learning during their child health nursing practicum. The given scenario was about nursing care for children with asthma. The simulation learning was provided for 3 hours, and included a group discussion before the simulation and a debriefing. RESULTS: After the simulation, knowledge about and performance confidence in the nursing care of children with asthma significantly increased. The nursing students reported a high level of satisfaction with the simulation-based learning. There was a significant positive correlation between knowledge and performance confidence. CONCLUSION: Simulation-based learning was effective for nursing students in the nursing care of children with asthma. Our results suggest utilizing this new way of learning to strengthen the clinical experience of child health nursing in nursing students.
Asthma* ; Child Health ; Child* ; Education, Nursing ; Humans ; Learning* ; Nursing Care* ; Nursing* ; Patient Simulation ; Students, Nursing