No abstract available.

BACKGROUND: Pressure support ventilation(PSV) is a new form of mechanical ventilatory support that assists spontaneous inspiratory effort of an intubated patient with a clinician-selected amount of positive airway pressure. Low level pressure support during inspiration can overcome the resistive component of inspiratory work imposed by ah endotracheal tube. However the clinical efficacy of PSV as a weaning method has not been established yet. Object : The aim of study was to evaluate the efficacy of PSV when it is added to intermittent mandatory ventilation (IMV) in facilitating weaning process compared to IMV mode alone. METHOD: When the subject patients became clinically stable with their arterial blood gas analysis in acceptable range, they underwent weaning process either by IMV alone or by IMV plus PSV. The level of pressure support was held constant through the weaning period. For the patients who required mechanical ventilation for less than 72hr, 2h weaning trial was performed with IMV rate starting from 6/min. For the patients who required mechanical ventilation more than 72 hr, 7 hr weaning retrial was performed with IMV rate starting from 8/min. For the patients who failed three consecutive trials of weaning, retrial of weaning was attempted over 3 days with IMV rate starting from 8/min. Clinical characteristics, APACHE II score and nutritional status were compared. For all patients, heart rate, mean blood pressure and respiratory rate were mornitored for 48 hrs after weaning trial started. RESULTS: The total number of weaning trial was 37 in 23 patients(18 by IMV, 19 by IMV+PSV). Total ventilation time, APACHE II score and nutritional status were not statistically different between the two groups. The weaning success rate were not statistically different(38.3% by IMV, 42.1% by IMV+PSV) and the changes of mean blood pressure, heart rate, respiratory rate during first 48 hours were not different between the two groups. CONCLUSION: Low level PSV when added to IMV for weaning trial does not seem to improve the success rate of weaning from mechanical ventilation. PSV at 10cm H2O did not induce significant physiologic changes during weaning process.
APACHE ; Blood Gas Analysis ; Blood Pressure ; Heart Rate ; Humans ; Nutritional Status ; Respiration, Artificial ; Respiratory Rate ; Ventilation* ; Weaning*

PURPOSE: One of the most important adverse effects of long-term cyclosporine therapy is nephrotoxicity, the morphologic changes of which include interstitial fibrosis and arteriolar hyalinization. Recently, several authors have shown that osteopontin plays an important role in the development of interstitial fibrosis by acting as a macrophage chemoattractant and stimulating the production of TGF-beta in experimental cyclosporine nephrotoxicity. However, the relationship between osteopontin and TGF-beta in humans has not been clearly documented so far. We studied the expression of osteopontin and TGF-beta in children with minimal change nephrotic syndrome treated with cyclosporine to demonstrate whether there is a relationship between cyclosporine toxicity and osteopontin expression as previously shown in animal models. MATERIALS AND METHODS: Nineteen children (15 males and 4 females) were the subject of this study. Renal biopsies had been performed before and after the cyclosporine therapy (mean duration: 15.9 months). In 5 patients, additional biopsies were performed after completing the cyclosporine treatment (mean: 26 months). The expressions of osteopontin and TGF-beta were evaluated by immunohistochemistry in the glomeruli and tubulointerstitium. RESULTS: Osteopontin expression was significantly increased in the glomerular mesangium and tubules after cyclosporine treatment. But there was no statistically significant increase of TGF-beta in the interstitium. There was no significant increase in tubular osteopontin and interstitial TGF-beta expression in those cases developing interstitial fibrosis after cyclosporine treatment compared with cases those not developing interstitial fibrosis. No significant changes in osteopontin or TGF-beta expression were observed in subsequent 5 biopsy samples after discontinuation of cyclosporine compared with the first follow up biopsies. CONCLUSION: These results suggest that osteopontin is a nonspecific marker of renal injury rather than a mediator of interstitial fibrosis in cyclosporine nephrotoxicity of human.
Biopsy ; Child ; Cyclosporine* ; Fibrosis ; Follow-Up Studies ; Glomerular Mesangium ; Humans ; Hyalin ; Immunohistochemistry ; Macrophages ; Male ; Models, Animal ; Nephrosis, Lipoid* ; Osteopontin* ; Transforming Growth Factor beta

Somatostatinoma is a rare form of neuroendocrine tumor that was first described in 1977. Most tumors have involved the pancreas, and gastrointestinal tract involvement is rare. Somatostatinomas of the ampulla of Vater are extremely rare and present distinct clinical and pathologic differences. Pancreatic somatostatinoma has been associated with a clinical syndrome of dyspepsia, mild diabetes, cholelithiasis, steatorrhea, and hypochlorhydria, but duodenal somatostatinoma, in general, has been clinically silent. A further contrast is that duodenal carcinoid tumors, mainly gastrinoma, tended to be benign, whereas ampullary carcinoid tumors, mainly somatostatinoma, exhibited malignant behavior. Therefore, definite diagnosis is important for treatment and prognosis, and is performed by image study, immunohistochemistry and electron microscopic examination. We report a case of somatostatinoma of the ampulla of Vater in a 51-year-old male. He complained of generalized abdominal pain for a few days. Gastrofiberscopically, a 1.2 cm sized bulging mass was observed on the ampulla of Vater. Radiologically, on abdomen CT, a protruding enhancing mass was revealed in the duodenum. In octreoscan, there was an abnormal focus off increased radiouptake in the infrahepatic area. He underwent a pancreatoduodenectomy. Grossly, the mass was an intraluminary protruding polypoid submucosal mass with focal ulceration in the ampulla of Vater. Histologically, it showed well-differentiated nonpleomorphic tubular cell nest and psammoma bodies. Immunohistochemically, the tumor cells showed a neuroendocrine nature with synaptophysin immunostain and intense staining only for somatostatin.
Abdomen ; Abdominal Pain ; Achlorhydria ; Ampulla of Vater* ; Carcinoid Tumor ; Cholelithiasis ; Diagnosis ; Duodenum ; Dyspepsia ; Gastrinoma ; Gastrointestinal Tract ; Humans ; Immunohistochemistry ; Male ; Middle Aged ; Neuroendocrine Tumors ; Pancreas ; Pancreaticoduodenectomy ; Prognosis ; Somatostatin ; Somatostatinoma* ; Steatorrhea ; Synaptophysin ; Ulcer

BACKGROUND: Pressure support(PS) is becomimg a widely accepted method of mechanical ventilation either for total unloading or for partial unloading of respiratory muscle. The aim of the study was to find out if PS exert different effects on respiratory mechanics in synchronized intermittent mandatory ventilation(SIMV) and continuous positive airway pressure (CPAP) modes. METHODS: 5, 10 and 15 cm H2O of PS were sequentially applied in 14 patients(69+/-12 yrs, M:F=9:5) and respiratory rate (RR), tidal volume(VT), work of breathing(WOB), pressure time product(PTP), P(0.1), and T(1)/T(TOT) were measured using the CP-100 pulmonary monitor(Bicore, USA) in SIMV and CPAP modes respectively. RESULTS: 1) Common effects of PS on respiratory mechanics in both CPAP and SIMV modes As the level of PS was increased(0, 5, 10, 15 cm H2O), VT was increased in CPAP mode(0.28+/-0.09, 0.29+/-0.09, 0.31+/-0.11, 0.34+/-0.12 L, respectively, p=0.001), and also in SIMV mode(0.31+/-0.15, 0.32+/-0.09, 0.34+/-0.16, 0.36+/-0.15 L, respectively, p=0.0215). WOB was decreased in CPAP mode(1.40+/-1.02, 1.01+/-0.80, 0.80+/-0.85, 0.68+/-0.76 joule/L, respectively, p=0.0001), and in SIMV mode(0.97+/-0.77, 0.76+/-0.64, 0.57+/-0.55, 0.49+/-0.49 joule/L, respectively, p=0.0001). PTP was also decreased in CPAP mode(300+/-216, 217+/-165, 179+/-187, 122+/-114cm H2O * sec/min, respectively, p=0.0001), and in SIMV mode(218+/-181, 178+/-157, 130+/-147, 108+/-129cm H2O.sec/min, respectively, p=0.0017). 2) Different effects of PS on respiratory mechanics in CPAP and SIMV modes By application of PS (0, 5, 10, 15 cm H2O), RR was not changed in CPAP mode(27.9+/-6.7, 30.0+/-6.6, 26.1+/-9.1, 27.5+/-5.7/min, respectively, p=0.505), but it was decreased in SIMV mode (27.4+/-5.1, 27.8+/-6.5, 27.6+/-6.2, 25.1+/-5.4/min, respectively, p=0.0001). P(0.1) was reduced in CPAP mode(6.2+/-3.5, 4.8+/-2.8, 4.8+/-3.8, 3.9+/-2.5 cm H2O, respectively, p=0.0061), but not in SIMV mode(4.3+/-2.1, 4.0+/-1.8, 3.5+/-1.6, 3.5+/-1.9 cm H2O, respectively, p=0.054). T(1)/T(TOT) was decreased in CPAP mode(0.40+/-0.05, 0.39+/-0.04, 0.37+/-0.04, 0.35+/-0.04, respectively, p=0.0004), but not in SIMV mode(0.40+/-0.08, 0.35+/-0.07, 0.38+/-0.10, 0.37+/-0.10, respectively, p=0.287). 3) Comparison of respiratory mechanics between CPAP+PS and SIMV alone at same tidal volume. The tidal volume in CPAP+PS 10 cm H2O was comparable to that of SIMV alone. Under this condition, the RR(26.1+/-9.1, 27.4+/-5.1/min, respectively, p=0.516), WOB(0.80+/-0.85, 0.97+0.77 joule/L, respectively, p=0.485), P0.1(3.9+/-2.5, 4.3+/-2.1 cm H2O, respectively, p=0.481) were not different between the two methods, but PTP(179+/-187, 218+/-181 cmH2O.sec/min, respectively, p=0.042) and T(1)/T(TOT)(0.37+/-0.04, 0.40+/-0.08, respectively, p=0.026) were significantly lower in CPAP+PS than in SIMV alone. CONCLUSION: PS up to 15 cm H2O increased tidal volume, decreased work of breathing and pressure time product in both SIMV and CPAP modes. PS decreased respiration rate in SIMV mode but not in CPAP mode, while it reduced central respiratory drive(P(0.1)) and shortened duty cycle (T(1)/T(TOT)) in CPAP mode but not in SIMV mode. By 10 cm H2O of PS in CPAP mode, same tidal volume was obtained as in SIMV mode, and both methods were comparable in respect to RR, WOB, P(0.1), but CPAP+PS was superior in respect to the efficiency of the respiratory muscle work (PTP) and duty cycle(T(1)/T(TOT)).
Continuous Positive Airway Pressure ; Respiration, Artificial ; Respiratory Mechanics* ; Respiratory Muscles ; Respiratory Rate ; Tidal Volume ; Work of Breathing

A 64-year-old man was admitted for gross hematuria. Preoperative study revealed right renal cell carcinoma with inferior vena cava(IVC) tumor thrombus. Right radical nephrectomy was performed, and deep hypothermic circulatory arrest(DHCA) with retrograde cerebral perfusion(RCP) was used for extraction of tumor thrombus in the IVC. The thrombus originated from the right kidney, which extended the orifice of the gonadal vein in the left renal vein laterally, the hepatic vein superiorly, and 3 cm below the right renal vein inferiorly. The thrombus was removed completely without caval wall injury under DHCA with RCP, and the postoperative course was uneventful. He received immunotherapy with interferon, and followed up without any surgical problem.
Carcinoma, Renal Cell* ; Circulatory Arrest, Deep Hypothermia Induced* ; Gonads ; Hematuria ; Hepatic Veins ; Humans ; Immunotherapy ; Interferons ; Kidney ; Middle Aged ; Nephrectomy ; Renal Veins ; Thrombosis ; Veins ; Vena Cava, Inferior

Primary cardiac tumors are rare and about 20~25% of primary cardiac tumors are malignant. Moreover, primary malignant mesenchymoma of the heart is extremely rare. Recently, we have experienced two cases of cardiac malignant mesenchymoma. In the first case, malignant mesenchymoma which was originated from the posterior wall of the left atrium obstructing the mitral orifice was revealed pathologically in a 61-year-old woman with mitral regurgitation. The mass, which was 2.7 X 3.7cm in size on the posterior wall of left atrium, was extended to the posteromedial commissure and annulus of the mitral valve. The mass was resected partially without excision of the left atrial free wall. She was discharged after 30 days without any problems and she received chemotherapy and followed up for 19months. The second case was a 4 X 5cm in size, friable, yellow-whitish multilobulated mass in the left atrium which was originated from the left lower pulmonary vein. Multiple minor tumor nodules were found in the wall of the left atrium and the posterior leaflet of mitral valve. Partial mass excision and mitral valve replacement were performed.
Drug Therapy ; Female ; Heart ; Heart Atria ; Heart Neoplasms ; Humans ; Mesenchymoma* ; Middle Aged ; Mitral Valve ; Mitral Valve Insufficiency ; Pulmonary Veins

Pulmonary arteriovenous malformations(PAVM) are uncommon diseases. Brain abscesses could be a rare and devastating complication of PAVM. Central nervous complaints may be the first manifestations of PAVM. We report a case of PAVM presented by brain abscess, which was treated by craniotomy.
Abscess ; Arteriovenous Fistula* ; Brain Abscess* ; Brain* ; Craniotomy

Background: We prospectively evaluated the applicability and effect of noninvasive ventilation (NIV) in acute respiratory failure and tried to find out the parameters that could predict successful application of NIV. Methods: Twenty-six out of 106 patients with either acute ventilatory failure (VF: PaCO2> 43 mm Hg with pH <7.35) or oxygenation failure (OF: PaO2/FIO2 < 300 mm Hg with pH> or = 7.35) requiring mechanical ventilation were managed by NIV (CPAP + pressure support, or BiPAP) with face mask. Eleven out of 19 cases with VF (57.9%) (M: F=7: 4, 55.4 +/-14.6 yrs) and 15 out of 87 cases with OF (17.2%) (M: F= 12: 3, 50.6+/-15.6 yrs) were suitable for NIV. Respiratory rates, arterial blood gases and success rate of NIV were analyzed in each group. Results: 81.8% (9/11) of VF and 40% (6/15) of OF were successfully managed on NIV and were weaned from mechanical ventilator without resorting to endotracheal intubation. Complications were noted in 2 cases (nasal skin necrosis 1, gaseous gastric distension 1). In NIV for ventilatory failure, the respiration rate was significantly decreased at 12 hour of NIV (34+/-9 /min pre-NIV, 26+/-6 /min at 12 hour of NIV, p=0.045), while PaCO2 (87.3+/-20.6 mm Hg pre-NIV, 81.2+/-9.1 mm Hg at 24 hour of NIV) and pH (7.26 +/-0.04, 7.32 +/-0.02, respectively, p< 0.05) were both significantly decreased at 24 hour of NIV. In NIV for oxygenation failure, PaO2 were not different between the successful and the failed cases at pre-NIV and till 12 hours after NTV. The PaO2/FIO2 ratio, however, significantly improved at 0.5 hour of NIV in successful cases and were maintained at around 200 mm Hg (n=6: at baseline, 0.5h, 6h, 12h: 120.0+/-19.6, 218.9+/-98.3, 191.3+/-55.2, 232.8+/-17.6 mm Hg, respectively, p=0.0211), but it did not rise in the failed cases (n=9: 127.9+/-63.0, 116.8+/-24.4, 100.6 +/-34.6, 129.8+/-50.3 mm Hg, respectively, p=0.5319). Conclusion: From the above results we conclude that NIV is effective for hypercapnic respiratory failure and its success was heralded by reduction of respiration rate before the reduction in PaCO2 level. In hypoxic respiratory failure, NIV is much less effective, and the immediate improvement of PaO2/FIO2 ratio at 0.5h after application is thought to be a predictor of successful NIV.
Gases ; Health Resorts ; Humans ; Hydrogen-Ion Concentration ; Intubation, Intratracheal ; Masks ; Necrosis ; Noninvasive Ventilation ; Oxygen ; Prospective Studies ; Respiration, Artificial* ; Respiratory Insufficiency* ; Respiratory Rate ; Skin ; Ventilators, Mechanical

Stromal tumors of the gastrointestinal tract, especially of the esophagus, are rare. We had a case of malignant gastrointestinal stromal tumor(GIST) of the esophagus. A 46 years old woman was admitted for abnormal mass shadow in the chest radiograph. The mass was originated from the lower thoracic esophagus, and compressed the right lower pulmonary vein and the inferior vena cava. We removed the tumor externally without injuring of the esophageal mucosa via right posterolateral thoracotomy. The tumor was positive for CD 34 and CD 117, and diagnosed malignant GIST of the esophagus.
Esophagus* ; Female ; Gastrointestinal Stromal Tumors* ; Gastrointestinal Tract ; Humans ; Middle Aged ; Mucous Membrane ; Pulmonary Veins ; Radiography, Thoracic ; Thoracotomy ; Vena Cava, Inferior