Due to unknown safety concerns, sugammadex should not be administered to patients withend-stage renal disease (ESRD). However, because the supply of benzylisoquinolinium-typeneuromuscular blocking agents (NMBAs) has been discontinued, rocuronium is the onlynon-depolarizing NMBA that can be used in clinical settings in some countries, includingSouth Korea. The administration of sugammadex cannot be avoided to achieve rapid andcomplete neuromuscular recovery in patients with ESRD or renal transplantation after rocuronium administration. Although there has been a limited number of clinical studies involving the use of sugammadex in patients with ESRD, studies have shown that sugammadexcan effectively and safely reverse rocuronium-induced neuromuscular blockade (NMB) inpatients with ESRD, however recovery of neuromuscular function in patients with ESRD isslower than in patients with normal renal function. Nonetheless, safety-concerns are yet tobe addressed. Considering the small number of clinical studies, high heterogeneity amongstudies, and insufficient safety information, more extensive data on the efficacy and safetyof sugammadex in patients with ESRD are needed. In particular, it is important to securedata on safety, including residual NMB after surgery, recurarization and cardiorespiratorycomplications, anaphylactic reactions, and long-term morbidity and mortality. Furthermore,anesthesiologists should remember that performing proper quantitative neuromuscularmonitoring and neuromuscular management based on the monitoring signs are the mostessential requirements when using sugammadex in patients with ESRD.

OBJECTIVE: Treatment of intracranial dural arteriovenous fistulas (dAVFs) remains a challenge. However, after introduction of Onyx, transarterial approach is the preferred treatment option in many centers. We report our experience of dAVFs embolization with special emphasis on transarterial approach. METHODS: Seventeen embolization procedures were performed in 13 patients with dAVFs between Jan 2009 and Oct 2014. Clinical symptoms, location and type of fistulas, embolization methods, complications, radiological and clinical outcomes were evaluated using charts and PACS images. RESULTS: All 13 patients had symptomatic lesions. The locations of fistulas were transverse-sigmoid sinus in 6, middle fossa dura in 4, cavernous sinus in 2, and superior sagittal sinus in 1 patient. Cognard types were as follows : I in 4, IIa in 2, IIa+IIb in 5, and IV in 2. Embolization procedures were performed > or =2 times in 3 patients. Nine patients were treated with transarterial Onyx embolization alone. One of these required direct surgical puncture of middle meningeal artery. Complete obliteration of fistulas was achieved in 11/13 (85%) patients. There were no complications except for 1 case of Onyx migration in cavernous dAVF. Modified Rankin scale score at post-operative 3 months were 0 in 11, and 3 in 2 patients. CONCLUSION: Transarterial Onyx embolization can be a first line therapeutic option in patients with dAVFs. However, transvenous approach should be tried first in cavernous sinus dAVF because of the risk of intracranial migration of liquid embolic materials. Furthermore, combined surgical endovascular approach can be considered as a useful option in inaccessible route.
Cavernous Sinus ; Central Nervous System Vascular Malformations* ; Fistula ; Humans ; Meningeal Arteries ; Punctures ; Superior Sagittal Sinus

OBJECTIVE: The pathophysiology of chronic subdural hematoma (CSH) is not yet clear. Trauma alone is not sufficient to result in CSH in young individuals, while a trivial injury can result in CSH in older adults. Although the causality and apportionment of trauma are important issues in CSH, especially in terms of insurance, it is too obscure to solve all struggles. METHODS: There are three key factors for producing CSH. First, CSH necessitates a potential subdural reservoir. Other important precipitating factors are trauma and coagulopathy. However, these factors are not sufficient to cause CSH development. The trauma apportionment score (TAS) can be used to compare the relative importance of these three factors. Here, we applied the TAS to 239 consecutive cases of CSH. We retrospectively obtained the patients' history and laboratory results from their medical records. RESULTS: The TAS ranged from −5 to 5. The most common score was 0. If we defined the cause of CSH as being combined when the TAS was 0, then the cause was combined in 30 cases (12.6%). If we extended the criteria for a combined cause from 0 to −1 to 1, the cause was combined in 107 cases (44.8%). Regardless of the criteria used, traumatic CSHs were more common than were spontaneous CSHs. Spontaneous CSHs were more common in older than in younger patients (p < 0.01, Fisher's exact test). CONCLUSION: The TAS is a useful tool for differentiating the causality of CSH.
Adult ; Aging ; Craniocerebral Trauma ; Hematoma, Subdural, Chronic* ; Humans ; Insurance ; Intracranial Pressure ; Medical Records ; Precipitating Factors ; Retrospective Studies

Sudden cardiac death (SCD) refers to the unexpected natural death from a cardiac cause within a short time period, generally within an hour from the onset of symptoms, in a person without any prior fatal condition. Despite the tremendous advances in the field of cardiovascular medicine, the incidence of SCD continues to rise. In 60 to 80 percent of cases, SCD occurs in the patients with coronary artery disease. Most instances of SCD are thought to involve ventricular tachycardia degenerating to ventricular fibrillation and subsequent asystole. Since the implantable cardioverter defibrillator (ICD) is effective in terminating ventricular tachycardia and fibrillation, the application of ICD has increased markedly. However, the application of ICD needs to be individualized for the patient, similar to drug therapies in LV systolic dysfunction. This review discusses the current understanding on SCD, risk stratification, and management goals for reducing SCD, particularly with the ICD usage.
Coronary Artery Disease ; Death, Sudden, Cardiac ; Defibrillators ; Heart Arrest ; Humans ; Incidence ; Tachycardia, Ventricular ; Ventricular Fibrillation

Suppressing the verbal expression of anger is related to increased pain severity. We investigated the relationship between the pain and anger using a questionnaire in patients with back or neck pain. From August 2007 to January 2008, 173 patients visited our hospital due to back and/or neck pain. They answered the questionnaire before physical examination by themselves. Visual analog scale(VAS) was used to measure the intensity of the pain. The same method was used to measure the intensity and frequency of the anger. We also asked the degree of sleep disturbance, fatigue, loss of appetite, and mood. Psychological disturbances were relatively common; moderate to severe sleep disturbance in 66%, fatigue in 79%, loss of appetite in 55%, and depressed mood in 86%. More than a half answered their anger was moderate to severe in both frequency and degree. All psychological factors appeared to be strong contributors to the intensity of pain by a linear regression analysis. More than a half of the patients with back or neck pain have significant psychological problems. Proper evaluation and management of those psychological factors are important.
Anger ; Appetite ; Back Pain ; Fatigue ; Humans ; Linear Models ; Neck ; Neck Pain ; Physical Examination ; Surveys and Questionnaires

OBJECTIVES: There is a wide spectrum of cognitive dysfunction in geriatric depression due to heterogeneity. The Authors tried to investigate cognitive dysfunction in the elderly with depression and the association between geriatric depression and demographic variables such as sex, age, and education. METHODS: Total 101 non-demented participants living in the asylum for the aged had completed frontal lobe function test (executive function and conceptualization) and CERAD-K (the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease) to evaluate neuropsychological function. Symptoms of depression were evaluated by SGDS-K (Short Geriatric Depression Scale of Korean version). We divided the elderly into two groups (depressed, non-depressed group) to evaluate the differences in cognitive function. RESULTS: 30 (29.7%) of the subjects suffered depression and 50 (49.5%) had cognitive decline. Geriatric depression is not associated with age, sex, and education. Depressed older adults had lower executive function score in total group and cognitive decline group than non-depressed. Within cognitive decline group, subject with geriatric depression had lower scores in word fluency and word delayed recall than non-depressed. There was significant correlation between SGDS-K score and executive function. CONCLUSION: Subjects with geriatric depression had significant executive dysfunction. Executive dysfunction in depressed older adults may provide the basis for further investigation of mechanisms of geriatric depression. Timely identification of executive dysfunction fundamental to daily activities of depressed older adults may lead to coping strategies that will improve the prognosis of geriatric depression.
Adult ; Aged ; Depression* ; Education ; Executive Function ; Frontal Lobe ; Humans ; Population Characteristics ; Prognosis

OBJECTIVE: Age is a strong predictor of mortality in traumatic brain injuries. A surgical decision making is difficult especially for the elderly patients with severe head injuries. We studied so-called 'withholding a life-saving surgery' over a two year period at a university hospital. METHODS: We collected data from 227 elderly patients. In 35 patients with Glasgow Coma Score 3-8, 28 patients had lesions that required operation. A life-saving surgery was withheld in 15 patients either by doctors and/or the families (Group A). Surgery was performed in 13 patients (Group B). We retrospectively examined the medical records and radiological findings of these 28 patients. We calculated the predicted probability of 6 month mortality (IPM) and 6 month unfavorable outcome (IPU) to compare the result of decision by the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) calculator. RESULTS: Types of the mass lesion did not affect on the surgical decision making. None of the motor score 1 underwent surgery, while all patients with reactive pupils underwent surgery. Causes of injury or episodes of hypoxia/hypotension might have affected on the decision making, however, their role was not distinct. All patients in the group A died. In the group B, the outcome was unfavorable in 11 of 13 patients. Patients with high IPM or IPU were more common in group A than group B. Wrong decisions brought futile cares. CONCLUSION: Ethical training and developing decision-making skills are necessary including shared decision making.
Aged* ; Brain Injuries ; Coma ; Craniocerebral Trauma* ; Decision Making* ; Humans ; Medical Records ; Missions and Missionaries ; Mortality ; Patient Participation ; Prognosis ; Pupil ; Retrospective Studies

Vertebroplasty (VP) can effectively treat pain and immobility caused by vertebral compression fracture. Because of complications such as extravasation of bone cement (polymethylmethacrylate, PMMA) and adjacent vertebral fractures, some practitioners prefer to inject a small volume of PMMA. In that case, however, insufficient augmentation or a subsequent refracture of the treated vertebrae can occur. A 65-year-old woman visited our clinic complaining of unrelieved severe low back and bilateral flank pain even after she had undergone VP on the 1st and 4th (L1 and L4) lumbar vertebrae a month earlier. Radiologic findings showed the refracture of L1. We successfully performed the repeat VP by filling the vertebra with a sufficient volume of PMMA, and no complications occurred. The patient's pain and immobility resolved completely three days after the procedure and she remained symptom-free a month later. In conclusion, VP with small volume cement impaction may fail to relieve fracture-induced symptoms, and the refracture of an augmented vertebral body may occur. In this case, repeat VP can effectively resolve both the persistent symptoms and problems of new onset resulting from refracture of the augmented vertebral body due to insufficient volume of bone cement.
Female ; Flank Pain ; Fractures, Compression ; Humans ; Lumbar Vertebrae ; Polymethyl Methacrylate ; Spine ; Vertebroplasty

OBJECTIVE: Decompressive craniectomy is an effective therapy to relieve high intracranial pressure after acute brain damage. However, the optimal timing for cranioplasty after decompression is still controversial. Many authors reported that early cranioplasty may contribute to improve the cerebral blood flow and brain metabolism. However, despite all the advantages, there always remains a concern that early cranioplasty may increase the chance of infection. The purpose of this retrospective study is to investigate whether the early cranioplasty increase the infection rate. We also evaluated the risk factors of infection following cranioplasty. METHODS: We retrospectively examined the results of 131 patients who underwent cranioplasty in our institution between January 2008 and June 2015. We divided them into early (≤90 days) and late (>90 days after craniectomy) groups. We examined the risk factors of infection after cranioplasty. We analyzed the infection rate between two groups. RESULTS: There were more male patients (62%) than female (38%). The mean age was 49 years. Infection occurred in 17 patients (13%) after cranioplasty. The infection rate of early cranioplasty was lower than that of late cranioplasty (7% vs. 20%; p=0.02). Early cranioplasty, non-metal allograft materials, re-operation before cranioplasty and younger age were the significant factors in the infection rate after cranioplasty (p<0.05). Especially allograft was a significant risk factor of infection (odds ratio, 12.4; 95% confidence interval, 3.24–47.33; p<0.01). Younger age was also a significant risk factor of infection after cranioplasty by multivariable analysis (odds ratio, 0.96; 95% confidence interval, 0.96–0.99; p=0.02). CONCLUSION: Early cranioplasty did not increase the infection rate in this study. The use of non-metal allograft materials influenced a more important role in infection in cranioplasty. Actually, timing itself was not a significant risk factor in multivariate analysis. So the early cranioplasty may bring better outcomes in cognitive functions or wound without raising the infection rate.
Allografts ; Brain ; Cerebrovascular Circulation ; Cognition ; Decompression ; Decompressive Craniectomy ; Female ; Humans ; Intracranial Pressure ; Male ; Metabolism ; Multivariate Analysis ; Retrospective Studies ; Risk Factors ; Wounds and Injuries

OBJECTIVE: Interhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively. METHODS: From 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes. RESULTS: The male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment. CONCLUSION: IHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.
Consciousness ; Craniocerebral Trauma ; Diagnosis ; Female ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Headache ; Hematoma, Subdural* ; Humans ; Magnetic Resonance Imaging ; Male ; Retrospective Studies ; Symptom Assessment