목적: 병원에서 재가 및 시설로 퇴원한 환자가 지역사회에서 건강을 유지하기 위해서는 전환기 돌봄 서비스(Transitional care services)가 필요하다. 이를 위해 지역사회 내 의료서비스와 자원을 연계하는 주치의의 역할이 중요시된다. 본 연구에서는 선행연구를 바탕으로 일차진료 의사들의 환자중심성에 대한 인식을 파악하여 환자중심 기반의 서비스 제공을 위해 필요한 정책을 제시하였다. 또한 Transitional Care Service에 대한 일차진료 의사들의 인식을 확인하고 인구사회학적 요인과의 관계를 확인함으로써 서비스 우선순위를 도출하고자 하였다.방법: 본 연구는 전국의 가정의학과, 내과, 신경과 등 노인 질환과 관련 있는 과의 전문의 자격증이 있으며 자발적으로 온라인 설문조사에 참여할 의사를 표현한 일차진료 의사 259명을 대상으로 수행 되었다. 환자중심성 및 전환기 돌봄서비스에 대한 인식을 살펴보기 위해 구조화된 설문지를 개발하였 으며, 조사전문업체를 통해 2019년 10월 28일부터 2019년 11월 22일까지 온라인으로 설문조사를 수행 하였다.결과: 본 연구에 대한 주요 결과는 다음과 같다. 첫째, 일차진료 의사들을 대상으로 9가지 전환기 돌봄서비스 인식에 대해 살펴본 결과 “입원 시 진단, 건강상태, 치료계획 및 결과 에 대한 설명 (4.4)”과 “퇴원 후 자가 건강관리를 위한 정보 및 훈련 (4.2)” 에 대한 필요성이 높게 나타났다. 둘째, 35세 이상 일차진료 의사가 34세 이하 일차진료 의사보다 전환기 돌봄서비스에 대한 인식이 높게 나타 났다(F=7.3, p<0.01). 또한, 환자중심성에 대한 인식이 높을수록, 연령이 높을수록, 서울 외 지역에서 근무할수록 전환기 돌봄서비스에 대한 인식이 높게 나타났다.결론: 본 연구에서는 일차의료를 제공하는 의료진들을 위한 교육프로그램과 지역사회에서 일차의료 의사들을 중심으로 하는 지역 연계 방안을 제시하였다는 점에서 의의가 있다.

Remote ischemic preconditioning (IP), brief tolerating cycles of ischemia and reperfusion in remote non-vital organs, can reduce ischemic injury of the heart. IP induces cardiac protection by down-regulating iNOS or up-regulating eNOS. In addition, Akt has been known to protect myocardium against ischemia-reperfusion injury. This study was undertaken to observe the expression of iNOS, eNOS, Akt and phospho-Akt (p-Akt) in the rat myocardium after IP. Thirty-five weeks-old male Sprague-Dawley rats were divided into control and IP groups. The IP group was further subdivided into 3 groups based on the number of cycles of IP. For IP, left commom iliac artery was occluded 3, 6 and 10 cycles for 5 min of ischemia alternating with 5 min of reperfusion. The rat were sacrificed at 0, 3, 6, 24 and 72 hours of IP and the heart was removed. The expression of iNOS, eNOS, Akt and p-Akt in the rat myocardium was examined by immunohistochemical staining and Western blot analysis. The expression of iNOS was increased by IP and was higher in 10IP groups than 3IP and 6IP group. The expression of eNOS was increased or decreased by IP and was showed no difference with increasing episode of IP. The expression of Akt was decreased by IP at 24 and 72 hours after reperfusion, and showed no differences with increasing episode of IP. The expression of p-Akt was increased by IP and showed no difference with increasing episode of IP. These results suggest that hind limb ischemic preconditioning provides cardiac protection through up-regulation of eNOS and phosphorylation of Akt, however excessive episodes of remote preconditioning may induce the myocardial ischemic injury through overexpression of iNOS.
Animals ; Blotting, Western ; Extremities ; Heart ; Humans ; Iliac Artery ; Ischemia ; Ischemic Preconditioning ; Male ; Myocardium ; Phosphorylation ; Rats ; Rats, Sprague-Dawley ; Reperfusion ; Reperfusion Injury ; Up-Regulation

Biliary-enteric fistula is a rare disease, and the common causes of biliary-enteric fistula are gallstone, peptic ulcer, malignancy and trauma. It is known that the most common type of biliary-enteric fistula is the cholecysto-duodenal fistula, yet the combination of choledocho-duodeno-colonic fistula is a rare finding. A 78-year-old woman was admitted because she had suffered with right upper quadrant pain, a febrile sense and chills for 2 days. We confirmed the choledocho-duodeno-colonic fistula by performing gastroduodenoscopy, abdominal CT and an upper GI series. So, we report here on an usual case of choledocho-duodeno-colonic fistula, along with a review of the relevant literatures.
Aged ; Biliary Fistula ; Chills ; Female ; Fistula* ; Gallstones ; Humans ; Peptic Ulcer ; Rare Diseases ; Tomography, X-Ray Computed

In spite of the attention given to the study of mesenchymal stem cells derived periodontal ligament (PDL), there is a lack of information about canine PDL cells. In this study, we characterized canine PDL cells to clarify their stem cell properties, including self renewal, proliferate rate, stem cell markers and multipotency. PDL cells were obtained from extracted premolars of canines, following a colony forming assay and proliferation rate of sub-confluent cultures of cells for self-renewal, immunostaining for STRO-1 and CD146/MUC18 and a differentiation assay for multipotency. Canine PDL cells formed single-cells colonies and 25% of the PDL cells displayed positive staining for BrdU. The cells expressed the mesenchymal stem-cell markers, STRO-1 and CD146/MUC18. Under defined culture conditions, the cells differentiated into osteoblasts and adipocytes, but the cells didn't differentiated into chondrocytes. The findings of this study indicated that the canine PDL cells possess crucial stem cells properties, such as self-renewal and multipotency, and express the mesenchymal stem cell markers on their surface. The isolation and characterization of canine PDL cells makes it feasible to pursue preclinical models of periodontal regeneration in canine.
Adipocytes ; Bicuspid ; Bromodeoxyuridine ; Chondrocytes ; Mesenchymal Stromal Cells ; Osteoblasts ; Periodontal Ligament* ; Regeneration ; Stem Cells*

Background: In this study, with the aim of improving the quality of transitional care service for discharged patients, the Health Care Quality and Outcomes Indicators of the Organization for Economic Co-operation and Development and National Health Service Outcomes Framework of the UK were applied to derive service items for provision and develop evaluation indicators under categories of effectiveness, safety, and patient-centeredness.Method: A scoping review was conducted to derive core concepts and evidence materials/data for transitional care service. For the derived items of transitional care service and evaluation indicators, a three-round Delphi study was conducted with experts in the fields of healthcare/ medicineursing/social welfare. Results: First, as a result of the scoping review, components of transitional care service (assessment of need by period of transitional care service, multi-professional team, connection to community resources, etc.) and themes for outcome indicators (effectiveness, patient safety, patient-centeredness) were derived. Second, by classifying the items for assessment according to the hospitalization and transition period and conducting a Delphi study to derive service items for transitional care service, during the hospitalization period, presence/absence of a caregiver and need for a caregiver, activities of daily living, and necessity for home-based care services were identified as items of high priority. Regarding patient safety, risk of falls and fractures during hospitalization, and necessity for medication reconciliation were identified as the items of high importance. For the transition period, provision of education regarding adequate responses and handling of emergencies, provision of information and guidance on application of services for basic livelihood security program beneficiaries, and education for patient skills in self-management of health were derived as items of high priority. Third, for the derivation of outcome indicators for transitional care service, in the “effectiveness” category, the experts rated a reduction in the 30-day readmission rate as an item of high importance along with a decrease in emergency department visits, reduction in preventable admissions as indicators of high relevance. In terms of “patient safety,” a decrease in drug adverse reactions, and reduction in the incidence of falls and pressure ulcers were identified as indicators of high priority. Finally, for the category of “patient-centeredness,” patient experience assessment, level of service satisfaction reported by patients and their caregivers, and reducing burden on caregivers were identified as indicators of high priority. Conclusion This study suggest practical implications for the service with high relevance and necessity for transitional period. It also presented outcome indicators of transitional care service to contribute toward an improvement in the quality of care.

INTRODUCTION: Adult stem cells generate differentiated cells beyond their own tissue boundaries. To prove that stem cells derived from bone marrow is capable of therapeutic application in cerebral ischemic patients, we performed this study. MATERIAL AND METHOD: We transplanted adult stem cells derived from bone marrow of the patient's iliac bone to 5 patients with cerebral infarction. Of 5 patients, two patients had internal carotid artery occlusion, two patients had severe stenosis of the middle cerebral artery, remaining one patient had occlusion of the branch of the middle cerebral artery. At first, we performed extracranial-intracranial bypass surgery in all patients, and then implanted bone marrow stem cell in the infarcted brain and boder zone area directly under the microscopic navigator and also injected bone marrow stem cells through the grafted vessel to the infarcted area. Two weeks after bypass surgery, we confirmed the patency of bypass graft with external carotid angiography. In the same setting, mesenchymal stem cells acquired from autologous bone marrow were superselectively injected into the bypass graft via a microcatheter. Postoperative evaluation of the patients was decided to the neurological status and the degree of reduction of the high signal area on the T2 image of the postoperative MRI. RESULT: All patients who underwent bypass surgery with stem cell implantation had an uneventful postoperative course and showed some improvement of preoperative neurologic dysfunction. Postoperative significant improvement of cerebral vasoreactivity to acetazolamide was showed in all patients. On postoperative 3 months MRI, three patients showed significant reduction of the high signal area on the T2 image, and also improved neurological status on those patients. Other one patient showed moderate degree of the reduction of the high signal area on T2 image of the postoperative MRI, but neurological status of that patient slightly improved. Remaining one patient who showed poor circulation via bypass graft does neither reduction of the high signal area on T2 image of the postoperative MRI nor improvement of the neurological status of that patient. CONCLUSION: In patients of fixed cerebral infarction with major neurologic deficit, EC-IC bypass surgery is not effective, even though infarcted area filled by grafted vessel extensively. In those patients, autologous bone marrow stem cell implantation combined with bypass seems to be expect neuronal regeneration.
Acetazolamide ; Adult Stem Cells ; Angiography ; Bone Marrow* ; Brain ; Carotid Artery, Internal ; Cerebral Infarction* ; Constriction, Pathologic ; Humans ; Magnetic Resonance Imaging ; Mesenchymal Stromal Cells ; Middle Cerebral Artery ; Neurologic Manifestations ; Neurons* ; Regeneration* ; Stem Cell Transplantation* ; Stem Cells* ; Transplants

BACKGROUND: One quarter to one third of patients with NSCLC present with primary tumors that although confined to the thorax are too extensive for surgical resection. Until resently standard treatment for these patients had been thoracic radiation, which produces tumor regression in most patients but few cures and dismal 5-year survival rate. The fact that death for most patients with stage III tumors is caused by distant metastases has promped a reevaluation of combined modality treatment approaches that include systemic chemotherapy. Therefore, we report the results observed in a study to evaluate the effect of multimodality treatment in locally advanced non-small cell lung cancer from 1/91 to 8/93 in CNUH. METHOD: We grouped the patients according to the treatment modalities and evaluated response rate, median survival and the effect of prognostic variables. Among 67 patients evaluated, twenty seven patients classified with group A, received cisplatin and etoposide containing combination chemotherapy alone, eighteen patients, classified with group B, received chemotherapy and radiotherapy, fifteen patients, group C, received neoadjuvant or adjuvant chemotherapy and surgery with/without radiation therapy, seven patients, group D, received only supportive care. RESULT: The major response rate for group A and B was 37% and 61% respectively. There was no statistically significant difference in response rate between A and B groups(p=0.97). The analysis of prognostic factors showed that differences of age, sex, pathology, blood type, smoking year, stage and ECOG performance did not related to improvement in survival. Median survival time was 8.6 months for group A, 13.4 months for group B, 19.2 months for group C, and 5.4 months for group D, respectively and there was statistically significant difference(p=0.003), suggesting that multimodality therapy was associated with signigicant improvement in survival. Subset survival analysis showed a significant therapeutic effect for earlier stage and good performance state(p=0.007, 0.009, respectively). A possible survival advantages were observed for major response groups. CONCLUSION: It was suggested that multimodality therapy for the management of patients who had stage III disease, has yielded good median survival and long survival for seleted patients. But, it is necessory to validate above result with further investigation in large scale and in prospective randomized trials.
Carcinoma, Non-Small-Cell Lung* ; Chemotherapy, Adjuvant ; Cisplatin ; Drug Therapy ; Drug Therapy, Combination ; Etoposide ; Humans ; Neoplasm Metastasis ; Pathology ; Prospective Studies ; Radiotherapy ; Smoke ; Smoking ; Survival Rate ; Thorax

Klippel-Trenaunay-Weber syndrome is a rare congenital disorders which is characterized by the presence of multiple hemangiomata, arteriovenous fistulas and unilateral limb hypertrophy. There has been some reports that Klippel-Trenaunay-Weber syndrome was diagnosed at birth or infant, but the prenatal diagnosis was very difficult in pregnant women who have not family history. Recently, the prenatal diagnosis of Klippel-Trenaunay-Weber syndrome has been occasionally reported according to improvement of prenatal ultrasound. We recently experienced two cases of Klippel-Trenaunay-Weber syndrome. So we report our cases with brief review of literature.
Arteriovenous Fistula ; Congenital, Hereditary, and Neonatal Diseases and Abnormalities ; Diagnosis* ; Extremities ; Female ; Humans ; Hypertrophy ; Infant ; Klippel-Trenaunay-Weber Syndrome* ; Parturition ; Pregnant Women ; Prenatal Diagnosis ; Ultrasonography

OBJECTIVES: Extracranial-intracranial (EC-IC)bypass procedures have proved useful in selected patients with cerebral ischemia. We have experienced EC-IC bypass procedures in 85 patients with hemodynamic cerebral ischemia, moya moya and complicated aneurysm. In this study, complications after EC-IC bypass procedures was investigated. METHODS: Authors performed EC-IC bypass surgery for augmentation of cerebral blood flow in 85 patients for recent 7 years. Of 85 patients, the pathologic lesions were artherosclerotic hemodynamic cerebral ischemia in 60, moya moya in 14, complicated aneurysm in 9, and traumatic occlusion of the carotid artery in 2. An superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in 67 cases and graft bypass with saphenous vein or radial artery in 18 cases. RESULTS: Of 85 patients who underwent bypass surgery, 63 had an uneventful postoperative course. Fifteen patients had hyperperfusion syndrome that included temporary neurologic deficit in 7, reperfusion hemorrhage in 3, seizure in 3, and neusea and vomiting in 2. Five patients had wound problems. Permanant neurologic deficit and complete obstruction of the preoperative stenotic lesion occured in one respectively. All patients except three cases of reperfusion hemorrhage and one case of permanent neurologic deficit recovered completely. Two of three cases of reperfusion hemorrhage and one case of permanent neurologic deficit recovered with minor neurologic deficit, and the remaining one case of reperfusion hemorrhage died. CONCLUSION: EC-IC bypass surgery is a reliable and reasonably safe method for establishing new pathways of collateral circulation to the brain. However, this operation can have potential complications by relative hyperperfusion of chronically hypoperfused and presumably dysautoregulated region, and new flow pattern after bypass. Bypass is deferred to 8 weeks till impaired autoregulation is restored after acute cerebral infarction. And blood pressure should be controlled closely throughout the immediate postoperative period.
Aneurysm ; Blood Pressure ; Brain ; Brain Ischemia ; Carotid Arteries ; Cerebral Arteries ; Cerebral Infarction ; Collateral Circulation ; Hemodynamics ; Hemorrhage ; Homeostasis ; Humans ; Neurologic Manifestations ; Postoperative Period ; Radial Artery ; Reperfusion ; Saphenous Vein ; Seizures ; Transplants ; Vomiting ; Wounds and Injuries

Klippel-Trenaunay-Weber syndrome is a rare sporadically occurring congenital soft tissue anomaly characterized by cutaneous hemangiomata, hemihypertrophy and occasionally arteriovenous malformations(AVMs). No definite genetic defect has been identified. The appearance is a soft tissue mass of an extremity, usually affecting the adjacent trunk, hydrops fetalis, ascites, abdominal hemangiomatous masses, and hepatomegaly. When diagnosed prenatally, the disorder may be severe. Thrombocytopenia due to platelet consumption within the hemangioma and high output cardiac failure may complicate the outcome. Termination of pregnancy can be offered in severe forms, otherwise no alteration of management in expected. The management of newborns is primarily nonoperative, but some may benefit from surgical intervention. We report a case of Klippel-Trenaunay-Weber syndrome diagnosed prenatally by ultrasonogram in the second trimester and subsequently was terminated, with a brief review of literature.
Ascites ; Blood Platelets ; Extremities ; Female ; Heart Failure ; Hemangioma ; Hepatomegaly ; Humans ; Hydrops Fetalis ; Infant, Newborn ; Klippel-Trenaunay-Weber Syndrome* ; Pregnancy ; Pregnancy Trimester, Second ; Prenatal Diagnosis ; Thrombocytopenia ; Ultrasonography