Subspecialty board certification is a post-graduate program in which clinicians can acquire the qualifications for special areas or techniques, after they have received a board certification in a specialty in clinical medicine. Considering the trend of increasingly sub-classified and professionalized medicine and the higher demand on specialized medical services, introduction of subspecialty board certification is inevitable. However, given the characteristics of the medical environment in Korea, such as the medical payment system, a possibility of undesirable outcomes should not be overlooked. An imprudent administration of the specialty board system would cause conflict and split within communities of medical professionals and also produce confusion among medical consumers. Accordingly, the establishment of subspecialty board system should proceed based on academic communications as well as organic collaboration with the parent academic society and/or the relevant academic societies. Individuals can submit an application for a subspecialty board qualification under the agreement of specialized academic societies which have already been authorized, but the authorization of the societies is determined following a rigorous assessment by the Korean Academy of Medical Sciences (KAMS). An active intervention by KAMS is essential for maintaining the quality of specialty board system and preventing imprudent administration. KAMS will make the best effort to prevent distribution of unauthorized certificates and to rectify rational implementation of the subspecialty board certification system.
Accreditation ; Certification ; Clinical Medicine ; Cooperative Behavior ; Humans ; Korea ; Parents ; Specialty Boards

The mechanism of development of pulmonary edema associated with -sympathomimetic agent is still not fully understood. 2-sympathomimetic drugs such as ritodrine, terbutaline, and fenoterol are widely used for the treatment of premature uterine contraction. We describe a case of pulmonary edema that occurred suddenly during Cesarean section in a previously healthy parturient, associated with ritodrine pretreatment for 5 days in an attempt to arrest preterm labor. Pulmonary edema was completely treated with mechanical ventilation and diuretic therapy.
Cesarean Section* ; Female ; Fenoterol ; Humans ; Obstetric Labor, Premature ; Pregnancy ; Pulmonary Edema* ; Respiration, Artificial ; Ritodrine* ; Terbutaline ; Uterine Contraction

Intramural implantation is among the rarest forms of ectopic pregnancy.Since the first description by Perli, 21 cases were reported in worldwide literatures.The pathologic criteria required for intramural pregnancy is that the product of conception is completely surrounded by uterine musculature and is separated from the uterine cavity and the fallopian tube or round ligament.The previous history of uterine injury or adenomyosis is known as possible etiology of intramural implantation. Because the early diagnosis is very difficult, most cases is found after onset of complication such as a uterine rupture or hemoperitoneum. We have recently experienced a case of intramural pregnancy diagnosed and treated by laparoscopy in a 9 weeks gestation nulliparous woman without previous history of uterine injury or disease, and report with a brief review of literatures.
Adenomyosis ; Early Diagnosis ; Fallopian Tubes ; Female ; Fertilization ; Hemoperitoneum ; Humans ; Laparoscopy ; Pregnancy ; Pregnancy, Ectopic ; Uterine Rupture ; Round Ligaments

No abstract available.
Respiratory Insufficiency* ; Ventilators, Mechanical* ; Weaning*

Cervical plexus block has been evaluated clinically for surgery of the anterior neck in 13 patients during the 10 months(from July 1981 to April 1982) at the Department of Anesthesiology in Capital Armed Forces General Hospital. We have assessed CPB for technique, onset, anesthetized area, duration, complication and supplimentary agents, and reviewed the anatomical aspects of cervical plexus. The distribution of injected local anesthetics was demonstrated under radiography using Urographin. We experienced incomplete block in 9 cases which needed substitution with Thalamonal. The incidence of complications was few and most significant complication seen in this study was respiratory difficulty. However, There was no evidence for phrenic nerve paralysis. Cervical plexus block was performed safely and effectively for surgery of the anterior neck.
Incidence

Deliberately induced hypotension reduces bleeding in operative fields, therby facilitating the surgical manipulation of a highly vascularized lesion and enabling a better dissection to be made. Hypocapnia is a technique by which the regional cerebral blood flow is reduced, effecting a decrease in the intracranial volume. The monitoring of end-tidal CO2 tension(PECO2) is widely done since the amount of end-tidal CO2 tension reflects indirectly the value of the degree of arterial CO2 tension(PaCO2). During hypotension, increased physiologic dead space my produce the widened PaCO2-PECO2 gradient and this large gradient makes PECO2 an unreliable indication of PaCO2. There are many reports on hypotensive agents and techniques. Induced hypotension with halothane has been reported to be a relatively safe and useful method by Murtagh(1960) and Schettini, et al (1967). We reported 100 cases of halothane induce hypotensive anesthesia for intracranial aneurysm surgery in 1979. The present study reports concerning the hypotensive anesthesia for 259 cases of intracranial aneurysm surgery, which were performed at Severance Hospital of the Yonsei University College of Medicine from 1972 to 1985. We evaluated prospectively the PaCO2-PECO2 gradient with modern infrared capnographs during the induced hypotension of 25 cases, which was performed for intracranial aneurysm surgery at this hospital. The result of the retrospective and prostpective studies were as follows. A. Retrospective study 1) Halothane and enflurane were used as the primary anesthetics in 246 and 13 cases, respectively. Hydralasine, nitroprusside, and trimetaphan were supplementarily used for inducing hypotension in 29, 19 and 15 cases, respectively. 2) The mean arterial blood pressure of the lowest blood pressure in the induced hypotension group was 57.2+/-9.3 mmHg, and the mean arterial blood pressure of the highest blood pressures during the induction fo anesthesia was 111.3+/-20.8mmHg. 3) There was no significant difference in the perioperative hemoglobins, hematocrits, and serum electrolytes. 4) In the introperative period gas analysis revealed respiratory alkalosis(arterial CO2 tension and pH were 29.7+/-6.7mmHg and 7.485+/-0.078, respectively). In other values there was no significant change. 5) The mortality rate in 259 cases of intracranial aneurysm surgery was 6.2%. B. Prospective study There was no significant difference in the PaCO2-PECO2 gradients between in the hypotensive period (5.5+/-3.8 mmHg) and in the normotensiveperiod(4.3+/-3.4mmHg). In conclusion, the technique of using induced hypotension with the inhalation anesthetics, halothane or enflurane, is a safe and useful one to use in performing surgery for intracranial aneurysm, and end-tidal carbon dioxide tension can be used as an indirect measure of arterial carbon dioxide during the induced hypotension.
Anesthesia* ; Anesthetics ; Anesthetics, Inhalation ; Arterial Pressure ; Blood Pressure ; Carbon Dioxide ; Electrolytes ; Enflurane ; Halothane ; Hematocrit ; Hemorrhage ; Hydrogen-Ion Concentration ; Hypocapnia ; Hypotension ; Intracranial Aneurysm* ; Mortality ; Nitroprusside ; Prospective Studies ; Retrospective Studies ; Trimethaphan

Comflicting results have been reported on whether ketamine potentiates the neuromuscular effect of succinylcholine or other non-depolarizing agents. Notably, there has been no reported clinical evatuation of the influence of ketamine upon the neuromuscular action of vecuronium a new muscle relaxant. The present study was undertaken to estimate the influence of ketamine upon the neuromuscular action of vecuronium with a single bolus injection of ED95. Forty-five ASA class l or ll surgical patients were divided into three groups: l, ll and lll and were given thiopental sodium(5mg/kg), ketamine 3mg/kg and ketamine 5mg/kg as induction agents, respectively. The duration and recovery index of group ll and lll (35.20+/-2.30 and 16.20+/-1.37 min., 52.60+/-3.98 and 25.47+/-3.78min., respectively) were longer than those in group l (24.87+/-1.59 and 10.66 +/- 1.23 min.). But group l had a lower TOF ratio(27.40+/-3.09%) at 75% single twitch recovery than group ll and lll (41.87+/-3.25 and 45.27+/-3.67%, respectively). The increase in duration and the recovery index of group lll were greater than that of group ll. It was concluded that ketamine woudly potentiate the neuromuscular action of vecuronium in a dose-dependent manner. We suggest that combination of ketamine and vecuronium requires careful postoperative neuromuscular monitoring for the recovery from a vecuronium induced neuromuscular block.
Humans ; Ketamine* ; Neuromuscular Agents ; Neuromuscular Blockade* ; Neuromuscular Monitoring ; Succinylcholine ; Thiopental ; Vecuronium Bromide

Prolonged intubation of the trachea in the treatment of acute respiratory failure has become commonplace in the Intensive Care Units during the last decade. We defined prolonged endotracheal intubation as cases in which endotracheal intubation is required more than 7 days, and then experiences 202 caaes out of 5,866 Intensive Care Unit patients from March 1981 to February 1986 in Severance Hospital, Yonsei Medical Complex were evaluated. The results were as follows ; 1) The number of patients were 202 cases in total, and male and females were 130 and 69 cases. The teen-age groups was most common,69 crises(33.7%) and fortiea was 35 cases (17.3%) . 2) The patients of internal medioine department was the mast common, 23.3% and pediatric an? neurosurgical department fellowed in order. 3) The moat common causes of acute respiratory failure is central nervous srstem disotraders and ARDS (Adult Respiratory Distress Syndrome) . 4) Average stay in Intensive Care Unit was 23.5 day, from 3 to 208 days. Nintr-nine cases(49%) were impreved and the remainder (103 caaes) were expired. 5) Orotracheal intubation is performed in 144 cases (71.4%) and tracheostomy was done in 48 cased, among them, in 39 crises oro-and nasotracheal intubation was changed to trac: heostomy after 12 days. 6) Oro-or nasotracheal tube was changed 2.5 timers every 6,3 days. Mean intubation and tracheostomy days was 15.5 and 76.3 darts. 7) Ventilatory support was maintained in 199 caaeg and 12.1 days in endotraeheal intubation patients and 29.1 days in tracheostomy patients. 8) Complication developed in 29 cased awang them 10 cases were in oro- or nasotracheal intubation patients and 19 cartes were in tracheoatomr patients. Horseness, laryngeal edema, and sore throat were deueloped in 3,2 and 1 cartes, respectively, in orotracheal intubation patients and granuloma, traoheal stenosis, tracheal ulceration, an? vocal cord palsy were developed in 9,5,2, and 2 cartes, respectively, in traoheoatomy patents. From the above results, it can be concluded that tracheal complication was serious for the patients who required ventilatory support under prolonged endotracheal incubation. So we must try to Prevent the complication which develop after prolonged endotracheal intu- bation 7nd maintaining the pationts with cardio-respiratory support.
Female ; Granuloma ; Humans ; Intensive Care Units ; Intubation ; Intubation, Intratracheal* ; Laryngeal Edema ; Male ; Pharyngitis ; Respiratory Insufficiency ; Trachea ; Tracheal Stenosis ; Tracheostomy ; Ulcer ; Vocal Cord Paralysis

No abstract available.
Bezoars*

Paraneoplastic pemphigus is a distinct and rare autoimmune disease characterized by extensive and painful mucosal ulcerations and polymorphic desquamated skin lesions in the setting of an underlying neoplasm, typically of lymphoreticular origin. Thus difficulties in the management of anesthesia can be expected. A 66-years-old man was scheduled for removal of intraabdominal sarcoma associated with paraneoplastic pemphigus. Physical examination showed multiple erythematous bullae, crusts, plaques and target-like lesions on the whole body and desquamated erythematous skin lesions on the back and extremities. In the operating room, his right femoral artery was cannulated with a 20 G, 12.7 cm CVP catheter and left femoral and subclavian veins with 14 G, 20 cm CVP catheters, respectively. After application of 4 % lidocaine spray, his oropharynx and supraglottic area were evaluated under direct laryngoscopy and revealed multiple ulcerations on oral mucosa, but no distinct lesion on supraglottic area. Anesthesia was induced by rapid-sequence method with fentanyl, thiopental sodium and succinylcholine followed by endotracheal intubation. The endotracheal tube was held by a roll gauze around the neck and its cuff was minimally inflated to avoid overpressure against his tracheal wall. After the end of surgery, his oral cavity was suctioned with no remarkable bleeding, and tracheal wall including cuff-contacted area was evaluated under fiberoptic bronchoscopy, revealed intact wall without any bulla or ulceration. The patient was transferred to intensive care unit for proper postoperative management after extubation of endotracheal tube.
Anesthesia ; Autoimmune Diseases ; Bronchoscopy ; Catheters ; Extremities ; Femoral Artery ; Fentanyl ; Hemorrhage ; Humans ; Intensive Care Units ; Intubation, Intratracheal ; Laryngoscopy ; Lidocaine ; Mouth ; Mouth Mucosa ; Neck ; Operating Rooms ; Oropharynx ; Pemphigus* ; Physical Examination ; Sarcoma ; Skin ; Subclavian Vein ; Succinylcholine ; Suction ; Thiopental ; Ulcer