Introduction: Preoperative dialysis-dependent renal failure is a strong independent risk factor for in-hospital mortality and morbidity after open heart surgery. This retrospective study analyses the early outcome in dialysis-dependent renal failure patients who underwent elective open-heart surgery in the Institut Jantung Negara (IJN). Methods: We retrospectively analyse a series of 228 consecutive postoperative patients with dialysis-dependent (end stage renal failure (ESRF)) admitted to the adult cardiothoracic ICU in IJN between January 2012 and December 2016. Results: The overall early mortality rate included 34 patients (15.8%). Patients with ESRF underwent combined procedure recorded a very high mortality rate at 56.3%. Twenty-four patients (11.2%) needed resternotomy for postoperative bleeding or cardiac temponade. Postoperative mediastinitis rate was high, involving 13 patients (6%). The neurological and gastrointestinal complications rate were recorded at 2.3% (5 patients) and 6% (13 patients) respectively. In the group of patients (n=199) with sinus rhythm during the preoperative period, 100 patients (50.3%) developed postoperative AF. 77 patients (35.8%) stayed in hospital for more than 14 days. Conclusions: dialysis-dependent patients undergoing cardiac surgery poses higher perioperative risk of mortality and morbidity of 3-4 times higher compared to those patients with normal renal function. IJN shows acceptable perioperative risk of mortality and morbidity which is comparable to other centres

No abstract available.
Chorea ; Creutzfeldt-Jakob Syndrome

The Academy of Medicine (AMS) and the Ministry of Health (MOH) have developed the clinical practice guidelines on Attention Deficit Hyperactivity Disorder (ADHD) to provide doctors and patients in Singapore with evidence-based treatment for ADHD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on ADHD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
Attention Deficit Disorder with Hyperactivity ; diagnosis ; drug therapy ; therapy ; Caregivers ; Child ; Evidence-Based Medicine ; Humans ; Methylphenidate ; therapeutic use ; Parents ; Psychiatry ; methods ; standards ; Singapore ; Societies, Medical

BACKGROUND: Although amphotericin B (AMB) has a wide spectrum of activity that encompasses the majority of yeast isolates, there have been recent reports suggesting that some yeast isolates exhibit decreased susceptibility to AMB. However, in vitro AMB susceptibility of yeast species isolates from blood cultures in Korea has not been fully surveyed. METHODS: A total of 92 bloodstream yeast isolates from four Korean hospitals, representing 10 Candida species (69 isolates) and 4 non-Candida yeast species (23 isolates) were evaluated. AMB minimum inhibitory concentrations (MICs) were determined by two methods: the CLSI method and Etest. AMB minimum fungicidal concentrations (MFCs) were also determined. RESULTS: For all 92 yeast isolates, the CLSI method generated a restricted range of MICs (0.125 to 4 microgram/mL) with 3.3% exhibiting MICs > or =2 microgram/mL, and the corresponding MFC values ranged from 0.25 to 8 microgram/mL with 26.1% showing MFCs > or =2 microgram/mL. Etest produced the widest distribution of MICs, ranging from 0.03 to 32 microgram/mL. High AMB MICs (> or =0.38 microgram/mL) by Etest was observed in 34.8% of the isolates: Candida krusei (100%), Candida rugosa (100%), Trichosporon asashii (100%), Candida glabrata (82%), and Yarrowia lipolytica (75%). Etest disclosed that all isolates of Candida guilliermondii, Candida lusitaniae, Candida pelliculosa and Kodamaea ohmeri were highly susceptible to AMB (MIC < or =0.19 microgram/mL). CONCLUSIONS: Our study showed that Etest may be more useful to discriminate yeast isolates with reduced susceptibility to AMB, and some isolates of less common yeast species from Korea may have decreased AMB susceptibilities.
Amphotericin B/*pharmacology ; Antifungal Agents/*pharmacology ; Candida/drug effects/isolation & purification ; Candidiasis/microbiology ; Culture Media ; Humans ; Korea ; Microbial Sensitivity Tests ; Reagent Kits, Diagnostic ; Yeasts/*drug effects/isolation & purification

BACKGROUND: The aim of this study was to investigate the prevalence, clinical and laboratory findings of hereditary hemolytic anemia (HHA) in Korea from 1997 to 2006 and to develop the appropriate diagnostic approach for HHA. METHODS: By the use of questionnaires, information on the clinical and laboratory findings ofHHA diagnosed from 1997 to 2006 in Korea was collected and analyzed retrospectively. A total of 431 cases were enrolled in this study from 46 departments of 35 hospitals. RESULTS: The overall frequency of HHA did not change through the 10-year period for pediatrics but did show an increasing tendency for internal medicine. The overall male to female sex ratio did not show sex predominance (1.17:1), but a significant male predominance with a ratio of 1.49:1 was seen for pediatrics while a significant female predominance with a ratio of 1:1.97 was seen forinternal medicine. Of the total cases, 74.2% (282/431) were diagnosed before the age of 15 years. The etiologies of HHA were classified as red cell membrane defects, hemoglobinopathies, red cell enzyme deficiencies and unknown causes. There were 382 cases (88.6%) of red cell membrane defects with 376 cases (87.2%) of hereditary spherocytosis and 6 cases (1.4%) of hereditary elliptocytosis, 20 cases (4.6%) of hemoglobinopathies with 18 cases (4.2%) of beta-thalassemia, a case (0.2%) of alpha-thalassemia and a case (0.2%) of Hemoglobin Madrid, 7 cases (1.6%) of red cell enzyme deficiencies with 5 cases (1.2%) of glucose-6- phosphate dehydrogenase (G-6-PD) deficiency, a case (0.2%) of pyruvate kinase (PK) deficiency and a case (0.2%) of enolase deficiency, and 22 cases (5.1%) of unknown causes. The most common chief complaint in pediatric patients was pallor and that in adult patients was jaundice. In the red cell membrane defect group of patients, the level of hemoglobin was significantly higher than in adult patients. The mean corpuscular volume, mean corpuscular hemoglobin, corrected reticulocyte count, total and indirect bilirubin level and lactate dehydrogenase levels in the hemoglobinopathy group of patients were significantly lower than the values in the red cell membrane defect group of patients. The mean concentration of G-6-PD was 0.8+/-0.7U/1012RBC in the G-6-PD deficient patients, PK was 1.7U/1010 RBC in the PK deficient patient, and the level of enolase was 0.04U/g of Hb in the enolase deficient patient. CONCLUSION: The most prevalent cause of HHA in Korea during 1997 to 2006 was hereditary spherocytosis, but HHA by other causes such as hemoglobinopathy and red cell enzyme deficiency gradually increased with the development of molecular diagnostic methods and increasing general interest. However, the etiologies of HHA need to be pursued further in 5.1% of the patients. An systematic standard diagnostic approach is needed in a nationwide prospective study for correct diagnoses and appropriate management of HHA.
Adult ; alpha-Thalassemia ; Anemia, Hemolytic, Congenital* ; beta-Thalassemia ; Bilirubin ; Cell Membrane ; Diagnosis ; Elliptocytosis, Hereditary ; Erythrocyte Indices ; Female ; Hemoglobinopathies ; Humans ; Internal Medicine ; Jaundice ; Korea* ; L-Lactate Dehydrogenase ; Male ; Oxidoreductases ; Pallor ; Pathology, Molecular ; Pediatrics ; Phosphopyruvate Hydratase ; Prevalence ; Pyruvate Kinase ; Reticulocyte Count ; Retrospective Studies* ; Sex Ratio ; Surveys and Questionnaires

Introduction of tacrolimus has been accepted as one of the major advance in the management of rejection following solid organ transplantation. This open-label, multi-center study is designed to confirm the efficacy of tacrolimus in primary kidney transplantation. A total of 64 renal transplant recipients were recruited from 4 medical centers, and received dual drug therapy consists of tacrolimus and low-dose corticosteroids after kidney transplantation. Tacrolimus was started 2 days prior to the transplantation with the dosage of 0.2 mg/kg/day. Daily dose of tacrolimus was modulated to maintain the trough blood level between 15 ng/ml and 20 ng/ml for the first 3 months and between 10 ng/ml and 15 ng/ml for the next 3 months after the transplantation. Steroid pulse therapy with methylprednisolone was used as a first line modality of acute rejection treatment. Steroid resistant rejection was treated with anti- lymphocyte agents. Post-transplant diabetes mellitus was defined as the cases when patients who had no history of glucose intolerance need the use of oral hypoglycemics and/or insulin for 30 days or longer to control their hyperglycemia after transplantation. There were 51 live donor and 13 cadaveric donor transplantations. Live donor transplantation consisted with 33 related (10 HLA identical, 23 HLA haplo- identical) and 18 unrelated pairs. Mean age of the patients was 39.4 9.6 (range; 22-58). There were 36 male and 28 female patients. There were 21 acute rejection episodes in 17 patients (26.6%) during the first 6 months after transplantation. Six patients were treated with anti-lymphocyte agents, and 4 patients showed complete response but 2 episodes (9.5%) showed partial rescue. Six-month patient and graft survivals were 100% and 98.4%, respectively. A total of 18 patients (28.1%) experienced glucose intolerance during the study period. Tacrolimus showed satisfactory efficacy in primary kidney transplantation. Long-term follow up is needed for further evaluation of efficacy and safety.
Adrenal Cortex Hormones ; Cadaver ; Diabetes Mellitus ; Drug Therapy ; Female ; Follow-Up Studies ; Glucose Intolerance ; Graft Survival ; Humans ; Hyperglycemia ; Hypoglycemic Agents ; Insulin ; Kidney Transplantation ; Kidney* ; Lymphocytes ; Male ; Methylprednisolone ; Organ Transplantation ; Prospective Studies* ; Tacrolimus* ; Tissue Donors ; Transplantation ; Transplants

Cyclosporine (CsA) has been one of the main immunosuppressants after kidney transplantation since its introduction in Korea. There was remarkable improvement of graft survival in kidney transplantation with CsA, compared with azathioprine. Cipol-N(R)(Chong Kun Dang, Korea), microemulsion gelatin capsule formulation of CsA, is a new generic drug. This pure domestic brand of CsA was tested for bioequivalence in healthy adults compared with the reference drug of the same formulation, Sandimmun-Neoral(R)(Novartis, Switzerland) in 1997. This open-label, multi-center study is designed to evaluate the efficacy of Cipol-N(R) in primary kidney transplant recipients for 6 months after transplantation. A total of 59 patients from 4 medical centers were enrolled in the study. Maintenance immunosuppressive protocol was based on CsA and steroid dual therapy, which was induced 2 days prior to the operation. Acute rejection was diagnosed with clinical or pathological clue. Clinical criteria for the diagnosis of acute rejection were oliguria, graft swelling and tenderness, rising serum creatinine, fever, and papillary swelling and increased vascular resistant index on Doppler ultrasonography. Steroid pulse therapy was used as primary treatment. Steroid resistant acute rejection was treated with anti-lymphocyte agents such as OKT3, ATG, or ALG. The primary efficacy endpoint was onset of acute rejection or treatment failure, defined as graft loss, death, or premature termination from the study for any reason. Incidence and severity of acute rejection, actual survival rate of patient and graft, function of the graft, pharmacokinetics of the Cipol-N(R), and the primary efficacy variables were evaluated 6 months after transplantation. All enrolled patients were included in the primary analyses of efficacy on the basis of intent to treat. Mean age of the patients was 37.1 10.4 years old. Male and female ratio was 42:17. There were 38 related pairs, which included 5 HLA identical and 33 HLA haplo-identical matches, and 21 unrelated pairs. A total of 10 patients were withdrawn from the study before post- transplant 6 months. The causes for premature withdrawal were patient's request without specific reason (6), partially rescued acute rejection (3), and patient's death (1). There were 27 episodes of acute rejection in 25 patients, which were diagnosed clinically (11) and pathologically (16). Steroid pulse therapy and anti-lymphocyte agent were used in 24 and 3 cases respectively. There were 4 patients, who showed partial rescue but no graft loss due to acute rejection. Patient and graft survival was 98.3% at post-transplant 6 months. Serum creatinine concentration showed 1.3-1.7 mg/dl all through the study period, which meant relatively stable graft function. Mean daily doses of Cipol-N(R) at post-transplant 1 and 6 months were 325 and 300 mg respectively. With this short term study, we can report that Cipol-N(R) showed relatively good efficacy in primary living donor kidney transplantation. Further study is needed for the evaluation of long term efficacy and safety.
Adult ; Azathioprine ; Creatinine ; Cyclosporine ; Diagnosis ; Female ; Fever ; Gelatin ; Graft Survival ; Humans ; Immunosuppressive Agents ; Incidence ; Kidney Transplantation ; Kidney* ; Korea ; Living Donors* ; Male ; Muromonab-CD3 ; Oliguria ; Pharmacokinetics ; Survival Rate ; Therapeutic Equivalency ; Transplantation ; Transplants ; Treatment Failure ; Ultrasonography, Doppler

Cyclosporine (CsA) has been one of the main immunosuppressants after kidney transplantation since its introduction in Korea. There was remarkable improvement of graft survival in kidney transplantation with CsA, compared with azathioprine. Cipol-N(R)(Chong Kun Dang, Korea), microemulsion gelatin capsule formulation of CsA, is a new generic drug. This pure domestic brand of CsA was tested for bioequivalence in healthy adults compared with the reference drug of the same formulation, Sandimmun-Neoral(R)(Novartis, Switzerland) in 1997. This open-label, multi-center study is designed to evaluate the efficacy of Cipol-N(R) in primary kidney transplant recipients for 6 months after transplantation. A total of 59 patients from 4 medical centers were enrolled in the study. Maintenance immunosuppressive protocol was based on CsA and steroid dual therapy, which was induced 2 days prior to the operation. Acute rejection was diagnosed with clinical or pathological clue. Clinical criteria for the diagnosis of acute rejection were oliguria, graft swelling and tenderness, rising serum creatinine, fever, and papillary swelling and increased vascular resistant index on Doppler ultrasonography. Steroid pulse therapy was used as primary treatment. Steroid resistant acute rejection was treated with anti-lymphocyte agents such as OKT3, ATG, or ALG. The primary efficacy endpoint was onset of acute rejection or treatment failure, defined as graft loss, death, or premature termination from the study for any reason. Incidence and severity of acute rejection, actual survival rate of patient and graft, function of the graft, pharmacokinetics of the Cipol-N(R), and the primary efficacy variables were evaluated 6 months after transplantation. All enrolled patients were included in the primary analyses of efficacy on the basis of intent to treat. Mean age of the patients was 37.1 10.4 years old. Male and female ratio was 42:17. There were 38 related pairs, which included 5 HLA identical and 33 HLA haplo-identical matches, and 21 unrelated pairs. A total of 10 patients were withdrawn from the study before post- transplant 6 months. The causes for premature withdrawal were patient's request without specific reason (6), partially rescued acute rejection (3), and patient's death (1). There were 27 episodes of acute rejection in 25 patients, which were diagnosed clinically (11) and pathologically (16). Steroid pulse therapy and anti-lymphocyte agent were used in 24 and 3 cases respectively. There were 4 patients, who showed partial rescue but no graft loss due to acute rejection. Patient and graft survival was 98.3% at post-transplant 6 months. Serum creatinine concentration showed 1.3-1.7 mg/dl all through the study period, which meant relatively stable graft function. Mean daily doses of Cipol-N(R) at post-transplant 1 and 6 months were 325 and 300 mg respectively. With this short term study, we can report that Cipol-N(R) showed relatively good efficacy in primary living donor kidney transplantation. Further study is needed for the evaluation of long term efficacy and safety.
Adult ; Azathioprine ; Creatinine ; Cyclosporine ; Diagnosis ; Female ; Fever ; Gelatin ; Graft Survival ; Humans ; Immunosuppressive Agents ; Incidence ; Kidney Transplantation ; Kidney* ; Korea ; Living Donors* ; Male ; Muromonab-CD3 ; Oliguria ; Pharmacokinetics ; Survival Rate ; Therapeutic Equivalency ; Transplantation ; Transplants ; Treatment Failure ; Ultrasonography, Doppler

Autoimmune hepatitis in children is a rare and severe inflammatory disease of unknown etiology, and progress to cirrohosis and liver failure, generally is responsive to immunosuppressive therapy. It is more prevalent in women than men, and characterized by the presence of circulating autoantibodies, a high serum globulin. Extrahepatic manifestations such as thyroiditis, ulcerative colitis, glomerulonephritis and autoimmune hemolytic anemia, are associated. We report, to our knowledge, the first case of autoimmune hepatitis in conjunction with choledochal cyst and pancreatitis in 11-year-old female patient. At the time of diagnosis, she suffered from acute upper abdominal pain, jaundice, and pallor. Laboratory findings showed Cooms positive hemolytic anemia, hypergammaglobulinemia, hyperbilirubinemia, and high serum transaminases. Antinuclear antibody was of homogeneous type. In liver biopsy, cellular infiltrates largely lymphocytes were noted. Treatment with corticosteroids induced clinical, biochemical remission, but subsequent withdrawal leaded to relapse. Incidentally choledochal cyst were found and then acute pancreatitis developed. After management for acute pancreatitis, surgical resection of cyst with hepatojejunostomy was performed.
Abdominal Pain ; Adrenal Cortex Hormones ; Anemia, Hemolytic ; Anemia, Hemolytic, Autoimmune ; Antibodies, Antinuclear ; Autoantibodies ; Biopsy ; Child ; Choledochal Cyst* ; Colitis, Ulcerative ; Diagnosis ; Female ; Glomerulonephritis ; Hepatitis, Autoimmune* ; Humans ; Hyperbilirubinemia ; Hypergammaglobulinemia ; Jaundice ; Liver ; Liver Failure ; Lymphocytes ; Male ; Pallor ; Pancreatitis* ; Recurrence ; Thyroid Gland ; Thyroiditis ; Transaminases

This technique in the conscious volunteers to study the neuromuscular blockade was described in which two different muscle relaxants of ED95X10(-1) in 20ml 0.9% saline were injected simultaneously into one arm and the contralateral arm below the occlusion site of circulation with tourniquet, and then two different neuromuscular blockades were compared following tourniquet released after 80% twitch depression. The benefits of this technique were obtained as following; 1) Simplicity, saving and safety from easily to set up and using low dose of muscle relaxant. 2) Expected results from pure effects of muscle relaxant without any drug interactions. 3) Time shortening of experimental study. 4) Saving time and experiments from simultaneously comparison of control with study group in one experiment. 5) The study of pure receptor binding with muscle relaxant, since a presumed plasma concentration of muscle relaxants is near or actually zero after release of the tourniquet when fresh blood had flushed the limb. Conclusively bilateral isolated forearm technique is elegant method to study the biophase binding interacted of relaxants and cholinerceptor.
Arm ; Depression ; Drug Interactions ; Extremities ; Forearm* ; Neuromuscular Blockade* ; Neuromuscular Blocking Agents ; Plasma ; Tourniquets ; Volunteers