• Tuberculosis and Respiratory Diseases
• /
• v.59 no.5
• /
• pp.522-529
• /
• 2005

Background : Several national societies have published guidelines for empirical antimicrobial therapy in patients with severe community-acquired pneumonia (SCAP). This study investigated the etiologies of SCAP in the Asan Medical Center and assessed the relationship between the initial empirical antimicrobial regimen and 30 day mortality rate. Method : retrospective analysis was performed on patients with SCAP admitted to the ICU between March 2002 and February 2004 in the Asan Medical Center. The basic demographic data, bacteriologic study results and initial antimicrobial regimen were examined for all patients. The clinical outcomes including the ICU length of stay, the ICU mortality rate, and 30 days mortality rates were assessed by the initial antimicrobial regimen. Results : One hundred sixteen consecutive patients were admitted to the ICU (mean age 66.5 years, 81.9 % male, 30 days mortality 28.4 %). The microbiologic diagnosis was established in 58 patients (50 %). The most common pathogens were S. pneumoniae (n=12), P. aeruginosae (n=9), K. pneumonia (n=9) and S. aureus (n=8). The initial empirical antimicrobial regimens were classified as: ${\beta}$-lactam plus macrolide; ${\beta}$-lactam plus fluoroquinolone; anti-Pseudomonal ${\beta}$-lactam plus fluoroquinolone; Aminoglycoside combination regimen; ${\beta}$-lactam plus clindamycin; and ${\beta}$-lactam alone. There were no statistical significant differences in the 30-day mortality rate according to the initial antimicrobial regimen (p = 0.682). Multivariate analysis revealed that acute renal failure, acute respiratory distress syndrome and K. pneumonae were independent risk factors related to the 30 day mortality rate. Conclusion : S. pneumoniae, P. aeruginosae, K. pneumonia and S. aureus were the most common causative pathogens in patients with SCAP and K. pneumoniae was an independent risk factor for 30 day mortality. The initial antimicrobial regimen was not associated with the 30-day mortality.

• Tuberculosis and Respiratory Diseases
• /
• v.45 no.6
• /
• pp.1143-1153
• /
• 1998

Background : Recent outbreaks of pulmonary disease due to drug-resistant strains of Mycobacterium Tuberculosis have resulted in significant morbidity and mortality in patients worldwide. We reviewed our experience to evaluate the effects of pulmonary resection on the management of multidrug-resistant tuberculosis. Method : A retrospective review was performed of 41 patients undergoing pulmonary resection for multidrug-resistant tuberculosis between January 1993 and December 1997. We divided these into 3 groups according to the radiologic findings : (1) patients who have reasonably localized lesion (Localized Lesion Group ; LLG) (2) patients who have cavitary lesions after pulmonary resection on chest roentgenogram (Remained Cavity Group : RCG) (3) patients who have Remained infiltrative lesions postoperatively (Remained infiltrative group : RIG). We evaluated the negative conversion rate after resection and overall response rate of the groups. Then they were compared with the results of the chemotherapy on the multi drug-resistant tuberculosis which has been outcome by Goble et al. Goble et al reported that negative conversion rate was 65% and overall response rate, 56% over a mean period of 5.1 months. Results : Seventy five point six percent were men and 24.4% women with a median age of 31 years (range, 16 to 60 years). Although the patients were treated preoperatively with multidrug regimens in an effort to reduce the mycobacterial burden, 22 of 41 were still sputum culture positive at the time of surgery. 20 of 22 patients(90.9%, p<0.01) responded which is defined as negative sputum cultures within 2 months postoperative. Of 26 patients with the sufficient follow up data, 19 have Remained sputum culture negative for a mean duration of 25.7 months (73.1%, p<0.05). The bulk of the disease was manifest in one lung, but lesser amounts of contralateral disease were demonstrated in 15, consisted of 8 in RIG and 7 in RCG, of 41. 12 of 12 patients (100%, p<0.01) who were sputum positive at the time of surgery in LLG converted successfully. 14 of 15 patients (93.3%, p<0.05) with the follow up have completed treatment and not relapsed for a mean period of 25. 7 months. The mean length of postoperative drug therapy of LLG was 12.2 months. In RIG, postoperative negative conversion rate was 83.3% which was not significant statistically. There was a statistical significance in overall response rate (100%, p<0.05) of RIG for a mean period of 24.4 months with a mean length of postoperative chemotherapy, 11.8 months. In RCG a statistically lower overall response rate (14.3%, p<0.01) has been revealed for a mean duration of follow up, 24.2 months. A negative conversion rate of RCG was 75% which was not significant statistically. Conclusion : Surgery plays an important role in the management of patients with multidrug-resistant Mycobacterium tuberculosis infection. Aggressive pulmonary resection should be performed for resistant Mycobacterium tuberculosis infection to avoid treatment failure or relapse. Especially all cavitary lesions on preoperative chest roentgenogram should be resected completely. If all of them could not be resected perfectly, you should not open the thorax.

• Tuberculosis and Respiratory Diseases
• /
• v.45 no.6
• /
• pp.1199-1213
• /
• 1998

Background : The number of immunocompromised hosts has been increasing steadily and a new pulmonary infiltrate in these patients is a potentially lethal condition which needs rapid diagnosis and treatment. In this study we sought to examine the clinical manifestations, radiologic findings, and therapeutic outcomes of pulmonary mycoses presenting as a new pulmonary infiltrate in immunocompromised hosts. Method : All cases presenting as a new pulmonary infiltrate in immunocompromised hosts and confirmed to be pulmonary mycoses by pathologic examination or by positive culture from a sterile site between October of 1996 and April of 1998 were included in the study and their chart and radiologic findings were retrospectively reviewed. Results : In all, 14 cases of pulmonary mycoses from 13 patients(male : female ratio = 8 : 5, median age 47 yr) were found. Twelve cases were diagnosed as aspergillosis while two were diagnosed as mucormycosis. Major risk factors for fungal infections were chemotherapy for hematologic malignancy(10 cases) and organ transplant recipients(4 cases). Three cases were receiving empirical amphotericin B at the time of appearance of new lung infiltrates. Cases in the hematologic malignancy group had more prominent symptoms : fever(9/10), cough(6/10), sputum(5/10), dyspnea(4/10), chest pain(5/10). Patients in the organ transplant group had minimal symptoms(p<0.05). On simple chest films, all of the cases presented as single or multiple nodules(6/14) or consolidations(8/14). High resolution computed tomograph showed peri-lesional ground glass opacities(14/14), pleural effusions(5/14), and cavitary changes(7/14). Definitive diagnostic methods were as follows : 10 cases underwent minithoracotomy, 2 underwent video-assisted thoracoscopic surgery, 1 underwent percutaneous needle aspiration and 1 case was diagnosed by culture of abscess fluid. All cases received treatment with amphotericin B with 1 case each being treated with liposomal amphotericin B and itraconazole due to renal toxicity. Lung lesion improved in 12 of 14 patient but 4 patients died before completing therapy. Conclusion : When a new lung infiltrate develops presenting either as a nodule or consolidation in a neutropenic patient with hematologic malignancy or in a transplant recipient, you should always consider pulmonary mycoses as one of the differential diagnosis. By performing aggressive work up and early treatment, we may improve prognosis of these patients.

• Tuberculosis and Respiratory Diseases
• /
• v.42 no.4
• /
• pp.481-491
• /
• 1995

Background: Recently there has been a trend of an increasing incidence of mediastinal tuberculous lymphadenitis(MTL) in adults. MTL often cause bronchial stenosis or esophago-mediastinal fistula. In spite of effective treatment, it is difficult to cure. Moreover, relapse frequently occurs. Authors analyzed chest CT findings and clinical features of 29 cases with MTL Methods: 29 cases with MTL were retrospectively studied with the clinical and radiologic features from April 1990 to March 1995 Results: 1) A total of 29 cases were studied. 12 cases were male and 17 cases were female. The male to female ratio was 1:1.4 Mean age was 29 years old. The 3rd decade(45%) was the most prevalent age group 2) The most common presenting symptoms and signs were palpable neck masses(62%) followed by cough(59%) and sputum(38%) 3) Except in one case of MTL, all patients had coexisting pulmonary tuberculosis, cervical tuberculous lymphadenitis, endobronchial tuberculosis and tuberculous pleurisy. Among the coexisting tuberculous diseases, Pulmonary tuberculosis was the most common(76%) 4) On simple chest X-ray, mediastinal enlargement was noted in 21 cases(72%), but it was not noted in 8 cases(28%). The most frequently involving site was the paratracheal node in 16 cases(72%). Rt side predominence(73%) was noted 5) Patterns of node appearance on a postcontrast CT scan were classified into 3 types. There were 19 cases(30%) of the Homogenous type, 30 cases(47%) of the Central low density type and 15 cases(23%) of the Peripheral fat obliteration type. The most common type was the central low density type. The most common lymph node size was 1~2 cm(88%) 6) The most frequently involved site was the paratracheal node in 26 cases(89%) by chest CT. Rt side(63%) was predominant 7) 9 cases(43%) had complete therapy and most common treatment duration was 13 - 18 months. 12 cases(57%) had incomplete continuing antituberculous medication and half of the cases had been treated above 19 months. Conclusion: Chest CT findings of MTL showed central low density area and peripheral rim enhancement, so this characteristic findings could differentiate it from other mediastinal diseases and help a diagnosis of tuberculosis. In spite of effective antituberculous medication, it is difficult to cure. Moreover, relapse frequently occurs. Further studies will be needed of the clinical features and the treatment of MTL.

• Tuberculosis and Respiratory Diseases
• /
• v.45 no.5
• /
• pp.1058-1066
• /
• 1998

Background: Actinomycotic infection is uncommon and primary actinomycosis of the lung and chest wall has been less frequently reported. This disease may present as chronic debilitating illness with radiologic manifestation simulating lung tumor, pulmonary infiltrating lesion, or chronic suppuration. Diagnosis of choice was not definded yet and role of bronchoscopy on diagnosis was not described yet. Methods: From 1989 to 1998, we experienced 17 cases of thoracic actinomycosis. We have reviewed the case notes of 17 patients with thoracic actinomycosis. The mean age at presentation was $53{\pm}13$ years, 11 were male. Results: Cough, hemoptysis, sputum production, chest pain and weight loss were the commonest symptoms. The mean delay between presentation and diagnosis was $6.6{\pm}7.8$ months. There were six patients who presented with a clinical picture of a suppurative lesion and eleven patients were suspected of having primary lung tumor initially. In no cases was made an accurate diagnosis at the time of hospital admission. Associated diseases were emphysema (1 case), bronchiectasis (2 cases) and tuberculosis (2 cases). Bronchoscopic findings were mucosal swelling and stenosis(n=4), mucosal swelling, stenosis and necrotic covering (n=2), mass (n=3), mass and necrotic covering (n=1) and normal(n=6). Radiologic findings were mass lesion(n=8), pneumonitis(n=3), atelectasis(n=3), pleural effusion(n=2), and normal(n=3). Final diagnosis was based on percutaneous needle aspiration and biopsy (n=3), bronchoscopic biopsy specimens (n=9), mediastinoscopic biopsy (n=1) and histologic examination of resected tissue in the remaining patients(n=4) who received surgical excision. Among 17 patients, 13 were treated medically and the other 4 received surgical intervention followed by antibiotic treatment. Regarding the surgically treated patients, suspected malignancy is the most common indication for operation. However. both medically and surgically treated patients achieved good clinical results. Conclusion: Thoracic actinomycosis is rare. but should still be considered in the differential diagnosis of a chrinic, localized pulmonary lesion. Thoracic actinomycosis may co-exist with pulmonary tuberculosis or lung cancer. If the lesion is located in the central of the lung. the bronchoscopy is recommanded for the diagnosis.

• The Journal of Korean Academy of Prosthodontics
• /
• v.46 no.2
• /
• pp.125-136
• /
• 2008

Statement of problem: Since the concept of osseointegration in dental implants was introduced by $Br{{\aa}}nemark$ et al, high long-term success rates have been achieved. Though the use of dental implants have increased dramatically, there are few studies on domestic implants with clinical and objective long-term data. Purpose: The aim of this retrospective study was to provide long-term data on the $Neoplan^{(R)}$ implant, which features a sandblasted and acid-etched surface and external connection. Material and methods: 96 $Neoplan^{(R)}$ implants placed in 25 patients in Yonsei University Hospital were examined to determine the effect of the factors on marginal bone loss, through clinical and radiographic results during 18 to 57 month period. Results: 1. Out of a total of 96 implants placed in 25 patients, two fixtures were lost, resulting in 97.9% of cumulative survival rate. 2. Throughout the study period, the survival rates were 96.8% in the maxilla and 98.5% in the mandible. The survival rates were 97.6% in the posterior regions and 100% in the anterior regions. 3. The mean bone loss for the first year after prosthesis placement and the mean annual bone loss after the first year for men were significantly higher than that of women (P<0.05). 4. The group of partial edentulism with no posterior teeth distal to the implant prosthesis showed significantly more bone loss compared to the group of partial edentulism with presence of posterior teeth distal to the implant prosthesis in terms of mean bone loss for the first year and after the first year (P<0.05). 5. The mean annual bone loss after the first year was more pronounced in posterior regions compared to anterior regions (P<0.05). 6. No significant difference in marginal bone loss was found in the following factors: jaws, type of prostheses, type of opposing dentition, and submerged /non-submerged implants (P<0.05). Conclusion: On the basis of these results, the factors influencing marginal bone loss were gender, type of edentulism, and location in the arch, while the factors such as arch, type of prostheses, type of opposing dentition, submerged / non- submerged implants had no significant effect on bone loss. In the present study, the cumulative survival rate of the $Neoplan^{(R)}$ implant with a sandblasted and acid-etched surface was 97.9% up to a maximum 57-month period. Further long-term investigations for this type of implant system and evaluation of other various domestic implant systems are needed in future studies.

• Tuberculosis and Respiratory Diseases
• /
• v.56 no.3
• /
• pp.280-288
• /
• 2004

Background : Lung protective strategies, using low tidal volume in ARDS, improve survival rate in ARDS. However, low tidal volume ventilation may promote alveolar de-recruitment. Therefore, alveolar recruitment is necessary to maintain arterial oxygenation and to prevent repetitive opening and closure of collapsed alveoli in lung protective strategies. There has been a recent report describing improvement in arterial oxygenation with use of recruitment maneuver. However, impact of recruitment on outcome of ARDS is unknown. We evaluated whether short-term survival difference existed in patients with ARDS, who were performed alveolar recruitment maneuver(ARM) and prone position, according to response of alveolar recruitment or not. Methods : All patients who were diagnosed with ADRS and received mechanical ventilation were included. ARM were sustained inflation($35-45cmH_2O$ CPAP for 30-40 sec.) or increasing level of PEEP. If these methods were ineffective, alveolar recruitment with prone position was done for at least 10 hours. $P_aO_2/FiO_2$(P/F) ratio was determined before and at 0.5 and 2 hours after ARM. We defined a responder if the P/F ratio was increased over 50% of baseline value. We compared 10-days and 30-days survival rate between responders and non-responders. Results : 20 patients(M:F=12:8, $63{\pm}14age$) were included. Among them, 12 patients were responders and 8 patients were non-responders. In responders, P/F ratio was increased from $92{\pm}25mmHg$ to $244{\pm}85mmHg$. In non-responders, P/F ratio increased from $138{\pm}37mmHg$ to $163{\pm}60mmHg$. Among non-responders, P/F ratio was improved over 50% in 2 patients after prone position. Overall, 14 patients were responders after ARM and prone position. The 10-days and 30-days survival rate in responders was significantly higher than in non-responders(86%, 57% in responders and 33%, 0% in non-responders)(p<0.05). There was no significant difference between responders and non-responders in age($71{\pm}11$, $60{\pm}14$), lung injury score($2.8{\pm}0.2$, $2.9{\pm}0.45$), simplified acute physiology score(SAPS) II ($35{\pm}4.6$, $34{\pm}5.7$), positive end-positive pressure level($15.6{\pm}1.9cmH_2O$, $14.5{\pm}2.1cmH_2O$). Conclusion : ARM may improve arterial oxygenation in some patients with ARDS. These responders in patients with ARDS showed significant higher 10-days and 30-days survival rate than non-responders patients with alveolar recruitment.

• The Journal of Korean Society for Radiation Therapy
• /
• v.32
• /
• pp.7-15
• /
• 2020

Purpose: In modern radiotherapy technology, several methods of image guided radiation therapy (IGRT) are used to deliver accurate doses to tumor target locations and normal organs, including CBCT (Cone Beam Computed Tomography) and other devices, ExacTrac System, other than CBCT equipped with linear accelerators. In previous studies comparing the two systems, positional errors were analysed rearwards using Offline-view or evaluated only with a Yaw rotation with the X, Y, and Z axes. In this study, when using CBCT and ExacTrac to perform 6 Degree of the Freedom(DoF) Online IGRT in a treatment center with two equipment, the difference between the set-up calibration values seen in each system, the time taken for patient set-up, and the radiation usefulness of the imaging device is evaluated. Materials and Methods: In order to evaluate the difference between mobile calibrations and exposure radiation dose, the glass dosimetry and Rando Phantom were used for 11 cancer patients with head circumference from March to October 2017 in order to assess the difference between mobile calibrations and the time taken from Set-up to shortly before IGRT. CBCT and ExacTrac System were used for IGRT of all patients. An average of 10 CBCT and ExacTrac images were obtained per patient during the total treatment period, and the difference in 6D Online Automation values between the two systems was calculated within the ROI setting. In this case, the area of interest designation in the image obtained from CBCT was fixed to the same anatomical structure as the image obtained through ExacTrac. The difference in positional values for the six axes (SI, AP, LR; Rotation group: Pitch, Roll, Rtn) between the two systems, the total time taken from patient set-up to just before IGRT, and exposure dose were measured and compared respectively with the RandoPhantom. Results: the set-up error in the phantom and patient was less than 1mm in the translation group and less than 1.5° in the rotation group, and the RMS values of all axes except the Rtn value were less than 1mm and 1°. The time taken to correct the set-up error in each system was an average of 256±47.6sec for IGRT using CBCT and 84±3.5sec for ExacTrac, respectively. Radiation exposure dose by IGRT per treatment was measured at 37 times higher than ExacTrac in CBCT and ExacTrac at 2.468mGy and 0.066mGy at Oral Mucosa among the 7 measurement locations in the head and neck area. Conclusion: Through 6D online automatic positioning between the CBCT and ExacTrac systems, the set-up error was found to be less than 1mm, 1.02°, including the patient's movement (random error), as well as the systematic error of the two systems. This error range is considered to be reasonable when considering that the PTV Margin is 3mm during the head and neck IMRT treatment in the present study. However, considering the changes in target and risk organs due to changes in patient weight during the treatment period, it is considered to be appropriately used in combination with CBCT.

• Pediatric Infection and Vaccine
• /
• v.8 no.2
• /
• pp.213-221
• /
• 2001

Propose : Tsutsugamushi fever is a acute febrile disease, which is caused by O. tsutsugamushi. Recently, this disease is increasingly reported in children. This study was undertaken to investigate clinical features of tsutsugamushi fever in children. Methods : This study involved 17 children with tsutsugamushi fever who were admitted to Masan Samsung hospital between September 1997 and December 2000. We investigated the age, sex ratio, clinical manifestations, laboratory findings, response of therapy and prognosis. Results : The age of patients was $6.9{\pm}3.6$ years, ranging from 6 months to 12 years and male predilection(58.8%) was noted and all cases of patients occured in October or November. The most common symptoms were fever in all cases and headache in 8(47.1%). The most common signs were skin rash in all cases, eschar in 14(82.4%) and lymphadenopathy 8(47.1%). Locations of the eschars were back and inguinal area in each 3 cases, neck and chest in each 2, popliteal area in 2, scalp and thigh in each 1. Laboratory findings included anemia in 1 case, leukopenia and thrombocytopenia in each 5, hematuria and proteinuria in each 1, ESR elevation in 2 and positive CRP in 12, AST elevation in 9 and ALT elevation in 7. Serologic diagnosis was made by passive hemagglutination assay(PHA) in 8 cases(47%) on admission, 4 cases in initial negative group were performed follow-up test at 2nd or 3rd weeks of illness and then all cases of 4 were converted to positive reaction. Clinical improvement was noticed in all cases after treatment to chloramhenicol or doxycycline. Mean duration for defervescence after treatment was $1.4{\pm}0.8$ days. Complications were interstitial pneumonia in 1 case and aseptic meningitis in 3, but all cases of patients were recovered without sequelae or recurrence. Conclusions : Tsutsugamushi fever in children was similiar to adult in the clinical features except male predilection. Early diagnosis and empirical treatment based on clinical manifestations such as fever, skin rash, eschar, lymphadenopathy is important and serologic diagnosis need to perform follow-up test at 2nd or 3rd weeks of illness.

• Pediatric Infection and Vaccine
• /
• v.14 no.2
• /
• pp.145-154
• /
• 2007

Purpose : Rotavirus is one of the most important etiologic agents of nosocomial infections among the neonates. This study was designed to investigate nosocomial rotavirus infection in neonates who were admitted to a postpartum-care center after birth. Methods : From March 2005 to September 2006, 957 healthy neonates were examined for rotavirus antigen in stool by immunochromatographic method and 216 neonates were rotavirus antigen positive within 24 hours after admitted to a postpartum-care center. We reviewed the nursing charts retrospectively such as characteristics, monthly distribution, birth hospitals, delivery methods, feeding types and clinical manifestations. Results : Among 957 neonates, 216 neonates (22.6%) were rotavirus antigen positive and there were no differences in sex, birth weight, gestational age. Monthly positive rate of rotavirus antigen showed diversity from 10% to 36%. According to birth hospitals, positive rate showed diversity from 3.5% to 53.6%. Out of 957 neonates, 655 cases (68.4%) were born of vaginal delivery and mean hospitalized duration was 2.4 days, 302 cases (31.6%) were born of cesarean section and mean hospitalized duration was 5.7 days. 17.6% of vaginal delivery and 33.4% of cesarean section were rotavirus antigen positive. The positive rate was higher in neonates by cesarean section than vaginal delivery (P<0.001). According to feeding types, positive rate of rotavirus antigen was lower in breast-fed group than formula-fed group (P<0.001). Proportion of symptomatic case among rotavirus antigen positive was 34.7%. Most common clinical manifestation was diarrhea (61.3%), following poor feeding (45.3%), fever (40.0%), vomiting (25.3%), delayed weight gain (12.0%), and decreased urine amount (5.3%). Conclusion : Some neonates were already infected before admission to a postpartum-care center. Without meticulous management, nosocomial rotavirus infection would transmit rapidly in a postpartum-care center spreading to the community. Recommendation of breast-feeding, routine rotavirus screeing test with or without symptom, and isolation of all rotavirus antigen positive neonates in a postpartum-care center seem to be necessary. Also attentive hygiene education and further investigations of rotavirus infection in a postpartum-care center would be needed.