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대량 객혈환자에서 기관지 동맥색전술의 효과 (Effect of Bronchial Artery Embolization(BAE) in Management of Massive Hemoptysis)

  • 여동승;이숙영;현대성;이상학;김석찬;최영미;서지원;안종현;송소향;김치홍;문화식;송접섭;박성학;김기태
    • Tuberculosis and Respiratory Diseases
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    • 제46권1호
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    • pp.53-64
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    • 1999
  • 연구배경: 대량객혈을 치료하지 않는 경우 사망률이 50% 이상으로 매우 높은 것으로 알려져 있다. 대부분의 경우 출혈이 기관지 동맥에서 발생하고, 기관지 동맥색전술은 75-90% 의 환자에서 즉각적인 지혈효과를 가져오므로 대량객혈의 효과적인 치료방법으로 받아들여 지고 있다. 저자들은 대량 객혈환자에서 기관지 동맥 색전술의 유용성과 효과를 알아 보고자 하였고 또한, 성공적인 색전술후 재출혈에 관여 하는 인자를 알아보고자하였다. 방 법: 1990년 2월부터 1996년 7월 까지 가톨릭 의과대학 소속 7개 부속병원에 객혈을 주소로 내원하여 2 회 이상 객혈을 보이거나, 1 일 400-600cc 이상 대량 객혈을 보이는 환자에서 동맥색전술을 시행한 환자중에서 1년이상 경과관찰이 가능한 146명을 대상으로 하였다. 결 과: 기관지 동맥색전술을 시행한 환자는 남자 98예(67.1%), 여자48예(32.9%)였고, 객혈의 원인 질환으로는 폐결핵 및 이와 동반된 병변이 106예(72.6%)로 가장 많았다. 지혈에 사용된 색전물질로는 Ivalon을 단독으로 사용한 예가 58예(39.7%)로 가장 많았고, Gelfoam만 사용한 예는 52예(35.6%), 코일과 Gelfoam을 병용한 예는 24예(16.4%), Ivalon과 Gelfoam을 병용한 예는 9예(6.2%), 코일만 사용한 예는 3예(2.1%)이었다. 기관지 동맥색전술을 이용한 24시간 이내의 지혈의 성공률은 95%였으며, 추적관찰 중 객혈의 재발은 36예(24.7%)였고, 2 회이상 재발한 환자는 6예(4.1%)였다. 기관지 동맥색전술의 합병증은 40명(27.4%)의 환자에서 총 58 건수가 발생하였는데, 발열이 22 건(37.9%)으로 가장 많았고, 흉통 9건(32.8%), 두통 4건(6.9%), 오심 및 구토 3건(5.2%), 부정맥 2건(3.4%)순으로 나타났고, 기타 기침, 요통, 마비성장폐색, 배뇨장애, 하지감각 소실, 견갑골 통증, 저혈압, 두드러기등이 각각 1건씩 발생하였다. 초기 기관지동맥 조영술 소견상 색전의 대상이 양측성인 경우, 체측부동맥-폐동맥간 단락이 있는 경우, 신생혈관 형성, 동맥류, 출혈의 직접적인 소견인 조영제외 누출, 체측부동맥이 영양동맥으로 관여한 경우 등 이들 모두에서 재발군과 비재발군 사이에서 유의한 차이를 보이지 않았다(P>0.05). 원인 질환별, 지혈에 사용한 색전물질, 공동이 있는 경우, 국균종이 동반된 경우, 기관지 확장증이 동반된 경우, 폐기종이 동반된 경우 모두 재발군과 비재발군 사이에서 유의한 차이를 보이지 않았으나(P>0.05), 늑막에 병변이 있는 경우 양군 사이에 유의한 차이가 있었다(P<0.05). 결 론: 기관지 동맥색전술은 대량 객혈시 안전하고, 심각한 합병증의 빈도가 적은 시술로서 특히 초기 지혈효과가 뛰어난 시술방법으로 사료된다. 초기 기관지 동맥조영술 소견에서 출혈의 재발을 예견할 수 있는 의미있는 지표는 없었으나, 늑막에 병변이 있는 경우 재발의 빈도가 높은 것으로 보아 향후 이에 대한 재검토가 필요할 것으로 사료된다.

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내원경위 분석과 환자 특성 평가에 따른 2차 진료기관으로서 구강내과 역할에 대한 연구 (A Study on the Function of Oral Medicine as the Secondary Clinic Based on Analysis on Admissive Channel and Case Features)

  • 이유미;이정현;임현대
    • Journal of Oral Medicine and Pain
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    • 제31권3호
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    • pp.199-210
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    • 2006
  • 구강내과에 내원하는 환자에 대한 역학 연구가 1970년대 이후로 계속 이루어져 왔으며, 대부분이 대학병원내의 구강내과를 중심으로 이루어져 왓다. 구강내과가 개설한 이후에 많은 전문인력이 배출되었으며, 치과의 각계 각층에서 활발한 활동을 보여주고 있다. 치과병원이 대형화되어가는 추세에 있어 대학병원급이 아닌 2차 진료기관에서의 구강내과의 역할이 새삼 부각되고 있다. 이렇듯 대형치과병원이나 종합병원내의 치과병원에 구강내과가 개설됨에 따라 2차 진료기관에서의 구강내과 환자의 내원 분석이나 환자의 특성, 환자의 구성 등에 대한 연구가 전무함에 이에 대한 연구가 필요하리라 생각하여 대전 선병원 구강내과에 내원하는 환자 100명에게 설문지 작성을 통한 역학 조사를 실시하여 다음의 결과를 얻었다. 1. 썬병원 구강내과 환자의 평균나이는 $29.21{\pm}11.31$(n=100)세 였으며, 여자 71명(평균나이 $29.63{\pm}11.29$세) 남자 29명(평균나이 $28.17{\pm}11.48$세)였으며, 최종학력은 고등졸 이상이 78%로 고학력을 지니고 있었다..현재 불편해 하는 증상은 턱관절 통증이 65%으로 제일 많았으며 내원하게 된 동기는 인터넷 검색 11%, 방송매체 10% 주변사람의 소개가 38% 였으며, 같은 불편감으로 다른 병원을 내원한 경험이 있는경우가 56%이었다. 본병원에 가도록 의뢰한 다른 병원은 치과의원은 20%를 나타내었으며, 현재의 불편감이 구강내과에서 진료받아야 하는 지 사전에 인지하고 있는 경우는 38%, 그렇지 않은 경우는 62%였으며 응답한 대상자의 51%가 한달 안쪽에 그 사실을 알게 되었다고 응답하였다. 2. 두경부에의 동통은 58%에서 호소 하였으며, 이러한 통증으로 인하여 일상 생활에 지장이있다고 대답한 경우는 22%였다. 지속적인 통증은 14% 간헐적인 통증은 68%에서 나타났으며, 통증의 성질은 둔한 통증이 23%였다. 3. 사회재적응 평가 척도를 이용한 생활 변화량의 비교에서는 3년이내의 변화량에서 두경부 동통이 있는군과 없는 군사이에 유의성을 보였으며 6개월이내의 변화량에서는 유의성을 보이지 않았다. 4. 일주일간 겪었던 일에 대한 설문에서는 동통이 있는 군과 아닌 군의비교에서 일주일동안 긴장감을 지닌 날의 수와 예전부터 즐겨 하던 일의감소, 갑작스런 공포를 느낌 항목에서 유의성을 보였으며, 기분이 즐겁고 들뜨다 항목과 외모에의 관심 감소항목에서는 유의한 차이를 보이지는 않았으나 유의함에 근접하였다 5. 조급함을 평가하는 설문지에서는 동통군이 비록 약간 더 상승을 보였으나 통계학적으로 유의한 차이를 나타내지는 않았다. 6. 스트레스로 인한 증상 발현은 잇몸에 근질거리는 감각이나 이가솟는 듯한 느낌의 잇몸 증상과 뒷머리가 당기거나 목덜미가 뻣뻣하다의 항목 에서 두경부 동통군과 비동통군 사이에 유의한 차이를 보였으며 볼안쪽이나 잇몸에 껍질이 벗겨지면서 피가 남의 항목과 스트레스시 여드름 뾰로지, 두통의 항목에서 유의성은 보이지 않았으나 유의수준에 근접하였다.

한국인의 만성 기관지염의 급성 악화 환자를 대상으로 한 Moxifloxacin 400mg 1 일 1회 요법과 Clarithromycin 500mg 1일 2회 요법의 치료효과 및 안전성 비교 (A Multicenter, Randomized, Open, Comparative Study for the Efficacy and Safety of Oral Moxifloxacin 400 mg Once a Day and Clarithromycin 500 mg Twice Daily in Korean Patients with Acute Exacerbations of Chronic Bronchitis)

  • 김승준;김석찬;이숙영;윤형규;김태연;김영균;송정섭;박성학;김호중;정만표;서지영;권오정;이신형;강경호;이이형;황성철;한명호
    • Tuberculosis and Respiratory Diseases
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    • 제49권6호
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    • pp.740-751
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    • 2000
  • 연구배경 : Moxifloxacin은 광범위한 미생물에 대한 뛰어난 효과, 안전한profile과 유리한 약물동력을 바탕으로 기존의 fluoroquinolones보다 한단계 진보된 약물이라고 할 수 있다. 이러한 효과는 베타-락탐계 혹은 기타 항생제에 내성을 보이는 미생물들에 대해 매우 유효하다. Moxifloxacin은 특히 Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Chlamydia pneumoniae, Legionella spp. 그리고 Mycoplasma pneumoniae에 의해 유발되는 호흡기 감염에 특히 유용하다고 알려져 있다. 방법 : 다기관, 무작위, 공개, 비교시험으로 만성기관지염의 급성악화 환자를 대상으로 moxifloxacin 400 mg 1일 1회 7일 투여와 clarithromycin 500 mg 1일 2회 7일 투여 그룹간의 안전성과 유효성을 비교하였다. 결과 : 170명의 환자 중에서 87명이 moxifloxacin 투여군 이었고 83명이 clarithromycin 투여군이었다. Moxifloxacin 투여군종에서 76명(세균학적 효과분석은 35명), clarithromycin 투여군중에서 77명(세균학적 효과분석은 31명)이 치료효과분석에 포함되었으며 모든 환자에서 안전성을 분석하였다. 임상적 성공율은 Moxifloxacin 투여군 76명중에서 70명(92.1%) 이었고 clarithromycin 투여군 77명중에서 71명(92.2%) 으로 유사하였다. 세균학적 Moxifloxacin 투여군이 73.5%, clarithromycin 투여군이 54.8% 으로 Moxifloxacin 투여군에서 높게 나타났으나 통계적으로 유의한 차이는 보이지 않았다(p=0.098). 내원시 시행한 객담의 세균 감수성 검사에서 moxifloxacin 투여군이 clarithromycin 투여군보다 Streptococcus pneumoniae, Pseudomonas aeruginosa, Klebsiella pneumoniae에서 높은 감수성을 보여주었다(p<0.001). 이상반응은 moxifloxacin 투여군 86명중에서 12.8% 에서 나타났고, clarithromycin 투여군 83명중에서 21.7%에서 발생하였다. 두통(4.7% vs 4.8%, 각각 moxifloxacin 투여군 vs clarithromycin 투여군)과 소화불량(2.3% vs 6.0%, 각각 moxifloxacin투여군 vs clarithromycin 투여군) 이 두 군에서 가장 흔한 이상 반응이었다. 결론 : 본 임상시혐의 결과, 만성기관지염의 급성악화 환자의 치료에 있어서 moxifloxacin 400 mg 1일 1회 7일간 요법은 clarithromycin 500 mg 1일 2회 요법과 비교할 때 임상적으로 동등한 결과를 나타냈으며 미생물학적으로 우월한 결과를 보여주었다.

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농촌(農村) 주민(住民)들의 의료필요도(醫療必要度)에 관(關)한 연구(硏究) (A Study Concerning Health Needs in Rural Korea)

  • 이성관;김두희;정종학;정극수;박상빈;최정헌;홍순호;라진훈
    • Journal of Preventive Medicine and Public Health
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    • 제7권1호
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    • pp.29-94
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    • 1974
  • Today most developed countries provide modern medical care for most of the population. The rural area is the more neglected area in the medical and health field. In public health, the philosophy is that medical care for in maintenance of health is a basic right of man; it should not be discriminated against racial, environmental or financial situations. The deficiency of the medical care system, cultural bias, economic development, and ignorance of the residents about health care brought about the shortage of medical personnel and facilities on the rural areas. Moreover, medical students and physicians have been taught less about rural health care than about urban health care. Medical care, therefore, is insufficient in terms of health care personnel/and facilities in rural areas. Under such a situation, there is growing concern about the health problems among the rural population. The findings presented in this report are useful measures of the major health problems and even more important, as a guide to planning for improved medical care systems. It is hoped that findings from this study will be useful to those responsible for improving the delivery of health service for the rural population. Objectives: -to determine the health status of the residents in the rural areas. -to assess the rural population's needs in terms of health and medical care. -to make recommendations concerning improvement in the delivery of health and medical care for the rural population. Procedures: For the sampling design, the ideal would be to sample according to the proportion of the composition age-groups. As the health problems would be different by group, the sample was divided into 10 different age-groups. If the sample were allocated by proportion of composition of each age group, some age groups would be too small to estimate the health problem. The sample size of each age-group population was 100 people/age-groups. Personal interviews were conducted by specially trained medical students. The interviews dealt at length with current health status, medical care problems, utilization of medical services, medical cost paid for medical care and attitudes toward health. In addition, more information was gained from the public health field, including environmental sanitation, maternal and child health, family planning, tuberculosis control, and dental health. The sample Sample size was one fourth of total population: 1,438 The aged 10-14 years showed the largest number of 254 and the aged under one year was the smallest number of 81. Participation in examination Examination sessions usually were held in the morning every Tuesday, Wenesday, and Thursday for 3 hours at each session at the Namchun Health station. In general, the rate of participation in medical examination was low especially in ages between 10-19 years old. The highest rate of participation among are groups was the under one year age-group by 100 percent. The lowest use rate as low as 3% of those in the age-groups 10-19 years who are attending junior and senior high school in Taegu city so the time was not convenient for them to recieve examinations. Among the over 20 years old group, the rate of participation of female was higher than that of males. The results are as follows: A. Publie health problems Population: The number of pre-school age group who required child health was 724, among them infants numbered 96. Number of eligible women aged 15-44 years was 1,279, and women with husband who need maternal health numbered 700. The age-group of 65 years or older was 201 needed more health care and 65 of them had disabilities. (Table 2). Environmental sanitation: Seventy-nine percent of the residents relied upon well water as a primary source of dringking water. Ninety-three percent of the drinking water supply was rated as unfited quality for drinking. More than 90% of latrines were unhygienic, in structure design and sanitation (Table 15). Maternal and child health: Maternal health Average number of pregnancies of eligible women was 4 times. There was almost no pre- and post-natal care. Pregnancy wastage Still births was 33 per 1,000 live births. Spontaneous abortion was 156 per 1,000 live births. Induced abortion was 137 per 1,000 live births. Delivery condition More than 90 percent of deliveries were conducted at home. Attendants at last delivery were laymen by 76% and delivery without attendants was 14%. The rate of non-sterilized scissors as an instrument used to cut the umbilical cord was as high as 54% and of sickles was 14%. The rate of difficult delivery counted for 3%. Maternal death rate estimates about 35 per 10,000 live births. Child health Consultation rate for child health was almost non existant. In general, vaccination rate of children was low; vaccination rates for children aged 0-5 years with BCG and small pox were 34 and 28 percent respectively. The rate of vaccination with DPT and Polio were 23 and 25% respectively but the rate of the complete three injections were as low as 5 and 3% respectively. The number of dead children was 280 per 1,000 living children. Infants death rate was 45 per 1,000 live births (Table 16), Family planning: Approval rate of married women for family planning was as high as 86%. The rate of experiences of contraception in the past was 51%. The current rate of contraception was 37%. Willingness to use contraception in the future was as high as 86% (Table 17). Tuberculosis control: Number of registration patients at the health center currently was 25. The number indicates one eighth of estimate number of tuberculosis in the area. Number of discharged cases in the past accounted for 79 which showed 50% of active cases when discharged time. Rate of complete treatment among reasons of discharge in the past as low as 28%. There needs to be a follow up observation of the discharged cases (Table 18). Dental problems: More than 50% of the total population have at least one or more dental problems. (Table 19) B. Medical care problems Incidence rate: 1. In one month Incidence rate of medical care problems during one month was 19.6 percent. Among these health problems which required rest at home were 11.8 percent. The estimated number of patients in the total population is 1,206. The health problems reported most frequently in interviews during one month are: GI trouble, respiratory disease, neuralgia, skin disease, and communicable disease-in that order, The rate of health problems by age groups was highest in the 1-4 age group and in the 60 years or over age group, the lowest rate was the 10-14 year age group. In general, 0-29 year age group except the 1-4 year age group was low incidence rate. After 30 years old the rate of health problems increases gradually with aging. Eighty-three percent of health problems that occured during one month were solved by primary medical care procedures. Seventeen percent of health problems needed secondary care. Days rested at home because of illness during one month were 0.7 days per interviewee and 8days per patient and it accounts for 2,161 days for the total productive population in the area. (Table 20) 2. In a year The incidence rate of medical care problems during a year was 74.8%, among them health problems which required rest at home was 37 percent. Estimated number of patients in the total population during a year was 4,600. The health problems that occured most frequently among the interviewees during a year were: Cold (30%), GI trouble (18), respiratory disease (11), anemia (10), diarrhea (10), neuralgia (10), parasite disease (9), ENT (7), skin (7), headache (7), trauma (4), communicable disease (3), and circulatory disease (3) -in that order. The rate of health problems by age groups was highest in the infants group, thereafter the rate decreased gradually until the age 15-19 year age group which showed the lowest, and then the rate increased gradually with aging. Eighty-seven percent of health problems during a year were solved by primary medical care. Thirteen percent of them needed secondary medical care procedures. Days rested at home because of illness during a year were 16 days per interviewee and 44 days per patient and it accounted for 57,335 days lost among productive age group in the area (Table 21). Among those given medical examination, the conditions observed most frequently were respiratory disease, GI trouble, parasite disease, neuralgia, skin disease, trauma, tuberculosis, anemia, chronic obstructive lung disease, eye disorders-in that order (Table 22). The main health problems required secondary medical care are as fellows: (previous page). Utilization of medical care (treatment) The rate of treatment by various medical facilities for all health problems during one month was 73 percent. The rate of receiving of medical care of those who have health problems which required rest at home was 52% while the rate of those who have health problems which did not required rest was 61 percent (Table 23). The rate of receiving of medical care for all health problems during a year was 67 percent. The rate of receiving of medical care of those who have health problems which required rest at home was 82 percent while the rate of those who have health problems which did not required rest was as low as 53 percent (Table 24). Types of medical facilitied used were as follows: Hospital and clinics: 32-35% Herb clinics: 9-10% Drugstore: 53-58% Hospitalization Rate of hospitalization was 1.7% and the estimate number of hospitalizations among the total population during a year will be 107 persons (Table 25). Medical cost: Average medical cost per person during one month and a year were 171 and 2,800 won respectively. Average medical cost per patient during one month and a year were 1,109 and 3,740 won respectively. Average cost per household during a year was 15,800 won (Table 26, 27). Solution measures for health and medical care problems in rural area: A. Health problems which could be solved by paramedical workers such as nurses, midwives and aid nurses etc. are as follows: 1. Improvement of environmental sanitation 2. MCH except medical care problems 3. Family planning except surgical intervention 4. Tuberculosis control except diagnosis and prescription 5. Dental care except operational intervention 6. Health education for residents for improvement of utilization of medical facilities and early diagnosis etc. B. Medical care problems 1. Eighty-five percent of health problems could be solved by primary care procedures by general practitioners. 2. Fifteen percent of health problems need secondary medical procedures by a specialist. C. Medical cost Concidering the economic situation in rural area the amount of 2,062 won per residents during a year will be burdensome, so financial assistance is needed gorvernment to solve health and medical care problems for rural people.

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