We assessed the efficacy of a 4-week nurse-led exercise rehabilitation (ER) program in improving the quality of life (QOL) of breast cancer survivors (BCS) receiving an implant-based breast reconstruction. The eligible patients were equally randomized to either of both groups: the intervention group (n = 30; a 4-week nurse-led ER program) and the control group (n = 30; a 4-week physical therapist-supervised one). Both after a 4-week ER program and at baseline, the patients were evaluated for the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and Fatigue Severity Scale (FSS) scores. There was a significantly higher degree of increase in global health status/QOL scores, physical functioning scores, role functioning scores, and emotional functioning scores at 4 weeks from baseline in the intervention group as compared with the control group (p = 0.001). However, there was a significantly higher degree of decrease in fatigue scores, nausea/vomiting scores, pain scores, dyspnea scores, and FSS scores in the intervention group as compared with the control group (p = 0.001). In conclusion, our results indicate that a 4-week nurse-led ER program might be effective in the QOL in BCS receiving a post-mastectomy implant-based reconstruction using the Motiva ErgonomixTM Round SilkSurface.

1Department of Family Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea; 2Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea; 3Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea; 4Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea

To apply a new airway treatment to humans, preclinical studies in an appropriate animal model is needed. Canine, porcine and leporine tracheas have been employed as animal airway stenosis models using various methods such as chemical caustic agents, laser, and electrocautery. However, existing models take a long time to develop (3–8 weeks) and the mechanism of stenosis is different from that in humans. The aim of the present study was to establish a new and fast tracheal stenosis model in pigs using a combination of cuff overpressure intubation (COI) and electrocautery. Fourteen pigs were divided into three groups: tracheal cautery (TC) group (n=3), COI group (n=3), and COI-TC combination group (n=8). Cuff overpressure (200/400/500 mmHg) was applied using a 9-mm endotracheal tube. Tracheal cautery (40/60 watts) was performed using a rigid bronchoscopic electrocoagulator. After intervention, the pigs were observed for 3 weeks and bronchoscopy was performed every 7 days. When the cross-sectional area decreased by > 50%, it was confirmed that tracheal stenosis was established. The time for tracheal stenosis was 14 days in the TC group and 7 days in the COI-TC combination group. In the COI group, no stenosis occurred. In the COI-TC group, electrocautery (40 watts) immediately after intubation for >1 h with a cuff pressure of 200 mmHg or more resulted in sufficient tracheal stenosis within 7 days. Moreover, the degree of tracheal stenosis increased in proportion to the cuff pressure and tracheal intubation time. The combined use of cuff overpressure and electrocautery helped to establish tracheal stenosis in pigs rapidly.

Background: Several studies have reported that abdominal fat and muscle changes occur in diabetic patients. However, there are few studies about such changes among prediabetic patients. In this study, we evaluated the differences in abdominal fat and muscles based on abdominopelvic computed tomography in prediabetic and diabetic subjects compared to normal subjects.Methods: We performed a cross-sectional study using health examination data from March 2014 to June 2019 at Ulsan University Hospital and classified subjects into normal, prediabetic, and diabetic groups. We analyzed the body mass index corrected area of intra-abdominal components among the three groups using inverse probability treatment weighting (IPTW) analysis.Results: Overall, 8,030 subjects were enrolled; 5,137 (64.0%), 2,364 (29.4%), and 529 (6.6%) subjects were included in the normal, prediabetic, and diabetic groups, respectively. After IPTW adjustment of baseline characteristics, there were significant differences in log visceral adipose tissue index (VATI; 1.22±0.64 cm2/[kg/m2] vs. 1.30±0.63 cm2/[kg/m2] vs. 1.47±0.64 cm2/[kg/m2], P<0.001) and low-attenuation muscle index (LAMI; 1.02±0.36 cm2/[kg/m2] vs. 1.03±0.36 cm2/[kg/m2] vs. 1.09±0.36 cm2/[kg/m2], P<0.001) among the normal, prediabetic, and diabetic groups. Prediabetic subjects had higher log VATI (estimated coefficient= 0.082, P<0.001), and diabetic subjects had higher log VATI (estimated coefficient=0.248, P<0.001) and LAMI (estimated coefficient=0.078, P<0.001) compared to normal subjects.Conclusion: Considering that VATI and LAMI represented visceral fat and lipid-rich skeletal muscle volumes, respectively, visceral obesity was identified in both prediabetic and diabetic subjects compared to normal subjects in this study. However, intra-muscular fat infiltration was observed in diabetic subjects only.

Purpose: Low-attenuation muscle area (LAMA) and normal-attenuation muscle area (NAMA) indicate lipid-rich and lipid-poor skeletal muscle areas, respectively.Additionally, intermuscular adipose tissue (IMAT) indicates localized fat between muscle groups.In this study, we aimed to evaluate the intramuscular and intermuscular fat infiltration in individuals with chronic obstructive pulmonary disease (COPD) by performing quantitative assessment of the LAMA, NAMA, and IMAT observed on abdominopelvic computed tomography (APCT) images.Patients and Methods: We performed a cross-sectional study using data of subjects who underwent a general health examination with APCT at Ulsan University Hospital between March 2014 and June 2019.We classified the subjects into control and COPD groups based on age, smoking history, and pulmonary function results.We compared the attenuation and body mass index adjusted area of intra-abdominal components between the two groups using propensity score matching.We also evaluated these outcomes in COPD subgroups (mild and moderate stage subjects).Results: Overall, 6,965 subjects were initially enrolled, and 250 pairs of control and COPD subjects were selected after propensity score matching.The NAMA attenuation (unstandardized β=-1.168,P<0.001) was lower, and the IMAT (unstandardized β=0.042,P=0.006) and LAMA (unstandardized β=0.120,P<0.001) indexes were greater in the COPD group than in the control group.In subgroup analysis, those with mild and moderate COPD also had high IMAT (unstandardized β=0.037,P=0.009 and unstandardized β=0.045,P<0.001) and LAMA (unstandardized β=0.089,P=0.002 and unstandardized β=0.147,P<0.001) indexes compared to the control subjects.However, the NAMA attenuation (unstandardized β=-1.075,P<0.001) and NAMA index (unstandardized β=-0.133,P=0.015) were significantly lower in moderate COPD subjects only.Conclusion: Our study showed that intramuscular and intermuscular abdominal fat infiltration could be present in subjects with mild COPD, and it might be exacerbated in those with moderate COPD.

Purpose: Work-related asthma (WRA) occupies about 10%-30% of all asthma cases. Among 2 subtypes of WRA (occupational asthma (OA) and work-exacerbated asthma [WEA]), the rate of WEA has been reported to increase recently. WRA is described as having worse characteristics than non-WRA (NWRA), while WEA is known to show similar severity to OA in terms of symptoms and exacerbations. However, these data were mainly based on indirect surveys. Ulsan is a highly industrialized city in Korea; therefore, it is estimated to have a high incidence of WRA. This study aimed to identify the characteristics of WRA in the city. Methods: This was a prospective asthma cohort study of individuals diagnosed with asthma and treated at Ulsan University Hospital between Jan 2015 and Dec 2016. Baseline characteristics and work-related inquiry (9 questionnaires) were investigated at enrollment. Various severity indices and job change were then investigated for the longitudinal analysis at 12 months after enrollment. Results: In total, 217 asthma patients completed the study. WRA accounted for 17% (36/217), with an equal number of WEA and OA (18 patients each). Before the work-related survey, only 33% (n = 12) of WRA patients (22% [4/18] of WEA and 44% (8/18) of OA) were diagnosed with WRA by the attending physicians. Compared to the NWRA group and the OA subgroup, the WEA subgroup had more outpatient visits, more oral corticosteroids prescriptions, and trends of low asthma control test scores and severe asthma. The rate of job change was markedly lower in the WEA subgroup than in the OA subgroup (20% vs. 5%). Conclusions: The overall prevalence of WRA (17%) was similar to those of previous studies, but the share of WEA was high (50% of WRA). WEA was more severe than OA or NWRA. The possible reason for this severity is ongoing workplace exposure.

Central airway obstruction (CAO) can be attributed to several benign or malignant conditions. Although surgery is the preferred therapeutic option for the management of CAO, bronchoscopic treatment can be performed in scenarios where the surgical procedure is not possible. Recent years have witnessed several improvements in the field of bronchoscopic treatment, especially with regard to airway stents. Current research involves new attempts to overcome the existing shortcomings pertaining to the stents (migration, mucostasis, and granulation tissue formation). The authors have recently developed a new silicone airway stent (GINA stent) with an anti-migration design, dynamic structure that enables the reduction of stent cross-sectional area, and radio-opacity. The present study aimed to evaluate the mechanical characteristics and performance of the novel GINA stent using a porcine tracheal stenosis model. In the current study, all the tests involved the comparison of the GINA stent [outer diameter (OD, mm): 14; length (L, mm): 55] with the Dumon stent (OD: 14; L: 50). The mechanical tests were performed using a digital force gauge, in order to determine the anti-migration force, expansion force, and flexibility. The present study evaluated the short-term (3 weeks) performance of the two stents after implantation [GINA (n = 4) vs. Dumon (n = 3)] in the porcine tracheal stenosis model. The results pertaining to the comparison of the mechanical properties of the GINA and Dumon stents are stated as follows: anti-migration force (18.4 vs. 12.8 N, P = 0.008); expansion force (11.9 vs. 14.5 N, P = 0.008); and flexibility (3.1 vs. 4.5 N, P = 0.008). The results pertaining to the comparison of the short-term performance of the GINA and Dumon stents are stated as follows: mucus retention (0/4 vs. 0/3); granulation tissue formation (0/4 vs. 0/3); and migration (1/4 vs. 2/3). The GINA stent displayed better mechanical properties and comparable short-term performance, compared to the Dumon stent.

BACKGROUND:A high hematocrit level in patients with erythrocytosis is linked with increased blood viscosity and increased risk of thromboembolism. Therefore, it is necessary to adequately lower the hematocrit level before performing a high-risk surgery.CASE:A 67-year-old male was scheduled for aortic valve replacement due to severe aortic stenosis. The preoperative hematocrit level of this patient was very high due to secondary polycythemia by hypoxia. We decided to perform acute normovolemic hemodilution after anesthetic induction to reduce the risk of thromboembolism in the patient. The patient was discharged after a successful surgery and a post-operative period without any side effects.CONCLUSIONS:We estimate that patients with secondary polycythemia may benefit from acute normovolemic hemodilution to reduce their hematocrit levels while undergoing cardiac surgery using cardiopulmonary bypass. However, it is necessary to control the hematocrit level, since a significant decrease can cause side effects.

Background: Active tuberculosis (TB) develops in approximately 10% of people with a latent tuberculosis infection (LTBI). TB guidelines recommend that LTBI screening and treatments target high-risk patients. Malignancies are not universally considered a high-risk factor for active TB. This study aimed to determine the degrees to which active TB risk was associated with various cancers in a Korean population. Methods: This study involved patients aged >= 20 years who were diagnosed with cancer at Ulsan University Hospital (UUH) from January 2000 to December 2014 and individuals who visited UUEI for health screening and were age- and sex-matched randomly with cases in a 1:2 ratio. Using retrospective cohort study, the development of bacteriologically con firmed TB (BCTB) within 3 years after enrollment was investigated. The relative risks of BCTB were estimated using incidence rate ratios (IRRs) and a Poisson regression analysis. Results: During the study period, 380 of 34,783 cancer patients and 79 of 69,566 control subjects developed BCTB, yielding respective incidence rates of 535 and 37/100,000 person-years, respectively. In all cancer cases, the IRR of BCTB was 14.30, and especially high rates were associated with the following cancers: esophageal cancer (74.72), multiple myeloma (70.76), lung cancer (50.35), pancreatic cancer (46.04), leukemia (40.45), head and neck cancer (24.60), and lymphoma (22.67). Conclusions: The incidence of active TB was higher in cancer patients than in control subjects. In particular, lung cancer, esophageal cancer, pancreatic cancer, hematologic malignancy and head and neck cancer were identified as high-risk factors for active TB, as indicated by IRRs of 20-75. These findings suggest that patients with high-risk cancers should be targeted for LTBI screening and treatment.

Masseter muscle rigidity (MMR), known as the ‘jaw of steel’, sometimes makes laryngoscope unusable due to the stiffness of the jaw. MMR during general anesthesia was previously considered as an early episode of malignant hyperthermia (MH). Generally, MMR occurs in the pediatric patients after induction with succinylcholine and volatile agents. However, MMR following the administration of non-depolarizing muscle relaxants is uncommon, although described in some reports. We report a case of 62-year-old male patient which developed MMR following intravenous administration of rocuronium during induction of anesthesia. Our patient was not found to be vulnerable to MH. Although fiberoptic nasotracheal intubation had been successfully performed in our case, an unanticipated difficult airway due to MMR can be experienced at any time. Therefore, we should be aware that, although rare, MMR can occur after using non-depolarizing muscle relaxant. Additionally, in case of any incident of MMR, anesthesiologists need to recognize the management of a difficult airway and to maintain adequate oxygenation in a variety of methods according to a difficult airway algorithm.

Bronchoscopy has a lower diagnostic yield for peripheral lung lesions (PLL). Endobronchial ultrasound guide sheath transbronchial lung biopsy (EBUS GS TBLB) has been used to overcome such limitation. Recent studies revealed that combined methods (e.g., EBUS GS TBLB plus electromagnetic navigation [EMN] or virtual bronchoscopic navigation [VBN]) further improve the diagnostic yield. However, those systems are associated with a high cost burden. Accordingly, we attempted to use VBN by computed tomography (CT) workstation (Aquarius iNtuition, TeraRecon) not dedicated only for VBN as an adjunctive tool for EBUS GS TBLB. We performed a prospective registry study to investigate whether VBN by CT workstation could improve the diagnostic yield of PLL. Between February 2017 and February 2018, 128 patients with PLL were divided into 2 groups (VBN and non-VBN [NVBN]). In NVBN group (n = 64), EBUS GS TBLB was performed using a hand-drawn bronchial map based on CT images. VBN group (n = 64) underwent EBUS GS TBLB using VBN images. VBN using CT workstation did not improve the diagnostic yield of EBUS GS TBLB for PLL (VBN vs NVBN, 72% vs 80%,P = .284). VBN slightly reduced procedure time (minute [mean +/- SD], 25.31 +/- 10.33 vs 25.81 +/- 9.22), navigation time (time to find the lesion) (9.10 +/- 7.88 vs 9.50 +/- 7.14), and fluoroscopy time (2.23 +/- 2.39 vs 2.86 +/- 4.61), while these differences were not statistically significant. The diagnostic yield of EBUS GS TBLB was not improved with VBN (compared with using a hand-drawn bronchial map). Although VBN slightly shortened the procedure-related times, which were not significantly different.

Whole lung lavage (WLL) is a therapeutic procedure to remove accumulated material by infusing and draining the lungs with lavage fluid. This procedure has been regarded as the current standard of care to treat pulmonary alveolar proteinosis. However, the WLL protocol has not yet been standardized and the technique has been refined and modified a number of times. A rapid infusion system is a device used to infuse blood or other fluids at precise rates and normothermic conditions. This device is not typically used in WLL, which relies on the passive infusion of fluids using the gravitational force. However, in this study we performed WLL using a rapid infusion system, since we aimed to take advantage of its shorter operation time and greater degree of control over fluid volume and temperature. The patient's symptoms improved without the occurrence of any complications.

In video-assisted thoracoscopic surgery (VATS), general anesthesia with endotracheal intubation was considered an optimal method of anesthesia for a long time. However, complications due to general anesthesia and one-lung ventilation have become a problem. In recent years, epidural anesthesia without endotracheal intubation has been attempted in various thoracic surgical procedures with various advantages and disadvantages reported. We compared postoperative pain and prognosis when different anesthesia methods were used in a patient who underwent the same operation twice in the interval of one year. When non-intubated videoassisted thoracoscopic surgery (NIVATS) underwent under epidural anesthesia, postoperative pain score was lower, adverse events were fewer, and the hospital stay was shorter than that of VATS. The patient also expressed high subjective satisfaction. Like previous studies, the results favored NIVATS under epidural anesthesia. However, greater attention and proficiency are required from the anesthesiologist for proper analgesia and sedation.

Introduction: In Korea, since the adoption of MELD-based allocation system in June 2016, there happened an issue that too many livers were allocated to alcoholic patients. It’s because alcoholic hepatitis patients whose MELD score were very high outnumbered the deceased donor. Some insisted that a liver graft from a deceased donor, which is a valuable social resources should not be allocated to the alcoholic patients. We studied rates and timing of alcohol relapse including harmful drinking and preoperative factors that could predict alcohol relapse. Method: Alcohol relapse among 42 patients who underwent liver transplantation for alcoholic liver disease was investigated. Follow periods were from 3 to 85 months. Alcohol relapse was diagnosed by interviewing the patients. Time to alcohol relapse after LT was recorded. Preoperative factors including 6 month sobriety, history of major psychiatric disease, history of drug addiction, marital state and type of transplantation (living donor or deceased donor) were analysed in relation to alcohol relapse. Result: Alcohol relapse occurred in 10 (25%) patients including harmful drinking in 4 (10%). Any preoperative factors including 6 month sobriety could not predict alcohol relapse or relapse into harmful drinking. There was no patient with history of drug addiction. Alcohol relapse rates were not different significantly between LDLT and DDLT groups. All the relapses into harmful drinking occurred within 3 months after LT. One patient who was getting into harmful drinking 2 months after LT stopped drinking for the next 6 months until now by aggressive education that let him know himself in trouble by drinking. Conclusion: Pre-transplant prediction of alcohol relapse is barely feasible in patients with alcoholic liver disease. Aggressive monitoring and managing alcohol relapse in the very early postoperative period may be more helpful in preventing the patient go into harmful drinking

Background: Surgical Apgar score (SAS) is a 10-point system that measures estimated blood loss, lowest heart rate and lowest mean blood pressure during surgery, and is known to be associated with postoperative complications. The purpose of this study was to evaluate the relationship between SAS and postoperative major complications in patient admitted to intensive care unit (ICU) after surgery. Methods: We retrospectively reviewed 543 patients who were admitted to the ICU for 8 months. SAS, patient’s demographics and postoperative outcomes were collected and analyzed based on anesthetic record and several medical records in an electronic chart system built in hospital. The patients were divided into three groups based on their SAS. The postoperative major complications, duration of ICU stay and duration of hospital stay were compared among the three groups. Results: In the low score group, the rate emergency, trauma and hepatobiliary operation were high. In this group, the duration of ICU and hospital stay, use of mechanical ventilation and inotropic in ICU, and postoperative complication were also increased. SAS also had a weak negative correlation with ICU stay and hospital stay. Postoperative complication and mortality rate doubled when compared to reference group (SAS 7-10) according to univariate logistic regression. Conclusions: In patients admitted to ICU after surgery, SAS, which can be measured during surgery, is closely related to postoperative parameters including major complications, mortality, and ICU stay. In other words, it is thought that the postoperative outcomes can be improved through appropriate monitoring and intervention for patients with low SAS score. Keywords: Intensive care unit; Postoperative complications; Surgical Apgar score

Malignant metastatic melanoma (MM) is the most lethal of all skin cancers, but detailed mechanisms for regulation of melanoma metastasis are not fully understood. Here, we demonstrated that developmentally regulated GTP‐binding protein 2 (DRG2) is required for the growth of primary tumors and for metastasis. DRG2 expression was significantly increased in MM compared with primary melanoma (PM) and dysplastic nevi. A correlation between DRG2 expression and poor disease‐specific survival in melanoma patients was also identified. Furthermore, inhibition of DRG2 suppressed the binding of Hypoxia‐inducible factor 1α to the VEGF‐A promoter region, expression of vascular endothelial growth factor (VEGF)‐A, and formation of endothelial cell tubes. In experimental mice, DRG2 depletion inhibited the growth of PM and lung metastases and increased survival. These results identify DRG2 as a critical regulator of VEGF‐A expression and of growth of PMs and lung metastases.

Laryngospasm, an occlusion of the glottis, can occur at any time during anesthesia, and is associated with serious perioperative complications such as hypoxia, hypercabia, aspiration, bronchospasm, arrhythmia, prolonged recovery, cardiac collapse, and eventually catastrophic death. Importantly, postoperative negative pressure pulmonary edema (NPPE) is a rare, but well described life-threatening complication related to acute and chronic upper airway obstruction. Sugammadex well known for affirmatively reducing the postoperative pulmonary complications associated with residual neuromuscular blockade may have an indirect role in triggering the negative intrathoracic pressure by raising a rapid and efficacious respiratory muscle strength in acute upper airway obstruction. Herein, we report a case of postoperative NPPE following repetitive laryngospasm even after reversal of rocuronium-induced neuromuscular blockade using sugammadex.

BackgroundThe QT variability index (QTVI)–a non-invasive measure of beat-to-beat QT interval (QTI) fluctuations–is related to myocardial repolarization lability. The QTVI represents the relationship between QTI and the RR interval. Elevated QTVI is associated with an increased risk of malignant ventricular arrhythmias and sudden death. We investigated the influence of general anesthesia and tourniquets on the QTVI.MethodsWe studied fifty patients who received total knee replacement arthroplasty under sevoflurane anesthesia. We measured QTI, corrected QTI (QTc), T-wave peak-to-end interval (TPE), QTVI, and heart rate variability. All variables were calculated at baseline (B), 30 min after general anesthesia (A), 30 min (TQ1) and 60 min (TQ2) after tourniquet inflation, and at tourniquet deflation (TQR).ResultsProlongation of QTI was detected at all times, and QTc was significantly prolonged TQR. TPE was unchanged during general anesthesia. The QTVI was significantly decreased and more negative during anesthesia and tourniquet inflation. After deflation of the tourniquet, the QTVI was restored to preanesthetic values. Low frequency (LF) was significantly decreased during general anesthesia, but high frequency (HF) was somewhat maintained, except at TQ2. The LF/HF ratio was significantly decreased at A and TQ2.ConclusionsSevoflurane based general anesthesia induced repolarization stability and, more negativity of the QTVI, in patients undergoing total knee replacement arthroplasty.