종설 : 야간 혈압의 임상적 의의

윤소윤 ( So Yoon Yoon ),편욱범 ( Wook Bum Pyun ) 대한내과학회 2011 대한내과학회지 Vol.80 No.1

It was impossible to measure the nighttime blood pressure in patients with hypertension for more than one hundred years. The introduction of ambulatory blood pressure monitoring made it possible to evaluate the nighttime blood pressure and clinical significances in recent 40 years. There are tremendous evidences for proving that the nighttime blood pressure is the more powerful predictor in cardiovascular morbidity and mortality than conventional office and ambulatory daytime blood pressure. The cardiovascular mortality can be reduced when 5% of nighttime blood pressure decreased from Ohasama registry report. So investigators should reevaluate the antihypertensive drugs in the view points of nighttime blood pressure reduction. And changing the administration schedule of antihypertensive drugs, so called chronotherapy, is effective for controlling the nighttime blood pressure and modifying the blood pressure circadian rhythm. Korean Ambulatory Blood Pressure (KORABP), nationwide ambulatory blood pressure monitoring registry in Korea, may answer unproved questions for controlling nighttime blood pressure. (Korean J Med 2011;80:31-35)

포스트 코로나 시대 준비를 위한 임상실습 교육 고찰

정소미(So-Mi Jeong),고아라(Ara Ko),편욱범(Wook Bum Pyun),태정현(Chung Hyun Tae) 학습자중심교과교육학회 2023 학습자중심교과교육연구 Vol.23 No.20

목적 본 연구는 COVID-19 시대 임상실습교육 점검하고 포스트 코로나 시대 임상실습교육의 방향 설정을 위한 기초 정보 마련을 목적으로 하였다. 방법 본 연구는 서울 소재 E-대학교 의과대학에서 2022년 12월 임상실습 교육 개선을 위하여 임상실습 과별로 진행한 ‘임상실습 선진화 회의’의 회의록과 각 임상 실습과에서 제출한 ‘2023학년도 임상실습 개선 계획서’를 대상으로 하였다. 포커스 그룹 인터뷰 분석방법을 차용하여 분석하였다. 결과 첫째, COVID-19 시기, 임상실습 교육에 영향을 미친 요소를 살펴본 결과, 임상실습 교육의 긍정적 요소와 임상실습 교육의 부정적 요소 2개 영역에서 8개 범주, 17개 하위범주가 도출되었다. 둘째, 포스트 코로나 시대 준비를 위한 임상실습 개선 계획을 살펴본 결과, 임상실습 교육 실시 전 교육 개선 노력과 임상실습 중 교육 운영 개선 노력, 장기적 개선의 3개 영역에서 6개 범주, 23개 하위범주가 도출되었다. 셋째, 포스트 코로나 시대 임상실습을 위해 필요한 사항을 살펴본 결과, 포스트 코로나 시대 임상실습 교육을 위한 제언, 포스트 코로나 시대 임상실습 교육을 위해 필요한 지원의 2개 영역에서 6개 범주, 11개 하위범주가 도출되었다. 결론 본 연구를 통해 COVID-19 시기 이루어진 임상실습 교육을 점검하고 포스트 코로나 시대 임상실습 개선을 위한 시사점을 도출하였다. 본 연구의 결과는 향후 임상실습 교육 개선에 기초자료가 될 것이며, 궁극적으로 임상실습 교육의 질 향상에 기여할 수 있을 것이다. Objectives This study aimed to examine clinical clerkship education in the COVID-19 era and gather fundamental information for setting the direction of clinical clerkship education in the post-COVID era. Methods This study focused on the minutes of the ‘Clinical clerkship Advancement Conference’ held in December 2022 and the ‘2023 Clinical clerkship Improvement Plans’ submitted by each clinical clerkship department at E-Medical School in Seoul. The study employed the Focused Group Interview analysis method. Results First, when examining the factors that influenced clinical clerkship education during the COVID-19 peri-od, a total of 8 categories and 17 subcategories were identified in two domains: positive factors of clinical clerkship education and negative factors of clinical clerkship education. Second, when examining the improvement plans for clinical clerkship education in preparation for the post-COVID era, a total of 6 categories and 23 subcategories were derived from three domains: efforts for pre-implementation education improvement, efforts for operational improvement of clinical clerkship education, and long-term improvement. Third, when exploring the requirements for clinical clerkship in the post-COVID era, a total of 6 categories and 11 subcategories were identified in two do-mains: recommendations for clinical clerkship education in the post-COVID era and necessary support for clinical clerkship education in the post-COVID era. Conclusions This study examined the clinical clerkship education conducted during the COVID-19 period and de-rived implications for improving clinical clerkship in the post-COVID era. The findings of this study will serve as foundational data for future improvements in clinical clerkship education and ultimately contribute to enhancing the quality of clinical clerkship education.

90세 이상 초고령 환자에서 수술 전 심장 초음파 검사 분석

김유리 ( Yoo Ri Kim ),조인정 ( In Jeong Cho ),신길자 ( Gil Ja Shin ),편욱범 ( Wook Bum Pyun ) 대한내과학회 2009 대한내과학회지 Vol.77 No.2

Background/Aims: Adverse cardiac events pose a significant perioperative risk to patients undergoing noncardiac surgery, especially geriatric patients. This study presents resting echocardiography data for a population older than 90 years. Methods: We performed transthoracic echocardiography in 108 patients who were older than 90 years and scheduled to undergo noncardiac surgery between November 1, 2004, and September 22, 2008, and evaluated their cal histories and electrocardiograms. Results: The 108 patients included 73 (67.3%) women and 35 (32.7%) men with a mean age of 92.05±2.77 years (range 90-104). Their medical histories included hypertension in 38.9% and diabetes mellitus in 15.7%. The average left ventricular end diastolic dimension and ejection fraction were 49.0±6.3 mm and 62.9±11.1%, respectively. Six (5.6%) patients had clinically significant aortic regurgitation and seven (6.5%) had mitral regurgitation as pathologic changes of aging. Six patients had mild to moderate aortic stenosis, found incidentally, that did not affect the clinical decision regarding the scheduled operation. The diastolic parameters showed that most of the patients (87%) had grade I relaxation abnormalities. The average mitral inflow E/A, deceleration time, and E/E`s were 0.69±0.33, 266±82 msec, and 11.15±3.88, respectively. Conclusions: Echocardiography cannot predict all of the postoperative cardiovascular complications and risks, but it is useful for screening for significant left ventricular dysfunction, valvular abnormalities, and as a guide for managing extremely old patients in the perioperative period. (Korean J 77:193-199, 2009)

단독 좌전하행관동맥 질환의 치료에서 약물치료 , 풍선확장술 , 스텐트삽입술간의 비교관찰

조승연(Seung Yun Cho),장양수(Yang Soo Jang),이동일(Dong Il Lee),편욱범(Wook Bum Pyun),최동훈(Dong Hoon Choi),심원흠(Won Heum Shim) 대한내과학회 1999 대한내과학회지 Vol.57 No.5

N/A With recent advances in transarterial interventional technique, there is a tendency to treat single LAD lesion with balloon angioplasty or stent insertion rather than with medical therapy alone. Therefore, it is important to evaluate the long-term clinical outcomes of such interventional therapy. Methods : Subjects are comprised of patients who underwent coronary angiogram from 1993 to 1996 and diagnosed as having single LAD lesion without decrease of left ventricular fuction. The incidence of major ischemic complications, revascularization and reduction of angina pectoris after different therapeutic strategies in these patients are evaluated. Result : 1) There was total of 190 patients. Patients receiving medical therapy, balloon angioplasty and stent insertion were 70, 75, and 45 respectively. There was no significant difference in mean age, sex ratio, and risk factors of coronary artery occlusive disease between each groups. 2) The medical therapy group(30%) had a significantly lower incidence of proximal stenosis lesion compared to the balloon angioplasty group (45%) and stent insertion group(52%) according to the location of the lesion(p<0.05). The lesion characteristics according to the AHA/ACC criteria showed that the proportion of type A lesion was significantly higher in the balloon angioplasty group(33.3%) compared to the medical therapy group(8.6%) and stent insertion group(13.3%), whereas the proportion of type C lesion was significantly higher in the medical therapy group(41.4%) compared to the balloon angioplasty group(14.3%) and stent insertion group(22.2%). 3) The incidence of ischemic complication were low with 9 out of total 190 patients during follow up consisting of 2 cases of cardiogenic death(1.1%) and 7 cases of acute myocardial infarction(3.7%). 4) During the follow-up period revascularization was performed in 10% of medical therapy group, 27% of balloon angioplasty group and 22% of stent insertion group. There was higher rate of revascularization in patients who received interventional therapy. 5) During the mean follow-up period of 38 months, event-free survival rate was 85% in the patient group receiving medical therapy, 71% in the patient group undergoing balloon angioplasty and 74% in the patient group undergoing stent insertion. There was lower incidence of major events in medical therapy patients, but the difference of the rate among each group was not significant. In considering the patients with proximal LAD stenotic lesion, event-free survival rate was 73% in medical therapy group, 75% in balloon angioplasty group and 81% in stent insertion group, but the difference between each groups did not show any significant difference. 6) Follow-up of each study groups at 6 months, 1 year and 3 years showed that the proportion of chest pain-free patients in balloon angioplasty and stent insertion group were higher than those in medical therapy group despite the lack of statistical significance(p>0.05). Conclusion : For patients with single LAD stenotic lesion interventional therapies such as balloon angioplasty and stent insertion might be more effective without statistical signigicance in reducing chest pain compared to medical therapy. There was no significant difference in the incidence of ischemic complication and rate of revascularization among different study groups. Further studies will be needed to clarify the beneficial effects of interventional coronary artery therapy such as improvement of chest pain, increased exercise capacity, and improved quality of life along with other parameters. (Korean. J. Med 57:896-905, 1999)

Urea Kinetic Modeling 을 이용한 지속적 혈액투석 환자의 영양 상태 평가

최규복(Gyu Bog Choi),변정란(Jung Lan Byun),박정은(Jeong Eun Park),이은영(Eun Young Lee),이지수(Ji Soo Lee),편욱범(Wook Bum Pyun),고영엽(Young Youp Koh),윤견일(Kyun Ill Yoon) 대한내과학회 1994 대한내과학회지 Vol.46 No.2

N/A Objectives: Nutritional factors play a role in the morbidity and mortality of patients in maintenance hemodialysis as well as in their quality of life and ultimate rehabilitative potential. It was reported that if the deviation of urea distribution volume calculated by Urea Kinetic Modeling(UKM) (Vol-Dev) from Anthropometric volume exceeded the acceptable range, clinical application of the NPCR (normalized protein catabolic rate) as nutritional index might be inappropriate. And it was also reported that if the KT/Vurea without consideration of residual renal function (D-KT/V) was above 1.5 or below 0.8, the NPCR might be inaccurate. So we selected patients whose Vol-Dev was within the acceptable range and grouped according to the D-KT/V. Then we analyzed the relationship between the NPCR and other nutritional parameters. Methods: We selected 17patients undergoing maintenance hemodialysis with adequate Vol-Dev level and grouped as group 1 if D-KT/V was between 0.8 and 1. 5, as group 2 if D-KT/V was below 0.8 or over l.5, We measured the mean level of albumin, calcium, phosphorus and hematocrit and calculated midarm muscle area (MAMA), midarm fat area (MAFA) as anthropometric measurements. Results: 1) Nutritional Index: There were no differences in serum albumin, calcium, phosphorus and hematocrit between two groups. The mean MAMA of group 1 (37.4cm2) was not different from that of group 2(27.9cm2), but mean MAFA of group 1(19.2cm2) was significantly higher than that of group 2(14.3cm2). The NPCR of group 1 (1.00) was not different from that of group 2(1.12). 2) UKM Parameter: The mean level of D-KT/V as single dialysis dose in group 1 (1.23) was significantly lower than that of group 2(1.69) and the mean level of TW-KT/V as weekly dialysis dose in Group 1 (3.17) was significantly lower than that of Group 2(4.05). The mean level of TWR-KT/V as weekly dialysis dose with consideration of residual renal function in Group 1(3.24) was significantly lower than that of Group 2(4.07) also. 3) Correlation between NFCR and dialysis dose: There was no correlation between D-KT/V and NPCR in both Group. In group 1, there was positive correlation between NPCR and TW-KT/V or TWR-KT/V. But in group 2, there was no correlation between NPCR and TW-KT/V or TWR-KT/U. 4) Correlation between NPCR and Nutritional Index: There was no correlation between NPCR and serum nutritional index (albumin, calcium, phosphorus, hematocrit). There was also no correlation between NPCR and anthropometric parameter (MAMA, MAFA). Conclusions: It is not likely that the NPCR reflects the protein catabolic rate accurately in case of D-KT/V exceeded adequate level (0.8≤, ≤1.5). Although the protein catabolic rate might be increased due to the effect of dialysis itself, there was no significant change in the nutritional status of patients. Even though the D-KT/V was within the adequate level, it is difficult to evaluate the patients nutritional status with NPCR only.

혈액투석 환자에서 혈관내피세포 기능이상과 관련된 인자들에 관한 연구

류정화 ( Jung Hwa Ryu ),유민아 ( Min A Yu ),류동열 ( Dong Ryeol Ryu ),김승정 ( Seung Jung Kim ),최규복 ( Kyu Bok Choi ),윤견일 ( Kyun Il Yoon ),강덕희 ( Duk Hee Kang ),편욱범 ( Wook Bum Pyun ),신길자 ( Gil Ja Shin ) 대한신장학회 2008 Kidney Research and Clinical Practice Vol.27 No.2

목적: 동맥경화성 심혈관계 질환은 아직도 투석 환자에서 사망의 가장 흔한 원인이다. 혈관내피세포의 기능이상은 동맥경화증 발생의 가장 초기 단계에 발생하는 중요한 과정으로, 비가역적인 변화인 동맥경화증과는 달리 회복 가능한 가역적인 변화이므로, 이 단계에서의 조기 진단과 치료가 가능하다면 환자의 예후 향상에 크게 기여할 수 있을 것이다. 따라서, 본 연구에서는 혈액투석 환자의 혈관내피세포 및 평활근세포의 기능을 조사하고 심혈관계 질환의 발생과 예후 결정에 중요한 인자인 전신염증반응의 지표, 환자의 영양 상태 및 기타 생화학적 지표와의 상관관계를 조사하였다. 방법: 임상적으로 안정된 혈액투석 환자 37명 (평균연령 51.8세, 평균투석기간 37.9개월)와 11명의 건강 대조군, 24명의 고혈압 대조군에서 상완동맥 도플러 초음파를 이용하여 혈관내피세포 기능을 측정하였다. 내피세포 의존성 혈관확장능 (FMD), 니트로글리세린을 설하로 투여한 후의 내피세포 비의존성 혈관확장능 (EIV), 최대반응시간 (PT) 등의 지표를 측정하고, 허혈성 심질환 (IHD)의 이환 여부, 환자의 영양 상태, hsCRP 농도 및 다른 생화학적 지표와의 상관관계를 조사하였다. 결과: 1. 혈액투석 환자의 FMD와 EIV는 건강 대조군에 비하여 감소되어 있었고, 각 반응의 PT는 두 대조군에 비해 지연되어 있었다. 고혈압 대조군에서는 FMD만 감소되어 있었고 EIV는 정상 대조군과 유사하였다. 2. FMD와 EIV는 혈중 hsCRP 농도와 각각 의미 있는 음의 상관관계가 있었으나, 연령, 투석기간, RAS 차단제의 복용 여부, 알부민, 프리알부민, 총콜레스테롤, 중성지방, 호모시스테인 농도와는 상관관계가 없었다. 3. 투석 환자 중 IHD가 있는 환자가 IHD가 없는 환자에 비하여 평균투석기간이 길었고, SGA에 의해 평가된 영양실조 환자가 많았다. hsCRP의 농도는 IHD가 있는 환자에서 증가되어 있었다 (중앙값: 1.43 vs. 0.15 mg/dL, p<0.05). IHD가 있는 환자에서 FMD (4.1±2.5 vs. 6.4±2.6%, p<0.05)와 EIV (8.7±4.1 vs. 13.8±7.2%, p<0.05)가 유의하게 감소되어 있었다. 결론: 혈액투석 환자에서 환자의 전신염증반응은 혈관내 피세포와 평활근세포의 기능 결정에 중요한 역할을 할 것으로 생각된다. CRP 농도의 증가가 전신염증반응 존재의 간접적인 지표인지 또는 혈관 기능이상에 직접적으로 작용하는지의 여부와 그 기전에 대해서는 향후 전향적인 연구와 in vitro 실험이 필요할 것으로 사료된다. Purpose: Endothelial dysfunction is an event in the atherosclerotic process usually considered reversible at its early stage. Early detection, therefor, may improve the prognosis in the cardiovascular disease. The aim of this study was to investigate the vascular function in hemodialysis (HD) patients and to explore its relation to other various parameters with a specific emphasis on systemic inflammatory reaction (SIR), nutritional status and the presence of ischemic heart disease (IHD). Methods: Flow-mediated endothelium-dependent vasodilatation (FMD) was measured, using Doppler sonogram, in 37 stable HD patients, 11 healthy people and 24 hypertensive controls. Nitroglycerineinduced endothelium-independent vasodilatation (EIV) and peak reaction time (PT) of each FMD and EIV were also measured. Results: FMD in HD patients was decreased compared to healthy group whereas it was comparable in HD patients and hypertensive control. EIV in HD patients was significantly decreased compared to healthy and hypertensive controls. PT of each FMD and EIV was significantly delayed in HD patients. Each FMD and EIV showed a negative correlation with serum hsCRP level, but no significant correlations of FMD with other parameters were noted. Both FMD and EIV were further decreased in HD patients with IHD than non-IHD group. Conclusion: Our study confirmed a characteristic pattern of vascular dysfunction in HD patients: the impaired endothelial and smooth muscle function with a delayed reaction time. Importantly, SIR was one of the important factors determining vascular dysfunction in HD patients. Further studies will be necessary to define the causative role of SIR on endothelial dysfunction and the effect of inflammation-modulating therapy.

유지 혈액투석 환자에서 단기간의 빈혈 개선에 따른 혈중 Amino-Terminal Pro B-type Natriuretic Peptide (NT-pro BNP)치 및 심초음파 소견의 변화

류동열 ( Dong Ryeol Ryu ),류정화 ( Jung Hwa Ryu ),배기선 ( Ki Sun Bae ),유민아 ( Min A Yu ),임종백 ( Jong Baeck Lim ),김승정 ( Seung Jung Kim ),편욱범 ( Wook Bum Pyun ),최규복 ( Kyu Bok Choi ),신길자 ( Gil Ja Shin ),윤견일 ( Kyun 대한신장학회 2006 Kidney Research and Clinical Practice Vol.25 No.5

비악성 상대정맥 증후군의 경피적 스텐트삽입술 중 발생한 급성 폐부종 1예

백은경 ( Eun Kyung Baek ),오지영 ( Ji Young Oh ),강민정 ( Min Jung Kang ),신길자 ( Gil Ja Shin ),이순남 ( Soon Nam Lee ),정익모 ( Ick Mo Chung ),편욱범 ( Wook Bum Pyun ) 대한내과학회 2008 대한내과학회지 Vol.74 No.2

상대정맥 증후군의 비악성 원인은 염증, 특발성 종격동 섬유화, 대동맥류, 방사선 치료에 의한 섬유화 등이 주를 이루었으나, 최근에는 카테터의 장기간 거치 혹은 인공 심박동기, 제세동기 등에 의한 의인성 상대정맥 증후군이 증가추세에 있다. 상대정맥 증후군의 치료는 일반적으로 방사선치료와 항암치료 등이 알려져 있으나, 비악성 원인에 의한 경우는 스텐트 삽입을 통한 치료가 최근 대두되고 있다. 본 증례에서는 안면 부종, 양측 상지 부종으로 내원한 환자에서 혈관 조영술을 통하여 상대정맥 증후군을 확인하였고, 자기공명영상과 전산화 단층 촬영에서는 원인이 될 만한 특이소견이 없어 비악성 상대정맥 증후군으로 진단하였다. 환자는 스텐트 삽입술을 통하여 성공적으로 상대정맥 증후군을 치료받았으나, 스텐트 삽입 직후 드문 합병증인 폐부종을 경험하였기에 이를 문헌고찰과 함께 보고하는 바이다. The superior vena cava (SVC) syndrome results from the disturbance of blood flow in superior vena cava caused by the obstruction. The most common etiology of this condition is the external compression by a malignant tumor. Other causes include thrombus from a pacemaker, defibrillator or central venous catheters. The conventional treatment is radiation and chemotherapy. Recently stenting has been used as a first-line therapeutic strategy for non-malignant cases with balloon and self-expanding stents. In our report, a 77 year-old woman had the SVC syndrome without identification of an underlying disease. A percutaneous endovascular intervention was performed. The stent was placed successfully but just after the procedure, the venous return immediately increased and acute pulmonary edema developed. The patient improved after intravenous diuretics and oxygen. Here we report our experience and review the medical literatures for the management of the non-malignant SVC syndrome, with percutaneous endovascular intervention and the rare complication of pulmonary edema. (Korean J Med 74:192-197, 2008)

쇄골하동맥 스텐트 삽입술의 조기결과

편욱범,윤영섭,최동훈,장양수,심원흠 대한순환기학회 1999 Korean Circulation Journal Vol.29 No.5

간헐적인 파행을 주소로 하는 하지의 동맥경화증

편욱범 대한노인병학회 2002 대한노인병학회지 Vol.6 No.4