Exposure to Mycobacterium tuberculosis during flexible bronchoscopy in patients with unexpected pulmonary tuberculosis

나해정,엄중섭,이지원,장선미,송승언,목정하,조은정,김미현,이광하,김기욱,이민기 대한결핵 및 호흡기학회 2015 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.120 No.-

Background and objective: Recent guidelines recommend the use of a fit-tested N95 particulate respirator during bronchoscopy when pulmonary tuberculosis (PTB) is suspected. When bronchoscopy is performed in patients with unsuspected PTB, Mycobacterium tuberculosis (MTB) is occasionally cultured; therefore, healthcare workers are unexpectedly exposed to MTB. This study determined the incidence of unexpected MTB exposure and related factors during bronchoscopy. Methods: This retrospective study examined 1650 patients who underwent bronchoscopy from 2011-2013 for suspected respiratory disease other than PTB. The results of bronchial washing, bronchoalveolar lavage, and post-bronchoscopic sputum were reviewed. Results: Of the 1650 patients, 76 (4.6%) were unexpectedly diagnosed with PTB. The presence of anthracofibrosis (OR, 3.878; 95% CI, 1.291-11.650; P = 0.016), bronchiectasis (OR, 1.974; 95% CI, 1.095-3.557; P = 0.024), or atelectasis (OR, 1.740; 95% CI, 1.010-2.903; P = 0.046) on chest computed tomography (CT) scans was independently associated with an unexpected diagnosis of PTB at bronchoscopy. Conclusions: Unexpected exposure to MTB during bronchoscopy is underestimated. Higher-grade precautions, such as a fit-tested N95 particulate respirator, should be considered when anthracofibrosis, bronchiectasis, or atelectasis is found in chest CT results.

F-16 : 부산지역 한 국립대 병원에서 경험한 결핵 진단 시 광범위한 폐파괴 를 동반한 환자들의 치료 및 추적관찰 현황

나해정,조은정,목정하,김미현,김기욱,박혜경,이민기,이광하 대한결핵 및 호흡기학회 2013 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.116 No.-

목적: 결핵에 의한 폐파괴는 다양한 호흡기증상과 폐기능 감소의 장애를 초래하고 호흡부전의 한 원인이 되므로 결핵 진단 시 광범위한 폐파괴를 동반한 환자들은 전문의료진에 의한 지속적인 관리가 필요하나 부산지역에서는 이러한 환자들에 대한 연구가 제한적이다. 본 연구는 부산지역의 한 3차 국립대병원에서 결핵 진단 시 광범위한 폐파괴가 동반된 환자들의 치료 및 추적관찰 현황을 조사하였다. 방법: 2007년 1월 1일부터 2011년 12월 31일까지 부산대학교병원에서 결핵으로 진단받은 환자 중 진단 시 단순흉부엑스선상 전폐야 중 25% 이상의 폐파괴가 동반된 환자 161명을 대상으로 의무기록을 분석하였다. 결과: 환자들의 평균 나이는 54.9±15.6세이었고, 남자가 131명(81.4%)이었다. 93명(57.8%)은 결핵 초치료이었고, 16명(9.9%)에서 다재내성 결핵으로 진단되었다. 결핵 치료 중 본원 의료진의 판단에 의해 하급의료기관으로 전원 한 경우는 37명(23.0%)이었으나 36명(22.4%)에서 는 치료 중 환자 본인의 자의에 의해 전원하였다. 결핵 치료에도 불구하고, 37명(23.0%)은 입원 치료 중 사망하였으며, 진단 시 단순흉부엑스 선상 50% 이상의 폐 파괴가 동반된 환자들에게서 사망률이 더 높았다(61.0% vs 17.0%, p<0.001). 결핵 치료 종료 후 생존이 확인된 78명중 본원에서 계속적으로 외래 방문 하였던 환자는 54명(69.2%)이었는데, 이들 중 29명(53.7%)에서 폐기능 검사가 시행되었고, 50% 이상의 폐 파괴가 동반된 환자들에게서 FEV1이 유의하게 낮았다(37.2±9.7% vs 51.4±13.6%, p=0.023). 치료 후 1년 6개월 동안 추적관찰 기간 중 6명(7.6%)의 환자가 사망하였다. 결론: 본 연구에서 결핵 진단 시 광범위한 폐파괴가 있는 환자들은 치료 및 치료후에도 계속적인 추적 관찰이 필요함을 보여주었다.

Clinical Application of the Quick Sepsis-Related Organ Failure Assessment Score at Intensive Care Unit Admission in Patients with Bacteremia: A Single-Center Experience of Korea

나해정,정은숙,김인수,김원영,이광하 대한중환자의학회 2017 Acute and Critical Care Vol.32 No.3

Background: We evaluated the clinical usefulness of the quick Sepsis-Related Organ Failure Assessment (qSOFA) score (based on the 2016 definition of sepsis) at intensive care unit admission in Korean patients with bacteremia. Methods: We retrospectively analyzed clinical data from 236 patients between March 2011 and February 2016. In addition to the qSOFA, the Modified Early Warning score (MEWS) and systemic inflammatory response syndrome (SIRS) criteria were calculated. Results: The patients’ median age was 69 years, and 61.0% were male. Of the patients, 127 (53.8%) had a qSOFA score ≥2 points. They had significantly higher rates of septic shock, thrombocytopenia, and hyperlactatemia, and increased requirements for ventilator care, neuromuscular blocking agents, vasopressors, and hemodialysis within 72 hours after intensive care unit admission. They also had a significantly higher 28-day mortality rate. When analyzed using common thresholds (MEWS ≥5 and ≥2 SIRS criteria), patients with a MEWS ≥5 had the same results as those with a qSOFA score ≥2 (P < 0.05). However, patients with ≥2 SIRS criteria showed no significant differences. Conclusions: Our results show that a qSOFA score ≥2 at admission is a useful screening tool for predicting disease severity and medical resource usage within 72 hours after admission, and for predicting 28-day mortality rates in patients with bacteremia. In addition, qSOFA scores may be more useful than SIRS criteria in terms of prognostic utility.

P-125 : 면역 억제상태에서 치료 중 역설적 반응이 동반된 Mycobacterium kansasii 폐질환 1예

나해정,조은정,목정하,김미현,김기욱,박혜경,이민기,이광하 대한결핵 및 호흡기학회 2013 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.116 No.-

서론: 결핵 치료 중 볼 수 있는 역설적 반응은(paradoxical response) 비결핵 항산균 폐질환 치료에서는 드문 것으로 알려져 있다. 저자들은 면역 억제상태 환자에게서 치료 중 역설적 반응이 동반된 Mycobacterium kansasii 폐질환 1예를 경험하였기에 보고하는 바이다. 증례: 2년 전 급성림프구백혈병 진단 받고 유지화학요법 중인 66세 남자가 객혈을 주소로 내원하여 객담 항산균도말 검사에서 양성소견으로 isoniazide, rifampicin, ethambutol, pyrazinamide로 치료를 시작하였고 이후 배양검사에서 Mycobacterium kansasii가 동정되어, M. kansasii에 의한 폐질환으로 진단하여 isoniazide, rifampicin, ethambutol 3제 요법으로 치료를 계속하였다. 치료 9개월 후 오른쪽 목의 통증 및 종창 발생 하였고, 목전산화단층촬영에서 오른쪽 빗장위림프절(supraclavicular lymph node) 부위에 림프절염 의심 소견 확인되어 세침흡인생검 시행하였다. 조직검사 결과상 괴사를 동반한 만성 육아종성 염증이 관찰되었고, 조직에 대한 항산균도말 검사에서 양성이 나왔으며, 배양검사에서 균이 동정 되지는 않았으나 비결핵 항산균 중합효소연쇄반응(polymerase chain reaction)에서 양성이 확인되었다. M. kansasii 치료 중 발생한 역설적 반응에 의한 림프절염이 발생한 것으로 생각하고 항결핵 치료 지속하였다. 이후 목의 종창은 호전되었고, 추적 목전산화단층촬영에서도 오른쪽 빗장위림프절에서 관찰되던 괴사성 림프절 소견은 사라졌다. 현재 항결핵 치료 지속하면서 외래에서 추적 관찰 중이다. 결론: 본 증례는 면역 억제 상태에서 M. kansasii 폐질환 치료 중 역설적 반응으로 림프절염이 발생하였으나 계속적인 치료 후 호전되었던 증례로 면역 억제 상태에서 M. kansasii 폐질환 치료 중인 경우 새로운 병변이 나타나거나 기존 병변이 심화되는 경우 일시적인 역설적 반응도 고려해야 함을 보여주는 증례이다.

P-6 Clinical application of the quick Sepsis-related Organ Failure Assessment in intensive care unit patients with bacteremia: A single-center study in Korea

나해정,김태화,김인수,정은숙,이광하 대한결핵 및 호흡기학회 2016 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.121 No.-

Background: According to the new international sepsis guidelines (Sepsis-3), patients with a quick Sepsis-related Organ Failure Assessment (qSOFA) score of greater than or equal to 2 are more likely to have a poor outcome. Our study evaluated the clinical usefulness of the qSOFA score in patients with bacteremia at the time of intensive care unit (ICU) admission. Methods: We retrospectively analyzed clinical data from the medical records of 158 patients with infectious diseases who had a positive blood culture within 3 days after ICU admission in a tertiary care hospital between March 2011 and February 2015. Results: The patients` median age was 69 (range 22-87) years, and 61.4% were male. Of the 158 patients, 83 (52.5%) had altered mentality, 76 (48.1%) had a respiratory rate of 22/min or greater and 95 (60.1%) had a systolic blood pressure of 100 mmHg or less. The patients with a qSOFA of 2 or more had a higher incidence of pneumonia as a cause of sepsis (49.4. vs. 25.4%, p = 0.002), neutropenic state at diagnosis of sepsis (12.6 vs. 2.8%, p=0.039), Gram-negative bacteremia (46.0 vs. 29.6%, p=0.048), and candidemia (17.2 vs. 5.6%, p=0.028). Univariate logistic regression analysis showed that a qSOFA score of 2 or more was associated with 28-day mortality in our cohort (odds ratio = 2.820, p=0.002). Conclusion: In our study, a qSOFA score of 2 or more was associated with greater disease severity and a higher 28-day mortality rate. Also, patients with a qSOFA score of 2 or more had a higher incidence of pneumonia, neutropenia, Gram-negative bacteremia, and candidemia.

P-62 Association of disease knowledge level and quality of life in chronic obstructive pulmonary disease: A single-center study in Busan

나해정,조은정,목정하,김미현,박혜경,이민기,김기욱 대한결핵 및 호흡기학회 2016 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.121 No.-

Background and objective: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and the loss of disability-adjusted life years worldwide. COPD also leads to a reduced quality of life (QoL). Various studies have evaluated the risk factors affecting QoL in patients with COPD. However, the relationship between COPD knowledge level and QoL has not been examined. This study thus evaluated this relationship. Methods: We retrospectively analyzed clinical data from the medical records of 191 patients with COPD seen between January 2011 and December 2011 in a tertiary care hospital. The subjects` general QoL measure (SF-36), disease-specific QoL measure (the St. George`s Respiratory Questionnaire, SGRQ), and Bristol COPD Knowledge Questionnaire (BCKQ) were collected. Results: COPD knowledge was correlated with the general QoL, but not with the disease-specific QoL. The BCKQ score was positively correlated with the SF-36 (P = 0.004) and moderately correlated with the physical (SF-36 PCS) and mental (SF-36 MCS) component summaries (r = 0.390 and r = 0.396, respectively), but not with the SGRQ (P = 0.979). The SF-36 score was more strongly correlated in the severe stages of COPD (r = 0.422). Conclusion: The COPD patients with greater disease knowledge had a better general QoL, but COPD disease knowledge was not associated with the disease-specific QoL.

TP-47 : 비소세포폐암에서 폐결핵이 미치는 영향

장선미,나해정,조은정,목정하,김미현,이광하,김기욱,박혜경,이민기 대한결핵 및 호흡기학회 2013 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.116 No.0

목적: 폐결핵과 폐암과의 연관성에 대한 최근 연구에서 과거 폐결핵이 있었던 선암환자에서 Epidermal Growth Factor Receptor (EGFR) 돌연변이의 빈도가 높음이 보고되었다. 이에 본 연구에서는 비소세포폐암에서 폐결핵병력이 미치는 영향을 알아보고자 하였다. 방법: 2009년부터 2013년 4월까지 비소세포폐암을 진단받은 환자에서 영상학적으로 폐결핵 병변이 있었던 결핵군과 결핵병력이 없는 비결핵 군을 비교하였다. 성적: 전체 288명이 포함되었고 연령은 66.1±8.8세, 남성이 82.6%이었다. 조직학적 유형은 선암(50.0%)이 가장 많았으며 다음으로 편평세 포암(40.6%)이었다. EGFR 돌연변이는 24.6%에서 양성이었고, exon 21이 8.2%로 가장 많았다. K-ras 돌연변이는 18.6%에서 양성이었다. 결핵군은 145명으로, 선암이 가장 많았으나(46.9%) 통계적인 유의성은 없었다. EGFR 돌연변이는 여성, 비흡연자에서 증가하였으나, 결핵병 력과는 연관성이 없었다. 폐결핵의 영상학적 위치와 폐암의 조직유형, EGFR 돌연변이와의 연관성은 없었으며, 결핵병력과 생존율과의 연관 성도 보이지 않았다. 결론: 결핵군에서 선암의 발생이 가장 많았으나, 결핵병력과 EGFR, K-ras 돌연변이와의 연관성은 없었으며, 생존율에도 차이를 보이지 않았다.

부산 지역 한 국립대병원에서의 경피적 심폐체외순환 치료 경험

신동훈,이민진,나해정,장선미,오준혁 고신대학교(의대) 고신대학교 의과대학 학술지 2015 고신대학교 의과대학 학술지 Vol.30 No.1

Objectives: Cardiopulmonary support has been used to treat the patients with refractory cardiogenic shock since 1950s. In advent of portable system its use has been widened considerably. In this retrospective study, we report our single center experience concerning possible indications, complications and outcomes of percutanous cardiopulmonary support (PCPS) Methods: From January 2013 to March 2014, we searched the patients who were supported by PCPS system by reviewing the medical records in cardiology department at our Hospital. Infectious organism was limited to what was identified within 2 weeks after weaning of PCPS. Results: A total of 9 patients were supported by PCPS with CAPIOX CX® system (Terumo inc., Tokyo, Japan) initially for ST-segment elevation myocardial infarction/non ST-segment elevation myocardial infarction in 4 patients, myocarditis in 3 patients, valvular heart disease in 1 patient, and acute respiratory distress syndrome in 1 patient. The mean duration of PCPS support was 79.1±76.6 hours and 5 of them were recovered and discharged alive. All the patients needed transfusions of various forms of blood products. And there was one major stroke and one hyperbilirubinemia in related to PCPS treatment. Conclusions: PCPS treatment was a valuable means to treat the patients with cardiovascular collapse, but not without costs. Efforts to reduce its associated complications should be made to improve outcomes.

Monosomal and complex karyotypes as prognostic parameters in patients with International Prognostic Scoring System higher risk myelodysplastic syndrome treated with azacitidine

황경림,송무곤,신호진,나해정,신동헌,김중근,문준호,안재숙,송익찬,홍준식,이경원,정주섭 대한혈액학회 2014 Blood Research Vol.49 No.4

Background Azacitidine (AZA) is standard care for patients with myelodysplastic syndrome (MDS) who have not had allogeneic stem cell transplantation. Chromosomal abnormalities (CA) including complex karyotype (CK) or monosomal karyotype (MK) are associated with clinical outcome in patients with MDS. Methods We investigated which prognostic factors including CAs would predict clinical outcomes in patients with International Prognostic Scoring System (IPSS) higher risk MDS treated with AZA, retrospectively. CK was defined as the presence of three or more numerical or structural CAs. MK was defined as the presence of two or more distinct autosomal monosomies or single autosomal monosomy with at least one additional structural CA. Results A total of 243 patients who treated with AZA, were enrolled. CK was present in 124 patients and MK was present in 90 patients. Bone marrow blasts ≥15% and CK were associated with poorer response (P=0.038, P=0.007) and overall survival (OS) (P<0.001, P <0.001) independently. Although MK in CK group was not associated with prognosis, non-MK status in non-CK group reflected favorable OS (P=0.005). The group including >3 CAs was associated with poorer OS (group including <3 CAs vs. only three CAs, P=0.001; group with >3 CAs vs. only three CAs, P=0.001). Conclusion CK was an important prognostic parameter associated with worse outcome. MK may predict poor survival in only non-CK status. The higher number of CAs was associated with poorer survival.

Monosomal and complex karyotypes as prognostic parameters in patients with International Prognostic Scoring System higher risk myelodysplastic syndrome treated with azacitidine

황경림,송무곤,신호진,나해정,신동헌,김중근,문준호,안재숙,송익찬,홍준식,이경원,정주섭 대한혈액학회 2014 Blood Research Vol.49 No.4

Background Azacitidine (AZA) is standard care for patients with myelodysplastic syndrome (MDS) who have not had allogeneic stem cell transplantation. Chromosomal abnormalities (CA) including complex karyotype (CK) or monosomal karyotype (MK) are associated with clinical outcome in patients with MDS. Methods We investigated which prognostic factors including CAs would predict clinical outcomes in patients with International Prognostic Scoring System (IPSS) higher risk MDS treated with AZA, retrospectively. CK was defined as the presence of three or more numerical or structural CAs. MK was defined as the presence of two or more distinct autosomal monosomies or single autosomal monosomy with at least one additional structural CA. Results A total of 243 patients who treated with AZA, were enrolled. CK was present in 124 patients and MK was present in 90 patients. Bone marrow blasts ≥15% and CK were associated with poorer response (P=0.038, P=0.007) and overall survival (OS) (P<0.001, P <0.001) independently. Although MK in CK group was not associated with prognosis, non-MK status in non-CK group reflected favorable OS (P=0.005). The group including >3 CAs was associated with poorer OS (group including <3 CAs vs. only three CAs, P=0.001; group with >3 CAs vs. only three CAs, P=0.001). Conclusion CK was an important prognostic parameter associated with worse outcome. MK may predict poor survival in only non-CK status. The higher number of CAs was associated with poorer survival.