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박훈석,최범순,홍유아,정병하,김형욱,박철휘,양철우,진동찬,김용수 연세대학교의과대학 2012 Yonsei medical journal Vol.53 No.6
A 27-year-old man presented at the emergency room with hemoptysis. His blood pressure was 180/100 mm Hg, and he had no history of hypertension. Chest radiographs showed bilateral infiltration, suggestive of alveolar hemorrhage. His laboratory data were consistent with acute kidney injury. His serum creatinine level increased abruptly; therefore, renal biopsy was performed. Steroid pulse therapy was administered because of a strong suspicion of immune-mediated pulmonary renal syndrome. Renal biopsy showed proliferative endarteritis, fibrinoid necrosis, and intraluminal thrombi in the vessels without crescent formation or necrotizing lesions. Steroid pulse therapy rapidly tapered and stopped. His serum creatinine level gradually decreased with strict blood pressure control. Ten months after discharge, his blood pressure was approximately 120/80 mm Hg with a serum creatinine level of 1.98 mg/dL. Pulmonary renal syndrome is generally caused by an immune-mediated mechanism. However, malignant hypertension accompanying renal insufficiency and heart dysfunction causing end-organ damage can create a pulmonary hemorrhage, similar to pulmonary renal syndrome caused by an immune-mediated mechanism. The present case shows that hypertension, a common disease, can possibly cause pulmonary renal syndrome, a rare condition.
수술 받은 과거력이 없는 고령 환자에 발생한 횡행결장간막 탈장 1예
박훈석 ( Hoon Suk Park ),김진일 ( Jin Il Kim ),김명석 ( Myoung Seok Kim ),김순섭 ( Soon Sub Kim ),조세현 ( Se Hyun Cho ),박수헌 ( Soo Heon Park ),한준열 ( Joon Yeol Han ),김재광 ( Jae Kwang Kim ) 대한소화기학회 2006 대한소화기학회지 Vol.48 No.4
Internal hernia is defined as the herniation of viscera through an anatomic or pathologic opening within the boundaries of peritoneal cavity. Transmesocolic hernia, a subtype of internal hernia, has a herniated sac through the transverse mesocolon. Transmesocolic hernia has been rarely described in the literature, and most of reported cases were associated with a history of operation or congenital anormaly. A 72-year-old female with chronic intermittent abdominal pain and bloating was admitted. Small bowel series showed multiple jejunal loops confined to the left upper quadrant of abdomen. Abdomen spiral computed tomography (CT) showed a cluster of mildly dilated small bowel loops with mesenteries on the same area. On the three-dimensional reconstruction CT scan, a herniated sac through the transverse mesocolon was identified. She was diagnosed as transmesocolic hernia by using the three-dimensional reconstruction CT and small bowel series, without surgical exploration. The symptoms were managed with conservative measures. (Korean J Gastroenterol 2006;48:286-289)
감염의 형태와 위험인자에 근거한 후방 척추 유합술 후 감염의 예방법
안동기,박훈석,김태우,전태환,양종화,최대정 대한척추외과학회 2009 대한척추외과학회지 Vol.16 No.4
연구계획: 후향적 예비분석 및 전향적 연구 연구목적: 후방기기 고정술을 사용한 후방 척추 유합술에서 감염 예방 수칙을 설정하고 그 효과를 알아보았다. 대상 및 방법: 2년간 수술받은 583예(Ⅰ군)을 대상으로 감염율, 감염의 형태 그리고 위험인자를 조사하고, 이후 4개월 간 수술받은 88예를 대상으로 수술실 공기, 수술창, 수술 참가자들의 손, 이식골, 후방기기에서 세균 검사를 하여 오 염 경로를 추정하였다. 이를 토대로 설정한 감염 예방 수칙을 시행 후 1년간 수술한 354예(Ⅱ군)을 대상으로 감염 발 생이 감소하였는가를 조사하였다. 결과: I군중 20예(3.4%)에서 감염이 발생하였다. 감염 형태는 표재성 창상 감염(4예), 심부 창상 감염(4예), 추체간 골 수염(7예), 척추경 나사못 주변부 골수염(4예), 창상 감염을 동반한 척추경 나사못 주변부 골수염(1예)로 분류되었다. 수술실 공기와 수술창에서 동일한 균주(표피 포도상구균)가 배양되었다. 후방 추체간 유합술(p=0.034), 하절기 (p=0.025), 재수술(p=0.087)시 감염이 호발하였다(신뢰구간 10%). 이상을 근거로 다음과 같은 여섯 가지 감염 예방 수 칙(후방 추체간 유합술의 제한된 적용, 개선된 창상 세척 방법, 추체 삽입물 개방 전 냉방기 작동중지 및 삽입직전 추 체 삽입물 개방, 후방기기 고정술 전 주수술자의 수술 가운 갱의, 국소골 세척 후 이식)을 설정하였다. 이를 시행한 후 수술에서는(II군) 2예(0.6%)에서 감염이 발생하였다(p=0.005, odds ratio=0.162; 95% confidence interval=0.038 to 0.696). 결론: 수술실 공기에 장시간 노출되면 창상은 물론 이식골과 척추 삽입물 등도 세균 오염의 대상이 될 수 있으며, 오 염된 이식골과 척추 삽입물은 창상 감염을 통하지 않고도 추체간 골수염 또는 척추경 나사못 주변부 골수염 형태의 감염을 발생시킬 수 있을 것으로 생각된다. 본 연구의 감염 예방 수칙은 척추 유합술 후 감염 발생을 낮출 수 있는 유 용한 방법으로 생각된다. Study Design: This is a retrospective preparative study and prospective study Objective: We instituted and verified the precautions against postoperative spinal infection. Summary of the Literature Review: Postoperative infection comes from contamination during the operation and various strategies have been recommended to prevent it. Materials and Methods: 583 cases that underwent instrumented posterior spinal fusion during two years (group Ⅰ), were reviewed to discover the risk factors, and intraoperative cultures were done to detect the contamination routes and the causative microorganisms for the next 4 months. Six precautions, based on the results, were instituted. We analyzed 354 cases that underwent operation in the following year (group Ⅱ) using the precautions. Results: Twenty cases (3.4%) were infected in group I and the types of infection were superficial wound infection (4 cases), deep wound infection (4 cases), osteomyelitis around the interbody space (7 cases), osteomyelitis around the pedicle screws (4 cases) and a combination of wound infection and osteomyelitis around the pedicle screws (1 case). Infections happened more frequently in the cases of interbody fusion (p=0.034), revision (p=0.087) and those done in the summer season (p=0.025). S. epidermidis, as the causative bacteria, was cultured from both the operation environments and wounds. Six precautions based on the preliminary results were instituted as follows; irrigation method reformation, delayed opening of instruments, turning-off local air conditioners, changing of gowns before instrumentation, local bone irrigation and limited indications for interbody fusion. After implementation, two cases (0.6%) of infection developed in group II (p=0.002, odds ratio=0.160; 95% confidence interval = 0.037 to 0.688). Conclusion: Wounds, grafted bones or instruments can be contaminated under longer-time exposure to operating room air and so produce interbody or pedicle osteomyelitis without wound infection. The precautions were effective to decrease the postoperative infection rates following posterior spinal fusion.