위절제술 환자의 표준진료지침 개발 및 적용 효과

김은희,김철규,이순교,김순덕,이혜옥,권정순,이경미,이민미,심순미,유용만,신종식,강은희,이상일,김병식,오성태,육정환,박수길 한국의료QA학회 2003 한국의료질향상학회지 Vol.10 No.2

Background : Gastric cancer is the most common malignant tumor in Korea. surgical operation is one of the major treatment modalities for gastric cancer patients. Therefore, gastrectomy is one of the most common procedures in General Surgery. There were variation in length of hospital stay and medical treatment for gastrectomy between three surgeons at Asan Medical Center. Clinical pathways have received considerable attention as a tool for recucing the medical practice variation, increasing the efficiency of care process, and improving the quality of care. The aim of this study was to evaluate the effect of a clinical pathway for gastrectomy in gastric cancer patients. Methods : The clinical pathway for gastrectomy was developed and implemented by a multidisciplinary group in Asan Medical Center. A computerized clinical pathway program was developed and revised after a pilot test. A total of 145 patients underwent gastrectomy by three surgeons at Asan Medical Center. We compared the length of hospital stay, patient satisfaction, and unplanned readmission rate between the pre-pathway group(n=67) and the post-pathway group(n=78). We also investigated the degree of satisfaction among the physicians and nurses who were main end-users of the clinical pathway. Results : The clinical pathway was applied to all target patients. The average length of hospital stay was shortened from 12.7days to 10.6days(p<0.01). The degree of patient satisfaction with the care process changed from 90.3% to 89.2% after the implementation of the clinical pathway, but the difference was of satistically significant(p=0.761). Unplanned readmission rate was 2.9% in the pre-pathway group. More than 90% of physicians and nurses answered that the clinical pathway had been a useful tool in their medical practice. Conclusions : The findings of the study demonstrated that implementation of the clinical pathway for gastrectomy produced substantial reduction in the length of hospital stay while improving the quality of patient outcomes. The computerized clinical pathway program can be used as one of the powerful patient management tools for reducing the practice variations and increasing the efficiency of care process in Korea hospital settings.

티탄소 스트롬튬 상유전성 박막의 전기전도도 특성에 관한 연구

이우선,손경춘,김남오 조선대학교 에너지.자원신기술연구소 1999 에너지·자원신기술연구소 논문지 Vol.21 No.2

Temperature and frequency dispersion of dielectric permittivity was investigated on thin films of SrTiO_(3) deposited by on RF magnetron reactive sputtering. The thin films deposited on Ag/Si substrates. The SrTiO_(3) films was confirmed by XRD and it is exhibited by SEM that a uniform and fine grain structure. The electrical conduction of the films properties were dependent on temperature or frequency. Resistivity decrease with temperature and electric fild. Dielectric constant of the films properties were the highest value(ε_(r) = 300) and dependent on frequency.

품행장애 청소년을 위한 외래집단정신치료 치료요인

이후경,김선재,차정화,봉수연,안현주 대한신경정신의학회 2000 신경정신의학 Vol.39 No.2

연구목적: 집단정신치료는 또래집단을 중요시하는 품행장애 청소년의 치료로서 매우 효과적인 것으로 알려져 있으나 한국에서는 아직 활성화되지 못하고 있다. 이에 따라 저자들은 품행장애 청소년에게 효과적으로 적용될 수 있는 폐쇄형, 동질적인, 시간제한(10회), 외래집단정신치료를 주 1회 실시하였다. 본 연구의 목적은 ①품행장애 청소년을 대상으로 집단정신치료를 시행하여 효과성을 평가하고, ②치료요인을 조사하여, ③ 집단정신치료를 품행장애 청소년에게 효과적이면서 효율적으로 적용될 수 있는 치료방법으로 정착시키는 데 있다. 대상 및방법: 본 연구는 1998년 10월붜 12월까지, 1999년 4월부터 6월까지 두차례에 걸쳐 실시하였다. 대상군은 품행장애 범주에 해당하는 H고교 2학년 여학생 총 18명(4명 도중 탈락), 대조군은 같은 범주에 해당하는 H고교 2학년 여학생 중 치료에 참여하지 않은 총 18명(4명 도중 탈락)이었다. 평가도구로는 프로그램 실시 전후에 자기보고식 비행척도, 공격성척도, 충동성척도을 시행하였고, 매 회기가 끝난 직후 Yalom의 13가지 치료요인척도, 집단치료 만족도 설문지를 시행하였으며, 종결모임시 총평가 설문지를 시행하였다. 결과: 치료요인의 변화를 집단발단단계에 따라 전후반기로 나누어 비교하였을 때, 전반기(1∼5회)에 상위를 차지한 치료요인은 순서대로 실존적인자, 보편성, 카타르시스, 리더와의 동일시, 구성원과의 동일시이었으며, 후반기(6∼10회)에 상위를 차지한 치료요인은 카타르시스, 실존적인자, 리더와의 동일시, 구성원과의 동일시, 구성원의 조언이었다. 전반기에 비해 후반기에 상대적으로 카타르시스, 구성원의 조언이 상승하였고 보편성은 하락하였다. 이타주의와 일차가족집단의 교정적 반복발달은 전후반기 모두 최하위를 기록하였다. 집단치료 만족도 설문에서 전반기는 45.7%, 후반기에는 83.3%가 도움받는 것으로 나타났고, 총평가 설문에서 85.7%가 기회가 있다면 다음에도 참여하고 싶다고 보고하였다. 결론: 시간제한 외래집단정신치료가 품행장애 청소년 에게 적용할 때 매우 효과적이면서도 만족도가 높은 것으로 나타났다. 청소년을 대상으로 외래집단정신치료를 시행하는 것은 구성상의 어려움, 동기부족, 기금부족 등, 여러 제반 문제가 있으나 확대 시행되어야 할 것으로 생각된다. Objectives: Group psychotherapy is known to be an dffective treatment program for adolescents who attach importance to peer relationship, but it is not activated in Korea. Therefore, researchers performed weekly the closed, homogeneous, time-limited(10 sessions), outpatient group psychotherapy for adolescents with conduct disorder. Objectives of this study were as follows ; first, we practiced the group psychotherapy for adolescents with conduct disorder and evaluated its effectiveness ; second, we examined the therapeutic factors which were used by participants ; third, we intended to settlee down the group psychotherapy for adolescents with CD as an effective and efficient treatment modality. Methods: This study was performed two times from October to December in 1998 and from April to June in 1999. It was sponsored by Youth Counselling Center in H city. The case group were composed of 15 female students who were second grade in H high school, and 4 students were dropped out. The control group were composed of 18 female students who were same grade in H high school and 3 students were dropped out. Before and after this program, self-report delinquency scale, aggression scale and impulsivity scale were asked to them. And just after each session, Yalom 13 therapeutic factors scale and satisfaction questionnaire for group psychotherapy were asked to them. And at last meeting, total assessment questionnaire was asked to them. Results: We compared the change of therapeutic factors between the former half sessions (1-5) and the later half session(6-10), and the results were as follows ; in the former half, the upper ranks of therapeutic factors were existential factor, universality, catharsis, identi- fication with leader, and identification with members in order. And in the later half, the upper ranks of therapeutic factors were catharsis, existential factor, identification with leader, identi - fication with members, and guidance of members in order. The rank of catharsis and guidance of members went upward and the rank of universality went downward when we compared the ranks in the former half to those in the later half. Altruism and family enactment were the lowest ranked in both half. The satisfaction questionnair for group psychotherapy showed to be helped by participants at the rate of 45.7% in former half, 83.3% in later half. The total assessment questionnaire showed the willingness of re-participation at the rate of 85.7% if future opportunity of group psychotherapy is given for them. Conclusions: The time-limited group psychotherapy for adolescents diagnosed by conduct disorder was very effectively practiced and the participants reported high level of the satisfaction. The outpatient group psychotherapy for adolescents would be expanded and practiced though there are several accompanied problems including the difficulty of structuring, the deficit of motivation, and financial problem.

정신보건전문가를 위한 훈련집단

이후경,김선재,윤성철 大韓神經精神醫學會 2001 신경정신의학 Vol.40 No.5

연구목적 : 집단정신치료 전문가 수련과정에는 교습적인 과정, 구성원(환자)으로서의 경험, 리더(치료자)로서의 경험이 포함된다. 이에 따라 크게 ① 이론과 실제에 대한 강의, 사례발표회와 초독회 및 세미나, ② 관찰, ③ 훈련집단(워크샵 포함). ④ 지도감독으로 나누는데, 이 중에서 훈련집단과 지도감독이 가장 효과적인 교육방법으로 인정되고 있다. 저자들은 ① 정신과 영역에서 집단정신치료의 활성화, ② 집단정신치료에서 정신과의사들의 주도적인 역할수행, ③ 자격 있는 집단정신치료자의 훈련 및 양성을 목적으로 전공의를 포함하는 정신보건전문가들을 위한 훈련집단 모텔을 개발하여 실시하였다. 구체적인 연구목표는 다음과 같다. 첫째, 정신보건전문가들을 대상으로 훈련집단을 시행한 후 나타나는 방어기제, 자아기능의 변화를 살펴본다. 둘째, 참여자들이 도움 받은 것으로 보고한 치료요인을 알아본다. 셋째, 훈련집단 진행에서 나타나는 내용과 과정을 포함한 전체적인 특징을 분석한다. 넷째, 이를 통해 훈련집단을 정신보건전문가들의 개인적인 성장과 전문가로서의 자질을 키우는데 효과적인 교육방법으로 정착시키고, 나아가 집단정신치료 전문가 수련과정 및 자격요건을 확립하기 위한 기초자료로 삼는다. 방 법 : 본 연구는 1997년부터 2000년까지 5번에 걸쳐 실시되었다. 이 기간 중 참여자는 정신과전공의를 포함하여 정신보건분야에 종사하는 전문가들로서 총 37명이었고, 이 가운데 도중 탈락한 9명을 제외한 29명(남자 2명, 여자 27명)이 최종 대상군으로 선정되었다. 본 연구에서는 우선 대상자들이 훈련집단을 참여한 후 성격변화를 평가하기 위한 사전-사후검사 실험설계를 수행하였다. 연구도구로서 객관적 질문지 형태의 이화방어기제검사와 이고그램검사를 사용하였다. 그리고 매번 훈련집단이 끝난 직후 13가지 치료요인척도와 간단한 주관적 설문지를 작성하도록 하였고, 종결 시에 자기보고식 총평가 설문지를 실시하였다. 결 과 : 이화방어기제는 사전-사후검사 비교에서 성숙방어는 유의미한 증가를 보였고, 미성숙방어는 유의미한 감소를 보였으며, 자기애적방어와 신경증방어에서는 유의미한 차이가 없었다. 이고그램은 사전-사후검사 비교에서 양육적부모(NP), 어른(A), 자유로운아이(FC) 자아에서 유의미한 증가를 보였다. 상위를 차지한 치료요인은 순서대로 대인관계학습, 실존적 인자, 리더와의 동일시, 정화, 사회화 기술의 발달이었다. 총평가 설문에서 참여자의 100%에서 도움 받은 것으로 보고하였고, 48.3%에서 생활사의 변화를 보고하였으며, 89.7%에서 훈련집단을 다른 사람에게 적극적으로 권유하겠다고 하였고, 58.6%에서 재참여 의사를 밝혔다. 결 론 : 본 연구를 통해 참여자들은 방어기제와 자아기능의 변화를 보였다. 훈련집단 경험은 참여자들에게 자신을 돌아보고 마음의 갈등을 파악하며 상대방을 이해하는 경험을 제공한다. 또한 정신보건전문가에게 필수적인 집단현상에 대한 안목과 치료요인에 대한 이해를 증진시키고, 리더십 및 기법을 터득하게 하여 집단정신치료에 대한 자신감을 갖게 하며, 정신치료 전반에 대한 이해를 높일 수 있다. 그러므로 향후 정신보건분야에서 정신과전공의를 비롯한 정신보건전문가의 정신치료 및 집단정신치료의 교육 도구로서 훈련집단을 확대 적용할 필요가 있다. Objectives : Training group with mental health professionals includes didactic process, experience as a member(patient) and a leader(therapist). It is divided into four parts as like 1) lecture, case conference, book reading and seminar about theory and practice, 2) observation, 3) training group(including workshop), and 4) supervision. Among them, the training group and the supervision have been accepted as the most effective methods. Authors have developed and practiced the training group model for mental health professionals including psychiatric residents which aim for the activation of group psychotherapy in mental health area, psychiatrists' initiative in group psychotherapy area, and the training and nurturing of qualified mental health professionals. The objectives of this study are as follows ; firstly, we examine the change of defense mechanism and ego function after performing group psychotherapy for mental health professionals ; secondly, we analyze the therapeutic factors reported that participants were helped ; thirdly, we analyze main features which include group content and process manifested in training group ; lastly, we have objectives that the training group is settled down as an effective educational method to foster the personal growth and qualification as a specialist, and also that this study provides a basic research data to set up the training program and the requirements for group psychotherapy. Mothods : This study was performed 5 times from 1997 to 2000. The participants were composed of 37 mental health professionals including psychiatric residents. Among them, 29 participants(male 2, female 27) were chosen as the final subjects 9 participants dropped out in the process of this study. At first, we take an application of pre-treatment/post-treatment experimental design to evaluate the personality change after performing the training group. EDMT(Ewha Defence Mechanism Test) and EC(Egogram Checklist), the objective questionnaires, were used as the evaluation scale. And 13-therapeutic factor scale and simple subjective questionnaires were performed just after each session and the self-report total assessment questionnaires were performed at the end of this study. Results : To compare mean scores between pre-treatment and post-treatment in EDMT, the mature defense was increased significantly, the immature defense was decreased significantly, and the narcissistic defense and neurotic defense were not changed significantly. To compare mean scores between pre-treatment and post-treatment in EC, Nurturing parent(NP), Adult(A) and free Child(FC) were increased significantly. Therapeutic factors ranked highly were in-terpersonal learning, existential factor, Identification with therapist, catharsis, and socializing technique in order. The total assessment questionnaires reported that the 100% of participants were helped, the 48.3% of participants were changed in their lives, the 89.7% of participants would propose training group to others positively, and the 58.6% of participants had minds to join this kind of program if given again for them. Conclusions : This result showed that the defense mechanism and ego function of parti-cipants were changed. The training group experience makes participants reflect themselves, examine their conflicts and understand others. That also gives them chances of improving insight about group phenomena and understanding about therapeutic factors essential to the mental health professionals, having confidence on the group therapy by learning leadership and techniques, and improving understanding about the psychotherapy on the whole. Therefore, it is needed in the future that the training group would be widely adapted as an educational tool of psychotherapy and group psychotherapy for the mental health professionals as well as psychiatric residents in mental health area.

박복되는 현훈으로 발현한 보크트-고야나기-하라다 증후군 1예

이태경,남상원,박선아,성기범 대한평형의학회 2003 Research in Vestibular Science Vol.2 No.2

입원환자 대집단 사이코드라마 모델

이후경,윤성철,김선재 대한신경정신의학회 2000 신경정신의학 Vol.39 No.2

사이코드라마는 집단정신치료와 더불어 집단치료의 중요한 치료양식의 하나이며 모레노에 의해 시작 되었다. 사이코드라마는 국내 수련병원과 정신병원의 40∼50% 정도에서 시행되고 있으며 대부분 입원 환자를 대상으로 하여 진행되고 있다. 저자들은 한국 실정에 맞는 '입원환자 대집단 사이코드라마 모델을 개발하였는데, 일회성, 개발형, 구조화된 대집단의 성격을 띠고 있다. 본 모델의 특징은 첫째, 적은 노력으로 많은 환자들에게 최대의 치료효과를 거둘 수 있고, 둘째, 정신치료와 집단정신치료에 대한 훈련을 받은 정신과 의사라면(전공의 포함) 누구든지 접근할 수 있게 용이하고 간편하며, 셋째, 한 번에 많은 환자들을 치료적으로 접근할 수 있어서 저비용 고효율적이고, 넷째, 사이코드라마에 참여한 치료팀(전공의 포함)에게 정신치료와 집단정신치료적인 접근방식에 대한 교육적인 효과를 거둘 수 있다. 본 모델을 입원환자에 적용한 결과 전체 환자의 79.4%에서 도움 받은 것으로 보고하였다. 최근 의료보험 재정의 압박으로 개인정신치료의 비중이 줄어들고, 치료기간도 전통적인 장기치료에서 단기 또는 시간제한치료로 바뀌어 가고 있다. 또한 1995년 정신보건법 통과이후 정신건강에 대한 홍보와 계몽으로 이에 대한 욕구가 날로 증진되는 것에 반하여, 전신치료 분야에 대한 터무니없이 낮은 보험 수가와 전반적인 보험재정의 악화로 사실상 일대일 정신치료적인 접근을 불가능해지고, 게다가 대부분의 정신과 의사들의 과중한 환자 부담을 늘어가고 있는 실정이다. 이러한 상황에서 집단정신치료적인 접근은 입원 및 외래 환자들의 정신치료 서비스에 대한 요구를 충족시켜 줄 수 있는 적절한 대안이 될 수 있으며, 보험정책에도 부응할 수 있을 것으로 생각된다. 특히 많은 수의 입원환자들에게 적은 비용으로 정신치료적인 서비스를 동시에 제공할 수 있는 '입원환자 대집단 사이코드라마'는 중요한 치료양식으로 정착되어야 할 것으로 생각된다. As an alternative to group psychotherapy, worked out by Dr.Moreno, the psychodrama is being carried on mainly for a large group of inpatients at 40-50% of the country's psychiatric and training hospitals. The authors have developed a Korean psychodrama model for a group mental health having following characteristics : (1) a one-time treatment, (2) open-group therapy, and (3) structured, large group approach. Korean psychodrama model was proved to be a low cost, highly effective approach in that patients could be dealt with en masse to quite a satisfactory degree ; at the same time Korean psychodrama model is easily accessible for any psychiatric doctor or trainee in dealing with a patient. In addition, Korean psychodrama model is highly conducive to experiencing and training related people in psychotherapeutic practice as this model has shown up 79.4% approval rate among patients after treatment. Due to the recent crunch in medical insurance financing, psychotherapy is changing from individual long-term type to a more time-limited type. Despite the mental health law passed in 1995, from the human psychotherapy standpoing, the worsening economic situation has made it difficult for a psychiatrist to deal with patient on a one-to-one basis. As a result, the burden of most psychiatrists, is snowballing day by day. In this context psychodrama seems to be a promising, reliable alternative to group psychotherapy, both medically and economically. It will be a treatment modality for years to come.

1. 06㎛ Nd : YAG Laser를 이용한 요추간판탈출증의 경피적 수핵감압술

이흥선,변박장,최순관,신원한,권귀향,이인수,이경석,김범태 순천향대학교 1994 논문집 Vol.17 No.4

The 1.06㎛ Neodymium-YAG Laser(800 micron hemisherical) is revealed a useful tool for percutaneous laser disc decompression(PLDD). Especially PLDD would be applied to the management of lumbar disc herniation with minimal intervention. Total irradiated energy to one level of disc space was bout 1000 to 2000 joules. We performed this method at 10 levels, in 7 cases of patients, consisting of 4 males and 3 females with an average age of 37.7 years. Five cases showed excellent and good results, were observed. In two cases, open surgery was required because of unsatisfactory results. The best results were obtained in the protrusion type of disc herniation. We have summarized some advantages of PLDD: a) safe and simple procedure in an outpatient setting, b) avoiding general anesthesia, late spinal instability, c) possibility of repetitive use.

배양 신경세포의 분화에 따른 Transferrin 흡수와 그 수용체 발현에 대한 자기방사기록 및 면역세포화학적 연구

조사선,박광태,유영복,이경훈,박경한,황덕호,백상호 대한해부학회 1994 Anatomy & Cell Biology Vol.27 No.3

백서의 우울모형에서의 칼슘통로 길항제 에타베린(Ethaverine)의 항우울효과

이상경,김선희,김록우,윤성환,김용관,김경태,김영훈 대한신경정신의학회 2000 신경정신의학 Vol.39 No.2

연구목적: 본 전임상연구에서는 우울증의 두가지 동물모형을 통해 에타베린이 단독 혹은 이미프라민과 병용처치 되었을 때의 효과를 알아보고자 하였다. 방법: 표준화된 검사법인 강제수영검사를 사용하여 옹성백서에게 에타베린(20mg/kg) 및 이미프라민 (20mg/kg)을 단독 혹은 병용 처치하였을 때의 부동시간의 변화를 관찰하였고, 경도의 만성 스트레스를 3주간 가한 후 4주간 에타베린과 이미프라민을 단독 혹은 병용 처치하였을때의 자당섭취량의 변화를 관찰하였다. 결과: 약물을 1회 단기처치 및 7일간 장기처치한 강제수영검사에서 이미프라민 및 에타베린 단독처치는 대조군에 비하여 부동시간의 단축을 보였고 에타베린은 이미프라민의 부동시간 감소에 대한 증강작용을보였다. 경도의 만성스트레스 실험에서도 3주간의 스트레스로 인하여 감소된 백서의 자당섭취량을 이미 프라민 및 에타베린이 회복시켰으며, 치료초기에 두 약물의 병용처치효과가 두드러졌다. 결론: 본 연구의 결과는 에타베린이 향우울 효과를 가지고 있음을 시사하며, 삼환계 항우울제인 이미프라민의 항우울효과를 증강시키므로 에타베린의 임상적 활용 가능성을 보여준다. Objectives: This pre-clinical study was performed to assess the effects of ethaverine in the two kinds of behavioral models of depression in rats. Methods: We observed the changes of the immobility time in the froced swimming test and the quantity of sucrose consumed in the chronic mild stress model, using ethaverine(20mg/kg) alone, imipramine(20mg/kg) alone, or ethaverine and imipramine concomitantly. Results: In the forced swimming test, both single treatment and chronic treatment(for 7days) with imipramine or ethaverine significantly reduced the immobility time, and concomitant chronic treatment with ethaverine potentiated the effect of imipramine. In the chronic mild stress model, both imipramine and ethaverine reversed the decreased sucrose consumption induced by 3-week stress and concomitantly treated ethaverine potentiated the effect of imi-pramine in the early phase of treatment. Conclusions: The data suggest that ethaverine can be used alone or concomitantly with other antidepressants in the clinical situation.

알쯔하이머병 환자의 혈소판 아밀로이드 전구단백질 이상

이애영,조은경,김건익,김선국,손은희 대한치매학회 2003 Dementia and Neurocognitive Disorders Vol.2 No.2

Background:Although Alzheimer's disease (AD) is a progressive neurodegenerative disorder without any truly effective pharmacological treatment at present, early accurate diagnosis is important for the delaying of disease progression and proper management It would be desirable to have a peripheral biological marker to identify patients affected by AD Amyloid β-peptide originates from a larger precursor, the amyloid precursor protein (APP). which can be seen in the platelet of its equivalent to those found in brain. To investigate if there is a correlation between level of platelet APP isoform and AD, we evaluate a cohort of subjects including patients affected by sporadic AD, vascular dementia, and controls Subjects & Methods :Thirty-five patients with sporadic AD diagnosed according to the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Relatec Disorders criteria (NINCDS-ADRDA) and 26 vascular dementia patients diagnosed by the Diagnosis and Statistical Manual of Mental Disorders, Fouth Edition (DSM-Ⅳ) criteria and 12 controls were included Blood sample were drawn from fasting state and collected into 3 mL of 3.8% sodium citrate. Platelets were collected by centrifugation at 500 g for 20 minutes and washed. and the platelet pellet was stored at -80℃ until used APP was assessed by western blot analysis and quantified by densitometry using Image Analyzer Results:In platelets densitometer as well as the result of Western blot was higher compared with those of patients with non-Alzheimer dementia and controls We observed statistically significant reductions in the ratio of 120 kDa to 130 kDa APP to 110 kDa APP (APPr) for patients with probable AD compared with control subjects and patients with vascular dementia APPr levels in AD correlated with the severity of dementia measured by CDR. Accuracy levels measured by Receiver Operating Curve analysis showed that a cut-off level of 0.45 resulted in a sensitivity of 71% and a specificity of 74%, with an area under the curve of 0 793 Conclusion:Platelet APPr allowed to differentiate AD from normal aging and vascular dementia with high sensitivity and specificity These findings suggest that platelet APPr may be a helpful peripheral marker for diagnosis and clinical progression of Alzheimer disease.