우리나라 재난의학적 처치에 대한 연구 : 1993년 3월 29일 구포 열차 전복사고를 중심으로 한 연구 ANALYSIS OF RAILROAD COLLAPSED ACCIDENT OF GUPO

백광제,홍윤식 대한응급의학회 1993 대한응급의학회지 Vol.4 No.2

Disaster in an unexpected, chaotic, horrendous catastrophes and it may be either natural or human origin. Now a days, disasters are occurring at on increasing rate due to population growth and technological advancement. Medical disaster in an incident which produces such a number of causalities that makes the routine methods for patient care ar4e inadequate. The public no linger accept these consequences as "act of God" and they demand that disaster risks to be minimized and that any impact to be management in an orderly fashion. So emergency medical personnel must strive to achieve themselves to achieve the greatest good for the greatest number of potential survivors at the disaster scene. On 28 March 1993, a train carrying 600 passengers rolled over due to railroad collapse. About 170 passengers dies(25 before extrication) and 22 severe wounded survived. Problems in the organization at the scene, triage, and the communication contributed to the confusion in the management of victims. As analysis of this accident allows several lessons to be learn which might prevent or reduce the fatalities from future disaster. Although Korean community has relied on a model of disaster response deprived from the experience of military and civil defense planners for years. A better approach to organizing medical personnel for the incident with multiple causalities, which is based on the medical response of the emergency medical services organization, will be needed in the near future.

조혈모세포이식 후 골성장인자의 변화 및 골대사에 미치는 영향 : Impact on Bone Mineral Metabolism

백기현,오은숙,오기원,이원영,김혜수,권순용,한제호,강무일,차봉연,이광우,손호영,강성구,김춘추 대한내분비학회 2002 Endocrinology and metabolism Vol.17 No.5

연구배경: 각종 장기이식의 시행이 많아지고 이식 후 생존율이 증가함에 따라 이식 후 합병증에 대한 관심 또한 높아지고 있다. 조혈모세포이식 후에도 다양한 내분비적 합병증이 발생할 수 있으며 골격에 대한 합병증도 문제점으로 대두되고 있다. 조혈모세포 이식 후 발생하는 골소실에는 이식 후 초기의 골형성 저하와 골흡수 증가가 중요한 역할을 담당하리라고 추측되는데 이러한 골재형성불일치(biochemical uncoupling)에 골 성장인자들이 미치는 영향에 대해서는 알려진 바가 없다. 본 연구에서는 조혈모세포이식 전, 후로 말초 혈액에서 IGF-I, FGF-2, M-CSF같은 성장인자의 변화를 알아보고, 이들 성장인자의 변화가 조혈모세포이식 후의 골형과 골흡수에 미치는 영향 및 이식 후 발생되는 골량 소실과의 연관성을 확인해 보고자 하였다. 방법: 여러 가지 혈액질환으로 인해 동종 골수이식을 시행 받은 환자들을 전향적으로 관찰하였으며 이식 전 및 이식 후 1주, 2주, 3주, 4주 및 3개월, 6개월 1년에 말초 혈액에서 골교체표지자를 측정하였다. 이식 전 및 이식1년 후에 요추골 및 대퇴골 골밀도를 측정할 수 있었던 36명의 환자들을 대상으로 냉동 보관되어 있던 혈청을 이용하여 IGF-I, FGF-2 및 M-CSF를 시기별로 측정하였으며 이들 성장인자와 골교체표지자의 변화 및 골밀도 변화 사이의 상관관계를 확인하였다. 결과: 골흡수 표지자인 혈청 ICTP는 이식 전에 비해 이식 후 4주까지 점차 의의 있게 증가하다가 이후 6개월까지 더욱 증가한 후 감소하였다. 골형성 표지자인 osteocalcin은 이식 후 3주까지는 점차 감소하다가 이후 증가하여 이식 후 3개월 및 6개월에 기저치보다 통계적으로 유의하게 증가한 후 감소하였다. 혈청 IGF-I과 FGF-2는 각각 이식 후 3주 및 1주까지 의미있게 감소하다가 이후 증가하였으며 혈청 M-CSF는 이식 후 1주째에 기저치에 비해 의미 있게 증가하였다가 이후 기저치로 회복되었다. 이식 1년 후 평균 요추부 골밀도는 5.2% 감소하였고 평균 근위대퇴골 골밀도는 11.6% 감소하였다. 이식 전 및 이식 후 3주에 측정한 IGF-I과 같은 시기에 측정한 오스테오칼신 사이에 유의한 상관관계가 관찰되었으며 이식 후 3주째의 M-CSF와 골흡수표지자인 M-CSF 사이에서 의미 있는 양의 상관관계를 관찰할 수 있었다. 이식 후 3주 및 3개월에 IGF-I이 낮은 환자일수록 이식 1년 후 근위대퇴골에서의 골소실이 많은 것으로 분석되었다. 결론: 조혈모세포이식 후 발생하는 골소실에는 기존에 알려진 기저질환의 영향, 성호르몬의 감소, 면역억제의 투여, 골수기질세포와 조골세포의 손상 및 이식초기 사이토카인의 변화이외에도 골성장인자가 관련이 있음을 확인하였고, 이는 이식 후 발생되는 골량소실에 중요한 역할을 할 것이라고 사료된다. Background: A loss of bone mass is usually detected after a bone marrow transplantation (BMT), especially during the early post-transplant period. We recently reported that enhanced bone resorption following a BMT was related to both the steroid dose and the increase in IL-6. We also suggested damage to the marrow stromal microenvironment, by myoablation, partly explains the impaired bone formation following a BMT. It is well known that some growth factor play important role in bone growth and osteogenesis. However, the pathogenetic role of bone growth factors in post-BMT bone loss is unknown and data on the changes in the growth factors, in accordance with bone turnover markers and bone mineral density (BMD) changes are scarce. We investigated changes in bone growth factors such as IGF-I (Insulin-like growth factor-I), fibroblast growth factor-2 (FGF-2) and Macrophage colony stimulating factor (M-CSF), during the post-BMT period, and assessed whether the growth factor changes influenced the bone turnover and post-BMT bone loss. The present study is the first prospective study to describe the changes in bone growth factors following a BMT. Methods: We prospectively investigated 110 patients undergoing a BMT, and analyzed 36 patients (32.4±1.3 years, 17 men and 19 women) whose BMDs were measured before, and 1 year after, the BMT. The serum biochemical markers of bone turnover were measured before, 1, 2, 3 and 4 weeks, 3 and 6 months, and 1 year, after the BMT. The serum, FGF-2, IGF-I and M-CSF levels were measured before and 1 and 3 weeks, and 3 months after the BMT. The correlation between the changes of growth factors and various bone parameters was analyzed. Results: The mean bone losses in the lumbar spine and total proximal femur, calculated as the percentage change from the baseline to the level at 1 year, were 5.2(p<0.05) and 11.6%(p<0.01), respectively. the serum type I carboxyterminal telopeptide(ICTP), a bone resorption marker, increased progressively until 6 months after the BMT, but thereafter decreased, to the base value after 1 year. Serum osteocalcin, a bone formation marker, decreased progressively, until 3 weeks after the BMT but then increased transiently, and finally returned to the base level at 1 year. The serum IGF-I and FGF-2 also decreased progressively until 3 weeks 1 week after the BMT, respectively, then increased to the base values at 3 months. The serum M-CSF increased briskly at 1 week post-BMT, then decreased to the base level. There were positive correlations between the percentage changes from the baseline proximal femur BMD and the IGF-I levels 3 weeks and 3 months (r=0.52, p<0.01, r=0.41, p<0.05) post BMT. A significant correlation was found between the IGF-I and osteocalcin levels pre-BMT, and 3 weeks after the BMT. Another positive correlation was found between the M-CSF and the ICTP levels at 3 weeks post BMT (r=0.54, p<0.05). Conclusion: In conclusion, there were significant changes in the serum IGF-I, FGF-2 and M-CSF levels in the immediate post-BMT period, which were related to a decrease in bone formation and loss in the proximal femoral BMD during the year following the BMT (J Kor Soc Endocrinol 17:664∼674, 2002).

허혈 조건부여가 심근기능의 회복에 미치는 영향 : 적출 심장모델을 이용한 실험연구 Isolated heart experimental study

백광제,김준식,한승백,전영진,이인성 大韓應急醫學會 1999 대한응급의학회지 Vol.10 No.2

Background: Brief episode of coronary artery occlusion(i.e.,ischemic preconditioning) makes the heart more resistant to injury from a subsequent ischemic insult. Although a great deal of effort has been made in studying ischemic preconditioning, the underlying mechanism of ischemic preconditioning and its effect on hypothermic insult has not been elucidated. This study was performed to see whether ischemic preconditioning protects against the depression of cardiac contractility induced by hypothermic cardioplegic arrest/reperfusion. And recently, adenosine was known to have some correlation with the mechanism of preconditioning. If so, does this effect remain after the blockade of adenosine receptor by 8-phenyl theophyline? Method: Twenty-four Sprague-Dawley rat weighed 250-350g were used and divided into three groups. Rat hearts were removed rapidly, and each isolated heart paced with a rate of 180/min was perfused by modified Krebs-Hensleit buffer(KHB) solution on a Langendorff apparatus for an hour. After obtaining baseline data including left ventricular pressure(LVP), dp/dt, and coronary flow, cardiac arrest was induced by perfusion of 0℃ crystalloid cardioplegic(St Thomas) solution. After that, all hearts were stored in the same St Thomas solution at same temperature for 2 hours. In group Ⅰ(control group), the heart was reperfused by KHB solution. In group Ⅱ(preconditioning group), the heart was subjected to two 2-minute episode of global ischemia followed by 5 minute reperfusion with KHB solution(preconditioning) before cardiac arrest. In group Ⅲ(phenyl theophylline group), the heart was subjected to preconditioning procedure and 8-phenyl theophylline at 10μM in concentration was added to KHB solution at time of reperfusion. Observing parameter was obtained in each group at 10, 20, 40 and 60 minutes after starting reperfusion and compared statistically by use of one way ANOVA test(STASTICA, release 4.5). p-value less than 0.05 was considered significant. Results: Although depressed LVP, dp/dt, and coronary flow were seen in all groups during the reperfusion period, the preconditioned group showed more effective recovery of LVP than that of the control group, especially at 10, 20 and 40 minutes(p<.05). We failed to demonstrate the difference between the phenyl theophylline group and the control group(p=NS). Conclusion: These results suggest that ischemic preconditioning has protective effect on recovery state of hypothemic cardioplegic arrest/reperfusion. Its protective effect was limited during early reperfusion stage and was blocked by adenosine blocker.

성인성 호흡부전증(ARDS)의 호흡역학 개선을 위한 실험연구

백광제,김준식 大韓應急醫學會 1997 대한응급의학회지 Vol.8 No.1

The acute respiratory distress syndrome (ARDS) is a disorder of diffuse lung injury secondary to a wide variety of clinical insults including sepsis. It is manifested by impaired oxygenation, pulmonary edema, decreased static and dynamic compliance of lung, and increased airway resistance. Reduced lung compliance together with increased airway resistance is a hallmark of the syndrome and has generally been considered as the primary abnormality of lung mechanics. The study was designed to reproduce an ARDS condition in an animal model with acute lung injury and to determine whether these changes are reversed by inhalation of aerosolized bronchodilator such as salbutamol or nicorandil. Six adult mongrel dogs were exposed to intravenous oleic acid (0.08 ml/kg) mixed into a same amount of pure enthanol. We defined a condition of PaO2 less than 60 mmHg in FiO2 0.6 as an acute diffuse lung injury. Lung mechanics were deteriorated after oleic acid injection, from 27.33±2.73 to 17.50±7.47 cmH2O/1/sec in compliance and from 14.55±4.46 to 26.33±6.02 ml/cmH2O in airway resistance. Salbutamol or Nicorandil inhalation significantly improved lung compliance to 30.67±11.30 or 36.33±9.00 cmH2O/1/sec and airway resistance to 16.77±7.47 or 19.55±5.45 ml/cmH2O. From above data, we carefully concluded that compromized lung mechanics in adult respiratory distress syndrome could be effectively managed by inhalation of aerolized bronchodilator.

응급센터에 내원한 만성 폐쇄성 폐질환 환자에 대한 고찰

박승회,백광제,홍윤식 대한응급의학회 1993 대한응급의학회지 Vol.4 No.2

Chronic Obstrcitive Pulmonary Diseases(COPDs) produce significant morbvidity and mortality in human lives. COPD is a progressive disease that coexists with emphysema and chronic brochitis. The critical episodes depend on inciting or aggravating factors which can be classified into 3 ways. First, disease related aggravation. Second, Patient related aggravation. Third, Physician related(latrogenic). The authors reviewed 102 COPD patients who came to Korea University Hospital Emergency Medical center from March of 1992 to February of 1993. 1) Males were more frequently affected than females, and male to female ratio was 2.64 : 1 2) The average age of the patients were 62.8 years old. 3) The average number of hospital admission was 2.5 times and one patient was admitted 9 times for the same disease. 4) On an average, the patients had dyspneic symptoms for 15.6 years and the symptoms had developed since they were 47.8 years old. 5) The ratio between smokers and nonsmokers were3 2.1 : 1, the smokers had smoked for 36.3 years and the average amount of smoking was 1.5 pack per day. 6) After admission, sputum culture and sensitiveity test were done and the results were as follows : nonspceific organums 47 cases(46.0%), streptococcus 23 cases(22.5%), Pseudomonas 15 cases(14.7%), Hemophilus influenza 7 cases(6.8%), Klebsiella 5 cases(4.9%), Actinomycosis 3 cases (2.9%), Staphylococcus 2 cases(1.9%) 7) Aggravation factors for dyspnea were as follows : Upper Respiratory Tract Infection 40 cases(39.2%), Smoking 2.5 cases(24.5%), Pneumothorax 11 cases(10.8%), Pneumonia 7 cases(6.8%), Unknown origin 19 cases(18.6\%) 8) Prognosis after hospital admission were classified into 6 groups : 1. completely recovered 2. almost recovered 3. no improvement 4. hopeless discharge 5. expired within 48 hrs. 6. expired after 48hrs. The results were as follows : 87.3%(89 cases) discharged in almost recovered stated state, 1.9%(2 cases) discharged with no improvement, 4.9%(5 cases) were hoplessly discharged, 2.9%(3 cases) expired within 48 hrs, 2.9%(3 cases) expired after 48 hrs.

흉부외상 없이 발생한 흉부대동맥 절단증의 조기 진단 : 2례 보고 Two Cases Report

한승백,전영진,백광제,김준식,김정택,김광호,선경 大韓應急醫學會 1998 대한응급의학회지 Vol.9 No.4

Aortic transection or interruption is a rare condition which developed after an acute deceleration injury. Its occurrence depends on the location and direction of the force applied and is usually from motor vehicle accident or falling down. The exact incidence of aortic transection in trauma is not known but, when develops, only about 10-15% of the victims can survive and be transported to the hospital. Even in the survivors, majority of them will be fatal within a few days if a prompt diagnosis and surgical treatments are not made. Aggressive diagnostic work-up is recommended for the patients with high suspicious index, which would salvage the victims with this fatal condition. We report the experience of two cases of aortic transection or interruption following motor vehicle accidents.

진달래 꽃에 의한 Grayanotoxin 중독 3 례

김아진,김준식,신동운,백광제,한승백,이용주 대한응급의학회 2000 대한응급의학회지 Vol.11 No.3

Traditionally, the Rhododendron species has been used in gastrointestinal disorder or hypertension. Grayanotoxin exists in honey, flowers, pollen, and the nectar of the Rhododenron species. We experienced 3 cases of Grayanotoxin intoxication. The symptoms of intoxication were nausea, vomiting, hypotension, bradycardia, diplopia, dizziness, and chest discomfort. Generally, the treatment for Grayanotoxin intoxication is fluid resuscitation and injection of atropine sulfate. The patients who were intoxicated with Grayanotoxin were discharged without complication after supportive care.

급성 폐손상의 기계환기 치료에서 일회호흡량 변화가 미치는 영향 : 실험 연구

백광제,김준식,선경,전영진,한승백 대한외상학회 1999 大韓外傷學會誌 Vol.12 No.1

Background: Although the low tidal volume(TV) technique has been applied in the manage- ment of mechanical ventilation for patients with Acute Respiratory Distress Syndrome(ARDS) recently, there still remain controversies with regards to its effectiveness and hazard. Method: The study was designed to evaluate the effects of the amount of TV on hemody- namics, arterial blood gases, and airway pressures in an acute lung injury model by using six mongrel dogs. Each animal was paralyzed and intubated with applying mechanical ventilation at TV of 10mUkg, respiration rate of 20/min, FiO₂of 0.4, and Positive End Expiratory Pressure (PEEP) of 5cmH₂O. The lung injury was induced by injection of oleic acid dissolved in 99% ethanol(0.08ml/kg) into the pulmonary artery through a Swan-Ganz catheter. Parameters were observed with changes of TV to low(7ml/kg) and high(14ml/kg) accordingly, and the differ- ences between groups were compared statistically. Result: There were significant differences in airway pressure(16.5 ±2 vs. 23.3 ±3.4cmH₂O) and PaCO₂(54 ±12 vs. 42.8 ±9mmHg) between low and high TV(p$lt;0.01) while the differences in PaO₂(100.9 ±17 vs. 121.2 ±16mmHg) and mean Blood Pressure(BP)(96.0 ±12 vs. 106 ±19mmHg) were negligible(p=NS). Conclusion : Above results suggest that low TV keeps airway pressure low and does not deteriorate hemodynamics and oxygenation in the presence of hypezcapnia. We carefully sug- gest a low TV technique in the management of the patients with ARDS.

폐분리증 : 증례보고 A Case Report

백광제 건국대학교 1996 學術誌 Vol.40 No.2

Pulmonary sequestration is a masses of distorted, nonfunctioning, pulmonary tissue that have no normal connections with the bronchial tree and receive their blood from anomalous systemic arteries and it is the largest group of bronchopulmonary foregut malformation. Pulmonary sequestration is classified as ILS(intralobar pulmonary sequestration) and ELS(extralobar pulmonary sequestration). ILS is a disorder which is seperated from the normal lung tissue incompletely and ELS is a disorder which is separate from normal lung tissue completely and have its own pelural cover-age. In old patients the pulmonary sequestration is manifested by nonspecific symptoms and signs, such as dry cough, recurrent pulmonary infection, chest pain, hemoptysis. Diagnostic procedures are plain radiologic study, computerized tomography, angiography. But definite preoperative diagnosis is very difficult because there are no specific signs. The treatment of pulmonary sequestration is complete surgical resection with meticulous dissectin and division of aberrant artery. We experience a case of intratobar pulmonary sequestration which is treated by left lewer lobectomy.

실험쥐의 고농도 산소 폐손상에서 N - acetylcysteine 투여후 형태학적 변화

백광제,김준식 대한외상학회 1998 大韓外傷學會誌 Vol.11 No.1

Although oxygen therapy has been of clear benefits in many clinical settings, it also carries risk of oxygen toxicity to the lung tissue. But the physicians involved in emergency and intensive care are frequently confronted by situations in which prolonged hyperbaric therapy is a necessary management of the patient care. The biochemical basis of oxygen toxicity is increased production of highly reactive, partially reduced metabolites of oxygen, included hydrogen peroxide and free radicals, by cells in hyperoxia. We studied the effects of intravenous N-acetylcysteine(NAC). A free radical scavenger, upon the mouse which is exposured to hyperoxic condition for 96 hours. We found that the PMN inflammatory cells are much less infiltrated in NAC group and also less alveolar congestion, septum edema, and peribrochial edema. Thus, NAC significantly attenuated all morphologic pathologic changes in the hyperoxic model of mouse, possibly its ability to scavenge toxic oxygen free radicals.