Kosin Medical Journal

Case reports

Remimazolam in pediatric surgery under general anesthesia: a case series: Hong-Sik Shon, Seyeon Park, Jung-Pil Yoon, Yeong Min Yoo, Jimin Lee, Da Eun Lee, Hee Young Kim; Received January 8, 2024 Accepted April 1, 2024 Published online May 9, 2024; DOI: https://doi.org/10.7180/kmj.24.105 [Epub ahead of print]

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Abstract PDF PubReader ePub: Remimazolam is a promising drug for general anesthesia due to its rapid onset, short duration, and short context-sensitive half-life. However, its use in pediatric patients remains off-label, and limited prospective data have been published. Herein, we report successful anesthesia using remimazolam in pediatric patients who had a history of epilepsy or required shared airway surgery. In all cases, remimazolam provided general anesthesia, and flumazenil was used for reversal with rapid recovery. Remimazolam offers advantages for pediatric anesthesia in scenarios with a risk of seizure or shared airway surgery. However, the potential for higher bispectral index values and the risk of anaphylaxis in dextran-allergic patients necessitate caution and further research.

Total intravenous anesthesia using remimazolam for patients with heart failure with reduced ejection fraction: a case series: Jimin Lee, Ji-Uk Yoon, Gyeong-Jo Byeon, Hong-Sik Shon, Ahhyeon Yi, Hee Young Kim; Received December 16, 2023 Accepted April 3, 2024 Published online May 9, 2024; DOI: https://doi.org/10.7180/kmj.23.156 [Epub ahead of print]

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Abstract PDF PubReader ePub: Patients with heart failure undergoing surgery that requires general anesthesia face substantial perioperative risks; however, clear guidelines are not available for anesthesia management in patients with a reduced left ventricular ejection fraction. Traditional intravenous and volatile anesthetics require careful administration to prevent severe hypotension and bradycardia in patients with heart failure. Remimazolam has emerged as a promising alternative to conventional anesthetics because of its reduced cardiovascular depressive effects. We present three cases illustrating the successful use of remimazolam to induce and maintain general anesthesia in patients with heart failure and reduced cardiac function. Our cases demonstrate the safe use of remimazolam for general anesthesia in patients with heart failure and a reduced ejection fraction.

Editorial

What are the clinical usefulness and scientific value of intramuscular injection of autologous serum (autologous serum therapy) in patients with atopic dermatitis?: Dong-Ho Nahm; Kosin Med J. 2024;39(1):1-4. Published online March 25, 2024; DOI: https://doi.org/10.7180/kmj.24.109

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Review articles

Gastric cancer and metabolic syndrome: Hyeong Ho Jo; Kosin Med J. 2024;39(1):26-34. Published online March 22, 2024; DOI: https://doi.org/10.7180/kmj.24.108

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Abstract PDF PubReader ePub: Gastric cancer (GC), a prevalent disease in Asian countries, presents a substantial global health challenge. The risk factors for GC include Helicobacter pylori infection, diet, smoking, alcohol, and metabolic syndrome (MetS). This review meticulously examines the intricate connections between MetS and GC, focusing on visceral adipocytes, hormonal factors, obesity, and their impact on survival outcomes. Visceral adipocytes, which secrete inflammatory cytokines and hormones, play a pivotal role in influencing cancer development. Hormonal factors demonstrate nuanced associations with specific GC subtypes, underscoring the complexity of their impact. Large-scale studies exploring obesity-related factors reveal sex-specific nuances and underscore the importance of considering overall weight and body composition. Furthermore, the review explores the impact of eradication therapy for H. pylori infection, which is the most significant factor in the onset of GC, on the components of MetS. Additionally, the influence of MetS on postoperative outcomes and survival in GC patients highlights the interplay between therapeutic interventions and lifestyle factors. This comprehensive exploration sheds light on the multifaceted relationship between MetS and GC, providing valuable insights for future research and preventive strategies.

Clinical challenges and advancements in diagnosing Staphylococcus aureus-associated musculoskeletal infections: Irvin Oh; Kosin Med J. 2024;39(1):5-17. Published online March 22, 2024; DOI: https://doi.org/10.7180/kmj.24.104

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Abstract PDF PubReader ePub: Musculoskeletal infections (MSKI) present a significant health challenge, with a rising incidence linked to the aging population and advancements in orthopedic surgical care. Staphylococcus aureus is the most prevalent pathogen associated with orthopedic infections. The conventional culture method for identification of pathogen frequently lacks accuracy and is challenged by false-positive or false-negative results. Inflammatory markers such as the erythrocyte sedimentation rate and C-reactive protein are not site-specific or accurate, as they can be confounded by other medical conditions. Identifying the dominant pathogen and monitoring treatment response following surgical debridement and antibiotics therapy continues to pose challenges. Understanding the pathogenesis of MSKI is crucial for the development of innovative diagnostics and alternative therapeutics. S. aureus immune evasion stands out as a key component of the pathogenic mechanism, complicating clinical decisions. Other unique mechanisms such as biofilm and abscess formation, as well as osteocyte-lacuno canalicular network invasion, underscore the need for aggressive debridement and the complete removal of infected implants and bone tissues. Ongoing efforts focus on exploring and developing innovative diagnostics, such as serum immunoassays, next-generation sequencing of infected tissue, transcriptomics of peripheral blood mononuclear cells, and serum proteomics. These endeavors offer promising avenues for improved diagnostics, medical management, and innovative therapeutics for MSKI.

Original article

Clinical efficacy and safety of autologous serum intramuscular injection in patients with mild-to-moderate atopic dermatitis: a prospective, open-label, uncontrolled study: Gil-Soon Choi, Jong Bin Park, Young-Ho Kim, Hee-Kyoo Kim; Kosin Med J. 2024;39(1):51-59. Published online March 19, 2024; DOI: https://doi.org/10.7180/kmj.24.101

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Background
Autologous blood therapy (ABT) has been used to treat atopic dermatitis (AD) for over a century, even though evidence supporting its efficacy is lacking. We aimed to investigate the effectiveness and safety of autologous serum intramuscular injection (ASIM), which is a modified form of ABT, in treating mild-to-moderate AD.
Methods
This study was a 12-week, open-label, prospective, uncontrolled trial. Following a 4-week run-in period, 22 out of 25 screened patients received ASIM once a week for 4 weeks in conjunction with standard treatment. The primary outcome measure was the Eczema Area and Severity Index (EASI), while the secondary outcomes included the Scoring Atopic Dermatitis (SCORAD) score, Dermatologic Life Quality Index (DLQI), and patient ratings of pruritus, sleep difficulty, disease status, and treatment effectiveness. Safety parameters were also assessed.
Results
EASI scores showed a non-statistically significant trend toward improvement during ASIM intervention. Patients with at least a 50% improvement in the EASI score at 4 weeks were older and had lower peripheral eosinophil counts (p<0.05). Secondary endpoints, including the SCORAD score, pruritus, sleep difficulty, and DLQI, demonstrated statistically significant improvements at week 4 compared to baseline (p<0.05). No significant adverse reactions were observed.
Conclusions
This pioneering study suggests that repeated ASIM may improve the clinical symptoms of mild-to-moderate AD, particularly in terms of pruritus and overall quality of life. However, further research with a larger sample size is required to establish the clinical significance of these findings.

Citations

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What are the clinical usefulness and scientific value of intramuscular injection of autologous serum (autologous serum therapy) in patients with atopic dermatitis?
Dong-Ho Nahm
Kosin Medical Journal.2024; 39(1): 1. CrossRef

Review article

Exploring the nexus between obesity, metabolic syndrome, and colorectal cancer: Jong Yoon Lee; Kosin Med J. 2024;39(1):18-25. Published online March 12, 2024; DOI: https://doi.org/10.7180/kmj.24.107

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Abstract PDF PubReader ePub: The increasing global prevalence of obesity and metabolic syndrome (MetS) is strongly associated with the incidence of colorectal cancer (CRC). Obesity and MetS detrimentally impact the treatment outcomes of CRC and share similar mechanisms that contribute to the development of CRC. Increased insulin resistance in patients with obesity is linked to CRC, and altered levels of sex hormones and adipokines affect cell growth and inflammation. Obesity and MetS also alter the gut microbiome. Bile acids, which are crucial for lipid metabolism, are elevated in patients with obesity. Moreover, specific bile acids are associated with colonic damage, inflammation, and the development of CRC. Obesity and MetS increase the risk of postoperative complications and affect the response to chemotherapy. The promotion of weight loss and the resolution of MetS can reduce the occurrence of CRC and increase treatment efficacy. Therefore, it is imperative to implement appropriate management strategies to address obesity and MetS with the aim of improving the prognosis and reducing the incidence of CRC. Moreover, additional research should be conducted to determine the optimal timing for tailored CRC screening in patients with obesity or MetS. In this review, we explore the impact of obesity and MetS on the development of CRC and examine potential strategies to mitigate CRC risk in individuals with obesity and MetS.

Case reports

Interpedicular approach in percutaneous sacroplasty for treating pain due to direct invasion of rectal cancer into the S3 body: a case report: Jinseok Yeo, Saeyoung Kim, Chang Sub Lee; Received November 14, 2023 Accepted January 7, 2024 Published online February 20, 2024; DOI: https://doi.org/10.7180/kmj.23.153 [Epub ahead of print]

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Abstract PDF PubReader ePub: Percutaneous sacroplasty is mainly used as an intervention for pain associated with sacral insufficiency fractures or sacral metastatic tumors. However, sacroplasty for managing the pain associated with direct sacral invasion of rectal cancer has been rarely reported. We present a case of a 74-year-old patient who underwent sacroplasty via the interpedicular approach under fluoroscopic guidance to relieve pain resulting from direct tumor invasion into the S3 body. After the procedure, the patient experienced immediate pain relief and did not feel worse pain with ambulation. Aside from peritumoral vascular leakage, no other significant complications occurred immediately post-procedure. Our results suggest that fluoroscopically guided interpedicular sacroplasty is a safe and effective option for relieving the pain associated with direct sacral invasion by rectal cancer.

Disseminated herpes zoster with vagus nerve involvement in a kidney transplant recipient: a case report: Dong Eon Kim, Da Woon Kim, Hyo Jin Kim, Harin Rhee, Sang Heon Song, Eun Young Seong; Received November 20, 2023 Accepted January 7, 2024 Published online February 19, 2024; DOI: https://doi.org/10.7180/kmj.23.154 [Epub ahead of print]

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Abstract PDF PubReader ePub: Herpes zoster virus infection is common and results in significant morbidity in patients who have undergone solid organ transplantation. Herpes zoster can involve the cranial nerves, and vagus nerve involvement is an infrequent primary manifestation of herpes zoster. Here, we describe a rare presentation of disseminated herpes zoster infection with vagus nerve involvement in a kidney transplant recipient. A 62-year-old man who had undergone kidney transplantation 3 years prior presented to our clinic with sore throat and hoarseness, followed by multiple vesicular-pustular rashes on the face and trunk. Flexible laryngoscopy revealed left paramedian vocal cord paralysis with multiple ulcerative lesions extending from the left pyriform sinus to the epiglottis. Computed tomography of the neck, abdomen, and chest revealed no significant abnormalities that could have caused vocal cord paralysis. We confirmed the diagnosis of disseminated herpes zoster after herpes zoster laryngitis based on positive blood tests and polymerase chain reaction for varicella zoster virus antibodies. The skin rashes and laryngeal ulcers rapidly resolved after treatment with intravenous acyclovir and high-dose steroids. The patient still had persistent dysphagia and microaspiration as assessed by a video fluoroscopic swallowing study, but showed improvement in dysphagia in response to swallowing rehabilitation therapy. This case provides valuable insights into the presenting symptoms of disseminated herpes zoster, which can cause acute vagus neuritis in solid organ transplantation recipients.

Cardiovascular collapse during transcatheter aortic valve replacement in monitored anesthesia care using an end-tidal carbon dioxide monitor: a case report: Wonjin Lee, Jaewoo Suh; Received June 29, 2023 Accepted October 16, 2023 Published online January 2, 2024; DOI: https://doi.org/10.7180/kmj.23.134 [Epub ahead of print]

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Abstract PDF PubReader ePub: Capnography is commonly used to monitor respiration during general anesthesia. However, it has limited utility in patients with respiratory distress during sedation. This case report examines capnography use in a transcatheter aortic valve replacement procedure performed on an elderly woman with severe aortic stenosis. A 73-year-old woman with a history of non-ST-elevation myocardial infarction and congenital heart failure presented with severe dyspnea caused by severe aortic stenosis. Transcatheter aortic valve replacement was preferred over surgery due to her comorbidities. Monitored anesthesia care was administered with a capnogram. During the procedure, the patient was sedated with remimazolam, maintaining a bispectral index range of 60–80 and a score of 2 on the Modified Observer’s Assessment of Alertness/Sedation scale. Although irregular breathing patterns and a gradual decrease in oxygen saturation were observed following remimazolam infusion, the patient’s respiration eventually stabilized. However, the patient experienced cardiovascular collapse 45 minutes after sedation began. The arterial carbon dioxide pressure measured by arterial blood gas analysis performed just before resuscitation was 68.4 mmHg. After one cycle of resuscitation, the patient recovered. The procedure was successfully performed under general anesthesia, which was replaced with monitored anesthesia care during resuscitation. Although most monitoring devices have similar utility for both general anesthesia and sedation, capnography has limitations for evaluating respiration during sedation, especially for patients with respiratory distress. Therefore, anesthesiologists or medical staff who provide sedation should not neglect periodical arterial carbon dioxide pressure observations via other methods, such as arterial blood gas analysis.

Original article

The effectiveness of Moodle's “Lesson” feature in pre-learning about arterial puncture and blood transfusion procedures: Haeyoung Lee, Sang-Shin Lee, Hyunyong Hwang; Kosin Med J. 2023;38(4):278-287. Published online December 29, 2023; DOI: https://doi.org/10.7180/kmj.23.150

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Abstract PDF PubReader ePub: Background
This study evaluated the effectiveness of Moodle’s “Lesson” feature as a pre-learning tool for clinical skills among medical students.
Methods
The performance of 69 fourth-year medical students during practical sessions on arterial puncture and blood transfusion was assessed. These students engaged in pre-learning activities via Moodle's “Lesson” feature. We analyzed the survey results to gauge students’ satisfaction and perceived usefulness of the pre-learning approach. Additionally, we compared the performance of the 2023 cohort, which took part in the pre-learning process, with students from 2020 to 2022 who did not have this preparatory component.
Results
Among the students surveyed, data from 59 respondents were analyzed. Satisfaction with the pre-learning segment was high, with a mean satisfaction score of 4.69 (standard deviation [SD]=0.62) and Cronbach’s alpha of 0.918. The tool's perceived usefulness was also rated highly, with a mean score of 4.77 (SD=0.53) and Cronbach’s alpha of 0.956. Students who used the pre-learning tool had a mean score of 84.20 (SD=14.74), whereas those who did not use the tool scored slightly lower, with a mean of 80.40 (SD=13.07); however, this difference was not statistically significant (p=0.196). Nonetheless, the 2023 cohort scores were generally higher across the various percentile measures than those of the 2020–2022 groups.
Conclusions
The pre-learning tool using the “Lesson” feature on Moodle proved useful and satisfactory for students learning clinical procedures. Further research with larger cohorts is required to validate these findings.

Review articles

Basic knowledge of endoscopic retrograde cholangiopancreatography: Jung Wook Lee; Kosin Med J. 2023;38(4):241-251. Published online December 26, 2023; DOI: https://doi.org/10.7180/kmj.23.151

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Abstract PDF PubReader ePub: Endoscopic retrograde cholangiopancreatography (ERCP) was first performed in the late 1960s. Due to advancements in instruments, devices, and techniques, ERCP has played an important role in the management and diagnosis of pancreatobiliary disorders. However, ERCP is accompanied by the risk of various complications even if performed by an expert. The incidence of ERCP complications is approximately 4% to 10%, while the incidence of fatal complications, such as death, is less than 0.5%. To prevent adverse events, experts performing ERCP must recognize and address ERCP-related complications and understand the various techniques. In this review, we summarize the complications and techniques of ERCP.

Prevention of myopia progression using orthokeratology: Stephanie Suzanne S. Garcia, Changzoo Kim; Kosin Med J. 2023;38(4):231-240. Published online December 26, 2023; DOI: https://doi.org/10.7180/kmj.23.141

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Abstract PDF PubReader ePub: The prevalence of myopia in children and juveniles has increased significantly in Korea and worldwide; in particular, the rates of myopia and high myopia in East Asia have grown rapidly. Myopia is easily corrected with spectacles or contact lenses. However, as children grow and mature, myopia can progress irreversibly and lead to vision-threatening complications. Thus, the prevention of myopia progression is an essential treatment goal. Many treatment strategies are being employed, including atropine eyedrops, specialized glasses, and orthokeratology (Ortho-K) lenses. Ortho-K is an effective treatment in managing myopia progression by lowering the rate of increase in refractive error and axial length. In this article, we review Ortho-K as a treatment for myopia progression, its history, mechanism, treatment regimen, and safety profile.

Editorial

The old biomarkers you know are still useful: D-dimer and troponin I: Sanghyun Lee; Kosin Med J. 2023;38(4):229-230. Published online December 20, 2023; DOI: https://doi.org/10.7180/kmj.23.155

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Case report

Selective adjuvant radiation therapy for distant lymph node metastasis in patients with stage 4B epithelial ovarian cancer: a case series: Eun Taeg Kim, Seung Yeon Oh, Sun Young Ma, Tae Hwa Lee, Won Gyu Kim; Kosin Med J. 2023;38(4):293-299. Published online December 20, 2023; DOI: https://doi.org/10.7180/kmj.23.146

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Abstract PDF PubReader ePub: Although the efficacy of surgery followed by taxane- and platinum-based systemic chemotherapy has been clearly demonstrated in the standard first-line treatment of epithelial ovarian cancer, the role of radiation therapy for distant lymph node metastasis in patients with epithelial ovarian cancer is not well-established due to a lack of reported studies. We identified four patients who underwent selective adjuvant radiation therapy for neck and para-aortic lymph node lesions after primary debulking surgery between 2020 and 2022, followed by platinum-based chemotherapy for stage 4B high-grade serous ovarian cancer. Through a retrospective review of medical records, we analyzed patient clinicopathologic features, treatment course, and imaging findings. The median age was 49.25 years (range, 46–54 years). All patients had the International Federation of Gynecology and Obstetrics stage 4B disease. Following primary debulking surgery, all patients received weekly paclitaxel-carboplatin chemotherapy and maintenance treatment with poly(ADP-ribose) polymerase (PARP) inhibitors. All patients received selective adjuvant radiation therapy for neck and para-aortic lymph node metastasis before PARP inhibitor maintenance. The median follow-up time was 36.75 months (range, 19–45 months). All patients achieved a complete response. None of the patients experienced disease recurrence or died during the follow-up period. The management of distant lymph node metastasis in patients with epithelial ovarian cancer remains a matter of debate. Selective adjuvant radiation therapy in first-line treatment for ovarian cancer appears to be a feasible approach with maintenance therapy for stage 4B epithelial ovarian cancer.

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