Hepatic veno-occlusive disease(VOD) is a major life-threatening complication of bone marrow transplantation(BMT) caused by high-dose chemotherapy or radiotherapy. The aim of this study is to evaluate the incidence, risk factors, prophylactic effects of low-dose heparin and pentoxifylline(PTX) and therapeutic response to recombinant human tissue plasminogen activator(rt-PA) in VOD patients with leukemia after allogeneic BMT.

Thirty-two consecutive leukemia patients who underwent HLA-matched allogeneic BMT were included in this study. VOD was clinically defined as having two of the following features : hyperbilirubinemia(≥2mg/dL), tender hepatomegaly, unexplained weight gain(>2% from baseline) and/or ascites. Low-dose heparin(l00unit/kg/day, IV) and PTX(1,600mg/day, P0) were administered for the prevention of VOD.

The median age of recipients in this study was 27(17 - 44) years. Patients were treated for the following diseases : 17(53.1%) for acute myeloid leukemia(AML), 10(31.3%) for acute lymphoblastic leukemia(ALL) and 5(15.6%) for chronic myeloid leukemia(CML). Fourteen patients(43.7%) were classified as having high-risk pre-BMT status. Of the 32 consecutive patients undergoing allogeneic BMT, 5(15.6%) developed VOD. A higher risk of developing VOD was associated with pre-BMT disease status(p<0.01). All VOD patients received rt-PA-based thrombolytic therapy and complete resolution was achieved in-4(80.0%) of 5 patients without significant bleeding complications.

Further studies are needed to develop more effective prophylactic and thera-peutic approaches of VOD in patients with high-risk leukemia after allogeneic BMT.

This study was performed to evaluate the impact of various peri-transplant factors on transfusion requirements in 45 patients with leukemia or severe aplastic anemia undergoing HLA-matched allogeneic bone marrow transplantation(BMT).

All patients were treated in an isolated room with HEPA filtration, and the combination of cyclosporin and short-course of methotrexate was used for GVHD prophylaxis. Patients received irradiated packed red cells to maintain the hematocrit ≥30% and irradiated platelet pheresis to keep the platelet count ≥20,000/µl.

In the first month, the mean(range) number of red cells and platelet pheresis were 4.9(0-21), 26.7(8-61), respectively. On univariate analyses, pre-BMT status(high-risk : 7.94±5.14 vs standard-risk: 3.78±2.99, p=0.0076) and concurrent infection(present : 8.41±4.70 vs absent : 3.33±2.72, p=0.0005) and sex incompatibility(match : 4.67±3.72 vs female → male : 3.78±3.07 vs male → female : 9.13±5.74, p=0.0161) were significantly associated with red cell requirements in the first month. Also, high-risk pre-BMT status(32.25±16.15 vs 20.25±14.64, p=0.0l56), the presence of concurrent infection(39.35±16.42 vs 15.33±5.67, p=0.0001) and veno-occlusive disease(45.00±14.47 vs 22.00±14.49, p=0.0055) increased platelet requirements significantly after allogeneic BMT. In particular, pre-BMT disease status was found to be independently associated with transfusion requirements.

This study demonstrates that pre-BMT status does influence transfusion requirements in the first month after HLA-matched allogeneic BMT. Further studies are necessary to confirm these results and to define optimal transfusion strategies.

Despite of recent advances in pharmacological treatment and improvement surgical and anesthetic techniques, subarachnoid hemorrhage(SHA) from ruptured intracranial aneurysms with poor clinical grades still carries unacceptably high morbidity and mortality rates. Recently surgery for aneurysmal SAH with poor clinical grade has increased interest.

The authors experienced 57 patients with poor clinical grade (Hunt and Hess grade IV-V) after ancurysmal SAH. Among them 25 patients were treated with immediate CSF drainage via ventriculostomy, blood pressure control, early angiography(except 3 patients) and surgery within 12 hour of admission.

The outcomes of patients were categorized using a four-tiered scale :

1) independent and working

2) impaired but independent

3) severly impaired and dependent

4) dead

The average age was 48(13-75) and the male to female ratio was 7:18 in surgical group. The average time to admission and surgery was 12 hours or less among the 25 patients. Among them 9 cases were dead, 2 cases were severly impaired and dependent, 3 cases were impaired but dependent, and 11 cases were independent and working. In this patient all cases, exception one could be ligated with a clip.

The above results suggest that the acute aggressive surgery based on appropriate selection in poor aneurysmal SAH patients can reduce of the mortality.

Spectral analysis of heart rate variability(HRV) resulted in a characteristic power spectrum with two main regions, a high frequency at 0.15-0.5Hz(HFP) corresponding to the parasympathetic system and a low frequency at 0.017-0.l5Hz(LFP) corresponding to both parasympathetic and sympathetic influences. The ratio of low : high frequency(LFP/HFP) has been postulated as an index of sympathetic activation. We propose that the LFP/HFP ratio will provide important information concerning autonomic nervous system activity during spinal anesthesia especially geriatric patients.

LFP, HFP and LFP/HFP were checked in 30 patients at the baseline and 5, 10, 15, 20, 25 and 30 minutes after subarachnoidal block. We divided patients into two groups: group 1 is 15 patients under 60 years old and group 2 is 15 patients over 65 years old, and we compared those parameters in both groups.

Spinal anesthesia did produce a significant decrease in LFP and HFP in both groups. But sympathetic-parasympathetic balance(LFP/HFP) increased at 5 minutes after spinal block. In group 1, LFP/HFP decreased at 10 minutes after spinal block, thereafter increased gradually. In group 2, LFP/HFP decreased at 10, 15 and 20 minutes and increased at 25 and 30 minutes after spinal block.

These data suggest that autonomic tone decreased with spinal anesthesia and sympathetic-parasympathetic balance decreased for a long time in geriatric patients.

To access the changes of cerebral blood flow velocity according to the time after surfactant administration, we prospectively studied in the Hyaline Membrane Disease using Doppler ultrasonography.

The patients were 26 infants. The mean gestational age was 3l⁴wks (range, 18⁴ to 38wk). The ratio of male : female was 16 : 10, mean weight was 1.76±0.88Kg, Apgar score at 5min was 6.9, and type of delivery was C-section : vaginal delivery 19 : 4. Before and after, 10, 30min, 1, 6, l2hr, 1, 3, 5, 7days after surfactant administration, peak systolic and end-diastolic flow velocity(PSFV, EDFV) were estimated by Doppler method measuring MCA flow velocity. The Resistive index was calculated according to the mathematics. For the evaluation of the clinical status, systolic and diastolic systemic BP, PaO₂, PaCO₂, FiO₂, pH, and respiratory rate(RR) were checked.

The cerebral blood flow velocity showed initial increase of PSFV just after synthetic surfactant administration, and the increased PSFV continued until the 30 minites and then decreased. PSFV returns to initial level at 6hr, and then increased again. The changes of EDFV was not significant. The changes of RI & PI were no significant changes. The effects of surfactant to the systemic BP had no significance. The changes of PaCO₂ and PaO₂ were not significant. FiO₂ showed steady improvement. Initial tachypnea and acidosis progressively improved without clinical significance.

The administration of Surfactant in the HMD patients results in transient increase of cerebral blood flow velocity.

This study was designed to develop the referral system of patient in small-sized industries and the medical delivery system in occupational health field.

We sampled randomly 5 workers per each company in 57 companies and investigated the healthcare utilization behavior, the need for referral system. The survey was done from April 1. 1998 to May 30. 1998 and the respondents were 213. On the basis of the results, we planned model for the referral system between Korean Industrial Health Association(KIHA) and Ewha Medical Center(EMC).

The complaints of the utilization of medical service are cumbersome process of registration and reservation, and discord between hours of duty and consultation. The referral system is needed in 76.7% of total respondents. 85.6% of workers want the night clinic, and 91.3% want to be included their family in this referral system.

We developed the referral system linking KIHA, EMC, and department of preventive medicine of Ewha Woman's University, which based on the result of survey. The service reflect the worker's the healthcare utilization behavior and need for referral system. The number of workers who referred by this system between Feb. 1998 and Jan. 1999 was 30, and replied by EMC after treating was 12. The number of referred patient is very law(30 spells), but the satisfaction of medical service is relatively high.

To promote the referral system, it is needed to propaganda the service of referral system to workers and managers of each company, to improve of quality of services of the hospital, and to establish the official referral system between department of preventive medicine of Ewha woman's university and each clinical department of Ewha Medical Center.