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A Study on the Motivation to Write Signing Advance Medical Directives (사전연명의료의향서 작성 동기에 관한 연구)

  • Chang, Kyung-Hee;Kang, Kyung-hee;Kim, Doo Ree;Lim, HyoNam;Kim, Kwang-Hwan
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.20 no.10
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    • pp.243-249
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    • 2019
  • This study examined the patient's advantage and respect self-decision to protect human dignity and values, who are on the pathway of the hospice palliative care and death process. The study subjects were the elderly who had signed the advance medical directives at C Christian religious facilities in S region. The survey period was started on July 1st, 2019 and lasted for ten days. The study resulted in four topics and eight sub-topics on the motivation for preparing advanced medical directives. The four topics were 'for children', 'fear of pain', 'want to clear my life', 'felt the necessity', and the sub-topics were 'don't want to make a burden to children', 'don't want to make a worry of medical expenses', 'fear of pain', 'have experience of taking caring of painful death process', 'relaxed mind', 'importance of self-decision', 'have known it before but now decided', and 'it is the new information and decided'. This research is meaningful in that it can form the basis for improving well-dying education programs for the good death of the elderly and supplementing effective systems for preparing advance medical directives.

Radiotherapy for pituitary adenomas: long-term outcome and complications

  • Rim, Chai-Hong;Yang, Dae-Sik;Park, Young-Je;Yoon, Won-Sup;Lee, Jung-Ae;Kim, Chul-Yong
    • Radiation Oncology Journal
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    • v.29 no.3
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    • pp.156-163
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    • 2011
  • Purpose: To evaluate long-term local control rate and toxicity in patients treated with external beam radiotherapy (EBRT) for pituitary adenomas. Materials and Methods: We retrospectively reviewed the medical records of 60 patients treated with EBRT for pituitary adenoma at Korea University Medical Center from 1996 and 2006. Thirty-five patients had hormone secreting tumors, 25 patients had non-secreting tumors. Fifty-seven patients had received postoperative radiotherapy (RT), and 3 had received RT alone. Median total dose was 54 Gy (range, 36 to 61.2 Gy). The definition of tumor progression were as follows: evidence of tumor progression on computed tomography or magnetic resonance imaging, worsening of clinical sign requiring additional operation or others, rising serum hormone level against a previously stable or falling value, and failure of controlling serum hormone level so that the hormone level had been far from optimal range until last follow-up. Age, sex, hormone secretion, tumor extension, tumor size, and radiation dose were analyzed for prognostic significance in tumor control. Results: Median follow-up was 5.7 years (range, 2 to 14.4 years). The 10-year actuarial local control rates for non-secreting and secreting adenomas were 96% and 66%, respectively. In univariate analysis, hormone secretion was significant prognostic factor (p = 0.042) and cavernous sinus extension was marginally significant factor (p = 0.054) for adverse local control. All other factors were not significant. In multivariate analysis, hormone secretion and gender were significant. Fifty-three patients had mass-effect symptoms (headache, dizziness, visual disturbance, hypopituitarism, loss of consciousness, and cranial nerve palsy). A total of 17 of 23 patients with headache and 27 of 34 patients with visual impairment were improved. Twenty-seven patients experienced symptoms of endocrine hypersecretion (galactorrhea, amenorrhea, irregular menstruation, decreased libido, gynecomastia, acromegaly, and Cushing's disease). Amenorrhea was abated in 7 of 10 patients, galactorrhea in 8 of 8 patients, acromegaly in 7 of 11 patients, Cushing's disease in 4 of 4 patients. Long-term complication was observed in 4 patients; 3 patients with cerebrovascular accident, 1 patient developed dementia. Of these patients, 3 of 4 received more than 60 Gy of irradiation. Conclusion: EBRT is highly effective in preventing recurrence and reducing mass effect of non-secreting adenoma. Effort to improve tumor control of secreting adenoma is required. Careful long-term follow-up is required when relatively high dose is applied. Modern radiosurgery or proton RT may be options to decrease late complications.

A Study on the Family Burden of the Mentally Ill in a Rural Area (농촌지역 정신질환자 가족 부담)

  • Lee, Weon-Young;Kim, Jung-Hoe;Nam, Chung-Hyun;Moon, Ok-Ryun;Shin, Young-Jeon
    • Journal of Preventive Medicine and Public Health
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    • v.32 no.3
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    • pp.400-414
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    • 1999
  • Objectives: This is a descriptive study which was carried out to identify characteristics of the chronic mentally ill and their families in a rural area and the influencing factors on family burden. Methods : Data was collected for seven months beginning April 1, 1998 by questionnaire from chronic mentally ill patients and their families in two towns and seven townships of the rural areas of Kyonggi Province. In additional to the mental diagnosis of the mentally ill patients, family burden was measured by interviewing the other family members using the questionnaire developed by Pai & Kapur (1981). Of those interviewed, 103 patients were selected for final analysis. Results : Of 103 mentally ill patients, 36.1% of the subjects were not under treatment. In particular, of 29 patients with schizophrenia, 48.3% of the subjects had stopped taking medication and 6.9% of the subjects had never been treated. According to the results of a specialized examination by a psychologist, 81% of patients were in need of Hospitalization. Most primary caregivers were parents. Of the 101 primary caregivers in the study, 39.6% were over 65 years old. In case of death of the primary caregiver, 50.5% of these 101 mentally ill patients would not have anyone to care for them. Of the various kinds of family burden, primary caregivers most often reported psychological stress. Overall, the families of dementia and schizophrenia patients complained of the most family burden. Through univariative analysis, the variables of sex, education and current treatment type of the patients, the relationship with the patient and marital status of the primary caregiver and the number of people living together in the household showed significant correlation with the family burden of schizophrenia patients. Univariative analysis also showed that there were a number of variables which were correlated to the family burden in mentally retarded patients. Concerning the need for mental health services, the most common requests were for entitlement to disability benefits and housing programs. Conclusions: Community mental health services in rural areas must be developed, planned and executed in consideration of the local situation. In particular, the development of various family support programs is needed in order to mitigate emotional, mental and economic burdens and carry out a positive role to care for and rehabilitate patients.

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Delirium Management: Diagnosis, Assessment, and Treatment in Palliative Care (섬망의 돌봄: 완화의료 영역에서의 진단, 평가 및 치료)

  • Seo, Min Seok;Lee, Yong Joo
    • The Korean Journal of Hospice and Palliative Care
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    • v.19 no.3
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    • pp.201-210
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    • 2016
  • Delirium is a common symptom in patients with terminal cancer. The prevalence increases in the dying phase. Delirium causes negative effects on quality of life for both patients and their families, and is associated with higher mortality. However, some studies reported that it tends to remain unrecognized in palliative care setting. That may be related with difficulties to distinguish the symptom from others with overlapping characteristics such as depression and dementia, and a lack of knowledge regarding assessment and diagnostic tools. We suggest that accurate recognition with validated tools and early diagnosis of the symptom should be highly prioritized in delirium management in palliative care setting. After diagnosing delirium, it is important to identify and address reversible precipitants such as medication, dehydration, and infection. Non-pharmacological interventions including comfortable environment for the patient and family education are also essential in the management strategy. If such interventions prove ineffective or insufficient to control hyperactive symptoms, pharmacologic interventions with antipsychotics and benzodiazepine can be considered. Until now, low levels of haloperidol remains the standard treatment despite a lack of evidence. Atypical antipsychotics such as olanzapine, quetiapine and risperidone reportedly have similar efficacy with a stronger sedating property and less adverse effect compared to haloperidol. Currently, delirium medications that can be used in palliative care setting require more clinical trials, and thus, clinical guidelines are not sufficiently available. We suggest that it is warranted to develop clinical guidelines based on well-designed clinical studies for palliative care patients.

Influence of Ischemic Lesions on $^{99m}Tc$-HMPAO SPECT Findings in the Diagnosis of Alzheimer's Disease ($^{99m}Tc$-HMPAO SPECT를 이용한 알쯔하이머병의 진단에서 허혈성 뇌병변이 미치는 영향)

  • Lee, Kyung-Han;Lee, Myung-Chul;Lee, Dong-Soo;Kwon, June-Soo;Kim, Jong-Ho;Chung, June-Key;Woo, Jong-In;Koh, Chang-Soon
    • The Korean Journal of Nuclear Medicine
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    • v.28 no.3
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    • pp.282-292
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    • 1994
  • Brain perfusion SPECT shows typical regional perfusion abnormalities in Alzheimer's disease(AD) and is useful for its diagnosis. However, there is also arguement that these patterns show significant overlap with other causes, and the accuracy for SPECT in differentiating AD has shown conflicting results. We postulate that the variation in re-ported results are partly due to a difference in patient or control selection with special reference to the mixture of ischemic cerebral disease in the studied population. To deter-mine the effect of ischemic lesions and the nature of control subjects on SPECT studies for AD, we performed $^{99m}Tc$-HMPAO single photon emission computed tomography (SPECT) in 11 probable AD patients with a low (<4) Hachinski ischemic score and 12 non-demented age matched controls. Magnetic resonance imaging(MRI) disclosed ischemic cerebral lesions in 27% (3/11) of the PAD group and 25% (3/12) of the control group. Regional perfusion indices were quantitated from the SPECT images as follows and the distribution of perfusion indices from both groups were compared. This was repeated with controls after excluding those with significant ischemic lesions by MRI : regional perfusion index = average regional count/average cerebellar count All PAD patients showed perfusion abnormality in SPECT. However, 53% (10/12) of controls also showed perfusion at-normalities, and no pattern could reliably differentiate the two groups. After excluding controls with significant cerebral ischemia, the difference in temporal and parietal perfusion index was increased. A decreased tempore-parietal and any parietal or temporal per-fusion index had a sensitivity of 18% and 36% in detecting AD, respectively. When using a separate group of normal age mathced controls, the indices showed an even more difference in the temporal and parietal lobes and the sensitivity of a decreased tempore-parietal and any parietal or temporal perfusion index had a sensitivity of 36% and 55% in detecting AD, respectively. Thus, the type of control with special reference to the pres-once of ischemic cerebral lesions contribute significantly to the accuracy of perfusion SPECT in diagnosing AD. This nay have particular importance in the diagnosis of AD in populations where the prevalance of cerebrovascular disease is high.

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A Study on Fall Accident (1개 종합병원 환자의 낙상에 관한 조사)

  • Lee, Hyeon-Suk;Kim, Mae-Ja
    • The Korean Nurse
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    • v.36 no.5
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    • pp.45-62
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    • 1998
  • The study was conducted from November 1995 to May 1996 at the one general hospital in Seoul. The total subjects of this study were 412 patients who have the experience of fall accident, among them 31 was who have fallen during hospitalization and 381 was who visited emergency room and out patient clinic. The purposes of this study were to determine the characteristics, risk factors and results of fall accident and to suggest the nursing strategies for prevention of fall. Data were collected by reviewing the medical records and interviewing with the fallers and their family members. For data analysis, spss/pc+ program was utilized for descriptive statistics, adjusted standardized $X^2$-test. The results of this study were as follows: 1) Total subjects were 412 fallers, of which 245(59.5%) were men and 167(40.5%) were women. Age were 0-14 years 79(19.2%), 15-44 years 125(30.4%), 45-64 years 104(25.2%), over 65 years 104(25.2%). 2) There was significant association between age and the sexes ($X^2$=39.17, P=0.00). 3) There was significant association between age and history of falls ($X^2$=44.41. P= .00). And history of falls in the elderly was significantly associated with falls. 4) There was significant association with age and medical diagnosis ($X^2$=140.66, P= .00), chief medical diagnosis were hypertension(34), diabetis mellitus(22), arthritis(11), stroke(8), fracture(7), pulmonary tuberculosis(6), dementia(5) and cataract(5), 5) There was significant association between age and intrinsic factors: cognitive impairment, mobility impairment, insomnia, emotional problems, urinary difficulty, visual impairments, hearing impairments, use of drugs (sedatives , antihypertensive drugs, diuretics, antidepressants) (P < 0.05). But there was no significant association between age and dizziness ($X^2$=2.87, P=.41). 6) 15.3% of total fallers were drunken state when they were fallen. 7) Environmental factors of fall accident were unusual posture (50.9%), slips(35.2%), trips (9.5%) and collision(4.4%). 8) Most of falls occurred during the day time, peak frequencies of falls occurred from 1pm to 6pm and 7am to 12am. 9) The places of fall accident were roads(22.6%), house-stairs 06.7%), rooms, floors, kitchen (11.2%), the roof-top, veranda, windows(10.9%), hospital(7.5%), ice or snowy ways(5.8%), bathroom(4.9%), playground, park(4.9%), subway-stairs(4.4%) and public-bathrooms (2.2%). 10) Activities at the time of fall accident were walking(37.6%), turning around or reaching for something(20.9%), going up or down stairs09.2%), exereise, working07.4%), up or down from a bed(2.7%), using wheelchair or walking aids, standing up or down from a chair(2.2%) and standing still(2.2%). 11) Anatomical locations of injuries by falls were head, face, neck(31.3%), lower extremities (29.9%). upper extremities(20.6%), spine, thorax, abdomen or pelvic contents(l1.4%) and unspecified(2.9%). 12) Types of injures were fracture(47.6%), bruises03.8%), laceration (13.3%), sprains(9.0%), headache(6.6%), abrasions(2.9%), intracranial hemorrage(2.4%) and burns(0.5%). 13) 41.5% of the fallers were hospitalized and average of hospitalization was 22.3 days. 14) The six fallers(1.46%) died from fall injuries. The two fallers died from intracranial hemorrage and the four fallers died of secondary infection; pneumonia(2), sepsis(1) and cell lulitis(1). It is suggested that 1) Further study is needed with larger sample size to identify the fall risk factors. 2) After the fall accident, comprehensive nursing care and regular physical exercise should be emphasized for the elderly person. 3) Safety education and safety facilities of the public place and home is necessary for fall prevention.

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Characteristics of Brain Perfusion in Patients of Parkinson's Disease (파킨슨병 환자의 뇌관류 분석)

  • Jeong, Young-Jin;Park, Min-Jung;Kim, Jae-Woo;Kang, Do-Young
    • Nuclear Medicine and Molecular Imaging
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    • v.42 no.1
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    • pp.17-28
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    • 2008
  • Purpose: It was well known that cerebral blood perfusion is normal or diffusely decreased in the majority of patients with Parkinson's disease (PD). Actually we interpreted brain perfusion SPECT images of PD patients in the clinical situation, we observed various cerebral perfusion patterns in patients with PD. So we performed brain perfusion SPECT to know the brain perfusion patterns of PD patients and the difference of perfusion patterns according to the sex and the age. Also we classified PD patients into small groups based on the brain perfusion pattern. Methods and Materials: Two hundred nineteen patients (M: 70, F: 149, mean age: $62.9{\pm}6.9$ y/o) who were diagnosed as PD without dementia clinically and 55 patients (M:15, F:40, mean age: $61.4{\pm}9.2$ y/o) as normal controls who had no past illness history were performed $^{99m}Tc$-HMP AO brain perfusion SPECT and neuropsychological test. Results: At first, we compared all patients with PD and normal controls. Brain perfusion in left inferior frontal gyrus, left insula, left transverse temporal gyrus, left inferior parietal lobule, left superior parietal lobule, right precuneus, right caudate tail were lower in patients with PD than normal controls. Secondly, we compared male and female patients with PD and normal controls, respectively. Brain perfusion SPECT showed more decreased cerebral perfusion in left hemisphere than right side in both male and female patients compared to normal controls. And there was larger hypoperfusion area in female patients compared with male. Thirdly, we classified patients with PD and normal controls into 4 groups according to the age and compared brain perfusion respectively. In patient below fifties, brain perfusion in both occipitoparietal and left temporal lobe were lower in PD group. As the patients with PD grew older, hypoperfusion area were shown in both frontal, temporal and limbic lobes. Fourthly, We were able to divide patients into small groups based on cerebral perfusion pattern. There was normal cerebral blood perfusion in 32 (14.7%) of 219 patients with PD, decreased perfusion on the frontal lobe in 45 patients (20.6%), the temporal lobe in 39 patients (17.4%), the parietal lobe in 39 patients (17.9%), the occipital lobe in 40 patients (18.3%), diffuse area in 14 patients (6.4%) and unclassified in 10 patients (4.6%). Fifthly, we compared the results of the neuropsychological test and cerebral perfusion pattern. There was no correlation between two tests except visuospatial function. Conclusion: Various perfusion state were found in patients with PD according to the age and sex. Also we were able to classify perfusion state into several groups and compare the neuropsychological test with cerebral perfusion.

The Effects of Sleep Apnea and Variables on Cognitive Function and the Mediating Effect of Depression (수면무호흡증과 수면변수가 인지기능에 미치는 영향과 우울증의 매개효과)

  • Park, Kyung Won;Kim, Hyeong Wook;Choi, Mal Rye;Kim, Byung Jo;Kim, Tae Hyung;Song, Ok Sun;Eun, Hun Jeong
    • Sleep Medicine and Psychophysiology
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    • v.24 no.2
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    • pp.86-96
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    • 2017
  • Objectives: This study aimed to analyze causality among sleep apnea, depression and cognitive function in patients with obstructive sleep apnea. Methods: We reviewed the medical records of 105 patients with sleep apnea and snoring who underwent overnight polysomnography (PSG). We analyzed various biological data, sleep variables (sleep duration and percentage) and respiratory variables [arousal index (AI), periodic leg movement index (PLM index), snoring Index (SI), mean SpO2, minimum SpO2, apnea-hypopnea index (AHI), and respiratory disturbance index (RDI)]. We also analyzed various data by sleep, cognition, and mood related scales: Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), snoring index by scale (SIS), Montreal Cognitive Assessment-Korean (Moca-K), Mini-mental State Examination-Korean (MMSE-K), clinical dementia rating (CDR), and Beck Depression Inventory (BDI). We analyzed causation among sleep, and respiratory, mood, and cognition related scales in obstructive sleep apnea patients. We analyzed the mediating effects of depression on sleep apnea patient cognition. Results: As Duration N1 increased and Total sleep time (TST) decreased, MOCA-K showed negative causality (p < 0.01). As BDI and supine RDI increased, causality was negatively related to MOCA-K (p < 0.01). As PSQI (p < 0.001) and SIS (p < 0.01) increased and as MMSE-K (p < 0.01) decreased, causality was positively related to BDI. BDI was found to mediate the effect of age on MOCA-K in patients with obstructive sleep apnea. Conclusion: Duration N1, total sleep time, BDI, and supine RDI were associated with cognitive function in obstructive sleep apnea patients. Depression measured by BDI partially mediated cognitive decline in obstructive sleep apnea patients.