물부족 해소를 위한 수자원 관리방안 연구(A study on the management method for resolving water stress)

노트 : 이 연구보고서의 내용은 국토연구원의 자체 연구물로서 정부의 정책이나 견해와는 상관없습니다

Assessment of cardiac sympathetic neuronal integrity by I-123-MIBG scan in patients with idopathic dilated cardiomyopathy and the correlation bet

의학과/박사[한글] 특발성 확장성 심근증은 심장이 비대되고 좌심실의 수축기능이 점진적으로 감소되는 예후가 불량한 심장질환이다. 심장이식이 약물 치료에 호전이 없는 중증 확장성 심근중 환자에게 새로운 치료방법으로 이용되고 있으나 심장 이식을 기다리는 환자와 심장 기증자간의 수적 불균형 문제로 특발성 확장성 심근증 환자 중 조기 사망의 위험성이 있는 환자와 상대적으로 위험이 낮은 환자를 구분할 수 있는 정확한 예후인자를 알 수 있으면 심장이식의 대상 선정 및 시기를 결정하는데 많은 도움을 줄 수 있다. Norepinephrine 의 유사체인 metaiodobenzylguanidine(MIBG)을 이용하여 심장 교감 신경계의 활동도를 비관혈적으로 측정하여 말기 심부전증 환자에서 심근 MIBG 흡수가 감소되어 있으며 심부전증의 유용한 예후인자로 이용될 수 있는 것으로 알려져 있다. 본 연구에서는 특발성 확장성 심 근증 환자 40예에서 I-123-MIBG 스캔으로 심장교감 신경계의 활동도를 측정하여 정상 대조군과의 차이를 비교하였고 특발성 확장성 심근중 환자의 다른 비관혈적 예후인자와 비교하여 심근 MIBG 흡수를 대변하는 MIBG 투여 4시간 후 심장 대 종격동의 MIBG 흡수비(delayed heart to mediastinum ratio, 이하 DHM비)의 예후인자로서의 의의를 분석하였고 DHM비와 특발성 확장성 심근증 환자의 이미 알려진 예후인자 즉 심초음파지수, 방사선 핵종 심실 조영술상의 좌심실 구혈율, 혈역학적지수 및 24시간 norepinephrine치와의 상관관계를 조사하여 I-123-MIBG 스캔의 유용성을 알아보고자 하였다. 특발성 확장성 심근증 환자 40예와 정상 대조군 10예에서 I-123-MIBG 스캔을 시행하여 다음과 같은 결과를 얻었다. 1. MIBG 투여 30분 및 4시간 후 심장의 pixel당 평균 MIBG 활동계수는 특발성 확장성 심근증 환자군에서 정상 대조군보다도 통계학적으로 유의하게 낮았으나(10.5±1.1 vs 12.3±1.0 ; 9.7±1.1 vs 12.1±0.9), 폐나 종격동에서는 두 군간에 유의한 차이는 없었다. 2. MIBG 투여 30분 및 4시간 후의 심장 대 폐의 평균 MIBG 흡수비(0.92±0.16 vs 1.17±0.15 ; 0.99±0.12 vs 1.29±0.11) 및 심장 대 종격동의 평균 MIBG 흡수비(1.58±0.22 vs 2.01±0.01 ; 1.49±0.22 vs 1.95±0.10)는 특발성 확장성 심근증 환자군에서 정상 대조군보다 통계학적으로 유의하게 낮았다. 3. 특발성 확장성 심근중 환자에서 DHM비는 NYHA functional class 3, 4인 군이 1, 2인 군보다도 통계학적으로 유의하게 낮았으나(1.39±0.23 vs 1.55±0.18), Doppler 경승모판막 혈류의 유형과는 유의한 차이를 보이지 않았으며, DHM비가 1.5 미만인 군에서 1.5 이상인 군보다도 통계학적으로 유의하게 환자의 연령이 많고(58.8±10.5세 vs 46.9±15.6세) 심박출계수가 낮았다(1.2 ±0.7 l/min/m**2 vs 1.7 ±0.6 l/min/m**2). 4. 특발성 확장성 심근증 환자에서 DHM비는 심초음파지수(좌심실 확장기말 내경, E파의 최고속도, E파의 감속시간, 심박출계수), 방사선 핵종 심실 조영술상의 좌심실 구혈율, 혈역학적지수(폐동맥 쐐기압, 좌심실 이완기말압력), 24시간 소변 norepinephrine 치들과 는 유의한 상관관계를 보이지 않았다. 이상의 결과로 특발성 확장성 심근증에서 I-123-MIBG 스캔은 심장 교감 신경계의 활동도를 측정하는데 유용하며 심근 MIBG 흡수가 확장성 심근증 환자에서 정상 대조군보다 유의하게 낮아 심장 교감 신경계의 손상을 알 수 있었으며 DHM비는 NYHA functional class 를 제외한 예후인자들과는 유의한 상관관계를 보이지 않아 특발성 확장성 심근중에서 NYHA functional class와 더불어 심근 MIBG 흡수 자체가 예후인자로 이용될 수 있으나 심근 Ml8G 흡수가 독립된 예후인자로 평가받기 위해서는 향후 계속적인 연구 및 추적관찰이 필 요하리라 생각된다. [영문] The prognosis of idiopathic dilated cardiomyopathy remains poor. Cardiac transplantation represents an alternative treatment for the most severe patients who have no other options. Unfortunately, a discrepancy exists between the number of candidates for heart transplantation and availability of donors. A method to discriminate between high and low risk patients with regard to mortality could help rationalize the indication of cardiac transplantation and it? timing. Of the available measurements, a diminished left ventricle ejection fraction has often been associated with mortality which is defined by 27% cutoff value have been prognostically useful. Measurements of adrenergic nervous system activation have also provided helpful information. However, these indices are not sufficiently discriminatory and the decision for heart transplantation re-mains difficult in individual patients. Iodine-123-metaiodobenzylguanidine(MIBG) is a norepinephrine analog which can be used to image the sympathetic innervation of the heart. Cardiac sympathetic neuronal integrity can be successfully evaluated with I-123-MIBG scintigraphy and the degree of cardiac MIBG uptake is known to be a Potent prognostic factor of congestive heart failure. The present study was designed to define the Prognostic value of myocardial MIBG uptake in patients with idiopathic dilated cardiomyopathy by I-123-MIBG scan and to investigate the correlation between delayed heart to mediastinum MIBG uptake(DHM) ratio which is representative of the myocardial MIBG uptake and prognostic factors namely echocardiographic variables, left ventricle ejection fraction in radionuclide ventriculography, hemodynamic variables, 24 hr urine norepinephrine which are well known determinants of survival in patients with idiopathic dilated cardiomyopathy. The results were summarized as follows: 1 . Early and delayed mean MIBG activity counts per pixel of heart were significantly lower inpatients with idiopathic dilated cardiomyopathy than in the normal control subjects(10.5±1.1 vs 12.3± 1.0 ; 9.7±1.1 vs 12.1±0.9). There was no significant difference in early and delayed mean MIBG activity counts of lung and mediastinum between the two groups. 2. Early and delayed mean cardiac MIBG uptake ratios of the heart to lung(0.92±0.16 vs 1.17±0.15 ; 0.99±0.12 vs 1.29±0.11) and heart to mediastinum(1.58±0.22 vs 2.01±0.01 : 1.49±0.22 vs 1.95±0.10) were significantly lower in patients with idiopathic dilated cardiomyopatky than the normal control subjects. 3. The DHM ratio was significantly lower in patients of NYHA functional clams 3, 4 than in those of NYHA functional class 1, 2(1.39±0.23 vs 1.55±0.18). There was no significant difference in DHM ratios between the two groups divided by Doppler transmitral inflow pattern(relaxation abnormality vs restrictive physiology). There was significant difference of age (58.8±10.5 years vs 46.9±15.6 years) divided by DHM ratio less than 1.5 and DHM ratio more than 1.5. There was more depressed cardiac index significantly(1.2±0.7 l/min/m**2 vs 1.7± 0.6 l/min/m**2) in patients of DHM ratio less than 1.5 than those of DHM ratio more than 1.5. 4. There was no significant correlation between the DHM ratio and eckocardiographic variables(LVEDD, Peak I velocity, E wave deceleration time, cardiac index), hemodynamic variables(PCWP, LVEDP), left ventricle ejection fraction in radionuclide ventri-culography and 24 hr urine norepinephrine. In conclusion I-123-MIBG scan is useful in the assessment of cardiac sympathetic neuronal integrity which permits defining patients at risk in idiopathic dilated cardioinyopathy, however the degree of myocardial MIBG uptake was not significantly correlated with prognostic factors except NYHA functional class. The myocardial MIBG uptake can he utilized as a Prognostic factor and helpful in making decisions of cardiac transplantation and evaluating their timing, but the serial clinical study and follow-up are necessary to evaluate the efficacy of myocardial MIBG up-take as an independent prognostic factor in patients with idiopathic dilated cardiomyopathy.restrictio

(A) study on the predictability of progression of chronic renal failure

의학과/석사[한글] 만성 신부전증(chronic renal failure)은 원인 신질환에 관계없이 지속적으로 신기능이 감소하는 특성을 가지고 있으며, 그간 만성 신부전증의 진행 예측에 관하여 여러 가지 수학적인 방법들이 제시되어 왔다. 만성 신부전증 환자에서 혈청 크레아티닌을 연속적으 로 관찰하여 혈청 크레아티닌의 역수치(1/Scr) 혹은 Log치(Log Scr)와 관찰 시간과의 관계에서 일직선이 수립된다는 사실이 알려져 있으며, 이러한 수치의 회기방정식(regression equation)을 이용하여 예후 방정식(prognostic equation)으로도 사용할 수 있다. 오늘날 이러한 방법들을 이용하여 여러가지 신질환의 진행과 치료 수단의 평가에 이용되고 있으나 그 정확도의 비교에 대한 보고나 성별, 연령, 원인 신질환등에 따른 차이에 대한 연구는 많지 않다. 이에 저자는 변형된 혈청 크레아티닌의 연속적인 측정으로 만성신부전의 진행을 정확히 예측할 수 있는지 알아보고저 만성 신부전증 환자 61예 에서 변형된 혈청 크레아티닌치와 시간과의 관계에서 예측오차(prediction error)를 구하고 또한 성별, 연령별, 원인 신질환별로 구분 분석하여 어떠한 요소가 만성 신부전증의 진행 예측에 영향을 주는지 관찰하여 다음과 같은 결론을 얻었다. 1. 1/Scr의 예측오차 중앙치(평균±표준오차)는 2.1(3.2±13.1)개월로서, Scr의 47(64.7±62.8)개월, Log Scr의 15.7(21±23.9)개월 보다 유의하게 적었다. Scr, 1/Scr, Log Sc r의 상관계수는 각각 0.910(0.895±0.090), -0.918(-0.889±0.101), 0.843(0,896±0.093)으로 세방법 모두상관계수가 높았다. 2. Scr, 1/Scr, Log Scr의 예측 오차를 성별로 비교하면 각각 남자(40예)의 경우 50.3(78.3±67.4)개월, 5.0(5.7±10.7)개월, 20.4(26.0±22.2)개월이었고 여자(21예)의 경우 33.8(39.0±43.8)개월, -1.2(-1.7±16.7)개월, 5.6(11.4±24.1)개월로서 세방법 모두 여자에서 통계학적으로 유의하게 적었다(p<0.05). 3. Scr, 1/Scr, Log Scr의 예측 오차를 연령별로 비교하면 각각 45세미만(23예)의 경우 52.8(86.6±71 4)개월, 4.5(6.4±11.7)개월, 20.1(28.1±23.9)개월이였고, 45세 이상 65세 미만(28예)의 경우 41.5(54.8±54.8)개월, 1.2(2.6±11.4)개월, 15.2(18.3±21.1)개월 이였고, 65세 이상(10예)의 경우 16.0(42.4±52.3)개월, -2.4(-2.9±18.6)개월, 3.0(12.1±20.6)개월로 어느 방법에서나 연령에 따른 예측오차의 차이는 없었다. 4. 원인 신질환별로 Scr, 1/Scr, Log Scr의 예측 오차를 비교해 보면 만성 사구체 신염(22예)의 경우 51.8(77.2±60.4)개월, 5.5(4.6±14.3)개월, 20.4(24.8±23.6)개월, 당뇨병성 신증(17예)의 경우 12.7(28.6±39.9)개월, -1.2(-0.2±9.9)개월, 4.6(8.8±17.1)개 월, 고혈압성 신증(7예)의 경우 56.2(62.7±56.8)개월, -0.2(-1.6±13.8)개월, 26.1(9.6±22.3)개월로 어는 방법에서나 원인 신질환에 따른 예측오차의 차이는 없었다. 이상의 결과로 만성 신부전증에서의 예측오차(prediction error)는 Scr, Log Scr 보다 1/Scr에서 유의하게 적었으며 1/Scr을 사용하는 경우 예측의 정확도가 가장 높았다. 또한 예측 오차는 여자가 남자보다 적어 성별로는 유의한 차이가 있었으나, 연령별, 원인 신 질환 별로는 차이를 보이지 않았다. A study on the predictability of progression of chronic renal failure Dong Hun Cha Department of Medical Science Graduate Schoo Yonsei University (Directed by Professor Dae Suk Han, M. D.) To predict the progression of chronic renal failure by means of mathematical models, the serum creatinine data of patients were linearized by reciprocal model(1/Scr) and logarithmic model (LogScr). Thereafter, regression equations of the transformed data were calculated and used as prognostic equations. When these models were applied to an individual case, the prediction of the progression of disease was claimed to be independent of the underlying renal disease, sex, age, and other factors influencing the progression of chronic renal failure. Today, there is a widespread use of these models in the evaluation of therapeutic trials and in the monitoring of various kidney disorders. However, only a few attempts have been made to assess the accuracy of these models. A high degree of accuracy is assumed exclusively because of the high correlation coefficients of the transformed serum creatinine data. The models may also be criticized on the basis that data outside the range of original data set were predicted. It is the aim of my study to reevaluate the accuracy of the prediction by application of the reciprocal and logarithmic model according to sex, age and the underlying renal disease. The results obtained in this study were as follows: 1. The summary of the 61 cases of chronic renal failure The mean age of all patients was 51.1 years old and the ratio of male:female was 40:21. The number of determinations from first Scr to last Scr was 6.5±3.4. The mean first Scr was 2.4±0.7mg/dl, the mean last Scr was 10.6±2.9mg/dl. The prediction interval was 13.1±10.4 months. The mean duration of observation period from first Scr to last Scr was 33.3±22.7 months. 2. Prediction error and correlation coefficient of total 61 patients The prediction error of Scr, 1/Scr, Log Scr was 64.7±62.8 months, 3.2±13.1 months and 21.0±23.9 months, respectively. The prediction error of the 1/Scr was smallest and this means that the accuracy of predictability of 1/Scr was highest among three models. The mean correlation coefficient of Scr, 1/Scr, Log Scr was 0.910, -0.918, 0.843, respectively. 3. Prediction error according to sex. The prediction error of male and female patients was 78.3±67.4 months and 39.0±43.8 months in Scr, 5.7±10.0 months and -1.7±16.7 months in 1/Scr, 26.0±22.4 months and 11.4±24.1 months in Log Scr. Significant differences were noted in all three models between male and female. 4. Prediction error according to age The prediction error of less than 45 years old, 45-65 years old more than 65 years old was 86.6±71.4 months, 54.5±54.8 months,42.4±52.3 months in Scr and 6.4±11.7 months, 2.6±11.4 months,-2.9±18.6 months in 1/Scr and 28.1±23.9 months, 18.3±21.1 months, 12.1±20,6 months in Log Scr. There was no significant difference between three different age subgroups regardless of models used. 5. Prediction error according to underlying renal disease The prediction errors of chronic glomerulonephritis, diabetic nephropathy, hypertensive golmerulosclerosis were 77.2± 60.4 months, 28.6±39.9 months, 62.7±56.8 months in Scr and 4.6±14.3 months, -0.2±9.9 months, 1.6±13.8 months in 1/Scr and 24.8±23.6 months,8.8±17.1 Months, 19.7±22.3 months in Log Scr. There was no significant difference between three different etiologic subgroups regardless of models used. In conclusion, the prediction error of the chronic renal failure was smallest in 1/Scr model than two other models indicating that the accuracy of the prediction was highest in 1/Scr model than two other models. There was significant difference of prediction error according to sex, but there was no significant difference of prediction error according to age and the underlying renal disease. [영문] To predict the progression of chronic renal failure by means of mathematical models, the serum creatinine data of patients were linearized by reciprocal model(1/Scr) and logarithmic model (LogScr). Thereafter, regression equations of the transformed data were calculated and used as prognostic equations. When these models were applied to an individual case, the prediction of the progression of disease was claimed to be independent of the underlying renal disease, sex, age, and other factors influencing the progression of chronic renal failure. Today, there is a widespread use of these models in the evaluation of therapeutic trials and in the monitoring of various kidney disorders. However, only a few attempts have been made to assess the accuracy of these models. A high degree of accuracy is assumed exclusively because of the high correlation coefficients of the transformed serum creatinine data. The models may also be criticized on the basis that data outside the range of original data set were predicted. It is the aim of my study to reevaluate the accuracy of the prediction by application of the reciprocal and logarithmic model according to sex, age and the underlying renal disease. The results obtained in this study were as follows: 1. The summary of the 61 cases of chronic renal failure The mean age of all patients was 51.1 years old and the ratio of male:female was 40:21. The number of determinations from first Scr to last Scr was 6.5±3.4. The mean first Scr was 2.4±0.7mg/dl, the mean last Scr was 10.6±2.9mg/dl. The prediction interval was 13.1±10.4 months. The mean duration of observation period from first Scr to last Scr was 33.3±22.7 months. 2. Prediction error and correlation coefficient of total 61 patients The prediction error of Scr, 1/Scr, Log Scr was 64.7±62.8 months, 3.2±13.1 months and 21.0±23.9 months, respectively. The prediction error of the 1/Scr was smallest and this means that the accuracy of predictability of 1/Scr was highest among three models. The mean correlation coefficient of Scr, 1/Scr, Log Scr was 0.910, -0.918, 0.843, respectively. 3. Prediction error according to sex. The prediction error of male and female patients was 78.3±67.4 months and 39.0±43.8 months in Scr, 5.7±10.0 months and -1.7±16.7 months in 1/Scr, 26.0±22.4 months and 11.4±24.1 months in Log Scr. Significant differences were noted in all three models between male and female. 4. Prediction error according to age The prediction error of less than 45 years old, 45-65 years old more than 65 years old was 86.6±71.4 months, 54.5±54.8 months,42.4±52.3 months in Scr and 6.4±11.7 months, 2.6±11.4 months,-2.9±18.6 months in 1/Scr and 28.1±23.9 months, 18.3±21.1 months, 12.1±20,6 months in Log Scr. There was no significant difference between three different age subgroups regardless of models used. 5. Prediction error according to underlying renal disease The prediction errors of chronic glomerulonephritis, diabetic nephropathy, hypertensive golmerulosclerosis were 77.2± 60.4 months, 28.6±39.9 months, 62.7±56.8 months in Scr and 4.6±14.3 months, -0.2±9.9 months, 1.6±13.8 months in 1/Scr and 24.8±23.6 months,8.8±17.1 Months, 19.7±22.3 months in Log Scr. There was no significant difference between three different etiologic subgroups regardless of models used. In conclusion, the prediction error of the chronic renal failure was smallest in 1/Scr model than two other models indicating that the accuracy of the prediction was highest in 1/Scr model than two other models. There was significant difference of prediction error according to sex, but there was no significant difference of prediction error according to age and the underlying renal disease.restrictio

Economy-ecology balance of Taejon city municipal solid waste management by LCA(Life Cycle Assessment) and WRAP(Waste Resources Allocation Program)

학위논문(석사) - 한국과학기술원 : 토목공학과, 1998.2, [ vi, 70 p. ]한국과학기술원 : 토목공학과

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