Targeted Temperature Management of Severe Lactic Acidosis in a Patient with MELAS Syndrome after Cardiac Arrest

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is known as a maternally inherited mitochondrial disease with a m.3243A>G mutation in the MT-TL1 gene. Here, we report a case of targeted temperature management in a MELAS patient who had a cardiac arrest and severe lactic acidosis after recurrent seizures.

Neuroleptic Malignant Syndrome Applied with Targeted Temperature Management

Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic emergency associated with the use of dopamine receptor-antagonist properties or the rapid withdrawal of dopaminergic medications. NMS is characterized by refractory hyperpyrexia, altered mental state, dysautonomia, and rigor. If hyperpyrexia persists, it can result in multiorgan failure. Herein, we report a case of NMS occurring after metoclopramide administration in a patient with pontine hemorrhage, which was successfully treated with targeted temperature management using a surface cooling device.

Targeted Temperature Management of Severe Lactic Acidosis in a Patient with MELAS Syndrome after Cardiac Arrest

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is known as a maternally inherited mitochondrial disease with a m.3243A>G mutation in the MT-TL1 gene. Here, we report a case of targeted temperature management in a MELAS patient who had a cardiac arrest and severe lactic acidosis after recurrent seizures.

Neuroleptic Malignant Syndrome Applied with Targeted Temperature Management

Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic emergency associated with the use of dopamine receptor-antagonist properties or the rapid withdrawal of dopaminergic medications. NMS is characterized by refractory hyperpyrexia, altered mental state, dysautonomia, and rigor. If hyperpyrexia persists, it can result in multiorgan failure. Herein, we report a case of NMS occurring after metoclopramide administration in a patient with pontine hemorrhage, which was successfully treated with targeted temperature management using a surface cooling device.

Delayed Lesions on Diffusion-Weighted Imaging in Initially Lesion-Negative Stroke Patients / 대한뇌졸중학회지

Background@#and Purpose Lesions on diffusion-weighted imaging (DWI) occasionally appear on follow-up magnetic resonance imaging (MRI) among initially DWI-negative but clinically suspicious stroke patients. We established the prevalence of positive conversion in DWI-negative stroke and determined the clinical factors associated with it. @*Methods@#This retrospective, observational, single-center study included 5,271 patients hospitalized due to stroke/transient ischemic attack (TIA) in a single university hospital during 2010 to 2017. Patients without initial DWI lesions underwent follow-up DWI imaging as a routine practice. Adjusted hazard ratios (aHRs) for recurrent stroke risk according to positive conversion were determined using Cox proportional hazard regression. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for positive conversion among initially DWI-negative patients were estimated. @*Results@#In total, 694 (13.2%) patients (mean±standard deviation age, 62.9±13.7 years; male, 404 [58.2%]) were initially DWI-negative. Among them, 22.5% had positive-conversion on follow-up DWI. Positive conversion was associated with a higher risk of recurrent stroke (aHR, 3.12; 95% CI, 1.56 to 6.26). Early neurologic deterioration (aOR, 15.1; 95% CI, 5.71 to 47.66), atrial fibrillation (aOR, 6.17; 95% CI, 3.23 to 12.01), smoking (aOR, 3.76; 95% CI, 2.19 to 6.63), pre-stroke dependency (aOR, 1.62; 95% CI, 1.15 to 2.27), objective hemiparesis (aOR, 4.39; 95% CI, 1.90 to 10.32), longer symptom duration (aOR, 2.17; 95% CI, 1.57 to 3.08), high cholesterol (aOR, 4.70; 95% CI, 1.78 to 12.77), National Institutes of Health Stroke Scale score (aOR, 1.44; 95% CI, 1.08 to 1.91), and high systolic blood pressure (aOR, 1.01; 95% CI, 1.00 to 1.02) were associated with a higher incidence of lesions with delayed appearance. Regarding the location of lesions on follow-up DWI, 34.6% and 21.2% were in the cortex and brainstem, respectively. @*Conclusions@#In DWI-negative stroke/TIA, positive conversion is associated with a higher risk of recurrent stroke. DWI-negative stroke with factors related to positive conversion may require follow-up MRI for a definitive diagnosis.

Clinical Value of New Staging Systems for Multiple Myeloma / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: We wanted to investigate the validity of the recently introduced Southwest Oncology Group (SWOG) staging system and the International Staging System (ISS) by comparing both systems with the widely accepted Durie/Salmon (DS) system for multiple myeloma patients. MATERIALS AND METHODS: Between 1992 and 2005, 85 multiple myeloma patients (men: women 41:44, median age: 63 years (range: 36~87)) with available baseline values of albumin and beta2-microglobulin were enrolled. The clinical and laboratory data were retrospectively obtained. RESULTS: According to the ISS, 11 patients were stage I (12.9%), 30 patients stage II (35.3%) and 44 patients stage III (51.8%). The median survivals of the ISS stages I, II and III were 78.6 months, 31.8 months and 15.1 months, respectively (p=0.015). The DS staging system was not able to predict the survival. For the SWOG staging system, 14 patients were stage I (16.4%), 27 patients stage II (31.8%), 27 patients stage III (31.8%) and 17 patients were stage IV (20.0%). The median survivals of the SWOG staging system stage I, II, III and IV were 78.6 months, 31.8 months, 11.6 months and 24.8 months, respectively (p=0.0075). CONCLUSION: The ISS staging system showed better reliability, simplicity and predictability for survival than the DS and SWOG staging systems for multiple myeloma patients.

Factors Affecting on Treatment of Hyponatremia in Hyponatremic Patients / 대한신장학회잡지

Hyponatremia, well known as a serious medical condition, is the most frequent electrolyte disorder in clinical medicine. The aim of this study is to bring to readers affecting factors in hyponatremia treatment and to suggest effective treatment guideline. We studied general characteristics, associated serum potassium change, relationship of sodium concentration in urine, and affecting factors on serum sodium correction in 76 hyponatremic patients who had admitted Hanyang University Kuri Hospital. These 73 hyponatremic patients were divided into 10 groups according to cause and treatment by retrospective analysis(1 group : G-I origin, 2 group : CRF, 3 group : CHF, 4 group: LC, 5 group : adrenal origin, 6 group : diuretics use, 7 group : CHF with di- uretics use, 8 group : LC with diuretics use, 9 group : polydypsia, 10 group : SIADH). Serum sodium were 124.2+/-6.9mEq/L in initial diagnosis, 125.6 +/-7.7mEq/L after 48 hour, and 129.8+/-6.3mEq/L in final evaluation. Among these hyponatremic patients, thirty patients' (41.1%) sodium correction rate were below 0.5mEq/L/hr during initial 48 hour and fifteen patients(20.5%) were corrected above 135mEq/l in serum sodium Initial serum potassium was average 4,07mEq/L, and 15 patients in 73 hyponatremic patients were hypokalemic feature. Eight patients of 15 hypokalemic patients were corrected to normal potassium level and in addition, four patients of 8 corrected patients were corrected to normal sodium level above 135mEq/L. The disease frequency were highest in GI origin (31.5%), followed by SIADH(20.5%) and LC(12.3%). In our study, hyponatremia correction was not related to patient sex, age, and initial serum sodium concentration. In conclusion, Hyponatremia prognosis was not related to initial serum sodium concentration and corection rate, but related to treatment of underlying disease. And hypokalemia acompanied by hyponetremia was corrected after correction of hyponatremia.

Clinical and Laboratory Features of Patients with Chronic Renal Disease at the Start and After the Chronic Maintenance Hemodialysis / 대한신장학회잡지

OBJECTIVE: We examined clinical and laoratory features retrospectively in 56 patients at the start and after the chronic maintenance hemodialysis in order to provide a more complete picture of the uremic symdrome in the dialysis era. for deciding the time when chronic hemodialysis must be started. METHODS: The records of 56 patients began chronic hemodialysis treatment at the Han Yang University Hospital from 1995 august until 1997 august were reviewed retrospectively. The information gathered included demographic data, renal diagnosis, uremic symptoms, biochemical values. RESULTS: The most prevalence of manifestation of uremia was general weakness (67.9%). Unexpected fin-dings were the wide ranges of serum creatinine levels (3.5 to 19.4mg/dL) and blood urea nitrogen levels (19 to 204mg/dL), creatinine clearance rate (1.2-17.4mL/ min), and the frequency of hyponatremia (19.6%), hypo-albuminemia (69.6%), and the anion gap above 14mByL was (66.7%). There was higher potassium leve1 in diabetes mellitus patients than non-diabetes mellitus patients(6.2+/-1.6mEq/L VS. 4.9+/-1.0mEq/L,p=01). Patients laboratory values were changed after the chronic maintenance hemodialysis-Albumin(3.2+/-0.8 to 3.6+/-0.5gm/dL, p=0.01), calcium (7.6+/-1.2 to 8.7+/-1.9mg/dL, p=0.01), he-matocrit(23.0+/-4.7 to 27.7+/-4.2% , p=0.01), phosphorus (5.6+/-2.1 to 4,6+/-1.4mg/dL, p=0.01), pH (7.30+/-0,1 to 7.35+/-0.2, p>0.05), anion gap (22,0+/-11.0 to 12.1+/-8.8mg/dL, p>0.05). CONCLUSION: Finally, uremic symptoms were expressed mainly gastro-intestinal and respiratory symptoms. Chronic renal failure associated with diabetes mellitus was earlier on set of uremic symptoms and higher level of serum potassium level than other underlying diseases. Uremic symptoms and laboratory values were almost corrected but metabolic acidosis was not corrected significantly after the chronic maintenance hemodialysis.

Impaired potassium handling after acute oral potassium loading in outpatients on standard dose of trimethoprim/sulfamethoxazole(TMP/SMX) / 대한내과학회지

BACKGROUND: TMP/SMX has been shown to cause hyperkalemia in a few outpatients on standard-dose. This prospective study was aimed at investigating other associated factors inducing clinically important hyperkalemia in outpatients on standard-dose of TMP/SMX. METHODS: Age-matched diabetic(n=22) and non-diabetic (n=20) patients with UTI on standard dose of TMP/SMX for 5 days were given acute oral intake of 40 mEq of potassium chloride(KCl). RESULTS: Before the intake of TMP/SMX, basal levels of serum potassium(K), serum BUN and creatinine, plasma renin activity(PRA), aldosterone(PA), and transtubular potassium gradient(TTKG) were comparable between diabetic and non-diabetic subjects. Also after TMP/SMX was taken, all parameters didnt reveal any overt changes except a slightly increased serum K but not significantly (from 4.20+/-0.15 to 4.14+/-0.21mEq/L in non-diabetics; from 4.13+/-0.18 to 4.25+/-0.13mEq/L in diabetics). Following acute oral KCl load, however, the peak increases of serum K changes were significantly higher in diabetics compared to non-diabetics(0.34 0.06 vs 0.62 0.09mEq/L, p 5.0 mEq/L). After KCl load, PRA did not show any significant changes, whereas PA was increased simultaneously with the increments of serum K in both diabetic subgroups hyperkalemic(n=8) and normokalemic (n=14) diabetics. But increment was blunted in hyperkalemic diabetic subgroup. TTKG was increased prominently in normokalemic diabetic subgroup(9.20 from 4.50), while it was slightly increased in hyperkalemic diabetic subgroup(4.63 from 3.79mEq/L). There was statistical difference between two subgroups(p < 0.05). In conclusion, Besides the known effect of blocking sodium channels in distal K secreting cells by TMP/SMX, insulinopenia(DM). Hypoaldosteronism with its decreased tubular bioactivity, and increased exogenous K intake in concert could cause clinically overt hyperkalemia on standard-dose of TMP/SMX. When standard- dose of TMP/SMX is administered to patients with deranged K homeostasis, especially to diabetics with hypoaldosteronism, blood K level should be monitored meticulously to avoid hyperkalemia.

Centrilobular Distribution of Ethylnitrosourea-Induced Hepatocellular Foci in the Mouse / 대한간학회지

BACKGROUND/AIMS: Hepatocytes on the hepatic lobule mipate from portal zone to centrilobular mea as the DNA synthesis within it. And also, the xenobiotic reactions reveal characteristic differences associated with zone specific metabolism in the liver acinus. In this study, the zonal distribution of ethylnitrosourea (ENU)-induced hepatic precancerous lesion was stereologically investigated. METHODS: Nine B6C3F1 mices were given I.p. injection of ENU (60 ug/pn body weight) when the pups were 15 days old prior to sacrifices at 8 weeks of life. All the 150 consecutive sections, 3 p m in thickness, were stained with hematoxylin and eosin and identified the basophilic precancerous lesions with 80-165 p m diameter in equatorial plane by the Zeiss microprojector. And then the distances from the center of selected foci to terminal hepatic vein or portal vein branches were estimated under the microscopic fields. As a control group, the same estimations were performed from the random points by the appointments of random digit table. RESULTS: Mean distance between ENU-induced 52 hepatocellular foci and the nearest terminal hepytic vein was 181.15+112.39 p m (Mean+ SD), but that of randomly selected 104 points was 291.73+157.98pm (Mean+5D) (Students t-test, p<0.0005). Substantially, 52.7% of ENU-induced 52 hepatocellular foci were within 300 p m from the terminal hepatic vein, but randomly selected 104 points were only 50.9% (Shapiro Wilk W test, w=0.819857, p=0.048038). Mean distance from ENU-induced 52 foci to portal vein was 398.85+149.98pm (Mean+SD), but that from the randomly selected 104 points was 315.87+145.79 pm (Mean+SD)(Students t-test, p<0.0005). CONCLUSION: Stereologically, ENU-induced mice liver cell foci distribute non-randomly to Zone III, centrilobular zone of mouse hepatic acini where promote invasion toward terminal hepatic veins.

Changes of Epidermal Growth Factor in Sera among the Patients with Chronic Hepatitis, Cirrhosis and Hepatocellular Carcinoma / 대한간학회지

BACKGROUND/AIMS: Epidermal growth factors (EGF) is known to activate mitogen activated protein kinase (MAP kinase) in hepatocytes by the route of both Raf-dependent and Raf-indefendent pathways. And this is likely to play important role in normal liver cell growth and regeneration. EGF is also reported as a potent mitogen and one of the angiogenic factors. To elucidate the dynamic changes of the serum concentration of epidermal growth factor in chronic liver disease and its correlation with role of EGF and mechanism of tumor development, this study is intended to employ an ELISA in 38 biopsy-proven cases. METHODS: Sera taken out of 5 patients with chronic persistent hepatitis. 4 patients with chronic active hepatitis, 19 patients with liver cirrhosis, 10 patients with hepato-cellular carcinoma that pathological diagnosis was proven later were tested for EGF employing Quantikine ELISA Kits (R & D Systems Inc. Minneapolis, MN). The statistical analysis was evaluated by student's t-test. RESULTS: EGF concentration was 253.33+ 69.5pg/ml(Mean+ SE) in hepatocellular carcinoma, 246.60+ 91.19pg/ml(Mean+ SE) in chronic active hepatitis, 222.71+ 115.97pg/ml (Mean+ SE) in chronic persistent hepatitis, 141.15+ 23.12pg/ml(Mean+ SE) in liver cirrhosis in orders. Serum EGF concentration in hepatocellular carcinoma was significantly higher than that in liver cirrhosis(p value=0.021695). However, comparing to the remaining other groups, no significant difference was found. CONCLUSION: These results support that the reconstruction of the capillary networks in liver cirrhosis resplts in down-regulation of the EGF in comparison to chronic hepatitis. But it is suggested that revaluation of EGF stimulates MAP kinase activity eventually playing in tumorigenesis of the liver with neoangiogenesis.