Is it Adequate to Determine Acetaminophen Toxicity Solely on Patients' History? An Analysis on Clinical Manifestation of Intoxication Patients with Positive Serum Acetaminophen Concentrations

PURPOSE: Acute acetaminophen intoxication is a common occurrence that can cause lethal complications. In most domestic emergency departments, clinicians tend to treat acetaminophen intoxication based on patients' history alone, simply due to the lack of a rapid acetaminophen laboratory test. We performed a 20-month study of intoxication patients to determine the correlation between the history of patients and serum laboratory tests for acetaminophen. METHODS: We took blood samples from 280 intoxication patients to evaluate whether laboratory findings detected traces of acetaminophen in the sample. Patients were then treated according to their history. Laboratory results came out after patients'discharge. Agreement between patients' history and laboratory results were analyzed. RESULTS: Among the 280 intoxicated patients enrolled, 38 patients had positive serum acetaminophen concentrations; 18 out of 38 patients did not represent a history suggesting acetaminophen intoxication. One patient without the history showed toxic serum acetaminophen concentration. Among the patients with the history, two patients with toxic serum acetaminophen concentration did not receive N-acetylcysteine (NAC) treatment due to their low reported doses, while other 2 patients without significant serum acetaminophen concentration did receive NAC treatment due to their high reported doses. CONCLUSION: This study showed a good overall agreement between history and laboratory test results. However, some cases showed inconsistencies between their history and laboratory test results. Therefore, in treating intoxication patients, a laboratory test of acetaminophen with rapid results should be available in most domestic emergency departments.

A Case of Endogenous Endophthalmitis and Multifocal Pneumonia Complicated by Renal Abscess and Sepsis due to Escherichia coli / 대한신장학회지

Metastatic or septic endogenous endophthalmitis is a rare, but devastating complication of systemic septicemia. This condition may become more common as the number of chronically debilitated patients and the use of invasive procedures increase. Many etiologic organisms (gram-positive, gram-negative and fungi) and many clinical conditions (pyelonephritis, endocarditis, meningitis, pneumonia) have been reported to cause endogenous endophthalmitis. Risk factors include most of the known reasons for immune suppression and chronic illness. A high clinical suspicion is required in early diagnosis and treatment. Early antibiotics and vitrectomy are more widely accepted as therapeutic modalities.

Acute Pancreatitis and Septic Shock Complicated after Ureteroscopic Stone Removal in a Patient with Ureter Stones / 대한신장학회지

Being relatively safe, Ureteroscopy is one of the techniques most widely used for upper urinary tract diseases. Two cases of acute pancreatitis following percutaneous nephrolithotomy have been reported, but in neither case was there any complications after ureteroscopic procedure in patients with percutaneous nephrostomy. A 49-year-old male was presented with sudden onset of fever and decreased mental activity just after ureteroscopic stone removal. He had received nephrolithotomy for staghorn calculus six months before and received percutaneous nephrostomy 2 months before. Urine and blood cultures showed Citrobacter freundii and serum amylase and lipase increased to 6,067 IU/L, 1,270 IU/L, respectively. Abdominal CT scan demonstrated perinephric inflammatory fluid collection and its direct extension to the tail portion of pancreas. With medical treatment including adequate antibiotics, urosepsis and acute pancreatitis was completely cured.

Budd-Chiari Syndrome Caused by Diaphragmatic Hernia of the Liver: A Case Report

Budd-Chiari syndrome is an uncommon disorder, and it is caused by obstruction of the hepatic venous outflow or inferior vena cava above the hepatic vein. It may result from a large number of conditions, including primary congenital obstructions of the hepatic veins or inferior vena cava by webs or bands. Secondary causes include trauma, polycythemia vera, chronic leukemia, pregnancy, tumors and use of oral contraceptives. No definitive etiologic factors have been identified in two thirds of all cases (1-3). We recently experienced a case of Budd-Chiari syndrome caused by diaphragmatic hernia in 21-year-old man. Postoperative follow up CT showed normal venous flow after reintroduction of the liver into the abdominal cavity and closure of the diaphragm defect.

Budd-Chiari Syndrome Caused by Diaphragmatic Hernia of the Liver: A Case Report

Budd-Chiari syndrome is an uncommon disorder, and it is caused by obstruction of the hepatic venous outflow or inferior vena cava above the hepatic vein. It may result from a large number of conditions, including primary congenital obstructions of the hepatic veins or inferior vena cava by webs or bands. Secondary causes include trauma, polycythemia vera, chronic leukemia, pregnancy, tumors and use of oral contraceptives. No definitive etiologic factors have been identified in two thirds of all cases (1-3). We recently experienced a case of Budd-Chiari syndrome caused by diaphragmatic hernia in 21-year-old man. Postoperative follow up CT showed normal venous flow after reintroduction of the liver into the abdominal cavity and closure of the diaphragm defect.

A Case of Renal Cell Carcinoma with Thyroid Metastasis / 대한내분비학회지

Metastatic thyroid cancer is uncommon but must be distinguished from primary thyroid cancer because of the differences in management and prognosis. Although renal cell carcinoma is one of the most common tumors that metastasize to the thyroid gland, such a case has never been reported in Korea. We describe the first case of metastatic renal cell carcinoma in the thyroid gland. A 66-year-old man presented with a neck mass detected about 6 weeks previously. He had undergone left nephrectomy due to renal cell carcinoma 8 years before and had remained disease-free thereafter. Computed tomography of the neck showed a 5 cm-sized thyroid mass. Fine needle aspiration cytology revealed some malignant cells containing intranuclear inclusions which were assumed to be papillary thyroid carcinoma. The patient underwent total thyroidectomy. Histologic diagnosis of the thyroid mass was metastatic renal cell carcinoma and further evaluation with chest computed tomography showed two enlarged mediastinal lymph nodes suggesting metastases. The previous history of malignancy should be scrutinized when managing a thyroid mass in patients with a prior or concomitant malignancy, and the possibility of metastasis should be carefully considered.

Adequate Duration of Medical Therapy for Koreans with Graves' Disease / 대한내분비학회지

BACKGROUND: Graves' disease is an organ specific autoimmune disease. Three kinds of therapeutic modalities(antithyroid drugs, ablation with radioactive iodine and subtotal thyroidectomy) are frequently performed for the management of this disease. The most popular therapeutic policy for the disease in Korea is antithyroid treatment. We analysed and compared the remission rates of all three modalities for Graves' disease, and evaluated the antithyroid modality to determine the correct duration of treatment. SUBJECTS AND METHODS: The medical records of 205 patients with Graves' disease were reviewed. For the evaluation of the antithyroid modality medical treatment, antithyroid drugs were administered for more than 1 year. The prognostic factors associated with remission were analysed by means of an ROC curve. RESULTS: 1) Of the 205 patients, proportions that received medical therapy, subtotal thyroidectomy and radioiodine therapy were 83.0, 14.1 and 2.9%, respectively. 2) The remission rates of the medical therapy, surgery and radioiodine therapy were 60.0, 96.5 and 83.0%, respectively. 3) The remission rate of the medical therapy was associated with the duration of medication and TBII activity. The determined proper duration for the antithyroid treatment was 26 months from the ROC curve analysis. CONCLUSION: The above results suggest that the proper duration of antithyroid treatment for Graves' disease is 26 months, after which time the subtotal thyroidectomy or radioiodine therapy should be considered if the disease has not remitted.

The Morphologic Changes of Parvalbumin- Immunoreactive Interneurons of the Dentate Gyrus in Kainate-Treated Mouse Hippocampal Slice Culture Epilepsy Model

PURPOSE: Loss of hippocampal interneurons in dentate gyrus has been reported in patients with severe temporal lobe epilepsy and in animals treated with kainic acid(KA). Interneurons contain Ca2+- binding protein parvalbumin(PV). The effects of kainic acid on parvalbumin-immunoreactive (PV-IR) interneurons in dentate gyrus were investigated in organotypic hippocampal slice cultures. METHODS: Cultured hippocampal slices from postnatal day nine C57/BL6 mice were exposed to 10 muM KA, and were observed at 0, 8, 24, 48, 72 hours after a one hour KA exposure. Neuronal injury was determined by morphologic changes of PV-IR interneuron in dentate gyrus. RESULTS: Transient(1 hour) exposure of hippocampal explant cultures to KA produced marked varicosities in dendrites of PV-IR interneuron in dentate gyrus and the shaft of interbeaded dendrite is often much thinner than those in control. The presence of varicosities in dendrites was reversible with KA washout. The dendrites of KA treated explants were no longer beaded at 8, 24, 48 and 72 hours after KA exposure. The number of cells in PV-IR interneurons in dentate gyrus was decreased at 0, 8 hours after exposure. But there was no significant difference in 24, 48 and 72 hours recovery group compared with control group. CONCLUSIONS: The results suggested that loss of PV-IR interneurons in dentate gyrus is transient, and is not accompanied by PV-IR interneuronal cell death.

A Case with Thyroid Tuberculosis Diagnosed by Non-operative Method / 대한내분비학회지

Tuberculosis of the thyroid gland is extremely rare, with a few surgically removed cases having been reported. The differential diagnosis, from malignancies and other non tuberculous granulomatous lesions, is impossible clinical grounds. We experienced a case of tuberculosis of the thyroid gland with palpable thyroid nodules, in a 23 year-old female patient. She was clinical and biochemically euthyroid. US and CT scans demonstrated a low density mass in the left low lobe of the thyroid gland. An FNAB showed caseous necrosis, and AFB stains demonstrated tuberculosis bacilli. We report a case of tuberculosis of the thyroid gland, diagnosed by a non-operative method.

Augmentation of Regional Cerebral Blood Flow Response by Repeated Administration of Methamphetamine in Rat / 대한정신약물학회지

OBJECTIVES: It was aimed to observe the regional cerebral blood flow (rCBF) response on methamphetamine challenge test in rats which were subjected to repeated administration of methamphetamine, and to investigate the mechanism(s) of changes in rCBF response in relation to the dopaminergic receptors and cyclic AMP. METHODS: Male Sprague-Dawley rats received daily injections of methamphetamine (0.3 mg/kg, i.p.) for 10 days, and were then allowed a 4-day drug-free period. Naive and methamphetamine-pretreated rats were challenged with topical application of methamphetamine on the surface of parietal cortex through a cranial window. The changes in rCBF were measured by laser-Doppler flowmetry. RESULTS: Acute topical application of methamphetamine dose-dependently increased rCBF with little effect on mean arterial blood pressure. The methamphetamine-induced increases in rCBF were significantly blocked by SCH23390, a D1-like receptor antagonist, but not by sulpiride, a D2-like receptor antagonist. Repeated administration of methamphetamine induced progressive augmentation of rCBF in response to the challenge of methamphetamine. Repeated administration of methamphetamine in combination with SKF38393, a D1-like receptor agonist, as well as with SCH23390 significantly attenuated the development of augmentation of rCBF response to methamphetamine. The augmentation of rCBF response was markedly inhibited by pretreatment with 2',3'-dideoxyadenosine, a specific adenylyl cyclase inhibitor, and Rp-cAMPS, a protein kinase A inhibitor, respectively. CONCLUSION: Based on these results, it is suggested that repeated administration of methamphetamine induces an augmentation of rCBF in response to the challenge of methamphetamine, and that D1-like receptor-mediated cyclic AMP plays a critical role in the development of augmentation of methamphetamine-induced rCBF response.

Comparison of the Plasma Concentrations of Nalbuphine after Epidural and Intravenous Administration / 대한마취과학회지

BACKGROUND: Nalbuphine is one of the opioid agonist-antagonists and is used frequently in the anesthetic field. Usage is focused on potent analgesic action and the adjuvant of narcotics because of less complications with preserved analgesia. The most common routes of administration for postoperative pain control are epidural and intravenous, so we compared both pharmacokinetic profiles. METHODS: Twelve patients were randomly divided into two groups. All patients were given a spinal anesthesia with tetracaine hydrochloride. One group (n = 6) received nalbuphine 10 mg via epidural route and another group (n = 6) received the same dose via intravenous route. Venous blood was drawn at 0, 0.25, 0.5, 1, 2, 4, 6 and 8 hours to measure plasma nalbuphine concentrations. Analysis was performed by high performance liquid chromatography with an electrochemical detector. RESULTS: At 0.25 hour, the plasma concentration of nalbuphine was significantly higher in the epidural administration group (49.48 +/- 4.98 ng/ml) than in the intravenous administration group (40.44 +/- 1.64 ng/ml). At 6 and 8 hours, the plasma concentration of nalbuphine was significantly higher in the epidural administration group (5.98 +/- 1.86 ng/ml, 3.85 +/- 0.94 ng/ml) than in the intravenous administration group (3.80 +/- 0.33 ng/ml, 2.43 +/- 0.32 ng/ml). Clearance, elimination half life, volume of distribution and AUC were not significantly different between the two groups. CONCLUSIONS: The plasma concentrations of nalbuphine via epidural route and intravenous route were similar in both groups after 0.25 hour to 6 hours. At 0.25 hour and after 6 hours, the epidural administration group had a higher plasma concentration of nalbuphine than the intravenous administration group.

Clinical Analysis and Comparison of Kawasaki Disease between Patients Younger than One Year of Age and Those over One Year of Age

PURPOSE: To identify the risk factors for coronary sequelae in Kawasaki disease, we analyzed and compared the clinical features and laboratory findings of Kawasaki disease in patients younger than one year of age with those over one year of age. METHODS: A retrospective chart review was conducted of all children with Kawasaki disease who were admitted to the Catholic University Taejon St. Mary's hospital between March 1992 and December 1997. RESULTS: Of 162 patients with Kawasaki disease, 36 patients(22.2%) were less than one year of age and four(11.1%) of them had coronary artery aneurysms. On the other hand, 126 patients (77.8%) were above 12 months and 15(11.9%) of them developed coronary artery aneurysms. The Kawasaki criteria signs were not significantly prominent(P<0.05) and maximal platelet count was higher in the infant group(P<0.05) but other clinical and laboratory findings were not different between the two groups. Comparative studies revealed that maximal platelet count was higher (P<0.05), and total duration of fever was significantly longer in the patients with coronary aneurysms(19 cases, P<0.001) than those without coronary aneurysms(143 cases). CONCLUSION: We cannot find any significant clinical and laboratory differences including coronary artery involvement in Kawasaki disease between less than one year of age and over one year. The age of onset seems not to be a predictor for the risk of coronary aneurysm. The principal signs of Kawasaki disease can be less prominent in infant. For this reason, early diagnosis utilizing laboratory findings are important, especially in the course of illness with prolonged fever.

A Case of Intracoronary Collaterals Misinterpreted as Segmental Stenosis in Kawasaki Disease: Descriptive Method of Coronary Arterial Lesions

Visualization of coronary collaterals in coronary arteriography performed in vivo constitutes an important finding, and particularly in the presence of coronary artery disease, it allows observations related to the hemodynamic consequences of the disease process. Undoubtedly, the presence of collateral flow indicates that a compensatory mechanism has developed to ameliorate the detrimental effect of blood flow cessation due to obstruction of the arterial pathways. By definition, intracoronary collaterals are connections between branches of the same coronary artery. In general, in a coronary arteriogram obtained in vivo, their incidence is lower than that of intercoronary collaterals. We experienced a case of intracollateral circulation, seen extending from the aneurysm through the first segment filled with the right ventricular branch like vessels (OC, Seg 1. CL, intra. Seg 1-2. ANl, Seg 1. CL, inter. Seg 4-8.). Intercollaterals originated from the distal circumflex branch of the left coronary artery, passing through a posterior descending branch and later filled the right ventricular branch of the right coronary artery (OC, Seg 15. LSmd, Seg 6. ANm, Seg 6-7. CL, inter. Seg 15-4.) in a 9-year-old male with Kawasaki disease.