Risk of Subsequent Events in Patients With Minor Ischemic Stroke or HighRisk Transient Ischemic Attack

This study aimed to present the prognosis after minor acute ischemic stroke (AIS) or transient ischemic attack (TIA), using a definition of subsequent stroke in accordance with recent clinical trials. In total, 9,506 patients with minor AIS (National Institutes of Health Stroke Scale ≤ 5) or high-risk TIA (acute lesions or ≥ 50% cerebral artery steno-occlusion) admitted between November 2010 and October 2013 were included. The primary outcome was the composite of stroke (progression of initial event or a subsequent event) and all-cause mortality. The cumulative incidence of stroke or death was 11.2% at 1 month, 13.3% at 3 months and 16.7% at 1 year. Incidence rate of stroke or death in the first month was 12.5 per 100 person-months: highest in patients with large artery atherosclerosis (17.0). The risk of subsequent events shortly after a minor AIS or high-risk TIA was substantial, particularly in patients with large artery atherosclerosis.

The Long-term Effects of Prostaglandin Analogues on Central Corneal Thickness and Intraocular Pressure

Purpose@#To evaluate the long-term effect of 0.005% latanoprost (LA) and 0.0015% tafluprost (TA) on intraocular pressure (IOP) and central corneal thickness (CCT) in glaucoma patients. @*Methods@#This study was a retrospective study, which enrolled open-angle glaucoma (OAG) patients treated with one of two prostaglandin analogues. The patients were observed for at least three years and underwent corneal thickness measurements at least once a year. Patients with a history of ocular surgery except cataract surgery or another glaucoma medication during the follow-up were excluded. Goldmann applanation tonometry and specular microscopy were used to measure the IOP and CCT, respectively. Changes in IOP and CCT were compared between the two groups. @*Results@#A total of 55 OAG patients (110 eyes) were enrolled. The patients were divided into two groups; one group (50 eyes) used LA as anti-glaucoma eye drops, and the other group (60 eyes) used TA. Statistically significant reductions in IOP and CCT were observed in both groups. The mean reduction in IOP over a three year period was -2.18 ± 2.83 mmHg in the LA group and -2.08 ± 2.40 mmHg in the TA group (paired t-test, p < 0.001, for both). In terms of CCT, the mean reduction was -20.24 ± 22.92 μm in the LA group and -32.90 ± 32.04 μm in the TA group (paired t-test, p < 0.001, for both) for three years. The decrease in CCT was not significantly different between the two groups (p = 0.061). There was no significant difference in the IOP reduction between the two drugs nor was there a significant correlation between the IOP and the CCT. @*Conclusions@#This study indicated that 0.005% LA and 0.0015% TA had similar effects on the reduction of IOP and CCT for three years without damaging the corneal endothelium.

History-indicated cerclage: the association between previous preterm history and cerclage outcome

OBJECTIVE: Our hospital's policy is to perform history-indicated cerclage (HIC) for pregnant patients with 1 or more second-trimester pregnancy losses. Recently, the American College of Obstetricians and Gynecologists (ACOG) guideline regarding indications for HIC was changed from 3 or more previous second-trimester fetal losses to one or more. In this study, we aimed to evaluate the efficacy of the revised guideline and to investigate the association between previous preterm history and cerclage outcome. METHODS: We conducted a retrospective observational study of cases of HIC in singleton pregnancies performed at our hospital between January 2007 and June 2016. We compared the perioperative complications and incidences of preterm delivery in patients with one previous second-trimester pregnancy loss against those in patients with ≥2 losses. RESULTS: The incidence of preterm delivery (< 32 weeks) was significantly lower in patients with one previous second-trimester pregnancy loss than in those with ≥2 losses (15/194 [8%] vs. 28/205 [14%]). In the 1 loss and ≥2 losses groups, the rates of preterm premature rupture of membranes (PPROM) were 7% and 8%, the rates of PPROM at < 32 weeks 2.1% and 3.4%, and the ratios of neonatal intensive care unit admission 10% and 17%, respectively. CONCLUSION: Comparison of HIC in one previous second-trimester pregnancy loss group with HIC in the 2 or more previous second-trimester pregnancy loss group found no difference in pregnancy outcome. This finding supports the amended ACOG guideline for HIC indications. Based on our results, we also propose development of a new protocol for HIC-related complications.

Preoperative and postoperative serum C-reactive protein levels to predict the outcome of ultrasound-indicated cerclage

OBJECTIVE: To assess the role of preoperative and postoperative serum C-reactive protein (CRP) level on the prediction of pregnancy outcomes following ultrasound-indicated cerclage (UIC). METHODS: We retrospectively reviewed the medical records 44 women who underwent UIC between January 2011 and December 2011. UIC was performed between 14 and 24 weeks of gestation in women with short cervix. We divided UIC patients into two groups according to the gestational age at delivery (34 weeks) and compared the two groups. Group A was defined as patients who delivered ≥34 weeks of gestation, and group B as patients delivered <34 weeks. Correlation and receiver-operating characteristic curves were also analyzed for the prediction of preterm birth after UIC. RESULTS: Thirty women delivered ≥34 weeks (group A) and 14 women delivered <34 weeks (group B). Pre- and post-cerclage CRP were significantly lower in group A (pre-cerclage CRP, 1.1±1.0 vs. 11.4±6.2 mg/dL, P<0.001; post-cerclage CRP, 0.6±0.5 vs. 7.4±7.2 mg/dL, P<0.001). The mean gestational age at delivery in group A was 37.7±1.8 weeks and that in group B was 26.9±4.3 weeks (P<0.001). There were significant negative correlations between pre- and post-cerclage CRP and latency from UIC to delivery (r=-0.82, P<0.001; r=-0.70, P<0.001, respectively). CONCLUSION: Both pre- and post-cerclage CRP were useful in predicting the preterm birth following UIC.

Cardiac Involvement of Churg-Strauss Syndrome as a Reversible Cause of Dilated Cardiomyopathy

A 31-year-old male who had been treated for Churg-Strauss syndrome (CSS) presented with sudden onset of dysarthria. Brain magnetic resonance imaging (MRI) showed acute multifocal bilateral cerebral infarctions suggesting embolic causes. Cardiac MRI showed dilated cardiomyopathy with severe biventricular dysfunction with intracardiac thrombi, and multiple high signal intensity spots in myocardium of the left ventricle with multifocal delayed enhancement suggesting multifocal myocarditis due to small vessel vasculitis associated with CSS. After anticoagulation therapy, treatments for heart failure, and immunosuppressive therapy including parenteral steroids and cyclophosphamide to control CSS, the symptoms and signs of heart failure and cardiac function of the patient were improved. Considering the pathophysiologic mechanism of cardiac involvement in CSS, immunosuppressive therapy to control the disease activity of CSS should be taken into account, besides usual management for heart failure.

Stress Cardiomyopathy due to Misuse of Transdermal Fentanyl Patches in an Elderly Patient

Stress cardiomyopathy is characterized by transient systolic dysfunction of the apical and/or mid segment of the left ventricle. The main pathophysiology of stress cardiomyopathy is the excessive release of catecholamine. Opioid withdrawal can initiate a surge of catecholamine and an attack of stress cardiomyopathy. In this case, we report a case of stress cardiomyopathy due to iatrogenic withdrawal from transdermal fentanyl.

The safety of cesarean myomectomy in women with large myomas

OBJECTIVE: To evaluate the safety of cesarean myomectomy in large myomas sized >5 cm. METHODS: One hundred sixty-five pregnant women with myomas who delivered via cesarean section were identified. Ninety-six women had cesarean section without myomectomy, and 65 women underwent cesarean myomectomy. We compared the maternal characteristics, neonatal weight, myoma types, and operative outcomes between two groups. We further analyzed cesarean myomectomy group according to myoma size. The large myoma was defined as myoma >5 cm in size. The maternal characteristics, neonatal weight, and myoma types were compared between two groups. We also compared the operative outcomes such as preoperative and postoperative hemoglobin, operative time, and hospitalized days between two groups. RESULTS: There were no significant differences in the maternal characteristics, myoma types, neonatal weight and operative outcomes between cesarean section without myomectomy and cesarean myomectomy. The subgroup analysis according to myoma size (>5 cm or not) in cesarean myomectomy group revealed that there were no significant differences in the mean hemoglobin change (1.2 vs. 1.3 mg/dL, P=0.6), operative time (90.5 vs. 93.1 minutes, P=0.46), and the length of hospital stay (4.7 vs. 5.2 days, P=0.15) between two groups. The comparison of maternal characteristics, neonatal weight, and myoma types between two groups also showed no statistical significance. CONCLUSION: Cesarean myomectomy in patients with large myomas is a safe and effective procedure.

Developed diplopia and ptosis due to a nonfunctioning pituitary macroadenoma during pregnancy

Physiologic pituitary enlargement is common during normal pregnancy. However, symptoms such as diplopia, blurred vision and headache resulting from physiologic pituitary enlargement are very rare during pregnancy. A 39-year-old woman complained of sudden diplopia and left eye ptosis at 33th weeks of gestation. An magnetic resonance imaging (MRI) demonstrated the pituitary enlargement compressing the optic chiasm. Notwithstanding the medication of bromocriptine, her symptoms did not regress during pregnancy. At 5 months after delivery, her symptoms dramatically resolved without any surgery, and her visual acuity was normalized. Her MRI scan also revealed more decreased size of pituitary gland compared to antenatal MRI. We report a case of visual loss due to the physiologic pituitary enlargement of nonfunctioning adenoma during pregnancy, which regressed spontaneously after delivery without any surgery.

Comparison of Coronary Plaque and Stenosis Between Coronary Computed Tomography Angiography and Virtual Histology-Intravascular Ultrasound in Asymptomatic Patients with Risk Factors for Coronary Artery Disease

OBJECTIVES: The purpose of the study was to compare plaque characteristics by coronary computed tomography angiography (CCTA) with those by virtual histology-intravascular ultrasound (VH-IVUS). METHODS: We enrolled 50 asymptomatic patients with diabetes mellitus or more than two risk factors for coronary artery disease such as hypertension, smoking, and hyperlipidemia. If the patient had a coronary lesion (plaque with more than 50% stenosis or calcium score more than 100), we recommended coronary angiography and VH-IVUS and compared CCTA findings with VH-IVUS findings. RESULTS: 35 patients (70%) had coronary lesions, and we performed both CCTA and VH-IVUS in 23 patients. All 23 patients had multiple risk factors, and the majority of target lesions were located at left anterior descending artery (73.9%), and calcium score of lesion site was 106+/-162 with plaque volume of 232+/-153 mm3 by CCTA. Calcium score of lesion site was significantly greater in diabetic patients (n=14) than non-diabetic patients (n=9) (118+/-159 vs. 88+/-175, p=0.038). By VH-IVUS, plaque volume was 174+/-127 mm3, absolute necrotic core (NC) volume was 22+/-21 mm3, and relative NC volume was 20.8+/-8.7%. Absolute dense calcium (DC) volume and absolute NC volumes were significantly greater in diabetic patients than non-diabetic patients (11.5+/-13.8 mm3 vs. 9.1+/-11.0 mm3, p=0.028, and 23.9+/-24.7 mm3 vs. 18.1+/-14.3 mm3, p=0.035, respectively). Plaque volume by CCTA correlated with that of VH-IVUS (r=0.742, p<0.001), and plaque volume by CCTA correlated with absolute NC volume by VH-IVUS (r=0.621, p<0.001), and calcium score of lesion site by CCTA correlated with absolute dense calcium volume by VH-IVUS (r=0.478, p=0.028). CONCLUSION: Coronary lesion was detected by CCTA in 70% of asymptomatic patients with multiple coronary risk factors, and parameters detected by CCTA correlated well with those detected by VH-IVUS.

Progressive Dilation of the Left Atrium and Ventricle after Acute Myocardial Infarction Is Associated with High Mortality

BACKGROUND AND OBJECTIVES: The purpose of this study is to identify the prevalence of progressive dilation in patients with acute myocardial infarction (AMI) combined with heart failure (HF) and determine the prognostic significance and associated factors with a geometric change of an infarcted heart. SUBJECTS AND METHODS: A total of 1310 AMI patients with HF (63.9+/-12.5 years, 70% male) between November 2005 and April 2011 underwent echocardiography at admission and one year later. Left ventricular (LV) remodeling is defined as 20% progression, and left atria (LA) remodeling is 10% compared with the initial volume index. RESULTS: The prevalence of both LA and LV remodeling was 13.9%; LV only was 9.3%, LA only 22.8% and non-remodeling was 55.1%, respectively. In the non-remodeling group, Killip class II was more frequent (83.9%, p<0.001) whereas in other remodeling groups, Killip class III was more frequent. Initial wall motion score index, ejection fraction, maximal cardiac enzyme, high sensitive C-reactive protein, B type natriuretic peptide, and triglyceride serum levels were significantly associated with heart remodeling. All causes of death occurred in 168 cases (12.8%) during the follow-up period. Mortality was the highest in the LV and LA remodeling group (20.9%) and the lowest in the non-remodeling group (11.4%). During the period of follow-up, the cumulative survival rate was significantly lower in the groups of LA and LV remodeling than in others (log rank p=0.006). CONCLUSION: Total mortality was significantly increased in patients AMI with geometrically progressive LA and LV dilatation.

Comparison of clinical effects according to dosage of fentanyl added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean section

BACKGROUND: Spinal anesthesia for cesarean section is widely used technique for rapid induction, high success rate and excellent intraoperative and postoperative analgesia. Potentiating the effect of intrathecal local anesthetics by addition of opioid for cesarean section is well known. In this study, we compared the clinical effects when different doses of fentanyl were combined with intrathecal hyperbaric bupivacaine. METHODS: Ninety six healthy term parturients were randomly divided into four groups: Group C (control), : Group F10 (fentanyl 10 microg), : Group F15 (fentanyl 15 microg), F: Group F20 (fentanyl 20 microg). In every group, 0.5% heavy bupivacaine was added according to the adjusted dose regimen. We observed the maximal level of the sensory block and motor block, the quality of intraoperative analgesia, the duration of effective analgesia and the side effects. RESULTS: There were no significant differences between four groups in maximal level and recovery rate of sensory and motor block. Quality of intraopertive analgesia and muscle relaxation was increasing by increasing dosage of intrathecal opioids. Duration of effective analgesia was significantly prolonged in Group F15 and F20 than Group C and F10, but there were no differences between Group F15 and F20. And the frequencies of side effects such as hypotension, max sedation level were increasing by increasing dosage of intrathecal opioids. The Apgar scores were normal, and there were no differences between the four groups. CONCLUSIONS: The addition of fentanyl 15 microg for spinal anesthesia provides adequate intraoperative analgesia and good postoperative analgesia without significant adverse effects.

Abrupt formation of intracardiac thrombus during cardiopulmonary bypass with full heparinization: A case report / 대한마취과학회지

Intracardiac thrombus during cardiopulmonary bypass (CPB) with full heparinization is very rare but fatal. A 60-year-old woman was scheduled for aortic and mitral valve repairs with a maze procedure for mixed aortic and mitral valvular heart disease with atrial fibrillation. Preoperative transthoracic echocardiography and cardiac computed tomography showed moderate aortic regurgitation and moderate mitral stenosis with regurgitation. There was no intracardiac thrombus. Aortic and mitral valve repairs with the maze procedure were successfully performed without unexpected events. During CPB weaning, a mobile hyper-echogenic mass in the left atrium was detected on transesophageal echocardiography. After cardiac arrest, it was surgically removed. On completion of the operation, weaning from CPB was accomplished uneventfully. The patient fully recovered and was discharged from the intensive care unit on her third postoperative day.

Incidental ipsilateral subclavian vein catheterization via right internal jugular venous route: A case report

Central venous catheterization is frequently performed for perioperative management and intravenous access. However, the complications of central venous catheterization are numerous and include malposition, pneumothorax, hemothorax, chylothorax, thrombosis, extravasation of the infusate and infection. Although the malpositioning of the central venous catheter has been widely reported, there are few reports of ipsilateral subclavian vein catheterization via the right internal jugular venous route. In this case, we describe a misplacement of a right internal venous catheterization into the ipsilateral subclavian vein and suggest the possible causative factors.

A Case of Cryptogenic Stroke Associated with Patent Foramen Ovale Coexisting with Pulmonary Embolisms, Deep Vein Thromboses, and Renal Artery Infarctions

A paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt, and is commonly related to patent foramen ovale (PFO). However, coexisting pulmonary embolisms, deep vein thromboses (DVT), and multipe systemic arterial embolisms, associated with PFO, are rare. Here, we report a patient who had a cryptogenic ischemic stroke, associated with PFO, which is complicated with a massive pulmonary thromboembolism, DVT, and renal infarctions, and subsequently, the patient was treated using a thrombolytic therapy.

General anesthesia for cesarean section in a patient with multiple sclerosis: A case report

A 34-year-old female with multiple sclerosis (MS) was scheduled Cesarean section. She had been suffering from MS for 10 years and the symptoms of MS were paraplegia and urinary incontinence. After informed consent, anesthesia was induced with propofol and maintained with nitrous oxide, sevoflurane and fentanyl. Rocuronium was used for muscle relaxation and tracheal intubation. Train of four (TOF) ratio and bispectral index scale were monitored for adequate muscle relaxation and depth of anesthesia. She gave birth to a baby within 7 minutes after skin incision. When operation was over, TOF ratio was 0.8. She emerged from general anesthesia smoothly and was extubated. There was no febrile event or exacerbation of MS after Cesarean section under general anesthesia. We report a safe anesthetic management of the parturient with MS, using sevoflurane.

Reversible Splenial Lesion in a Patient With Acute Alcohol Intoxication

No abstract available.

A Case of Vancomycin Resistant Enterococcal Urinary Tract Infection and Pseudomembranous Colitis Co-Infection / 대한신장학회지

Infections are the second leading cause of mortality among patients with end-stage renal disease (ESRD). Recently, colonization or infection with vancomycin-resistant enterococci (VRE) is increasing in prevalence at many institutions and is often reported in dialysis patients. Enterococci are generally considered to be of low pathogenicity but may cause urinary tract infection, bacteremia, endocarditis or meningitis in debilitated patients. Three cases of VRE peritonitis in patients on CAPD were reported, but there was no report of VRE urinary tract infection (UTI) in hemodialysis patients in Korea. We present a case of VRE UTI with pseudomembranous colitis (PMC) in an ESRD patient with anal VRE colonization. The VRE UTI was treated successfully with linezolid.

A Case of Severe Acute Renal Failure Due to Sodium Bromate Intoxication / 대한신장학회지

Bromate is an oxidizing agent used as a permanent wave neutralizer. Accidental or deliberate ingestion of bromate has rarely been reported, but is potentially severe. We report a 36-year-old female hairdresser, who was admitted due to nausea and vomiting after ingestion of sodium bromate. The patient was successfully treated with hemodialysis therapy and renal function recovered without any complication. The clinicians must remember that early therapeutic measures, including hemodialysis, should be taken as soon as possible to prevent irreversible hearing loss and renal failure.

A Case of Adult Minimal Change Nephrotic Syndrome Associated with Thin Basement Membrane Nephropathy / 대한신장학회지

Thin basement membrane nephropathy (TBMN) is characterized by persistent hematuria, mild proteinuria, normal renal function and family history of hematuria. Many studies report that TBMN commonly occurs together with other glomerular diseases such as minimal change nephrotic syndrome, membranous nephropathy, IgA nephropathy and focal segmental glomerulosclerosis. Especially, the case of TBMN with minimal change nephrotic syndrome has been rare. We report a case of adult minimal change nephrotic syndrome with TBMN in a 44-year-old female with general edema and microscopic hematuria. On renal biopsy, electron microscopic examination demonstrated diffuse thinning of glomerular basement membrane with the thickness less than 250nm and diffuse foot process effacement. Treatment with corticosteroid resulted in complete remission of proteinuria.

Pulmonary thromboembolism after tourniquet inflation under spinal anesthesia: A case report / 대한마취과학회지

Pulmonary thromboembolism is one of the most important causes of morbidity and mortality in patients undergoing lower extremity orthopedic surgery. Early diagnosis and appropriate management are important clinical challenges. In this case, massive pulmonary embolism causing sudden cardiac arrest was attributed to use of tourniquet inflation during lower extremity orthopedic surgery. Resuscitation procedures were initiated and transesophageal echocardiography revealed pulmonary thromboembolism. Patients with high suspicion for the presence of deep vein thrombus must be monitored thoroughly during limb exsanguinations.