A Comparison of the Short-Term Effects of a Botulinum Toxin Type A and Triamcinolone Acetate Injection on Adhesive Capsulitis of the Shoulder

OBJECTIVE: To evaluate the short-term clinical effects of the intra-articular injection of botulinum toxin type A (BoNT-A) for the treatment of adhesive capsulitis. METHODS: A prospective, controlled trial compared the effects of intra-articular BoNT-A (Dysport; 200 IU, n=15) with the steroid triamcinolone acetate (TA; 20 mg, n=13) in patients suffering from adhesive capsulitis of the shoulder. All patients were evaluated using a Numeric Rating Scale (NRS) of the pain intensity and a measurement of the range of motion (ROM) at baseline (before treatment) and at 2, 4, and 8 weeks post-treatment. RESULTS: The NRS at 2 weeks (BoNT-A vs. TA; 5.0 vs. 5.2), 4 weeks (4.1 vs. 4.9) and 8 weeks (3.8 vs. 4.6) of both treatment groups were significantly lower than that measured at baseline (7.4 vs. 7.6). The ROM of patients' shoulders increased significantly from baseline in both treatment groups. There was no significant difference in the NRS of pain intensity or the ROM between the two groups. Reduction in the pain intensity score was maintained for 8 weeks post-injection in both groups. There were no significant adverse events in either treatment group. CONCLUSION: The results suggest that there are no significant short-term differences between the intra-articular injections of BoNT-A and TA. Although BoNT-A has a high cost, it may be used as a safe alternative of TA to avoid the steroid-induced side effects or as a second-line agent, for patients who have failed to respond to the current treatments.

Myelopathy Caused by Spinal Dural Arterio-Venous Fistula after First Lumbar Vertebral Body Fracture: A Case Report

Spinal dural arteriovenous fistula is a rare vascular lesion of the spinal cord associated with progressive myelopathy. Symptoms include progressive gait dysfunction, weakness, sensory loss, and bowel and bladder dysfunction. Because these symptoms overlap with other common causes of myelopathy and the disease is rare, spinal dural arteriovenous fistula is often not suspected and the time to diagnosis is long. We report the case of a 60-year-old woman who presented with progressive lower limb weakness and gait disturbance diagnosed as spinal dural arteriovenous fistula involving a fractured L1 vertebral body.

The Intra-articular Shoulder Injection of Botulinum Toxin A on Stroke Patients with Complex Regional Pain Syndrome

OBJECTIVE: To evaluate the short-term clinical effects of intra-articular shoulder injection with botulinum toxin type A (BoNT-A) in acute hemiplegic stroke patients with complex regional pain syndrome type I (CRPS I). METHOD: Fifty patients were assigned at random to receive intra-articular shoulder injection. The treatment groups were divided into two groups: BoNT-A group, 200 IU of BoNT-A and 2 ml of normal saline; triamcinolone acetonide (TA) group, 20 mg of triamcinolone and 2 ml of 2% lidocaine. Uptake ratio of quantitative three phase bone scintigraphy (QTPBS) was calculated by dividing the radioactivity count on the affected side by that on the unaffected side. Shoulder pain was assessed by visual analogue scale (VAS) and neuropathic pain scale (NPS). Range of motion (ROM) of shoulder joint and functional independence measurement (FIM) of upper limb were evaluated. All of them were measured before injection, and 4 weeks after injection. RESULTS: After 4 weeks, the uptake ratio of blood pool phase was significantly decreased in hands of BoNT-A group than TA group. VAS, ROM and upper extremity FIM was similarly improved in both groups. Pain intensity and cold pain of NPS were similarly decreased in both groups. Hot pain and dull pain of NPS decreased more significantly in BoNT-A group than TA group. CONCLUSION: In the short-term, intra-articular BoNT-A shoulder injection maybe has the therapeutic effect on acute CRPS I related stroke. And the uptake ratio of blood pool phase of the hand of QTPBS may be useful to assess the therapeutic effect of CRPS after acute stroke.

A Case of Ischemic Angina with Heart Failure due to Congenital Coronary Aterial Anomaly

Coronary artery fistula is an unusual anomaly in elderly patients that consists of a communication bet- ween one of the coronary arteries and other cardiac chambers or veins. It causes many cardiac compli- cations due to hemodynamic changes, and thus has recognized its clinical significance. It occurs usually in congenital origin, but also occurs secondarily in traumatic or neoplastic or artherosclerotic coronary diseases. Congenital coronary artery fistula is a very rare congenital anomaly that results in multiple hemodynamic complications. It has reported rarely in elderly patients, that induces myocardial ischemia due to coronary steal syndrome and heart failure that caused by diastolic volume overload via a left to left shunt. We observed a 68-year-old male patient with exertional chest pain and dyspnea, in whom selective coronary angiography revealed abnormal reticular communication between left anterior descending artery and left circumflex artery and drained to left ventricle through multiple microfistulous channels. We report this patient case who complicated by myocardial ischemia and left ventricular failure those caused by hemodynamic complication due to multiple coronary artery-left ventricular fistulae.

A Case of Ischemic Angina with Heart Failure due to Congenital Coronary Aterial Anomaly

Coronary artery fistula is an unusual anomaly in elderly patients that consists of a communication bet- ween one of the coronary arteries and other cardiac chambers or veins. It causes many cardiac compli- cations due to hemodynamic changes, and thus has recognized its clinical significance. It occurs usually in congenital origin, but also occurs secondarily in traumatic or neoplastic or artherosclerotic coronary diseases. Congenital coronary artery fistula is a very rare congenital anomaly that results in multiple hemodynamic complications. It has reported rarely in elderly patients, that induces myocardial ischemia due to coronary steal syndrome and heart failure that caused by diastolic volume overload via a left to left shunt. We observed a 68-year-old male patient with exertional chest pain and dyspnea, in whom selective coronary angiography revealed abnormal reticular communication between left anterior descending artery and left circumflex artery and drained to left ventricle through multiple microfistulous channels. We report this patient case who complicated by myocardial ischemia and left ventricular failure those caused by hemodynamic complication due to multiple coronary artery-left ventricular fistulae.

A Case of Early Gastric Cancer with IgA Nephropathy in the Elderly Patient

IgA nephropathy is the most common form of glomerulonephritis characterized by deposit of IgA on mesangium. We experienced an elderly patient who was admitted for generalized edema, and diagnosed IgA nephropathy and early gastric cancer concomittantly. It has been reported that the incidence of nephrotic syndrome combined with malignancy increases with aging. Moreover, close relationship between IgA nephropathy and malignancy has been reported especially in the elderly patient. So, active investigations for possible malignancy are required in case of elderly patient with IgA nephropathy. In this case, we found improved proteinuria and hematuria of the patient after tumor resection during following up. This case suggest causal association between early gastric cancer and IgA nephropathy clinically.

Assessment of Left Ventricular Diastolic functions in Elderly Patients with Pulmonary congestion and in Asymptomatic Elders

BACKGROUND: The recent studies shows that LV relaxation abnormalities are the important factors of heart failure in elders. To determine the association between LV diastolic functions and heart failure, we assessed LV diastolic functions in elderly patients with pulmonary congestion and in asymptomatic elders by using pulsed doppler echocardiography. METHODS: In order to assess LV diastolic function, we performed pulsed doppler echocardiography to elderly patients with pulmonary congestion and asymptomatic elders from Mar.2001 to Sep.2001. The following parameters were used as indices of LV diastolic function; Mitral E wave(E), Mitral A wave(A), Deceleration time(DT), Isovolumic relaxation time(IVRT), Systolic pulmonary venous flow(PVs), Diastolic pulmonary venous flow(PVd). RESULTS: In elderly patients groups, there was significant increase in deceleration time compared with asymptomatic elders(255.83+/-54.41 vs 210.80+/-48.53, p<0.05). There was significant increase in isovolumic relaxation time in elderly patient group compared with asymptomatic elders(123.06+/-25.07 vs 98.78+/-15.12, p<0.01). Although there was no significant difference, decreased E/A ratio and increased PVs/PVd were noted in both groups. CONCLUSIONS: The results shows that the impairments of LV diastolic function were noted in both groups. Especially DT and JVRT were significant increase in elderly patient group with pulmonary congestion. Therefore these parameters, such as DT, IVRT, can be helpful as predictive indices of diastolic heart failure in elders.

Comparison of Left Ventricular Diastolic dysfunctions in Chronic Renal Failure(CRF) Patients and in Elderly Patients

BACKGROUND: We consider that heart failure in elderly and Chronic renal failure patients is closely related to LV diastolic dysfunction. To determine the association between LV diastolic functions and heart failure, we assessed LV diastolic functions in elderly patients with pulmonary congestion and in Chronic renal failure patients by using pulsed doppler echocardiography. METHODS: In order to assess LV diastolic function, we performed pulsed doppler echocardiography on elderly patients with pulmonary congestion and Chronic Renal Failure patients from Nov; 2000 to June; 2001. The following parameters were used as indices of LV diastolic function; Mitral E wave(E), Mitral A wave(A), F/A ratio, Deceleration time(DT), Isovolumic relaxation time(IVRT), Systolic pulmonary venous flow(PVs), Diastolic pulmonary venous flow(PVd), PVs/PVd ratio. RESULTS: In elderly patients groups with pulmonary congestion, there was significant decreased in E/A ratio compared with CRF patients(0.693+/-0.18 vs 0.905+/-0.116, p<0.01). There was significant increase in deceleration time and isovolumic relaxation time in elderly patients with pulmonary congestion compared with CRF patients(DT 255.83+/-54.41 vs 210.80+/-48.53 p<0.05, IVRT; 123.06+/-26.07 vs 98.75+/-15.12, p<0.01). Although there was no significant difference, increased PVs/PVd ratio was noted in both groups. CONCLUSIONS: The results shows that the impairments of LV diastolic function were noted in both groups. Especially F/A ratio was significant decreased elderly patient group with pulmonary congestion and DT, IVRT were significant increase in elderly patient group with pulmonary congestion. Therefore Left ventricular relaxation is progressively impaired in old age and impaired LV relaxation results in in LV diastolic dysfunction But LV hypertrophy in ESRD patients results in LV diastolic dysfunction.

A Case of Severe Cough-induced Abdominal Wall Hematoma / 결핵

Severe cough may contribute to serous coplications such as pneumothorax, pneumomediastinum, rib fracture, subconjunctival hemorrhage, subdural hemorrhage and cough syncope. However abdominal wall hematoma is a rare complication. Because it usually presents with abdmoianal pain, abdominal wall hematoma needs to be differentiated from the acute surgical abdomen. A 78-year-old woman was admitted with right lower quadrant abdominal pain and a palpable mass for several days. She experienced abdominal pain after violent coughing associated with an upper respiratory tract in fection. Abdominal computed tomography revealed an approximately 7×4 cm sized, ill-defined, soft tissue density lesion in the right lower posterolateral abdominal wall. An abdominal wall hematoma was diagnosed. After admission, she had persistent right lower abdominal pain and an increasing mass. The mass was surgically removed and she was discharged without complications. In summary, when a patient complains of abdmonial pain after severe coughing, an abdominal wall hematomas as a differential diagnosis must be considered.