Spontaneous Intracranial Hypotension Complicated by Cerebral Venous Thrombosis Relieved by Epidural Blood Patch

Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache, diffuse dural thickening, and enhancement in magnetic resonance imaging. Cerebral venous thrombosis (CVT) has been reported to be a rare complication of SIH. There is no consensus in anticoagulation treatment of CVT secondarily caused by SIH. We report a female patient with SIH complicated by CVT and spontaneously regressed CVT not by anticoagulation but by epidural blood patch.

Frontal Sinusitis Presenting as Cluster-Like Headache

No abstract available.

Altered Regional Cerebral Blood Flow Associated with Mood and Sleep in Shift Workers: Cerebral Perfusion Magnetic Resonance Imaging Study

BACKGROUND AND PURPOSE: Shift work disrupts the body's circadian rhythms and increases the risk of health problems. Despite evidence of neuropsychological disturbances in shift workers (SW), the brain functional status as measured by brain perfusion in chronic shift work has not been evaluated previously. We investigated the regional cerebral blood flow (rCBF) in SW using perfusion MRI (pMRI) and evaluated the relationships between altered rCBF and sleep, mood, psychometric measures, and quality of life. METHODS: Fifteen rotational SW and 15 day workers (DW) were enrolled. The participants were all female nurses working at a university-affiliated hospital. During 2 weeks of actigraphy they underwent pMRI scanning and psychometric testing on the last day immediately after working. Demographic characteristics, insomnia, daytime sleepiness, and mood were compared between the groups. RESULTS: The participants were aged 35.3±2.9 years (mean±SD) and had been performing their current work for more than 2 years. The demographic characteristics did not differ between SW and DW, but the levels of insomnia, anxiety, depression, and hyperactivity-restlessness in psychometric measures were higher in SW than in DW. Cerebral perfusion in SW was significantly decreased in the cuneus, fusiform/parahippocampal gyri, and cerebellum of the right hemisphere, while it was increased in the inferior occipital gyrus of the left hemisphere. Perfusion changes in SW were significantly correlated with depression and insomnia severity. The onset and duration irregularity of sleep among SW were related to insomnia, mood, hyperactivity/ restlessness, and quality of life. CONCLUSIONS: SW experience considerably more insomnia and mood disturbances than do DW, and this is significantly related to perfusion changes in multiple brain areas.

Is the Presence of Headache Indispensable in Diagnosing Reversible Cerebral Vasoconstriction Syndrome?

No abstract available.

Sleep Onset Insomnia and Depression Discourage Patients from Using Positive Airway Pressure

OBJECTIVES: Despite the accumulating evidence of the effectiveness of positive airway pressure (PAP) therapy in obstructive sleep apnea (OSA) syndrome, adherence to PAP therapy is not high. Several factors reportedly affect PAP adherence; however, it remains unclear whether patients' symptoms were detrimental to adherence rate. This study is aimed at investigating the relationship between insomnia symptoms and adherence. METHODS: Retrospective analyses were performed in 359 patients with OSA (mean age 58.4±13.2 years; females, n=80). Logistic regression analyses were performed between PAP adherence with clinical factors and questionnaires, such as Epworth Sleepiness Scale, Insomnia Severity Index, and Beck Depression Inventory (BDI). RESULTS: PAP adherence was defined as the use of PAP for ≥4 h per night on 70% of nights during 30 consecutive days. The median follow-up time was 55 days (interquartile range, 30–119 days), and 54.3% showed poor adherence. Non-adherent patients showed more severe sleep onset insomnia, higher BDI, and higher nadir oxygen saturation (SaO₂). Patients with good adherence had higher apnea–hypopnea index, oxygen desaturation index, and respiratory arousal to total arousal ratio. Sleep onset insomnia [odds ratio (OR)=1.792, p=0.012], BDI (OR = 1.055, p=0.026), and nadir SaO₂ (OR=1.043, p=0.040) were independently associated with PAP non-adherence. CONCLUSIONS: Not the severity of insomnia but sleep onset insomnia was associated with PAP adherence, as well as depressive mood. It suggests that different interventions for reducing insomnia and depressive mood are needed to increase PAP adherence in patients with OSA.

Phenylephrine Induced Posterior Reversible Encephalopathy Syndrome during Resection of Solitary Pulmonary Nodule

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a neurological complication caused by cerebral hyperperfusion. CASE REPORT: A 46-year-old male presented with decreased mental status, left facial palsy, and left-sided weakness after video-assisted thoracoscopic surgery for a solitary pulmonary nodule. During the surgery, phenylephrine was infused intravenously for general anesthesia-induced hypotension. High signal intensity at the right parietooccipital lobe was noted on fluid-attenuated inversion recovering imaging and diffusion-weighted imaging. His neurological symptoms improved two days after initial presentation. Follow-up diffusion-weighted imaging showed resolution of the brain lesions 10 days after the surgery. CONCLUSIONS: We report a patient who presented with PRES after administration of phenylephrine during resection of a solitary pulmonary nodule. PRES should be considered for patients presented with acute neurologic symptoms following surgical procedures.

Lack of Association of Clinical Factors (SAMe-TT2R2) with CYP2C9/VKORC1 Genotype and Anticoagulation Control Quality / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Advantages of new oral anticoagulations may be greater in atrial fibrillation (AF) patients of poor anticoagulation control with warfarin. The SAMe-TT2R2 scoring system, based on clinical variables, was recently developed to aid in identifying these patients. In this study, we investigated the association of this clinical composite score with genetic factors related warfarin dosing and the quality of anticoagulation control. METHODS: Clinical and genetic data were collected from 380 consecutive Korean patients with AF (CHA2DS2-VASc score, 3.5+/-1.8) who were followed for an average of 4 years. We evaluated factors associated with time in therapeutic range (TTR, INR 2-3), including the CYP2C9 and VKORC1 genotypes and the SAMe-TT2R2 score (Sex female, Age two co-morbidities], Treatment [interacting drugs, e.g., amiodarone], Tobacco use within 2 years [doubled], and Race non-white [doubled]). RESULTS: The average SAMe-TT2R2 score was 3.4+/-0.9, range 2-7; and 153 patients (40.2%) had SAMe-TT2R2 scores > or =4. Time in specific INR ranges varied depending on the VKORC1 genotype but not with the CYP2C9 genotype or the SAMe-TT2R2 score. TTR was higher in patients with the VKORC1 1173C>T than in VKORC1 TT (61.7+/-16% vs. 56.7+/-17.4%, P=0.031). Multivariate testing showed that VKORC1 genotype but not the SAMe-TT2R2 score was significantly associated with labile INRs. There was no correlation between the SAMe-TT2R2 scores and pharmacogenetic data. CONCLUSIONS: A genetic factor, but none of the common clinical and demographic factors, as combined in the SAMe-TT2R2 score, was associated with the quality of anticoagulation control in Korean patients with AF.

Different Strategies for Transpancreatic Septotomy and Needle Knife Infundibulotomy Due to the Presence of Unintended Pancreatic Cannulation in Difficult Biliary Cannulation

BACKGROUND/AIMS: Several precut techniques have been used to gain biliary access for difficult cases. The aim of this study was to evaluate the success and complication rates of two precut techniques, transpancreatic septotomy (TPS) and needle knife infundibulotomy (NKI), in difficult biliary cannulation due to the presence of unintended pancreatic cannulation. METHODS: Eighty-six patients who failed standard biliary cannulation were included. TPS was performed when we failed to achieve biliary access despite 5 minutes of attempted cannulation or when more than three attempted unintended pancreatic cannulations occurred. If deep cannulation was not achieved within 5 minutes for any duct, NKI was performed. If this failed, we crossed over to the other technique in the second attempt. RESULTS: The initial total success rate of biliary cannulation was 88.4% (86.6% for the TPS group and 94.7% for the NKI group, p=0.447). After crossover of the techniques, the final success rate was 95.3%. The complication rate was 20.9% in patients with TPS and 15.8% in patients with NKI (p=0.753). CONCLUSIONS: The use of different strategies based on the presence of unintended pancreatic cannulation may help increase the success rate for difficult biliary cannulation without increasing complication rates.

Spontaneous Pneumomediastinum, Pneumopericardium, and Pneumothorax with Respiratory Failure in a Patient with AIDS and Pneumocystis jirovecii Pneumonia

Spontaneous pneumothorax occurs in up to 35% of patients with Pneumocystis jirovecii pneumonia. However, spontaneous pneumomediastinum and pneumopericardium are uncommon complications in patients infected with human immunodeficiency virus, with no reported incidence rates, even among patients with acquired immunodeficiency syndrome (AIDS) and P. jirovecii pneumonia. We report a case of spontaneous pneumomediastinum, pneumopericardium, and pneumothorax with respiratory failure during treatment of P. jirovecii pneumonia in a patient with AIDS; the P. jirovecii infection was confirmed by performing methenamine silver staining of bronchoalveolar lavage specimens. This case suggests that spontaneous pneumomediastinum and pneumopericardium should be considered in patients with AIDS and P. jirovecii pneumonia.

An Adult Moyamoya Disease Confirmed by Ring Finger Protein 213 Gene Test and Radiological Studies

A 63-year-old female complained of transient dysarthria. MRA was conducted to evaluate this symptom, revealing distal internal carotid artery occlusion with collateral vessel development, suggesting Moyamoya disease, which had not been detected in MRA performed 5 years previously. Vascular risk factors and laboratory findings suggested no cardiac or autoimmune diseases. The diameter of stenosis of the middle cerebral artery on high-resolution MRI was 2.11 mm, and genetic evaluation revealed mutation of the gene encoding ring finger protein 213 (RNF213). High-resolution MRI and gene studies are useful for distinguishing between Moyamoya disease and atherosclerosis.

A Case of Three Consecutive Events of Acute Myocardial Infarctions in Three Different Vessels

A 51-year-old man was being admitted to the emergency department with chest pains. He had a history of acute myocardial infarction (MI) on two prior occasions and was successfully treated with drug eluting stents. He was diagnosed with 3 consecutive events of acute MI in 3 different vessels. The consecutive events of acute MI in different vessels are a very rare case. He did not have risk factors, such as coagulation abnormality, clopidogrel resistance, patient's compliance and vessel abnormality, except for his cigarette smoking. We reported the first case with 3 consecutive events of acute MI in each 3 vessels during a long-term interval.

Cytomegalovirus Induced Interstitial Nephritis and Ureteral Stenosis in Renal Transplant Recipient

No abstract available.

Hospital Triage System in Mass Casualty Incident

PURPOSE: Effective triage at the emergency department entrance is the key to dealing with mass casualty incidents. However, in Korea, triage has been accomplished at the disaster scene or at the hospital in only a few cases. Thus, we report on the planning and preparation for triage at Asan Medical Center (AMC) for mass casualty incidents. METHODS: We review the AMC disaster plan and the triage systems used in previous disasters. Also, we review triage principles appearing in the literature. We describe basic hospital triage principles, which include the treatment site, the triage site, the triage officer, triage categories, and triage tags. RESULTS: 1) For external disaster, the emergency department is reassigned to four treatment sites before patients arrive. At the triage site, an emergency medicine specialist classifies patients into six groups according to treatment priority and resources. After classification, a triage tag is attached to each patient, and patients are moved to the previously designated treatment site. 2) For internal disaster, the head nurse (or senior nurse) classifies patients into three groups: urgent, minor, and delayed. The minor group is sent to the casualty collection point while the urgent and delayed groups are moved to the triage site. CONCLUSION: Hospitals should prepare a disaster plan. In particular, preplanning for triage is essential to cope with internal and external disasters. In addition, emergency medicine specialists should play a key role in disaster planning and are essential for successful implementation of the disaster plan.

Internal Disaster Mapping of Asan Medical Center

PURPOSE: Hospitals should be prepared for out-of-hospital (external) and in-hospital (internal) disasters. Mapping is vital for disaster management. Disaster situations can be quickly and comprehensibly understood through the use of disaster mapping. The purpose of this article is to design an internal disaster map for the Asan Medical Center (AMC). We expect this mapping to be helpful in making an internal disaster plan and in controlling an internal disaster. METHODS: Internal disasters were classified into three categories according to the disaster size and the response level, and the three categories were AMC Code I, II, and III. The triage was divided into 6 groups. AMC and its surrounding area were latticed at the interval of 50 meters. The essential elements of the internal disaster plan were drawn on the latticed map by using the procedures in the internal disaster plan. RESULTS: Internal disaster maps were designed for Code II and III internal disaster. Primary and secondary control lines enclosed the hospital area and the disaster site. A command post, a treatment area with a triage area, and a transport area were positioned in each disaster code map. Evacuation roots and traffic flow were drawn. Evacuation maps for intensive-care-unit and high-floor patients were designed in light of their limited mobility. Disaster ID cards and parking cards were also made. CONCLUSION: The internal disaster mapping of AMC will allow emergency medical personnel to visualize and verify their disaster plan and to quickly access critical information on the disaster situation. Also, it can be used for interagency communication.

B-Natriuretic Peptide (BNP) Assay for Diagnosis of Congestive Heart Failure

PURPOSE: Rapid diagnosis of congestive heart failure (CHF) is important for prompt and appropriate treatment, but is often difficult. The B-type natriuretic peptide (BNP) has been described as a powerful diagnostic test for heart failure. The goal of this study was to determine the diagnostic cutoff values of BNP, to evaluate useful factors for the diagnosis of CHF, and to develope a diagnostic algorithm for CHF with acute dyspnea patients. METHODS: BNP levels were obtained in 721 patients presenting to the emergency medical center with acute dyspnea from January 2001 to December 2002. With the use of inclusion criteria, 305 patients were excluded. Blood samples were collected by venipuncture and were analyzed by using Triage BNP assay. Included patients underwent echocardiography to evaluate the left ventricular (LV) dysfunction. RESULTS: The mean BNP concentration was higher in patients with CHF (n=214) than in those with other diagnose (517.31+/-37.70 pg/mL vs 75.53+/-11.25 pg/mL, p<0.001). At a blood concentration of 100 pg/mL, BNP showed a sensitivity of 79 %, a specificity of 83 %, a positive predictive value of 83%, and a negative predictive value of 79%. CONCLUSION: The BNP measurement is a useful tool in the diagnosis of CHF in patients presenting with dyspnea. We propose a diagnostic algorithm for CHF based on the BNP assay.

DAMGO, a micro-opioid agonist and cholecystokinin-octapeptide have dual modulatory effects on capsaicin-activated current in rat dorsal root ganglion neurons

Capsaicin, a pungent ingredient of hot pepper, elicits an intense burning pain when applied cutaneously and intradermally. Activation of capsaicin-gated channel in. C-type dorsal root ganglion (DRG) neurons produces nonselective cationic currents. Although electrophysiological and biochemical properties of capsaicin-activated current (ICAP) were studied, the regulatory mechanism and intracellular signaling pathway are still unclear. In the present study, we investigated the modulations of ICAP by DAMGO (micro-opioid agonist) and cholecystokinin octapeptide (CCK-8). In 18 out of 86 cells, the amplitude of ICAP was significantly increased by DAMGO and completely reversed after washout, while ICAP was decreased by DAMGO in 25 cells. In 43 cells, DAMGO had no effect on ICAP. Mean action potential duration was significantly different between 'increased-by-DAMGO' group and 'decreased-by-DAMGO' group. Mean amplitudes of IH were not significantly different between both groups. CCK-8 reversibly enhanced the amplitude of ICAP (5/13). DAMGO also increased ICAP amplitude significantly in the same cells. The amplitude of ICAP was increased in additive manner by combined applications of DAMGO and CCK-8 in these cells. These results suggest that DAMGO and CCK-8 can either increase or decrease ICAP presumably depending on the subtypes of DRG cells and classified by electrophysiological properties.

The effects of transforming growth factor-beta on the viability of human periodontal ligament cell and on the experimental tooth movement in rat / 대한치과교정학회지

The purpose of this study was to evaluate the effects of Transforming Growth Factor-beta (TGF-beta ) on the viability of human periodontal ligament cells, in-vitro and on the experimental tooth movement in rat, in-vivo. Human periodontal ligaments were cultured from the first premolar tooth extracted for the purpose of the orthodontic treatment. 0.1, 1, 5 and 10ng/ml of TGF-beta was given to the cultured wells, respectively and the viability was evaluated by MTT assay. Twenty Sprague-Dawley rats were divided into 5 experimental groups(4 rats in each) where 100g of force was applied from helical spring across the maxillary incisors. TGF- beta was injected via Hamilton syringe into the periodontal ligament at the mesial and the distal surface of a maxillary incisor of 2 rats in each experimental group. Phosphate buffer saline(PBS) was injected in 2 other rats as controls. Experimental groups were sacrificed at 1, 3. 7. 14 and 28 days after force application, respectively. The obtained tissues were evaluated histologically. The obtained results were as follows: 1.The viability of periodontal ligament cells in 0.1ng/ml of TGF-beta was not significantly different from that of control at 1-, 2- and 3-day of cultivation. 2.The viability of periodontal ligament cells was significantly increased at 3-day in 1ng/ml or 5ng/ml of TGF-beta, and at 2-, 3-day in 10ng/ml of of TGF-beta. 3. The zone of hyalinization in periodontal ligament in pressure side was smaller in TGF-beta injection group than that in control group at 3-day after the application of experimental force in rat. But no difference was seen after 7-day. 4.Osteoclastic activity and capillary prolieferation in pressure side were, greater in TGF-beta injection group than that in control group at 3-day to 7-day. 5.0steoblastic activity and new bone fomation in tension side were greater in TGF-beta injection group than that in control group at 3-day to 14-day.