Continuous Unilateral Cephalalgia Due to Systemic Lupus Erythematosus: A Case Report / Cefaleia unilateral contínua por lúpus eritematoso sistêmico: relato de caso

BACKGROUND: Hemicrania continua is a rare form of cephalalgia featuring a chronic and persistent headache in only one side of the head. OBJECTIVES: In this report, we present a case of a patient with hemicrania continua and systemic lupus erythematosus (SLE). METHODS: We collected patient data through the electronic medical record. Afterward, we reviewed the literature regarding hemicrania continua and its pathophysiology and correlation with neurovascular alterations, inflammation, and SLE. RESULTS: A 42-year-old woman visited the emergency department due to worsening constant unilateral cephalalgia that had been present for the past 6 months. The patient reported a highly intense (10/10) headache in the entire left hemicrania that radiated to the left shoulder. During physical examination, she presented with nystagmus, vertigo, and aggravated cephalalgia associated to body movement and, despite having no optic nerve thickening. In addition, she had jaundice, tachycardia, and splenomegaly. Complimentary exams found deep anemia, depletion in complement system and anti-nuclear factors, suggesting a possible hemolytic anemia (AIHA) due to SLE. Treatment was initiated with hydrocortisone and prednisone, associated with amitriptyline, fluoxetine and diazepam, reaching full remission. CONCLUSION: These syndromes have aggravated each other, and possibly the explanation for the cephalalgia remission was the control of AIHA and SLE. It features a rare case in literature and thus warrants discussion.

INTRODUÇÃO: Hemicrania contínua é uma forma rara de cefaléia caracterizada por cefaleia crônica e persistente em apenas um lado da cabeça. OBJETIVOS: Neste relato apresentamos o caso de um paciente com hemicrania contínua e lúpus eritematoso sistêmico (LES). MÉTODOS: Coletamos dados dos pacientes por meio do prontuário eletrônico. Posteriormente, revisamos a literatura sobre a hemicrania contínua e sua fisiopatologia e correlação com alterações neurovasculares, inflamação e LES. RESULTADOS: Uma mulher de 42 anos recorreu ao serviço de urgência devido ao agravamento da cefaleia unilateral constante, presente nos últimos 6 meses. O paciente relatou cefaleia de alta intensidade (10/10) em toda a hemicrânia esquerda com irradiação para o ombro esquerdo. Ao exame físico apresentava nistagmo, vertigem e cefaléia agravada associada à movimentação corporal e, apesar de não apresentar espessamento do nervo óptico. Além disso, ela apresentava icterícia, taquicardia e esplenomegalia. Os exames complementares evidenciaram anemia profunda, depleção do sistema complemento e fatores antinucleares, sugerindo uma possível anemia hemolítica (AIHA) por LES. Iniciou-se tratamento com hidrocortisona e prednisona, associadas a amitriptilina, fluoxetina e diazepam, atingindo remissão completa. CONCLUSÃO: Essas síndromes agravaram-se mutuamente e possivelmente a explicação para a remissão da cefaléia foi o controle da AIHA e do LES. Apresenta um caso raro na literatura e, portanto, merece discussão.

Pediatric Neurology Patients: Parental awareness of adverse effects of long-term Corticosteroid therapy

Background@#Corticosteroids are potent medications used to treat many inflammatory conditions in paediatric neurology practice. Although corticosteroids are beneficial, their adverse effects may be numerous and varied. As parents are the primary caregivers of paediatric patients, assessing their awareness is important. @*Methods@#To determine the parental awareness on the adverse effects of corticosteroid therapy in Paediatric Neurology Patients in the Neurology Unit at the Lady Ridgeway Hospital, Colombo, Sri Lanka, this descriptive cross-sectional study, looked at 300 parents of paediatric neurology patients on long-term corticosteroid therapy. Parents volunteered for the study and signed with informed consent. Ethical approval was obtained from the Ethics Review Committee of the same hospital. Data were collected using content validated, pre-tested self-administered questionnaire during January to March 2020. @*Results@#Of the total parents, the majority were mothers (87%, n=262) and more than 70% (n=211) of them completed their secondary education. Findings demonstrated that parents had average awareness about adverse effects of long-term steroid therapy including child's susceptibility to infections (69.0%, n=207), increase blood glucose levels (69.7%, n=209), moon face (60.3%. n=181), central obesity (60.3%, n=181), increase blood pressure levels (58.0%, n=174) and (irritability 50.3%, n=151) while poor awareness on adverse effects include buffalo humps (26.7%, n=80) increase fracture tendency (24.3%, n=73), tarry colour stools (24.3%, n=73), vision impairment (24.0%, n=72), glaucoma (17.3%, n=52), cataract (16.0%, n=48 ) and delayed wound healing (23.0%, n=69). According to the findings, overall mean (SD) knowledge percentage on parental awareness of adverse effects was found to be low (38.24 ± 20.57).@*Conclusion@#Since parental awareness of the adverse effects of long-term corticosteroid therapy is inconsistent, special attention is needed to plan and implement appropriate awareness sessions.

Systemic corticosteroid therapy in the post-acute period of COVID-19 pneumonia with torpid clinical and radiological evolution

Abstract COVID-19 pneumonia generates both immediate damage due to the viral effects and distant damage due to inflammatory immune deregulation. Systemic corticosteroid therapy has proven to be beneficial in the first part of the process, but its usefulness in post-acute damage is still unclear. The number of affected patients makes it imperative to find a treatment that reduces potential pulmonary sequelae. This series of cases included 18 patients admitted to polyvalent private medical institutions of Buenos Aires City: 15 were male and 3 were female; age 58.4 ± 13.6 years. History of most common comorbidities: AHT (4 patients), obesity (6 patients) and smoking (4 patients). Five patients had no medical history. All patients showed dyspnea, oxygen desaturation, and persistent or progressive tomo graphic abnormalities 14 days after their infection. All of them received dexamethasone according to current regulations. Subsequently, given the poor evolution, they were administered oral and/or intravenous corticosteroids with the same treatment used for secondary organizing pneumonia (OP). A transbronchial biopsy was performed in 6 of the patients, showing an OP pattern in 3 of them. Four weeks after the beginning of the treatment, all of the patients showed clinical improvement expressed by decreased dyspnea and the fact that they didn't require oxygen anymore and that all chest tomographies showed clearly reduced pulmonary parenchymal involve ment. Systemic corticosteroids administered in the post-acute period of COVID-19 have a clinical and radiological beneficial effect.

Corticoterapia con intención de rescate en pacientes con hepatitis autoinmune severa: ¿el trasplante hepático es evitable?

Resumen: Introducción: La hepatitis autoinmune es una enfermedad cuya presentación clínica inicial puede manifestarse de diversas formas, siendo su presentación aguda con aumento de los niveles de bilirrubina, caída de la función biosintética y necrosis masiva/submasiva o cirrosis en la histología, marcadores de severidad de la misma. La decisión de iniciar tratamiento con corticoides en este escenario resulta un desafío en la práctica clínica. Los objetivos del presente trabajo fueron evaluar el grado de respuesta al tratamiento, los predictores de respuesta, y la supervivencia global y libre de trasplante en pacientes cuyo debut clínico fue de forma aguda y severa. Resultados: Fueron incluidos 33 pacientes con bilirrubina total mayor a 2.5 mg/dl, sin tratamiento previo (naive), que cumplían criterios diagnósticos según el grupo internacional de hepatitis autoinmune. El 97% eran mujeres con una mediana de edad de 52 años, el 58% se encontraba en etapa de cirrosis con un MELD promedio de 24, y el 15% presentaba una necrosis masiva/submasiva en la muestra de biopsia hepática. En 27 casos se inició corticoterapia. El 66.7 % evolucionó con remisión completa, 14.8 % con remisión parcial, y en 18.5% hubo falla al tratamiento corticoideo. La colesterolemia basal y la presencia de encefalopatía hepática fueron predictores de no respuesta al tratamiento corticoideo, mientras que el MELD pre-tratamiento y la colesterolemia basal fueron las variables estadísticamente significativas asociadas a falla en el rescate del trasplante hepático. En los pacientes tratados con corticoides, la supervivencia global y libre de trasplante a 5 años en función del MELD (<25 vs ≥ 25) fue del 90% vs 60% respectivamente. Conclusión: Las altas tasas supervivencia logradas bajo tratamiento médico que fueron evidenciadas en esta serie reafirman la necesidad de priorizar el uso de corticoides en pacientes con hepatitis autoinmune aguda y severa.

Abstract: Introduction: Autoimmune hepatitis can initially manifest itself in various clinical ways. Its acute presentation with increased levels of bilirubin, fall of biosynthetic function and massive/submassive necrosis or cirrhosis in histology, is a marker of severity of it. The decision to start corticosteroid treatment in this scenario is a challenge in clinical practice. The objectives of this work were to assess the degree of response to treatment, response predictors, and overall and transplant-free survival in patients whose clinical debut was acute and severe. Results: 33 patients with total bilirubin greater than 2.5 mg/dL, without prior (naive) treatment, who met diagnostic criteria according to the international autoimmune hepatitis group, were included. 97% were women with a median age of 52, 58% were in the cirrhosis stage with an average MELD of 24, and 15% had massive/submassive necrosis in the liver biopsy sample. In 27 cases treatment with cortiocosteroids was initiated, 66.7% evolved with complete remission, 14.8% with partial remission, and in 18.5% there was failure of corticosteroid treatment. Basal cholesterol and the presence of hepatic encephalopathy were predictors of non-response to corticosteroid treatment, while pre-treatment MELD and basal cholesterol were the statistically significant variables associated with liver transplant rescue failure. In patients treated with corticosteroids, overall and transplant-free survival at 5 years based on MELD (<25 vs ≥ 25) was 90% vs 60% respectively. Conclusion: The high survival rates achieved under medical treatment that were demonstrated in this series reaffirm the need to prioritize the use of corticosteroids in patients with acute and severe autoimmune hepatitis.

Resumo: Introdução: A hepatite autoimune é uma doença cuja apresentação clínica inicial pode se manifestar de várias formas, sendo sua apresentação aguda com níveis elevados de bilirrubina, descida na função biossintética e necrose maciça/submassiva ou cirrose em histologia, marcadores de gravidade dela. A decisão de iniciar o tratamento corticosteroide nesse cenário é um desafio na prática clínica. Os objetivos deste trabalho foram avaliar o grau de resposta ao tratamento, preditores de resposta e sobrevida geral e livre de transplantes em pacientes cuja estréia clínica foi aguda e grave. Resultados: Foram incluídos 33 pacientes com bilirrubina total superior a 2,5 mg/dL, sem tratamento prévio (ingênuo), que atendiam aos critérios diagnósticos segundo o grupo internacional de hepatite autoimune. 97% eram mulheres com idade mediana de 52 anos, 58% estavam em estágio de cirrose com um MELD médio de 24, e 15% tinham necrose maciça/submassiva na amostra de biópsia hepática. Em 27 casos foi iniciado o tratamento médico e, em 6 casos, o transplante de fígado foi alcançado sem terapia prévia. 66,7% evoluíram com remissão completa, 14,8% com remissão parcial e, em 18,5%, houve falha no tratamento corticosteroide. O colesterol basal e a presença de encefalopatia hepática foram preditores de não resposta ao tratamento corticosteroide, enquanto o meld pré-tratamento e o colesterol basal foram as variáveis estatisticamente significativas associadas à falha de resgate do transplante de fígado. Em pacientes tratados com corticosteroides, a sobrevida geral e livre de transplante aos 5 anos com base no MELD (<25 vs ≥ 25) foi de 90% vs 60%, respectivamente. Conclusão: As altas taxas de sobrevivência alcançadas sob tratamento médico demonstrado nesta série reafirmam a necessidade de priorizar o uso de corticosteroides em pacientes com hepatite autoimune aguda e grave.

Management of idiopathic granulomatous mastitis: a surgical experience of ten cases

Granulomatous mastitis is a chronic inflammatory condition of the breast that is rarely described in literature. It mimics breast abscess on clinical presentation giving dilemma to the surgeon. The etiology can be infectious, autoimmune or idiopathic. The various modalities of treatment for idiopathic granulomatous mastitis includes drainage of abscess, antibiotics and corticosteroid therapy. This is a case series of ten cases of diagnosed with granulomatous mastitis treated in the period of 2 years from 2018 and 2019 in Department of General Surgery, MGM Hospital Navi Mumbai. The data of all the patients were collected from records. They were following at regular intervals in the outpatient department to assess recurrence. The mean age of the patients was 41 years (range 26–47 years). Six patients gave history of breast-feeding in the last 5 years, one was lactating at the time of presentation. One of the patients was treated empirically for Tuberculous mastitis for the opposite breast. Others had no history suggestive of tuberculosis or other connective tissue diseases, such as rheumatoid arthritis or sarcoidosis USG breast was performed in all cases. Hypoechoic abscess was seen in 5 cases. The time taken for complete resolution of the disease was ranging from 2 weeks to 2 months. All patients had an uneventful recovery and no recurrences reported till now. GM is a rare benign breast disease that is difficult to distinguish from other inflammatory breast diseases or cancer. The diagnosis of GM must be based on a multidisciplinary approach. Surgical management followed by antibiotics was found to be sufficient to treat the condition in our patients. Corticosteroids need not be administered in all cases of this benign breast disease.

Uso convencional de surfactante en recién nacidos con enfermedad de membrana hialina / Conventional use of surfactant in newborns with hyaline membrane disease

La enfermedad de membrana hialina se debe a la deficiencia de surfactante en los pulmones de los recién nacidos especialmente los menores de 37 semanas de gestación. El manejo materno con corticoides prenatales en este grupo, disminuye la morbimortalidad asociada a esta patología neonatal. Se analiza desde el punto de la evidencia actualmente existente la administración de surfactante a estos prematuros y se revisa el tipo de surfactante a administrar, cuando es el mejor momento para administrarlo, la dosis y la forma de administrarlo.

Hyaline membrane disease is due to surfactant deficiency in the lungs of newborns, especially those younger than 37 weeks gestation. Maternal management with prenatal corticosteroids in this group reduces the morbidity and mortality associated with this neonatal pathology. The administration of surfactant to these preterm infants is analyzed from the point of the currently existing evidence and the type of surfactant to be administered is reviewed, when is the best time to administer it, the dose and the form of administration.

Síndrome nefrótico congénito. Reporte de caso y revisión del enfoque diagnóstico / Congenital nephrotic syndrome. Case report and review of its diagnostic work up

Resumen El síndrome nefrótico se define como la unión de proteinuria masiva, hipoalbuminemia e hiperlipidemia, que pueden asociarse a edemas e hipercoagulabilidad. Se origina de una anormalidad de la barrera de filtración glomerular con una fuga masiva de proteína y los efectos secundarios consecuentes. En sus formas primarias, ocurre con una incidencia de 1-3 por cada 100.000 niños menores de 16 años. La forma congénita es una variante poco frecuente del síndrome nefrótico, la cual se presenta en el nacimiento o dentro de los tres primeros meses de vida, y suele ser resistente a la corticoterapia. Se debe evaluar primero la existencia de infecciones congénitas y luego buscar las enfermedades monogénicas más comunes, finalmente se puede recurrir a la secuenciación de nueva generación para buscar mutaciones en los demás genes candidatos. Se presenta el caso de una niña con síndrome nefrótico congénito de difícil control, enfatizando en el proceso diagnóstico y el manejo de soporte. Se resalta la importancia de la asesoría genética a la familia en todos los casos.

Abstract A nephrotic syndrome is defined as the association of massive proteinuria, hypoalbuminemia and hyperlipidemia, which may be associated with edema and hypercoagulability. It originates from an abnormality of the glomerular filtration barrier with a massive protein leak and the consequent side effects. In its primary forms, it occurs with an incidence of 1 - 3 per 100,000 children under 16 years of age. The congenital form is a rare variant of the nephrotic syndrome, which occurs at birth or within the first three months of life and is usually resistant to corticosteroid therapy. Congenital infections and most common related monogenic diseases should be tested. Finally, new generation sequencing must be used to search for mutations in other candidate genes. We present the case of a girl with congenital nephrotic syndrome difficult to control, emphasizing the diagnostic process and support management. The importance of genetic counseling to the family in all cases is highlighted.

Pathophysiology and Management of Alcoholic Liver Disease: Update 2016

Alcoholic liver disease (ALD) is a leading cause of cirrhosis, liver cancer, and acute and chronic liver failure and as such causes significant morbidity and mortality. While alcohol consumption is slightly decreasing in several European countries, it is rising in others and remains high in many countries around the world. The pathophysiology of ALD is still incompletely understood but relates largely to the direct toxic effects of alcohol and its main intermediate, acetaldehyde. Recently, novel putative mechanisms have been identified in systematic scans covering the entire human genome and raise new hypotheses on previously unknown pathways. The latter also identify host genetic risk factors for significant liver injury, which may help design prognostic risk scores. The diagnosis of ALD is relatively easy with a panel of well-evaluated tests and only rarely requires a liver biopsy. Treatment of ALD is difficult and grounded in abstinence as the pivotal therapeutic goal; once cirrhosis is established, treatment largely resembles that of other etiologies of advanced liver damage. Liver transplantation is a sound option for carefully selected patients with cirrhosis and alcoholic hepatitis because relapse rates are low and prognosis is comparable to other etiologies. Still, many countries are restrictive in allocating donor livers for ALD patients. Overall, few therapeutic options exist for severe ALD. However, there is good evidence of benefit for only corticosteroids in severe alcoholic hepatitis, while most other efforts are of limited efficacy. Considering the immense burden of ALD worldwide, efforts of medical professionals and industry partners to develop targeted therapies in ALF has been disappointingly low.

Severe Paresthesia as a Rare Presenting Symptom of Subacute Thyroiditis / General Medicine

In this case report, we describe a male patient with subacute thyroiditis with severe paresthesia in a glove-and-stocking type distribution and thyroid gland tenderness but with minimal symptoms of hyperthyroidism. His paresthesia improved and then disappeared within several days after low dose oral prednisolone was initiated. As possible mechanisms for his severe paresthesia, we propose the following: 1) thyrotoxic effect on the peripheral nerves, and 2) generalized inflammatory effect on the peripheral nerves akin to that in the thyroid gland. Subacute thyroiditis may need to be considered as one of differential diagnoses for severe paresthesia.

Factores obstétricos claves en los resultados neonatales y a los dos años de seguimiento en la prematuridad extrema / Influence of obstetrical factors in the neonatal outcome and after two-year follow-up in extreme preterm

Objetivo: Analizar la morbimortalidad en pretérminos extremos evaluando la influencia de factores obstétricos. Método: Estudio retrospectivo de 132 casos nacidos entre las semanas 23 y 27 en el Hospital La Paz, desde 2003 a 2005. Se establecieron tres grupos obstétricos: Amenaza de Parto Pretérmino, Rotura Prematura de Membranas y la asociación de ambas. Se evaluaron como variables obstétricas: tocolisis, corticoterapia, motivo de finalización de la gestación y vía de parto, y como variables en niños: mortalidad y morbilidad respiratoria, neurológica, visual y auditiva en neonatos y a los dos años. Resultados: Los casos con amenaza de parto pretérmino presentaron mayor displasia broncopulmonar y ductus arterioso persistente que los otros dos grupos obstétricos (p=0,03). Las pacientes con amenaza de parto pretérmino y tocolisis desarrollaron menos hemorragia intraventricular [36,4 por ciento (12/33)] e infarto periventricular (0 por ciento) que los casos sin tocolisis, en los que aparecieron en el 68,4 por ciento (13/19) y 31,6 por ciento(6/19), respectivamente (p=0,03 y p=0,001). Además en este subgrupo, los casos que recibieron corticoterapia desarrollaron menos infarto periventricular (0 por ciento) y parálisis cerebral a los 2 años [6,7 por ciento (2/30)], que los que no la recibieron, en los que apareció un 40 por ciento (6/15) de infarto y un 40 por ciento (4/10) de parálisis cerebral, respectivamente (p=0,0001 y p=0,02). La hemorragia intraventricular y la parálisis cerebral fueron más frecuentes en partos vaginales de casos con amenaza de parto pretérmino que en cesáreas [63,3 por ciento (19/30) y 26,1 por ciento (6/23) frente a 27,3 por ciento (6/22) y 0 por ciento; p=0,01 y 0,03]. Conclusión: La conducta obstétrica puede modificar el pronóstico neonatal y a los 2 años de seguimiento.

Objective: Analyse morbidity and mortality in extreme preterm at birth and at 2 year follow-up evaluating the influence of obstetrical factors. Methods: Retrospective study of 132 cases born between weeks 23 and 27 at La Paz Hospital from 2003 to 2005. Three obstetrical groups were established: Threat of Preterm Birth, Premature Rupture of Membranes and the combination of both. The following were evaluated as obstetrical variables: tocolysis, corticosteroid therapy and type of delivery. As variables in children: mortality and respiratory, neurological, visual and auditive morbidity in neonates and two years of age. Results: In the cases of threat of preterm birth a greater bronchopulmonary dysplasia and persistent ductus arteriosus appeared than in the other two obstetrical groups (p=0.03). Focusing on the threat of birth group, the cases with maternal tocolysis developed fewer neurological complications, intraventricular hemorrhage of 36.4 percent (12/33) and periventricular infarct of 0 percent, whereas the cases without tocolysis showed 68.4 percent (13/19) and 31.6 percent (6/19) respectively (p=0.03, p=0.001). Also in this subgroup, the cases that received corticosteroid therapy developed less periventricular infarct (0 percent) and cerebral palsy at age 2 [6.7 percent (2/30)] than the ones that did not receive it in which the percentages were 40 percent (6/15) and 40 percent (4/10) (p=0.0001 and p=0.02 respectively). Also, intraventricular hemorrhage and cerebral palsy were more frequent in vaginal delivery than in caesarean sections in this subgroup [63.3 percent (19/30) and 26.1 percent (6/23) against 27.3 percent (6/22) and 0 percent; p=0.01 and p=0.03)]. Conclusion: Obstetrical characteristics and behaviour can have a decisive impact in the neonatal outcome and after two-year follow-up.

Efficacy and safety of topical aspirin for persistent lichen simplex chronicus: A double blind, randomized, placebo-controlled crossover trial

OBJECTIVE: To establish the effectiveness and safety of topical aspirin on patients with persistent lichen simplex chronicus (LSC) despite corticosteroid therapy METHODS: Fifty-four male and female patients with LSC who underwent topical corticosteroid therapy in the past were randomized to receive 3 percent aspirin ointment for two weeks followed by placebo ointment for two weeks or placebo first followed by aspirin with a crossover design after a 2-week washout period on a preselected involved area. Outcomes looked for were pruritus by visual analogue scale (VAS), activities of daily living score (ADLS), size of lesion, number of skin markings and photographic assessment score (PAS). All comparisons were done both on per protocol and intention-to-treat bases. RESULTS: Data were complete for 42 (77.8 percent) subjects. On per protocol analysis, there were significantly greater reductions in lesion size and number of skin markings on aspirin use than on placebo use (p=0.005 and p0.001, respectively). Proportions of subjects with improved signs and symptoms were all significantly greater in the aspirin group than in the placebo group (69 percent versus 9.5 percent by VAS, 85.7 percent versus 19 percent by ADLS and 100 percent versus 4.8 percent by PAS; all 0.001). Intention-to-treat analysis of the results had similar findings. One adverse event of transient burning sensation after topical aspirin use was reported. CONCLUSION: Topical aspirin can be safely used for two weeks and is significantly more effective than topical placebo in decreasing pruritus and impairment of activities of daily living, as well as in improving the size and morphology of LSC lesions.

A Case of Drug Induced Interstitial Pneumonitis by Gemcitabine / 결핵

Gemcitabine is an effective newly developed chemotherapeutic agent, which is increasingly being used to treat non-small cell lung, ovarian and breast cancers. Pulmonary toxicity is usually self-limiting mild dyspnea, bronchospasm, but severe pulmonary toxicity is rarely reported. Herein, we report drug induced interstitial lung disease associated with gemcitabine treatment. High resolution computerized tomogram (HRCT) showed an increased ground glass opacity and thickened septal lines. The patient showed a rapid good response with prednisolone treatment.

Effect of Intranasal Corticosteroid Therapy for Perennial Nonallergic Rhinitis and Perennial Allergic Rhinitis / 소아알레르기및호흡기학회지

PURPOSE: The efficacy of intranasal corticosteroids for the treatment of allergic rhinitis has been reported. But the efficacy of intranasal corticosteroids has not been compared between perennial nonallergic rhinitis (PNAR) and perennial allergic rhinitis (PAR). METHODS: Twenty-three patients with PNAR and 19 patients with PAR were enrolled in this study. Every patient received fluticasone propionate (FP) 200 g (100 g, bid) daily for 4weeks. Control group (n=16) was received only anti-histamine (hydroxyzine 0.6 mg/kg/dose) intermittently. Efficacy of FP was evaluated by the mean change in nasal congestion, rhinorrhea, nasal itching, sneezing and total nasal symptom score (a sum of patient ratings of nasal congestion, rhinorrhea, nasal itching, and sneezing). RESULTS: Both groups (PNAR and PAR) showed similar improvement of nasal symptom with FP 200 g compared with control. (P< 0.05) In the total population, both groups showed significant improvements from baseline in TNSS compared with control during each week of treatment. (P< 0.05) In PNAR and PAR, nasal congestion was significantly improved more than in control. (P< 0.01, P< 0.01) Rhinorrhea and itching in PAR were improved more than in control. (P=0.02, P=0.03) In sneezing, all three groups showed no differences. (P=1.00, P=0.31, P= 0.29) CONCLUSION: Intranasal FP is an effective treatment for perennial nonallergic rhinitis as same as perennial allergic rhinitis.

Clinical Course of Untreated Sarcoidosis / 결핵

BACKGROUND: Sarcoidosis, uncommon in Korea, has variable clinical course, ranging from benign self-limited recovery to life-long disability regardless of corticosteroid therapy. The purpose of this st udy is to observe the clinical course of untreated sarcoidosis. METHODS: Twenty four patients who were confirmed as sarcoidosis by tissue diagnosis were included. For average 12month follow-up periods, subjective symptoms, radiologic findings, and parameters of pulmonary function test(FVC, FEV1, DLco) were evaluated every 3months compared between corticosteroid treated (n=5) and non-treated (n=19) patients. 'Deterioration' was defined if patients met more than one of followings (1) decrement in any parameters of pulmonary function test (2) worsening in the degree of dyspnea (3) increase in radiologic extents, and (4) newly developed extrapulmonary sarcoidosis. 'Stable' was defined as no significant interval changes in every parameters. 'Improvement' was defined as decrement of extension of the radiologic lesions without deterioration. RESULTS: Among 19 untreated sarcoidosis patient, one deteriorated, 14 improved (13 of them showed complete resolution in radiology), and 4 were remained stable. On the other hand, five corticosteroid treated patients, uveitis was developed in one, 2 improved, and 2 remained stable. CONCLUSION: These findings suggest that patient with sarcoidosis, especially those without serious extrapulmonary disease, has stable clinical course and would not need corticosteroid therapy.

A Case of Methotrexate: Associated Interstitial Pneumonitis in Rheumatoid Arthritis / 대한류마티스학회지

The use of oral methotrexate in a low dose given once weekly has become the mainstay of therapy for active and sustained rheumatoid arthritis. Pneumonitis can be expected to occur in patients taking low doses of methotrexate for rheumatoid arthritis. The pathology suggests that methotrexate pneumonitis is a hypersensitivity reaction although arguments have been put forth that it is idiosyncratic. Treatment of presumed methotrexate pneumonitis, even while waiting for special stains, cultures, or tissue sections from bronchoscopic biopsy, should be glucocorticoids given intravenously or by mouth. Empirical antibiotic treatment can be used until infectious causes are ruled out. In recent years there has been an increase in the number of reports of pulmonary complications associated with low-dose methotrexate therapy for rheumatic diseases. Among these complications interstitial pneumonitis has been most often reported (more than 35 cases since the first report in 1983). We report a case of methotrexateassociated pulmonary complication in rheumatoid arthritis confirmed by transbronchoscopic lung biopsy, which resolved by treatment of corticosteroid therapy.

Antenatal Corticosteroid Therapy to Prevent Neonatal Respiratory Distress Syndrome / 대한주산의학회잡지

OBJECTIVES: Our purpose was to determine the efficacy of maternal corticosteroid therapy in the prevention of neonatal respiratory distress syndrome. STUDY DESIGN: The data in this study was taken from 136 women who participated in prematurity prevention programs at two hospital. Of 136 women who were delivered at 25 to 34 weeks, 68 received dexamethasone and 68 did not. 'I'he frequency and relative risk of adverse outcomes, including repiratory distress syndrome, necrotizing enterocolitis, neonatal sepsis and maternal infection wcre compared by means of univariate techniques. RESULT: When dexamethansone was administered, there was a lower incidence of respiratory distress syndrome at between 30 to 32 weeks gestation (relative risk of treatment group vs control group=0.425, p0.05). I'here was no statistical difference between 33 weeks to 34 weeks (relative risk of treatment group vs control group=0.782, p>0.05). 'I'here was no statistical significance in the incidence of maternal infection, neonatal sepsis or necrotizing enterocolitis (p=0.808, p=0.698, p=0.559). CONCLUSION: Dexamethasone appears to significantly reduce neonatal respiratory distress syndrome at between 30 and 32 weeks gestation.

Clinical Findings of 68 Cases of Severe Alopecia Areata and the Results of Methyl Prednisolone Pulse Therapy / 대한피부과학회지

BACKGROUND: Extensive involvernent of alopecia areata seems to be different from the usual common type of alopecia areata in its damage to the patient and its pragnosis. The two forms are best dealt with differently. OBJECTIVE: We performed a clinical observation of a severe form of alopecia areata to understand to its course and therapeuic respones. METHODS: Clinical analysis of 68 cases of severe alopecia areata (37 alopecia totalis, 6 alopecia subtotalis, 13 alopecia universalis, 11 alopecia subtotal universalis, 1 ophiasis) was done for 9 years from 1985 to 1994. RESULTS: 1. The sex distribution was equal. The developrnent of hair loss started before the age of 30 in 67.6%(46/68). Twenty two patients(32.4%) developed the alopecia during the early twenties. The overall mean age was 26.4 years. 2. The duration from the initial hair loss to the involvement of the whole scalp was less than 3 months in 80%(40/50~) of patierits showing whole scalp baldness. 3. Exclamation mark hairs were seen in 85% (57/67) of severe alopecia areata. In 5 patients who were examined just at the start of the hair loss, exclamation mark hairs were found several weeks later. 4. When treated by methyl prednisolone pulse therapy, duration of the disease and type of involvement are the most important prognastic factors as follows. a) 71%(32/45) of patients with less than 6 months duration showed satisfyingly good results cosmetically, but this figure dropped to 30.4% (7/23) in patients with longer than 6 months duration. b) 83.7% (36/43) of patients with alopecia totalis or subtotalis showed good results but this figure dropped to 12%(3/25) in patients with alopecia universalis, subtotal universalis or ophiasis. 5. Methyl prednisolone pulse therapy seemed to be recommended in the acute stage of extensive involvement of alopecia areata. CONCLUSION: Severe alopecia areata has predilection for young adults and seems to show extensive involvement frorn its early stage. Exclamation mark hairs need some time to appear even in their early active stage of hair hedding. Pulse methyl prednisolone therapy is thought to be recommended when the disease is in its early active stage.

Clinical Findings of 68 Cases of Severe Alopecia Areata and the Results of Methyl Prednisolone Pulse Therapy / 대한피부과학회지

BACKGROUND: Extensive involvernent of alopecia areata seems to be different from the usual common type of alopecia areata in its damage to the patient and its pragnosis. The two forms are best dealt with differently. OBJECTIVE: We performed a clinical observation of a severe form of alopecia areata to understand to its course and therapeuic respones. METHODS: Clinical analysis of 68 cases of severe alopecia areata (37 alopecia totalis, 6 alopecia subtotalis, 13 alopecia universalis, 11 alopecia subtotal universalis, 1 ophiasis) was done for 9 years from 1985 to 1994. RESULTS: 1. The sex distribution was equal. The developrnent of hair loss started before the age of 30 in 67.6%(46/68). Twenty two patients(32.4%) developed the alopecia during the early twenties. The overall mean age was 26.4 years. 2. The duration from the initial hair loss to the involvement of the whole scalp was less than 3 months in 80%(40/50~) of patierits showing whole scalp baldness. 3. Exclamation mark hairs were seen in 85% (57/67) of severe alopecia areata. In 5 patients who were examined just at the start of the hair loss, exclamation mark hairs were found several weeks later. 4. When treated by methyl prednisolone pulse therapy, duration of the disease and type of involvement are the most important prognastic factors as follows. a) 71%(32/45) of patients with less than 6 months duration showed satisfyingly good results cosmetically, but this figure dropped to 30.4% (7/23) in patients with longer than 6 months duration. b) 83.7% (36/43) of patients with alopecia totalis or subtotalis showed good results but this figure dropped to 12%(3/25) in patients with alopecia universalis, subtotal universalis or ophiasis. 5. Methyl prednisolone pulse therapy seemed to be recommended in the acute stage of extensive involvement of alopecia areata. CONCLUSION: Severe alopecia areata has predilection for young adults and seems to show extensive involvement frorn its early stage. Exclamation mark hairs need some time to appear even in their early active stage of hair hedding. Pulse methyl prednisolone therapy is thought to be recommended when the disease is in its early active stage.

The Use of Corticosteroids and Bupivacaine for Pain Management in Lumbar Disc Herniation Patient

The introduction of microdiscectomy in lumbar spine surgery has resulted in a significant decrease in postoperative pain and length of hospital stay. Intraoperative application of long-acting local anesthetic agents and corticosteroids during lumbar discectomy have been used for the management of postoperative pain. However, the efficacy of local anesthetic agents and corticosteroids has not been reported. This study evaluated 30 patients undergoing lumbar microdiscectomy. These patients were divided into three groups. Group I(10 patients) received intramuscular Depomedrol and intravenous Solumedrol at the start of the operation. A gelfoam soaked with Depomedrol was placed over the affected nerve root following discectomy. In addition, bupivacaine was infiltrated into the paraspinal musculature at the skin incision and during closure. Group II(10 patients) received intramuscular bupivacaine and used a saline-soaked gelfoam. Group III(10 patients) acted as a control group without corticosteroids and bupivacaine. Patients in Group I had a statistically significantly shorter hospital stay(8.9 days) compared to the control group(14.9 days). Patients in Group I required less postoperative narcotic analgesia than the other groups. A larger percentage of patients in Group I reported reduction of lower back pain and radicular pain until #POD 3 compared to other groups. These results indicate that the combination of long-acting local anesthetic agents and corticosteroids can reduce postoperative discomfort and hospital stay.

Efficacy of High Dose Corticosteroid Therapy in Experimental Traumatic Optic Neuropathy

We investigated the efficacy of high dose corticosteroid therapy in the treatment of traumatic optic-neuropathy. We experimentally damaged the optic nerves of six white rabbits with a Hartman mosquito. Three of the rabbits were intravenously injected with 0.25mg/kg dexamethasone every six hours for a 48 hour period. The others were used as controls. In both groups, the optic nerves were removed after one month and stained with Hematoxyline-eosin, then examined microscopically. No histological differences were found in either the control or the experimental group.