A Case of Postural Orthostatic Tachycardia Syndrome Associated with Migraine and Fibromyalgia

Postural orthostatic tachycardia syndrome (POTS) refers to the presence of orthostatic intolerance with a heart rate (HR) increment of 30 beats per minute (bpm) or an absolute HR of 120 bpm or more. There are sporadic reports of the autonomic nervous system dysfunction in migraine and fibromyalgia. We report a case of POTS associated with migraine and fibromyalgia. The patient was managed with multidisciplinary therapies involving medication, education, and exercise which resulted in symptomatic improvement. We also review the literature on the association between POTS, migraine, and fibromyalgia.

Dose fentanyl injection for blunting the hemodynamic response to intubation increase the risk of reflex bradycardia during major abdominal surgery? / 대한마취과학회지

BACKGROUND: Although supplemental fentanyl has been widely used to blunt the hemodynamic responses to laryngoscopic intubation, its residual vagotonic effect may increase the risk of reflex bradycardia. We compared the incidence and severity of significant reflex bradycardia after a bolus injection of equivalent doses of fentanyl and remifentanil (control drug). METHODS: In this prospective, randomized, double-blind study, 220 adult patients undergoing major abdominal surgery were randomly assigned to receive fentanyl (1.5 microg/kg) or remifentanil (1.5 microg/kg). No anticholinergic prophylaxis was administered. Symptomatic reflex bradycardia was defined as a sudden decrease in heart rate to < 50 beats per minute (bpm) or to 50-59 bpm associated with a systolic arterial pressure < 70 mmHg in connection with surgical maneuvers. If bradycardia or hypotension developed, atropine or ephedrine was administered following a predefined treatment protocol. RESULTS: In total, 188 subjects (remifentanil, 95; fentanyl, 93) were included. The proportion of subjects with symptomatic reflex bradycardia in the fentanyl group was similar to that in the remifentanil group (30.1% vs. 28.4%, respectively). Atropine and/or ephedrine were needed similarly in both groups. The differences between the group of 55 patients who presented with symptomatic reflex bradycardia were not statistically significant with respect to the lowest heart rate, anesthetic depth-related data (bispectral index and end-tidal sevoflurane concentration), or the proportion of causative surgical maneuvers. CONCLUSIONS: Fentanyl (1.5 microg/kg) administered intravenously during anesthetic induction is unlikely to increase the incidence and severity of significant reflex bradycardia in patients undergoing major abdominal surgery.

Prognostic Estimation of Advanced Heart Failure With Low Left Ventricular Ejection Fraction and Wide QRS Interval

BACKGROUND AND OBJECTIVES: Cardiac resynchronization therapy (CRT) has been known to improve the outcome of advanced heart failure (HF) but is still underutilized in clinical practice. We investigated the prognosis of patients with advanced HF who were suitable for CRT but were treated with conventional strategies. We also developed a risk model to predict mortality to improve the facilitation of CRT. SUBJECTS AND METHODS: Patients with symptomatic HF with left ventricular ejection fraction 120 ms were consecutively enrolled at cardiovascular hospital. After excluding those patients who had received device therapy, 239 patients (160 males, mean 67+/-11 years) were eventually recruited. RESULTS: During a follow-up of 308+/-236 days, 56 (23%) patients died. Prior stroke, heart rate >90 bpm, serum Na or =1.5 mg/dL were identified as independent factors using Cox proportional hazards regression. Based on the risk model, points were assigned to each of the risk factors proportional to the regression coefficient, and patients were stratified into three risk groups: low- (0), intermediate-(1-5), and high-risk (>5 points). The 2-year mortality rates of each risk group were 5, 31, and 64 percent, respectively. The C statistic of the risk model was 0.78, and the model was validated in a cohort from a different institution where the C statistic was 0.80. CONCLUSION: The mortality of patients with advanced HF who were managed conventionally was effectively stratified using a risk model. It may be useful for clinicians to be more proactive about adopting CRT to improve patient prognosis.

Heart Rate Acceleration of a Subsidiary Pacemaker by beta-Adrenergic Stimulation

BACKGROUND AND OBJECTIVES: Recent evidence indicates that the membrane voltage and Ca2+ clocks jointly regulate sinoatrial node (SAN) automaticity. However, the mechanism of heart rhythm acceleration of the subsidiary pacemaker (SP) during beta-adrenergic stimulation is still unknown. Here we tested the hypothesis that the heart rate acceleration of the SP by beta-adrenergic stimulation involves synergistic interactions between both clock mechanisms. SUBJECTS AND METHODS: We performed optical mapping and pharmacological interventions in 15 isolated Langendorff-perfused canine right atriums (RA). The SP model was produced by ligation of the SAN artery at the mid portion of the sulcus terminalis. RESULTS: In the 6 RAs with an intact SAN, 1 micromol/L isoproterenol infusion increased the heart rate from 82+/-9 to 166+/-18 bpm (102%) with late diastolic Cai elevation (LDCAE) at the superior SAN. However, in the 6 SP models, the heart rate increased from 55+/-10 bpm to 106+/-11 bpm (92%, p=0.005) without LDCAE at the earliest activation site. The isoproterenol induced heart rate increase was reversed to 74+/-5 bpm (33% from baseline) by administering an infusion of the funny current blocker ZD 7288 (3 micromol/L, n=3), whereas, it was suppressed to 69+/-7 bpm (24% from baseline) by sarcoplasmic reticulum (SR) Ca2+ emptying with administering ryanodine (10 micromol/L) plus thapsigargin (200 nmol/L, n=3). The isoproterenol induced heart rate increase was completely abolished by combined treatment with funny current blocker and SR Ca2+ emptying (n=3). CONCLUSION: Acceleration of the Ca2+ clock in the SP plays an important role in the heart rate acceleration during beta-adrenergic stimulation, and this interacts synergistically with the voltage clock to increase the heart rate.

A Case of Non-Surgical Treatment in Hemodialysis Patient with Spontaneous Splenic Rupture / 대한신장학회지

Spontaneous splenic rupture is a rare disease but can cause a life threatening situation. It can occur under a pathological spleen such as infection, neoplastic, infiltrative and inflammatory disease. Although splenectomy is the treatment of choice for splenic rupture, it is uncertain that the effectiveness of non- surgical treatment in the hemodynamically stable patient. We report a case of a 66-year-old male undergoing hemodialysis for 4 years who presented to the emergency department with abdominal pain and distention. Blood pressure was 130/80 mmHg, heart rate was 108 bpm. White blood cell count was 7,130/mm3, hemoglobin was 6.7 g/dL, platelet was 156,000/mm3. PT INR was elevated up to 2.01 because he had taken warfarin due to splenic infarction. Abdominal CT scan revealed hemoperitoneum due to splenic rupture. We performed angiography but there was no active bleeding. We decided conservative management without embolization because of stable condition and increased bleeding risk in operation. He received 6 pints of packed red blood cell transfusion during continuous renal replacement therapy for 24 hours on ICU. He was discharged with complete recovery on the 21st hospital day. We suggest that non-surgical treatment in splenic rupture also could be considered in hemodynamically stable patients with a high risk of postoperative complication.

The change of T-wave on electrocardiogram after epinephrine test dose in spinal anesthetized adults / 대한마취과학회지

BACKGROUND: This study evaluated the efficacy of a T-wave change after the IV administration of low dose epinephrine containing the test dose during spinal anesthesia. METHODS: Eighty healthy adults undergoing spinal anesthesia were enrolled in this study. The subjects were divided randomly into the following 4 groups: Group S (n = 20) received 3 ml of normal saline, group L (n = 20) received 3 ml of 1.0% lidocaine, group E5 received 3 ml of 1.0% lidocaine with epinephrine 5 microgram, and group E10 received 3 ml of 1.0% lidocaine with epinephrine 10 microgram. The heart rate (HR) and T-wave amplitude were measured with an electrocardiogram and systolic blood pressure (SBP) using a non-invasive method. Positive responses were defined as an increase in HR > or = 20 bpm or SBP > or = 15 mmHg, or a decrease in the T-wave amplitude > or = 25%. RESULTS: The sensitivity (Ss), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) of the HR increases were 80%, 100%, 100%, and 83%, respectively, in groups E5 and E10. For the SBP increases, the Ss, Sp, PPV, and NPV were respectively, 55%, 100%, 100%, and 70% in group E5, and 80%, 100%, 100%, and 83% in group E10. For the > or = 25% decrease in T-wave amplitude, Ss, Sp, PPV, and NPV were respectively, 100%, 90%, 91%, and 100% in group E5, and 95%, 90%, 90%, and 95% in group E10. CONCLUSIONS: These results suggest that a change in the T-wave amplitude is useful for detecting the unintentional IV administration of low dose epinephrine during CSEA.

Incidental Detection of Ductal Carcinoma In Situ of the Breast from Bilateral Prophylactic Mastectomy of Asymptomatic BRCA2 Mutation Carrier: A Case Report / 한국유방암학회지

In women at high-risk for breast cancer with a BRCA mutation, bilateral prophylactic mastectomy (BPM) may achieve a risk reduction. A 35-year-old woman had a strong family history of breast and ovarian cancer. She had a regular checkup and found masses in both breasts that confirmed intraductal papillomas and atypical ductal hyperplasia after vacuum assisted mass excision. When she was referred to our clinic, the genetic testing for BRCA mutation was recommended to her sister that managed for ovarian cancer. It was resulted in the positive for the BRCA2 mutation, so she had checked the genetic testing which resulted in the same as the mutation. After sufficient counseling, she decided to undergo BPM and immediate reconstruction. She is satisfied with the result of surgery. This is the first report of BPM of asymptomatic BRCA2 mutation carrier in Korea and BPM should be considered as a risk-reducing option for BRCA mutation carriers.

[Effects of betamethasone and diclofenac-Na on sulfur mustard induced conjunctival epithelial and goblet cells injuries of rabbits in acute phase]

Sulfur mustard, Bis [2-chlorethy1] sulfide [HD], is one of the first chemical warfare agents to be used on a large scale. Anti inflammatory treatments might have the potential to prevent some aspects of the primary development of HD-induced lesions. The aim of the present study was to evaluate treatment effects of topically applied betamethasone [B] and diclofenac-Na [D] on the conjunctival epithelial lesions following HD exposure. A total of 36 rabbits were used. Animals were randomly divided to three control groups: [1] normal; [2] solution; [3] HD and three experimental groups: [4] betamethasone; [5] diclofenac-Na and [6] betamethasone-diclofenac-Na [BD]. In each group six animals were examined. Right eye of all animals was selected for experiment. In the experimental groups betamethasone and diclofenac-Na were applied after using HD solution. Application of drugs was performed 3 times a day for 2 weeks. Slit-lamp examinations were performed before exposure and subsequently at days 1, 2, 5, 7, and 14 by professional ophthalmologists. Animals were sacrificed after two weeks with chloroform. The eyes were enucleated. Specimens of palpebra were obtained for histological examination. There was not any significant difference between normal and solution groups. HD caused a significant decrease in goblet cells and cell infiltration in conjunctiva, injection and chemosis. All experimental groups were better than the HD group. Betamethasone in combination with diclofenac-Na was more effective than betamethasone and diclofenac-Na alone in decreasing eye injuries. Combination of betamethasone and diclofenac-Na are potential candidates for the treatment of ocular lesions following HD exposure

Anesthetic Requirements in Chronic Cord-injured Patients Undergoing Surgery below the Level of Injury / 대한마취과학회지

BACKGROUND: We determined the effect of spinal cord injury (SCI) on sevoflurane requirements and stress hormone responses, and sevoflurane concentration to block autonomic hyperreflexia (AHR) in SCI patients. METHODS: In the first series, sevoflurane concentrations to maintain bispectral index score (BIS) at 40-50 and stress hormone response were examined in 27 SCI patients undergoing surgery below the level of injury.Fifteen patients without SCI served as control.Measurements included end-tidal sevoflurane concentrations (ET(SEVO)), systolic blood pressure (SBP), heart rate (HR), catecholamines, vasopressin, and cortisol concentrations.In the second series, sevoflurane concentration to block AHR was examined in 31 SCI patients undergoing transurethral litholapaxy.When a patient developed an episode of AHR, the target sevoflurane concentration was maintained for 10 min, and then the procedure was repeated.Each target concentration was determined by up-down method based on SBP. RESULTS: During surgery, SBP, HR, and BIS were comparable between SCI and control.However, ETSEVO was significantly smaller in the SCI than the control.Plasma concentrations of norepinephrine, epinephrine and cortisol were significantly lower in the SCI than the control.SBP rose by 67 +/- 31 mmHg, whereas HR fell by 13 +/- 8 bpm during the 1st trial in the SCI (P < 0.01).Hypertensive events were associated with increases of norepinephrine concentrations.ETSEVO required to prevent AHR were 3.12% in 50% of patients, 3.83% in 95% of patients. CONCLUSIONS: SCI reduces the anesthetic requirement by 39%, and decreases stress hormone responses during surgery below the level of injury.To prevent AHR in 95% of SCI patients undergoing litholapaxy, ETSEVO 3.83% may be required.

Influência dos compostos fenólicos de especiarias sobre a lipoperoxidação e o perfil lipídico de tecidos de ratos / Influence of spices phenolic compounds on lipoperoxidation and lipid profile of rats tissues

OBJETIVO: Este trabalho avaliou o efeito antioxidante dos compostos fenólicos de uma mistura de especiarias (mostarda, canela e erva-doce) sobre o metabolismo dos ácidos graxos das séries ómega3 e ómega6. MÉTODOS: Ratos Wistar recém desmamados receberam dieta rica em gorduras essenciais e um chá de especiarias. Após 45 dias, os animais foram sacrificados e tiveram seus tecidos coletados para análise das substâncias reativas ao ácido tiobarbitúrico e perfil lipídico. RESULTADOS: O chá fornecido aos animais apresentou atividade antioxidante equivalente ao hidroxitolueno butilado. Foram identificados no chá, os ácidos fenólicos catecol, salicílico e caféico; as enzimas cicloxigenase e lipoxigenase foram inibidas pelos extratos ricos nestes ácidos fenólicos. O perfil de ácidos graxos apresenta diferença entre os grupos teste e controles. Todos os tecidos dos grupos teste apresentaram menores valores em lipoperoxidação, em comparação aos controles. CONCLUSAO: Estes dados sugerem, portanto, um efeito antioxidante das substâncias fenólicas identificadas na mistura das especiarias, sobre os ácidos graxos das séries ómega3 e ómega6.

High-performance liquid chromatographic analysis of sulfur mustard reaction with amino acids and proteins

The interaction of sulfur mustard with aminoacids and proteins has been investigated in this study. Rats were injected with sublethal doses of sulfur mustard subcutaneously and intraperitoneally. At different time intervals, plasma and urine samples were collected. The binding affinity of sulfur mustard with urinary and plasma proteins and enzymes was studied for the first time using non-ideal size exclusion high-performance liquid chromatography [HPLC]. We observed that sulfur mustard reacts with proteins and enzymes containing cystein, arginine, and lysine residues