Atypical presentations of drug-induced hypersensitivity syndrome caused by carbamazepine with concurrent use of corticosteroid: Report of a case with a brief literature review

Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, KoreaCarbamazepine (CBZ) is the common antiepileptic drug prescribed for the management of neuropathic pain in patients with neurologic injury. CBZ can rarely be the causative agent to result in drug-induced hypersensitivity syndrome (DIHS), which is a life-threatening drug reaction. Delayed diagnosis of DIHS may occur in complicated clinical settings. We have reported a case of a 12-year-old girl whose initial manifestations of CBZ-induced DIHS were atypical due to concurrent administration of corticosteroids. After open biopsy of brainstem glioma, she was administered corticosteroids and CBZ to mitigate postoperative complications, including mild weakness of ankle dorsiflexion and otalgia. Not only fever but also elevation of liver enzymes and inflammatory markers were presented 1 month after CBZ initiation, without any skin rash or leukocytosis. A maculopapular rash on the whole body and leukocytosis developed afterward; consequently, the diagnostic criteria for DIHS were fulfilled. After discontinuation of CBZ, her fever and increased liver enzymes subsided and the rash slowly improved. This case indicates that typical signs, such as skin rash or leukocytosis, can be initially masked or delayed in CBZ-induced DIHS if it overlaps with corticosteroid administration. The atypical manifestations of DIHS should be considered if CBZ is concurrently administered with corticosteroids.

Exploratory Investigation of the Effects of Tactile Stimulation Using Air Pressure at the Auricular Vagus Nerve on Heart Rate Variability

Objective@#To explore the effects of tactile stimulation using air pressure at the auricular branch of the vagus nerve on autonomic activity in healthy individuals. @*Methods@#Three types of tactile stimulation were used in this study: continuous low-amplitude, continuous high-amplitude, and pulsed airflow. The tactile stimulations were provided to the cymba concha to investigate autonomic activity in 22 healthy participants. The mean heart rate (HR) and parameters of HR variability, including the standard deviation of R-R intervals (SDNN) and root mean square of successive R-R interval differences (RMSSD) were compared at baseline, stimulation, and recovery periods. @*Results@#Two-way repeated measures ANOVA indicated a significant main effect of time on HR (p=0.001), SDNN (p=0.003), and RMSSD (p<0.001). These parameters showed significant differences between baseline and stimulation periods and baseline and recovery periods in the post-hoc analyses. There were no significant differences in the changes induced by stimulation type and the interaction between time and stimulation type for all parameters. One-way repeated measures ANOVA showed that HR, SDNN, and RMSSD did not differ significantly among the three time periods during sham stimulation. @*Conclusion@#Parasympathetic activity can be enhanced by auricular tactile stimulation using air pressure, targeting the cymba concha. Further studies are warranted to investigate the optimal stimulation parameters for potential clinical significance.

Evaluation and Management of Dysphagia Based on Digital Health Technologies / 대한연하장애학회지

The need for non-contact practice during the COVID-19 pandemic has resulted in a rapidly growing interest in digital health technologies (DHTs). Until recently, swallowing evaluations and treatments have been performed face-to-face in the field of dysphagia, which has now encountered huge challenges in the COVID-19 era. This review aims to provide an overview of the DHTs, and investigate the current research trends of DHTs applied to dysphagia evaluation and management. Previous studies on dysphagia using DHTs were reviewed based on four categories: data, machine learning, wearable sensors, and telemedicine. The reports are further discussed for their current limitations and future potentials. We conclude that clinical utility and regulations need to be considered in developing new methods of swallowing evaluation and management based on DHTs.

Evaluation and Management of Dysphagia Based on Digital Health Technologies / 대한연하장애학회지

The need for non-contact practice during the COVID-19 pandemic has resulted in a rapidly growing interest in digital health technologies (DHTs). Until recently, swallowing evaluations and treatments have been performed face-to-face in the field of dysphagia, which has now encountered huge challenges in the COVID-19 era. This review aims to provide an overview of the DHTs, and investigate the current research trends of DHTs applied to dysphagia evaluation and management. Previous studies on dysphagia using DHTs were reviewed based on four categories: data, machine learning, wearable sensors, and telemedicine. The reports are further discussed for their current limitations and future potentials. We conclude that clinical utility and regulations need to be considered in developing new methods of swallowing evaluation and management based on DHTs.

Changes in Hyolaryngeal Movement During Swallowing in the Lateral Decubitus Posture

OBJECTIVE: To investigate the differences in hyolaryngeal kinematics at rest and during swallowing in the upright sitting (UP) and the lateral decubitus (LD) postures in healthy adults, and delineating any potential advantages of swallowing while in the LD posture. METHODS: Swallowing was videofluoroscopically evaluated in 20 healthy volunteers in UP and LD postures, based on the movements of hyoid bone, vocal folds, and the bolus head. Parameters included the Penetration-Aspiration Scale (PAS), horizontal and vertical displacement, horizontal and vertical initial position, horizontal and vertical peak position, time to peak position of the hyoid bone and vocal folds, and pharyngeal transit time (PTT). RESULTS: Nine participants were rated PAS 2 in the UP and 1 was rated PAS 2 in the LD (p=0.003) at least 1 out of 3 swallows each posture. The hyoid and vocal folds showed more anterior and superior peak and initial positions in the LD. In addition, swallowing resulted in greater vertical and smaller horizontal displacement of the hyoid in LD posture compared with UP. Time to peak position of the hyoid was shorter in LD. The maximal vertical and horizontal displacement of the vocal folds, and PTT were comparable between postures. CONCLUSION: The results showed that the peak and initial positions of the hyoid and larynx and the pattern of hyoid movement varied significantly depending on the body postures. This study suggests that the LD posture was one of the safe feeding postures without any increased risk compared with UP posture.

The Effect of Balloon Dilatation and/or Botulinum Toxin Injection on the Severe Dysphagic Patients with Cricopharyngeal Dysfunction: Case Series / 대한연하장애학회지

OBJECTIVE: To investigate changes of swallowing function after ballooning dilatation (BD) and the Botox injection (BI) into the cricopharyngeus muscle in patients with severe dysphagia. METHOD: Nine severe dysphagic patients with cricopharyngeal dysfunction (CPD) who underwent BD and/or BI into the cricopharyngeal muscle were retrospectively reviewd. Patients who had severe dysphagia (Functional Oral Intake Scale (FOIS)≤2) after at least 3 months of the conventional swallowing therapy were included by a thorough review of medical records with videofluoroscopic swallowing study (VFSS). Before and after several interventions (BD and/or BI), swallowing function was evaluated using VFSS. RESULT: Among 9 patients, 5 underwent both BD and BI, and the other 4 patients underwent only BD. Four among 9 cases showed that interventions were effective. Of the 5 cases with both BD and BI, 2 cases were effective for treatment of CPD. In all the effective 4 cases, pyriform sinus residue seemed to be related with FOIS. Of those cases, one case had long-term effect (more than 4 months) and the other 3 case had short term effect (less than 4 months). CONCLUSION: Interventions were effective in 4 among 9 cases with severe CPD and the therapeutic effect was sustained for more than 4 months. The results suggest that in CPD patients, the BD or BI into UES could be considered in selected patients.

Current State and Prospects of Development of Blood-based Biomarkers for Mild Traumatic Brain Injury

The current understanding of the pathophysiology of mild traumatic brain injury (mTBI) is, without doubt, incomplete. Nevertheless, we tried to summarize the state-of-the-art explanation of how the brain is continuously injured even after a single impact. We also reviewed the real struggle of diagnosing mTBI, which culminated in showing the potential of blood-based biomarkers as an alternative or complementary way to overcome this difficulty. Pathophysiology of mTBI is subdivided into primary and secondary injuries. Primary injury is caused by a direct impact on the head and brain. Secondary injury refers to the changes in energy metabolism and protein synthesis/degradation resulting from the biochemical cascades as follows; calcium influx, mitochondrial dysfunction, fractured microtubules, and Wallerian degeneration, neuroinflammation, and toxic proteinopathy. Since the diagnosis of mTBI is made through the initial clinical information, it is difficult and inaccurate to diagnose mTBI without the absence of a witness or sign of head trauma. Blood-based biomarkers are expected to play an important role in diagnosing mTBI and predicting functional outcomes, due to their feasibility and the recent progress of targeted proteomics techniques (i.e., liquid chromatography tandem mass spectrometry [LC-MS/MS]).

Influence of the Swallowing Posture and Liquid Thickness on the Ease of Pill Swallowing in Healthy Adults / 대한연하장애학회지

OBJECTIVE: To investigate the influence of the swallowing posture and liquid thickness on the easiness of pill swallowing in healthy adults. METHOD: The subjects were 12 healthy young group (19-40 years) and 10 elderly group (65- years). Each subject was examined under videofluoroscopy while swallowing barium-containing placebo pills with six different methods: free fluid with neutral (FN), chin down (FD), chin up (FU), head rotated to left (FL), head rotated to right postures (FR), and thickened fluid with neutral posture (TN). The subjects rated their ease of pill swallowing on a 5-point Likert scale. Time variables were evaluated from the videofluoroscopy images. RESULT: FD, FU and FL were rated significantly less comfortable than FN for pill swallowing. Duration from the start signal to the mandible angle and to laryngeal elevation was significantly prolonged with FD and FL compared to FN. Duration from the start signal to the upper esophageal sphincter was significantly prolonged with FD compared to FN. There were no significant differences on either easiness of swallowing or the time variables between FN and TN. Duration from the start signal to the mandible angle and to the upper esophageal sphincter was significantly longer in the elderly group than the young group with all swallowing methods except FU. In the elderly group, duration from the start signal to laryngeal elevation was significantly shorter with FU than FN. CONCLUSION: Chin down posture is uncomfortable and prolong swallowing time during pill swallowing. In the neutral posture, pill swallowing with thickened fluid is comparable to that with free fluid. Chin up posture may shorten pill swallowing time in elderly.

Clinical Outcomes of Conservative Treatment and Arthroscopic Repair of Rotator Cuff Tears: A Retrospective Observational Study

OBJECTIVE: To compare the clinical outcomes following conservative treatment and arthroscopic repair in patients with a rotator cuff tear. METHODS: In this retrospective study, patients aged >50 years with a symptomatic rotator cuff tear were reviewed. The rotator cuff tendons were evaluated using ultrasonography, shoulder magnetic resonance imaging or MR arthrography, and the patients with either a high-grade partial-thickness or small-to-medium-sized (≤3 cm) full-thickness tear were included in this study. The primary outcome measures were a pain assessment score and range of motion (ROM) at 1-year follow-up. The secondary outcomes were the rate of tear progression or retear along with the rate of symptom aggravation after the treatments. RESULTS: A total of 357 patients were enrolled, including 183 patients that received conservative treatment and 174 patients who received an arthroscopic repair. The pain assessment score (p50 years old with a less than medium-sized rotator cuff tear in a 1-year follow-up period. Further study is warranted to find the optimal combination of conservative treatment for a symptomatic rotator cuff tear.

Crystallization of Local Anesthetics When Mixed With Corticosteroid Solutions

OBJECTIVE: To evaluate at which pH level various local anesthetics precipitate, and to confirm which combination of corticosteroid and local anesthetic crystallizes. METHODS: Each of ropivacaine-HCl, bupivacaine-HCl, and lidocaine-HCl was mixed with 4 different concentrations of NaOH solutions. Also, each of the three local anesthetics was mixed with the same volume of 3 corticosteroid solutions (triamcinolone acetonide, dexamethasone sodium phosphate, and betamethasone sodium phosphate). Precipitation of the local anesthetics (or not) was observed, by the naked eye and by microscope. The pH of each solution and the size of the precipitated crystal were measured. RESULTS: Alkalinized with NaOH to a certain value of pH, local anesthetics precipitated (ropivacaine pH 6.9, bupivacaine pH 7.7, and lidocaine pH 12.9). Precipitation was observed as a cloudy appearance by the naked eye and as the aggregation of small particles (300 µm, pH 7.5). Ropivacaine with dexamethasone sodium phosphate also precipitated, but it was only observable by microscope (a few crystals of 10-100 µm, pH 7.0). Bupivacaine with betamethasone sodium phosphate formed precipitates of non-aggregated smaller particles (<10 µm, pH 7.7). Lidocaine mixed with corticosteroids did not precipitate. CONCLUSION: Ropivacaine and bupivacaine can precipitate by alkalinization at a physiological pH, and therefore also produce crystals at a physiological pH when they are mixed with betamethasone sodium phosphate. Thus, the potential risk should be noted for their use in interventions, such as epidural steroid injections.

Characteristics of Dysphagia in Severe Traumatic Brain Injury Patients: A Comparison With Stroke Patients

OBJECTIVE: To compare the swallowing characteristics of dysphagic patients with traumatic brain injury (TBI) with those of dysphagic stroke patients. METHODS: Forty-one patients with TBI were selected from medical records (between December 2004 to March 2013) and matched to patients with stroke (n=41) based on age, sex, and disease duration. Patients' swallowing characteristics were analyzed retrospectively using a videofluoroscopic swallowing study (VFSS) and compared between both groups. Following thorough review of medical records, patients who had a history of diseases that could affect swallowing function at the time of the study were excluded. Dysphagia characteristics and severity were evaluated using the American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale, clinical dysphagia scale, and the videofluoroscopic dysphagia scale. RESULTS: There was a significant difference in radiological lesion location (p=0.024) between the two groups. The most common VFSS finding was aspiration or penetration, followed by decreased laryngeal elevation and reduced epiglottis inversion. Swallowing function, VFSS findings, or quantified dysphagia severity showed no significant differences between the groups. In a subgroup analysis of TBI patients, the incidence of tube feeding was higher in patients with surgical intervention than in those without (p=0.011). CONCLUSION: The swallowing characteristics of dysphagic patients after TBI were comparable to those of dysphagic stroke patients. Common VFSS findings comprised aspiration or penetration, decreased laryngeal elevation, and reduced epiglottis inversion. Patients who underwent surgical intervention after TBI were at high risk of tube feeding requirement.

Successful Implantation of an Implantable Cardioverter-Defibrillator Through a Persistent Left Superior Vena Cava / 대한내과학회지

The prevalence of persistent left superior vena cava (PLSVC) in the general population has been estimated to be approximately 0.3%, as determined by autopsy. PLSVC is hemodynamically insignificant if it is not associated with other congenital cardiac anomalies, and usually goes unrecognized until a left superior approach to the heart is required. Here, we report a 60-year-old male diagnosed with dilated cardiomyopathy, who had survived an episode of sudden cardiac arrest with documented ventricular fibrillation. PLSVC was recognized incidentally while implanting an implantable cardioverter-defibrillator (ICD). The ICD was successfully implanted through the left superior vena cava via the coronary sinus using a straight stylet and an active fixation device.

Role of Dyssynchrony on Functional Mitral Regurgitation in Patients with Idiopathic Dilated Cardiomyopathy: A Comparison Study with Geometric Parameters of Mitral Apparatus

BACKGROUND: Functional mitral regurgitation (FMR) occurs commonly in patients with dilated cardiomyopathy (DCM). This study was conducted to explore the role of left ventricular (LV) dyssynchrony in developing FMR in patients with DCM in comparison with geometric parameters of the mitral apparatus. METHODS: Twenty patients without FMR and 33 patients with FMR [effective regurgitant orifice area (ERO) = 0.17 +/- 0.10 cm2] were enrolled. MR severity was estimated with ERO area. Dyssynchrony indices (DI) were measured using the standard deviations of time to peak myocardial systolic velocity between eight segments. Using real time 3D echocardiography, mitral valve tenting area (MVTa), anterior (APMD) and posterior papillary muscle distances (PPMD), LV sphericity, and tethering angle of anterior (Aalpha) and posterior leaflets (Palpha) were estimated. All geometrical measurements were corrected (c) by the height of each patient. RESULTS: The patient with FMR had significantly higher cDI, cMVTa, cAPMD and cPPMD, LV sphericity, Aalpha, and Palpha than the patients without FMR (all p < 0.05). With multiple logistic regression analysis, cMVTa (p = 0.017) found to be strongest predictor of FMR development. In patients with FMR, cMVTa (r = 0.868), cAPMD (r = 0.801), cPPMD (r = 0.742), Aalpha (r = 0.454), LV sphericity (r = 0.452), and DI (r = 0.410) showed significant correlation with ERO. On multivariate regression analysis, cMVTa and cAPMD (p < 0.001, p = 0.022, respectively) remained the strongest determinants of the degree of ERO and cAPMD (p < 0.001) remained the strongest determinant of the degree of cMVTa. CONCLUSION: Displacement of anterior papillary muscle and consequent mitral valve tenting seem to play a major role in developing FMR in DCM, while LV dyssynchrony seems to have no significant role.

Postcardiac Injury Syndrome after Percutaneous Coronary Intervention

The post cardiac injury syndrome is characterized by the development of a fever, pleuropericarditis, and parenchymal pulmonary infiltrates in the weeks following trauma to the pericardium or myocardium. According to previous reports, almost all cases develop after major cardiac surgery or a myocardial infarction. Recently, a few reports have described post cardiac injury syndrome as a complication of endovascular procedures such as percutaneous cardiac intervention. Here we describe an unusual case of post cardiac injury syndrome after a percutaneous coronary intervention.

Chronic Administration of Monosodium Glutamate under Chronic Variable Stress Impaired Hypothalamic-Pituitary-Adrenal Axis Function in Rats

The hypothalamic-pituitary-adrenal (HPA) axis is the primary endocrine system to respond to stress. The HPA axis may be affected by increased level of corticotrophin-releasing factors under chronic stress and by chronic administration of monosodium glutamate (MSG). The purpose of this study was to investigate whether chronic MSG administration aggravates chronic variable stress (CVS)-induced behavioral and hormonal changes. Twenty-four adult male Sprague-Dawley rats, weighing 200~220 g, were divided into 4 groups as follows: water administration (CON), MSG (3 g/kg) administration (MSG), CVS, and CVS with MSG (3 g/kg) administration (CVS+MSG). In addition, for the purpose of comparing the effect on plasma corticosterone levels between chronic stress and daily care or acute stress, 2 groups were added at the end of the experiment; the 2 new groups were as follows: naive mice (n=7) and mice exposed to restraint stress for 2 h just before decapitation (A-Str, n=7). In an open field test performed after the experiment, the CVS+MSG group significant decrease in activity. The increase in relative adrenal weights in the CVS and CVS+MSG group was significantly greater than those in the CON and/or MSG groups. In spite of the increase in the relative adrenal weight, there was a significant decrease in the plasma corticosterone levels in the CVS+MSG group as compared to all other groups, except the naive group. These results suggest that impaired HPA axis function as well as the decrease in the behavioral activity in adult rats can be induced by chronic MSG administration under CVS rather than CVS alone.

Does The Mitral Annulus Shrink or Enlarge During Systole? A Real-Time 3D Echocardiography Study

This study was conducted to explore the geometrical changes of the mitral annulus during systole. The 3D shape of the mitral annulus was reconstructed in 13 normal subjects who had normal structure of the mitral apparatus using real-time 3D echocardiography (RT3DE) and 3D computer software. The two orthogonal (antero-posterior and commissure-commissure) dimensions, the areas (2D projected and 3D surface) and the non-planarity of the mitral annulus were estimated during early, mid and late systole. We demonstrated that the MA had a "saddle shape" appearance and it consistently enlarged mainly in the antero-posterior direction from early to late systole with lessening of its non-planarity, as was determined by 3D reconstruction using RT3DE and 3D computer software.

A Case of Acute Myocardial Infarction with the Anomalous Origin of the Right Coronary Artery from the Ascending Aorta above the Left Sinus of Valsalva and Left Coronary Artery from the Posterior Sinus of Valsalva

Coronary anomalies are rare angiographic findings. Moreover, there are few reports of cases of an anomalous origin of the right coronary artery from the left sinus of Valsalva and of the left coronary artery from the posterior sinus of Valsalva. Here, we report a case with an anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva and the left coronary artery from the posterior sinus of Valsalva. This was observed in a patient who was treated for a myocardial infarction of the inferior wall caused by a thrombus in the proximal right coronary artery. The patient was treated successfully with the implantation of a stent in the anomalous origin of the right coronary artery using a 6Fr Amplatz left 1 catheter.

Development of a Web-based Donor Eligibility Expert System / 대한수혈학회지

BACKGROUND: The determination of blood donor eligibility has become critical and challenging to blood operators as so many conditions and restrictions should be considered to correctly decide the donor eligibility. Since the launching of the BIMS (Blood Information Management System) in May 2003, the demand of developing a more intelligent system to assist the determination of donor eligibility has been growing. The Korean Red Cross Blood Service intended to develop an expert system for donor eligibility determination with high efficiency and ease of use. METHODS: The content of the system was determined through the activity of a team consisting of medical doctors, nurses, safety managers, and the system developers. Algorithms were developed according to the donor history taking process. The efficiency of the system was tested by the comparison of the time needed for inquiries and the number of inappropriate blood collections before and after the implementation of the new system. RESULTS: The new system's user interface integrated many complicated work processes with a user-friendly flexibility. The types of decision included the restricted donations. The donor interviewers were highly satisfied with the system because almost all cases were correctly determined in a relatively short time. Using this system, the number of inappropriate blood collections was significantly lowered. CONCLUSION: We developed an expert system that can aide the donor eligibility determination process and prevent the violation of the related regulations. This system will contribute to enhancement of the blood safety as well as donor protection for our blood services.

Development of a Web-based Donor Eligibility Expert System / 대한수혈학회지

BACKGROUND: The determination of blood donor eligibility has become critical and challenging to blood operators as so many conditions and restrictions should be considered to correctly decide the donor eligibility. Since the launching of the BIMS (Blood Information Management System) in May 2003, the demand of developing a more intelligent system to assist the determination of donor eligibility has been growing. The Korean Red Cross Blood Service intended to develop an expert system for donor eligibility determination with high efficiency and ease of use. METHODS: The content of the system was determined through the activity of a team consisting of medical doctors, nurses, safety managers, and the system developers. Algorithms were developed according to the donor history taking process. The efficiency of the system was tested by the comparison of the time needed for inquiries and the number of inappropriate blood collections before and after the implementation of the new system. RESULTS: The new system's user interface integrated many complicated work processes with a user-friendly flexibility. The types of decision included the restricted donations. The donor interviewers were highly satisfied with the system because almost all cases were correctly determined in a relatively short time. Using this system, the number of inappropriate blood collections was significantly lowered. CONCLUSION: We developed an expert system that can aide the donor eligibility determination process and prevent the violation of the related regulations. This system will contribute to enhancement of the blood safety as well as donor protection for our blood services.

The Relationship between the Left Atrial Volume and the Maximum P-wave and P-wave Dispersion in Patients with Congestive Heart Failure

PURPOSE: A maximum P-wave duration (Pmax) of > or = 110msec and a P-wave dispersion (PWD) > or = 40msec are accepted indicators of a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse, respectively. The left atrial (LA) volume has been reported to be strongly associated with a systolic and diastolic dysfunction and is considered to be an index of atrial remodeling. We aimed to investigate the relationship between LA volume and Pmax or PWD in patients with congestive heart failure (CHF). PATIENTS AND METHODS: Sixty-one patients with CHF were enrolled in this study. The study population was classified into four groups: two groups were divided according to the Pmax (> or = 110msec or or = 40msec or or = 110ms or a PWD > or = 40ms and those with a Pmax < 110ms or a PWD < 40ms. The LAVi was independently associated with a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse. The LAVi can be used to identify patients with a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse with reasonably good accuracy. CONCLUSION: We concluded that a disturbance in interatrial conduction and an inhomogenous propagation of the sinus impulse in patients with CHF is associated with an increase in the LA volume and a deleterious systolic and diastolic dysfunction.