Awake craniotomy is indicated for tumor resection involving eloquent cortex. It allows the operator to perform appropriate cortical mapping during surgery and facilitate maximum tumor resection while minimizing neurologic deficit. Therefore anesthesia should provide adequate analgesia and sedation but also importantly a full consciousness and cooperation for neurologic testing. This case reports the use of target-controlled infusion (TCI) and monitoring of sedation and anesthetic depth through bispectral index (BIS), providing good control of sedation and analgesia to meet frequent changes throughout the different levels of the procedure while maintaining good condition for intraoperative brain mapping. We propose that TCI of propofol and remifentanil in combination may be a useful alternative for awake craniotomy requiring intraoperative brain mapping surgery.
Analgesia ; Anesthesia ; Brain Mapping ; Conscious Sedation ; Consciousness ; Craniotomy ; Neurologic Manifestations ; Piperidines ; Propofol

The thoracic spine is rigidly stabilized by the ribs, anterior and posterior longitudinal ligaments, and a sagittal orientation of the facet joints that resists axial rotation and horizontal translation. Thus, a significant force is required to cause a fracture and dislocation in the thoracic spine. A 32-year-old man was involved in a motor-vehicle accident and presented with complete paraplegia and spondyloptosis on the 8th thoracic vertebral segment. He also suffered with hypoxia and hypovolemic shock. Posterior reduction and fixation with pedicle screw was achieved with the anatomic alignment and rigid stability. This posterior technique for thoracic spondyloptosis is believed to be sufficient to make good alignment and solid fixation.
Adult ; Anoxia ; Dislocations ; Humans ; Longitudinal Ligaments ; Paraplegia ; Ribs ; Shock ; Spine ; Zygapophyseal Joint

NSAIDs are now the most widely prescribed of all drugs for the therapy of a large variety of disorders including rheumatologic disorders, and so the population of patients who are at risk for adverse effects of these drugs is rapidly expanding. A number of renal and electrolyte problems have been associated with the use of NSAIDs, including alterations in glome-rular filtration rate, hyperkalemia, acute interstitial nephritis and papillary necrosis. While the use of NSAIDs has also been associated with minimal change nephrotic syndrome, this complication has almost invariably occured in association with an acute interstitial nephritis. Recently, we experienced a case of minimal change nephrotic syndrome without significant interstitial inflammation associated with the use of NSAIDs. This patient is a 64-year-old female who developed the generalized edema and about 10kg of weight gain since three days ago. She had taken the anti-inflammatory drugs for five years intermittently and started taking diclofenac sodium, 25mg orally three times a day, 10 days before admission for increasing pain in her knees. Laboratory findings disclosed the following values WBC 5,200/mm3 with only 0.6% eosinophils, total serum protein 4.0g/dL, albumin 1.2 g/dL, BUN 17mg/dL, creatinine 0.8mg/dL, sodium 140 mmol/L, potassium 4.0mmol/L, chloride 113mmol/L, total cholesterol 338mg/dL, triglyceride 203mg/dL; 24-hour protein excretion 3.6g, creatinine clearance 52.8 mL/min ; serologic tests were unremarkable. A renal biopsy revealed no abnormality except for focal mild interstitial infiltration of chronic inflammatory cells with a few atrophic tubules on light microscopy. Immunofluorescence studies showed diffuse trace mesangial deposits of IgM, and electromicroscopy revealed diffuse obliteration of the epithelial foot process and villous transformation of the epitherial cell cytoplasms without electrondense deposits. These findings were consistent with minimal-change disease. Diclofenac was discontinued on admission because of the likelihood the renal disease was drugrelated and she treated with low-dose(40-80mg/d) of furosemide. Fourteen days after stopping diclofenac, her massive edema and weight gain resolved and laboratory studies showed a 24-hour urine protein excretion of 80mg and serum albumin of 2.7g/dL. There has been no relapse for five months since then.
Anti-Inflammatory Agents, Non-Steroidal ; Biopsy ; Cholesterol ; Creatinine ; Cytoplasm ; Diclofenac* ; Edema ; Eosinophils ; Female ; Filtration ; Fluorescent Antibody Technique ; Foot ; Furosemide ; Humans ; Hyperkalemia ; Immunoglobulin M ; Inflammation ; Knee ; Microscopy ; Middle Aged ; Necrosis ; Nephritis, Interstitial ; Nephrosis, Lipoid ; Potassium ; Recurrence ; Serologic Tests ; Serum Albumin ; Sodium ; Triglycerides ; Weight Gain

BACKGROUND/AIMS: Metformin is known to lower the risk of cancer and cancer mortality. However, the effect of metformin in stage IV colorectal cancer (CRC) patients with diabetes mellitus (DM) remains unknown. The aim of this study was to evaluate the effect of metformin on tumor response and survival in stage IV CRC patients with DM. METHODS: We identified 106 patients who were diagnosed with both stage IV CRC and DM (81 patients who underwent palliative chemotherapy and 25 patients who underwent curative resection). Retrospective data of each patient's clinical characteristics, tumor response, and survival rate were compared between two groups of patients who either were or were not administered metformin. RESULTS: For the palliative chemotherapy group, tumor response, change in target lesion size, progression free survival rate, and overall survival rate were not significantly different between the metformin group and the non-metformin group on univariate and multivariate analysis. For the curative resection patient group, metformin use was associated with increased disease free survival on univariate analysis (p=0.012) and multivariate analysis (hazard ratio, 0.024; 95% CI 0.001-0.435; p=0.010), but not with overall survival. CONCLUSIONS: Metformin use in stage IV CRC patients with diabetes was shown to be associated with a lower risk of tumor recurrence after curative resection.
Adult ; Aged ; Aged, 80 and over ; Antineoplastic Agents/therapeutic use ; Colorectal Neoplasms/drug therapy/*mortality/pathology ; Diabetes Mellitus/*drug therapy ; Disease-Free Survival ; Female ; Humans ; Hypoglycemic Agents/*therapeutic use ; Male ; Metformin/*therapeutic use ; Middle Aged ; Multivariate Analysis ; Neoplasm Staging ; Palliative Care ; Retrospective Studies ; Survival Rate

BACKGROUND/AIMS: Anemia in patients with inflammatory bowel disease significantly affects the quality of life. The aim of this study was to investigate the frequency of and risk factors for anemia and to describe the management of anemia in patients with intestinal Behcet's disease (BD) in actual clinical practice. METHODS: We included 64 patients with intestinal BD who visited the outpatient clinic of a tertiary referral center in June 2011 and had available laboratory data for the subsequent 6 months. RESULTS: Anemia was detected in 26 patients (40.6%). After 6 months, anemia was still present in 14 of these patients (53.8%). The cause of anemia was investigated in eight patients (30.8%), and oral iron supplementation was prescribed to four patients (15.4%). Of these four patients, two (50%) recovered completely within 6 months. Anemia was associated with a high Disease Activity Index for Intestinal Behcet's Disease (DAIBD, p=0.024), erythrocyte sedimentation rate (p=0.003), and C-reactive protein (p=0.049) in univariate analysis. In multivariate analysis, the factor predictive for anemia in patients with intestinal BD was a higher DAIBD (> or =40; odds ratio, 4.08; 95% confidence interval, 1.21 to 13.71; p=0.023). CONCLUSIONS: Although anemia is common in intestinal BD patients, its clinical importance is overlooked in daily practice. Moderate to severe disease activity is predictive of anemia.
Adult ; Anemia/drug therapy/epidemiology/*etiology ; Behcet Syndrome/blood/*complications/pathology ; Blood Sedimentation ; C-Reactive Protein/analysis ; Dietary Supplements ; Disease Management ; Female ; Humans ; Intestinal Diseases/blood/*complications/pathology ; Iron/therapeutic use ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Predictive Value of Tests ; Risk Factors ; Severity of Illness Index ; Trace Elements/therapeutic use

PURPOSE: Although there is a consensus about the need for surveillance colonoscopy after endoscopic resection, the interval remains controversial for large sessile colorectal polyps. The aim of this study was to evaluate the long-term outcome and the adequate surveillance colonoscopy interval required for sessile and flat colorectal polyps larger than 20 mm. MATERIALS AND METHODS: A total of 204 patients with large sessile and flat polyps who received endoscopic treatment from May 2005 to November 2011 in a tertiary referral center were included. RESULTS: The mean age was 65.1 years and 62.7% of the patients were male. The mean follow-up duration was 44.2 months and the median tumor size was 25 mm. One hundred and ten patients (53.9%) received a short interval surveillance colonoscopy (median interval of 6.3 months with range of 1-11 months) and 94 patients (46.1%) received a long interval surveillance colonoscopy (median interval of 13.6 months with range of 12-66 months). There were 14 patients (6.9%) who had local recurrence at the surveillance colonoscopy. Using multivariate regression analysis, a polyp size greater than 40 mm was shown to be independent risk factor for local recurrence. However, piecemeal resection and surveillance colonoscopy interval did not significantly influence local recurrence. CONCLUSION: Endoscopic treatment of large sessile colorectal polyps shows a favorable long-term outcome. Further prospective study is mandatory to define an adequate interval of surveillance colonoscopy.
Adult ; Aged ; Colonic Neoplasms/*diagnosis/pathology/surgery ; Colonic Polyps/*diagnosis/pathology/surgery ; *Colonoscopy ; Endoscopic Mucosal Resection ; Female ; Humans ; Male ; Middle Aged ; Neoplasm Recurrence, Local/*diagnosis ; Prospective Studies ; Time Factors ; Watchful Waiting/*methods

Baclofen (beta-4-chlorophenyl-gamma-aminobutyric acid), a gamma-aminobutyric acid (GABA) derivative, is commonly used for relief of spinal-origin spasm or pain. Baclofen is eliminated predominantly by the kidneys, putting patients with impaired renal function at particular risk for baclofen accumulation. The authors report on a case of baclofen-induced encephalopathy in a patient on continuous ambulatory peritoneal dialysis (CAPD). A 56 year old patient with ESRD on CAPD was admitted due to stuporous mental status after baclofen treatment. Brain imaging showed no specific abnormality. After intensive treatment of CAPD for 3 days, neurologic abnormality was completely recovered. Baclofen should not be recommended for patients with renal dysfunction. Although the best-known treatment choice for baclofen toxicity is hemodialysis, intensive CAPD can also be considered as an option for treatment of baclofen toxicity.
Baclofen ; gamma-Aminobutyric Acid ; Humans ; Kidney ; Kidney Failure, Chronic ; Neuroimaging ; Peritoneal Dialysis, Continuous Ambulatory ; Renal Dialysis ; Spasm ; Stupor

Cellular schwannoma is an uncommon variant of schwannomas that can occur in a peripheral nerve. Although cellular schwannomas typically do not differ in prognosis from regular schwannomas, they are known to cause local recurrence when not completely resected. Here, we report the case of a patient with cellular schwannoma of the posterior mediastinum, which recurred after 13 years.
Humans ; Mediastinal Neoplasms ; Mediastinum ; Neoplasm Recurrence, Local ; Neurilemmoma* ; Peripheral Nerves ; Prognosis ; Recurrence

BACKGROUND/AIMS: Adalimumab is effective for both remission induction and the maintenance of Crohn's disease (CD) in Western countries. We evaluated the efficacy of adalim-umab in the conventional step-up treatment approach for CD in Korea. METHODS: We retrospectively reviewed 62 patients with CD who were treated with adalimumab. Their Crohn's disease activity index (CDAI) was measured at weeks 4, 8, and 52. Clinical remission was defined as a CDAI score <150. Induction and maintenance outcomes were analyzed. RESULTS: Forty-one patients (66.1%) achieved a reduction of 70 CDAI points at week 8. Among them, 28 (45.2%) achieved clinical remission at week 8, 20 (32.3%) maintained remission at week 52. The absence of prior anti-tumor necrosis factor (TNF) therapy and Montreal classification L1 at baseline predicted clinical remission at week 8 in the multivariate logistic regression analysis. In the Cox proportional hazards model, the hazard ratio for the secondary loss of response during maintenance therapy after clinical remission induction was significantly higher in patients who showed initial mild CDAI severity or Montreal classification A3. CONCLUSIONS: In our study, anti-TNF therapy-naive and Montreal classification L1 were associated with adalimumab efficacy as induction therapy in CD. Further studies are warranted to determine the prognostic factors for the long-term response after adalimumab therapy.
Adalimumab/*therapeutic use ; Adolescent ; Adult ; Anti-Inflammatory Agents/*therapeutic use ; Crohn Disease/*drug therapy ; Female ; Humans ; Male ; Middle Aged ; Proportional Hazards Models ; Remission Induction/methods ; Republic of Korea ; Retrospective Studies ; Severity of Illness Index ; Treatment Outcome ; Young Adult

BACKGROUND AND OBJECTIVES: Drug-induced electrocardiographic QT interval prolongation is associated with the occurrence of a potentially lethal form of polymorphic ventricular tachycardia, termed 'torsades de pointes' (TdP). Women are at greater risk for the development of drug-induced TdP. To determine whether this may be the result of gender-specific differences in the effect of quinidine on cardiac repolarization, we compared the degree of quinidine-induced QT interval lengthening in young, healthy volunteers. SUBJECTS AND METHODS: Twelve women and 12 men each received a single intravenous dose of quinidine (4 mg/kg) or placebo in a single-blinded, randomized crossover trial. Total plasma concentrations of quinidine were measured, and QT and corrected QT intervals were analyzed. RESULTS: As expected, the mean QTc interval at baseline was longer for women than for men (443.6+/-26.9 vs 402.1+/-31.3 msec, respectively, p=0.037). The mean value of the maximal DeltaQTc after quinidine infusion was higher in women (134.4+/-46.4 vs 117.5+/-37.7 msec, respectively, p=0.029), and the mean value of the minimal DeltaQTc for 1 hour after quinidine infusion was also higher in the female group (47.6+/-15.7 vs 83.7+/-25.4 msec, p=0.034). However, there were no significant differences in the time courses of the changes in the quinidine-induced QTc and DeltaQTc interval between the two groups (p=0.092, and p=0.305, respectively). CONCLUSION: Quinidine causes greater QT prolongation in women at equivalent serum concentrations. This difference may contribute to the greater incidence of drug-induced TdP observed in women taking quinidine, and has implications for other cardiac and noncardiac drugs that prolong the QTc interval.
Asian Continental Ancestry Group ; Electrocardiography ; Female ; Healthy Volunteers ; Humans ; Incidence ; Male ; Plasma ; Quinidine ; Tachycardia, Ventricular