Lamotrigine is a newer anti-epileptic drug for adjunctive treatment of refractory epilepsy, partial seizures, generalized tonic-clonic seizures, and bipolar disorder. Lamotrigine overdose causes serious central nervous and cardiovascular problems, but reports are uncommon. Few lamotrigine overdoses have been described because anti-epileptic drug use is limited and usually used with combination of other anti-epileptic drugs. In addition, most patients visit emergency departments with multi-drug overdoses, so few cases of lamotrigine poisoning alone exist. We had a female patient visit our emergency department a couple of hours after a lamotrigine overdose treated with intravenous hydration and urine alkalization by NaHCO3. She recovered successfully without any evidence of renal injury. However, she developed profound rhabdomyolysis, a previously unreported complication of this medication. We suggest that serial creatine kinase levels should be measured after lamotrigine poisoning.
Bipolar Disorder ; Creatine Kinase ; Emergencies ; Epilepsies, Partial ; Female ; Humans ; Rhabdomyolysis ; Seizures ; Triazines

Extramammary Pagets disease(EMPD) of the vulva is an uncommon neoplasm which accounting for 2.5% of all vulvar malignancies and 0.02% of all female cancer. Several hundred cases have been reported worldwide since the first description by sir James Paget in 1874, It generally affects postrnenopausal age poup and presents high rate of recurrence but the precise incidence remines unclear, Although Paget's disease of the breast and the vulva are histologically similar, their histogenesis and biological behavior are considered to be significantly different and EMPD has gcnerally perceived rnore benign compared to that of the breast. Four histologic forms of vulvar EMPD have been recognized and treated vulvar EMPD in according to the 4 histologic classification. The high rate of recurtence disease remains a challenge for optimal management. Recently we experienced a case of Paget's disease of the vulva, diagnosed as an intraepithelial Pagets disease preoperatively and underwent radical vulvectomy and superiomedial thigh(SMT) flap, and present with a brief review of literature.
Breast ; Classification ; Female ; Humans ; Incidence ; Paget's Disease, Mammary ; Recurrence ; Vulva*

Meralgia paresthetica (MP), first described in 1878, is a sensory mononeuropathy of the lateral femoral cutaneous nerve (LFCN) characterized by pain, tingling, numbness, and paresthesias localized to the anterolateral thigh. There are many etiologies for MP, including those that are spontaneous (idiopathic, metabolic or mechanical) and iatrogenic (surgery, trauma). A 46-year-old female came to our emergency department (ED) with a right hip pain that developed after two days of an altered mental status from high amounts of multiple drugs (benzodiazepine, SSRI, and antipsychotics) to commit suicide. Her past medical and surgical histories were unremarkable. In addition, her vital signs were stable and her electrocardiography was unremarkable. On the other hand, laboratory tests showed an elevated creatinine kinase 14787 IU/L (normal range, 26~140 IU/L) and urine myoglobin >1000 ng/mL (normal range, 0~10 ng/mL). She was admitted to our ED for the management of rhabdomyolysis. The patient didn't slip down and slept on her right side for a long period. An initial pelvis and femur x-ray ruled out a fracture and a straight leg raise test was negative. We took a lumbar spine x-ray to rule out a herniated intervertebral disk because she complained of pain in the second and third lumbar distribution of her right thigh. These x-rays were unremarkable. We presumed she had a hip and thigh contusion and gave her painkillers, but her symptoms did not improved. After a day, the patient complained of numbness (5/10) rather than pain. We then suspected peripheral neuropathy. Her electromyography and nerve conduction velocity confirmed right LFCN neuropathy, MP. MP is often clinically diagnosed and treated conservatively. It is a neurologic disorder due to the entrapment of the LFCN. This case shows that a long period lacking in movement can cause MP. In future cases, the possibility of peripheral neuropathy should be considered, especially in mentally altered patients after drug intoxication.
Contusions ; Creatinine ; Electrocardiography ; Electromyography ; Emergencies ; Female ; Femur ; Hand ; Hip ; Humans ; Hypesthesia ; Intervertebral Disc ; Leg ; Mononeuropathies ; Myoglobin ; Nerve Compression Syndromes ; Nervous System Diseases ; Neural Conduction ; Paresthesia ; Pelvis ; Peripheral Nervous System Diseases ; Phosphotransferases ; Porphyrins ; Spine ; Suicide ; Thigh ; Vital Signs

Opioids are the one of the most commonly used drugs to control cancer pain all over the world. But, we should not overlook the potential risk of opioid intoxication because they have well-known detrimental side effects. The opioid intoxication can be diagnosed thorough various clinical manifestations. The altered mental status, respiratory depression, and miosis is very representative clinical features although these symptoms don't always appear together. Unfortunately the opioid-toxidrome can be varied. A 42 years old man came to our emergency room after taking about 900 mg morphine sulfate per oral. He was nearly alert and his respiration was normal. Even though his symptoms didn't deteriorated clinically, serial arterial blood gas analysis showed increase in PaCO2. So we decided to use intravenous naloxone. Soon, he was fully awaked and his pupils size was increased. After a continuous infusion of intravenous naloxone for 2 hours, PaCO2 decreased to normal range and his pupil size also returned to normal after 12 hours. Though the levels of serum amylase and lipase increased slightly, his pancreas was normal according to the abdominal computed tomography. He had nausea, vomit, and whole body itching after naloxone continuous infusion, but conservatively treated. We stopped the continuos infusion after 1 day because his laboratory results and physical examinations showed normal. As this case shows, it is very important to prescribe naloxone initially. If you suspect opioid intoxication, we recommend the initial use of naloxone even though a patient has atypical clinical features. In addition, we suggest intranasal administration of naloxone as safe and effective alternative and it's necessary to consider nalmefene that has a longer duration for opioid intoxication.
Administration, Intranasal ; Amylases ; Analgesics, Opioid ; Blood Gas Analysis ; Emergencies ; Humans ; Lipase ; Miosis ; Morphine ; Naloxone ; Naltrexone ; Nausea ; Pancreas ; Physical Examination ; Porphyrins ; Pruritus ; Pupil ; Reference Values ; Respiration ; Respiratory Insufficiency

PURPOSE: The overcrowding of the ECC (Emergency Care Center) is a significant problem for most general hospitals. This overcrowding can be a potential cause of undesirable outcomes in critically ill patients. The purpose of this study was to evaluate the effect of an alerting call, with a cellular phone, before the presentation of critically ill patients in overcrowded emergency care centers. METHODS: One hundred and two patients with cardiac arrest, altered mental status, dyspnea, and chest pain were brought to the emergency care center by 119 EMS (Emergency Medical Transport System) from July 2007 to August 2007 and March 2008 to April 2008 and were enrolled in this study. The EMS made 39 alerting calls with a cellular phone before arrival to the ECC. Each alerting call was answered by the senior resident emergency physician over a 24 hour period. We prospectively reviewed the data and compared the cases with an alerting call to those without such a call. RESULTS: Thirty-nine (38%) patients arrived at the ECC with an alerting call and 63 (62%) without one. The general characteristics between the two groups were not different. The mean duration for the initiation of care for the patients with a cardiac arrest, with an alerting call, was faster than for those who arrived without an alerting call; the difference in the start of compressions was significant (p=0.006). For patients with altered mental status, all variables studied showed a significant statistical difference (p<0.001) between the two study groups. For acute dyspnea and chest pain, the first set of vital signs (p=0.004) and the ABG (p=0.001) were significantly different between the two groups. The mean time to the initiation of care was faster for the patients with an alerting call than for those without an alerting call. CONCLUSION: The initiation of care in critically ill patients was significantly faster with a cellular phone alerting call before the patient's arrival to the ECC. Therefore, an alerting call from the 119 EMS to the ECC appears to improve the time to initiating emergency care of critically ill patients in the ECC.
Cellular Phone ; Chest Pain ; Critical Illness ; Crowding ; Dyspnea ; Emergencies ; Emergency Medical Services ; Heart Arrest ; Hospitals, General ; Humans ; Prospective Studies ; Vital Signs

PURPOSE: To study the effect of recombinant human epidermal growth factor (rhEGF) on oral mucositis induced by cisplatin and radiotherapy in a mouse model. MATERIALS AND METHODS: Twenty-four ICR mice were divided into three groups? the normal control group, the no rhEGF group (treatment with cisplatin and radiation) and the rhEGF group (treatment with cisplatin, radiation and rhEGF). A model of mucositis induced by cisplatin and radiotherapy was established by injecting mice with cisplatin (10 mg/kg) on day 1 and with radiation exposure (5 Gy/day) to the head and neck on days 1~5. rhEGF was administered subcutaneously on days -1 to 0 (1 mg/kg/day) and on days 3 to 5 (1 mg/kg/day). Evaluation included body weight, oral intake, and histology. RESULTS: For the comparison of the change of body weight between the rhEGF group and the no rhEGF group, a statistically significant difference was observed in the rhEGF group for the 5 days after day 3 of the experiment. The rhEGF group and no rhEGF group had reduced food intake until day 5 of the experiment, and then the mice demonstrated increased food intake after day 13 of the of experiment. When the histological examination was conducted on day 7 after treatment with cisplatin and radiation, the rhEGF group showed a focal cellular reaction in the epidermal layer of the mucosa, while the no rhEGF group did not show inflammation of the oral mucosa. CONCLUSION: These findings suggest that rhEGF has a potential to reduce the oral mucositis burden in mice after treatment with cisplatin and radiation. The optimal dose, number and timing of the administration of rhEGF require further investigation.
Animals ; Body Weight ; Cisplatin* ; Eating ; Epidermal Growth Factor* ; Head ; Humans* ; Inflammation ; Mice* ; Mice, Inbred ICR ; Mouth Mucosa ; Mucositis ; Mucous Membrane ; Neck ; Radiotherapy* ; Stomatitis*

Background: Regimens for the treatment of multidrug-resistant tuberculosis (MDR-TB) have been changed from injectable-containing regimens to all-oral regimens. The economic effectiveness of new all-oral regimens compared with conventional injectable-containing regimens was scarcely evaluated. This study was conducted to compare the cost-effectiveness between all-oral longer-course regimens (the oral regimen group) and conventional injectablecontaining regimens (the control group) to treat newly diagnosed MDR-TB patients. Methods: A health economic analysis over lifetime horizon (20 years) from the perspective of the healthcare system in Korea was conducted. We developed a combined simulation model of a decision tree model (initial two years) and two Markov models (remaining 18 years, sixmonth cycle length) to calculate the incremental cost-effectiveness ratio (ICER) between the two groups. The transition probabilities and cost in each cycle were assumed based on the published data and the analysis of health big data that combined country-level claims data and TB registry in 2013–2018. Results: The oral regimen group was assumed to spend 20,778 USD more and lived 1.093 years or 1.056 quality-adjusted life year (QALY) longer than the control group. The ICER of the base case was calculated to be 19,007 USD/life year gained and 19,674 USD/QALY. The results of sensitivity analyses showed that base case results were very robust and stable, and the oral regimen was cost-effective with a 100% probability for a willingness to pay more than 21,250 USD/QALY. Conclusion This study confirmed that the new all-oral longer regimens for the treatment of MDR-TB were cost-effective in replacing conventional injectable-containing regimens.