Horse chestnut (Aesculus hippocastanum) is a common tree found on roads and parks. The shape of the fruit is very similar to that of the edible Korean chestnut (Castanea crenata); thus, people can eat it by mistake. However, reports of the side effects and toxicity from ingestion are very rare. A 46-year-old male who had no unusual findings in the past had eaten horse chestnut seed which he had mistaken to be Korean chestnut. He visited the emergency department (ED) with complaints of epigastric pain, nausea, and sweating. Blood tests showed a slight increase in the levels of liver enzymes, serum amylase, and pancreatic amylase. During the monitoring, he complained of palpitations, and electrocardiogram showed atrial fibrillation. On the following day after conservative treatment, blood testing and electrocardiogram showed normal findings. He was discharged from the ED as he did not complain of any further symptoms. When a patient who has eaten horse chestnut visits the ED, blood examination and electrocardiogram monitoring are needed, and conservative treatment is required.

Propafenone is a Class Ic antidysrhythmic agent, used in the management of atrial fibrillation. This is also a calcium channel and a weak beta blocker. The conventional therapy of hypotension induced by propafenone overdose includes fluid resuscitation followed by inotropic support. NaHCO3 is considered to be the treatment of choice. We report a case of successful insulin therapy for propafenone-induced hypotension unresponsive to NaHCO3. A 41-year-old woman with a prior medical history of atrial fibrillation presented to the ED after ingesting 4500 mg of propafenone, prescribed for her atrial fibrillation treatment. On initial examination, she was alert with O2 saturation of 96% and normal vital sign. Fifteen minutes later, her electrocardiogram revealed polymorphic ventricular tachycardia and then changed to ventricular fibrillation. When CPR was stopped, her BP was 70/40 mmHg, HR was 68 beats/min with wide QRS complex. Normal saline and inotropics were administered rapidly to improve hypotension. And we injected NaHCO3. Her blood pH was kept between 7.45 and 7.55. But, BP was not improved. Refractory to the conventional therapy for sodium channel blocker toxicity, we decided to try insulin treatment, considering properties of propafenonen having beta and calcium channel blocking effect. We administered short-acting insulin. Her blood glucose level was kept euglycemia by continuous 5% dextrose infusions and tried to keep serum potassium normal range. Thirty minutes after adminstering insulin, her SBP was checked at 100 mmHg. She was discharged 8 days post-ingestion without further complications. Insulin must be considered in severe hypotension induced by propafenone overdose unresponsive to other conventional therapy.
Adult ; Atrial Fibrillation ; Blood Glucose ; Calcium Channels ; Cardiopulmonary Resuscitation ; Electrocardiography ; Female ; Glucose ; Humans ; Hydrogen-Ion Concentration ; Hypotension ; Insulin ; Insulin, Short-Acting ; Potassium ; Propafenone ; Reference Values ; Resuscitation ; Shock ; Sodium ; Sodium Bicarbonate ; Sodium Channels ; Tachycardia, Ventricular ; Ventricular Fibrillation ; Vital Signs

PURPOSE: Informed consent is a basic right of patients undergoing medical procedures, but the effect of the type of consent form on the risk of invasive procedures is controversial, and the recall of information by patients has been poor. This trial was designed to assess the effect of video-assisted information on verbal informed consent to allow central venous catheter (CVC) insertion in the emergency department. METHODS: A prospective, randomized controlled trial was done on adult emergency department patients undergoing CVC insertion. Patients were randomized to the intervention or the control group. The intervention group had consent obtained with the assistance of video information (video group). The control group received a conventional education process that was conducted by the physician (verbal group) regarding indications, risks, and treatment of complications due to the procedure. Outcome variables consisted of an anxiety score, heart rate, and systolic and diastolic blood pressure at baseline and immediately after informed consent. All participants completed a 5-question knowledge measurement and graded their satisfaction level after the explanation. RESULTS: Of 208 patients enrolled, nine withdrew, leaving 199 for analysis (video n=99; verbal n=100). The two groups were similar with regard to their baseline characteristics. The video group was significantly less anxious after informed consent (4.5+/-0.8 vs 5.8+/-1.0, p=0.029) and had a significantly lower heart rate (64+/-12 vs 73+/-10, p=0.027). Mean knowledge scores were higher in the video group (3.82+/-0.55) compared to the verbal group (2.94+/- 0.75) (p=0.01). Satisfaction regarding the information received was higher in the video group (4.09+/-1.08) than in the verbal group (3.15+/-1.04) (p=0.00). CONCLUSION: Video-assisted informed consent decreases anxiety and improves satisfaction scales in patients undergoing CVC insertion. The Video group showed better recall of information compared with the verbal group.
Adult ; Anxiety ; Blood Pressure ; Catheterization, Central Venous ; Central Venous Catheters ; Consent Forms ; Emergencies ; Heart Rate ; Humans ; Informed Consent ; Mental Recall ; Patient Education as Topic ; Prospective Studies ; Weights and Measures

Acardiac fetus in triplet pregnancy is a very rare, fatal congenital anomaly that had not been reported in Korea. It only occurs in multiple gestations associated with placental vascular anastomoses between the affected fetus and its co-twin. The major complications associated with acardiac fetus in triplet pregnancy are congestive heart failure in normal pumping fetus, maternal polyhydramnios, preterm labor, intrauterine fetal death, etc, and perinatal diagnosis can be made with the perinatal ultrasonographic examination. We report a case of acardiac fetus in a spontaneous triplet pregnancy at 23 weeks of gestational age with a brief review of the literature.
Diagnosis ; Female ; Fetal Death ; Fetus* ; Gestational Age ; Heart Failure ; Humans ; Korea ; Obstetric Labor, Premature ; Polyhydramnios ; Pregnancy ; Pregnancy, Triplet* ; Triplets*

The Prototheca species is achlorophyllic algae and rarely causes human infection. Human protothecosis presents clinically as a cutaneous infection, olecranon bursitis, and disseminated systemic disease. We report a case of human cutaneous protothecosis involving the left wrist. A 68-year-old man presented with an ill-defined erythematous lesion with crust at the dorsal aspect of his left wrist. A punch biopsy was performed to reveal the histologic features of granulomatous inflammation with necrosis at the upper dermis, containing Prototheca organisms, of which, the characteristic features were highlighted by special staining. Through a molecular study, the Prototheca zopfii species was identified.
Aged ; Biopsy ; Bursitis ; Dermis ; Humans* ; Inflammation ; Necrosis ; Olecranon Process ; Prototheca ; Wrist

BACKGROUND: The survival rate of grafted fat is difficult to predict, and repeated procedures are frequently required. In this study, the effects of the freezing period of harvested adipose tissue and the addition of human adipose tissue-derived stem cells (ASCs) on the process of fat absorption were studied. METHODS: Adipose tissue was obtained from patients who underwent a lipoaspirated fat graft. The fat tissue was cryopreserved at -20degrees C in a domestic refrigerator. A total of 40 nude mice were used. The mice in the experimental group received three different subcutaneous injections in the back: an injection of fresh fat and ASCs, an injection of fat that had been frozen for one month and ASCs, and an injection of fat that had been frozen for two months and ASCs. The control mice received fat grafts without ASCs. The mice were sacrificed at four or eight weeks after the procedure, and the grafted fat tissues were harvested. The extracted fat was evaluated using photographic analysis, volume measurements, and histological examination. RESULTS: In the control group, the fat resorption rates four weeks after transplantation in the grafts of fresh fat, fat that had been frozen for one month, and fat that had been frozen for two months were 21.14%, 22.46%, and 42.56%, respectively. In the experimental group, the corresponding resorption rates were 6.68%, 13.0%, and 33.9%, respectively. CONCLUSIONS: ASCs can increase the fat graft survival rate. The use of ASCs in fat grafting can reduce the need for repeated fat grafts and provide good long term results.
Absorption ; Adipose Tissue ; Animals ; Cryopreservation ; Freezing ; Graft Survival ; Humans* ; Injections, Subcutaneous ; Mice ; Mice, Nude ; Stem Cells* ; Survival Rate* ; Transplants

Background: The accurate pathologic diagnosis and subtyping of high-grade endometrial carcinoma are often problematic, due to its atypical and overlapping histopathological features. Methods: Three pathologists reviewed 21 surgically resected cases of advancedstage endometrial carcinoma. The primary diagnosis was based only on hematoxylin and eosin stained slides. When a discrepancy arose, a secondary diagnosis was made by additional review of immunohistochemical (IHC) stains. Finally, three pathologists discussed all cases and rendered a consensus diagnosis. Results: The primary diagnoses were identical in 13/21 cases (62%). The secondary diagnosis based on the addition of IHC results was concordant in four of eight discrepant cases. Among four cases with discrepancies occurring in this step, two cases subsequently reached a consensus diagnosis after a thorough discussion between three reviewers. Next-generation sequencing (NGS) study was performed in two cases in which it was difficult to distinguish between serous carcinoma and endometrioid carcinoma. Based on the sequencing results, a final diagnosis of serous carcinoma was rendered. The overall kappa for concordance between the original and consensus diagnosis was 0.566 (moderate agreement). Conclusions We investigated stepwise changes in interobserver diagnostic reproducibility in advanced-stage endometrial carcinoma. We demonstrated the utility of IHC and NGS study results in the histopathological diagnosis of advanced-stage endometrial carcinoma.

BACKGROUND/AIMS: The ballooning time in endoscopic papillary large balloon dilation (EPLBD) remains controversial. The aim of this study was to evaluate the significance of the ballooning time comparing an immediate balloon deflation method with a conventional ballooning time of > 45 seconds. METHODS: Between January 2010 and December 2010, 126 patients with bile duct stones treated with EPLBD and endoscopic sphincterotomy were divided according to the ballooning time: the immediate deflation group (n=56) and the conventional inflation group (ballooning time 45s to < 60s) (n=70). RESULTS: The overall success rate and the success rate of the first attempt of ERCP (endoscopic retrograde cholangio-pancreatography) were 96.4% (54/56) and 80.4% (45/56) in the immediate group and 97.1% (68/70) and 77.1% (54/70) in the conventional inflation group. There were no statistically significant differences in the overall success and the first attempt of ERCP success rate (p=0.99, p=0.66). The frequency of mechanical lithotripsy was 0% in the immediate deflation group and 7.1% in the conventional inflation group (p=0.065). Complications occurred in 3.6% (2/56) patients in the immediate deflation group and 8.6% (4/70) patients in the conventional inflation group (p=0.298). CONCLUSIONS: The ballooning time in EPLBD does not affect the outcomes of the treatment for bile duct stones. And the feasibility of the immediate deflation method in EPLBD is acceptable.
Bile Ducts* ; Cholangiopancreatography, Endoscopic Retrograde ; Choledocholithiasis ; Humans ; Inflation, Economic ; Lithotripsy ; Sphincterotomy, Endoscopic

PURPOSE: To evaluate the utility of ultrasound-assisted lumbar puncture in the emergency department. METHODS: This was a prospective randomized controlled trial. We enrolled patients who were 18 years of age or older from May to August 2007. Patients were divided into a classic lumbar puncture group (group A) and an ultrasoundassisted lumbar puncture group (group B). We compared the frequency of attempting the procedure, the procedure time, the failure rate of lumbar puncture, and the traumatic lumbar puncture between groups. RESULTS: Sixty-one patients were enrolled in the study. Thirty-two patients were in group A and 29 patients were in group B. There were 6 cases of failed lumbar puncture in group A and one case in group B (p=0.07), and there were 3 cases of traumatic lumbar puncture in group A, and one case in group B (p=0.35). It took 8.6+/-8.4 minutes to accomplish lumbar puncture in group A compared to 8.2+/-6.4 minutes in group B (p=0.85). Overall, the frequency of attempting the procedure was 2.3+/-1.8 in group A and, 1.6 +/-1.1 in group B (p=0.66). In elderly patients (age> or =60 years) the frequency of attempting the procedure was 4.0+/-2.5 in group A and 1.6+/-0.5 in group B (p=0.03). There were 4 cases of failed lumbar puncture in group A but none in group B. CONCLUSION: Emergency physicians did not generally attempt ultrasound-assisted lumbar puncture in the emergency department. For elderly patients(> or =60 years), however, it was an available tool for emergency physicians and employed more frequently.
Adult ; Aged ; Emergencies ; Humans ; Prospective Studies ; Spinal Puncture

Rapid ammonia elevation in blood with accompanying mental change should be considered as a true medical emergency. In such a case, action leading to immediate diagnosis and the earliest possible treatment must occur in order to minimize permanent brain damage. Hyperornithinemia- Hyperammonemia-Homocitrullinuria (HHH) syndrome is a rare inborn errors of metabolism and autosomal recessive metabolic disorder caused by a deficiency of the mitochondrial ornithine transporter at the cellular level. Emergency physicians should take account of the possibility of HHH syndrome in patients with unreasonable hyperammonemia coupled with altered mental status. We report a case of a 59-year old man who presented with headache, nausea, vomiting and altered mental status. His serologic test showed hyperornithinemia, hyperammomemia, and homocitrullinuria. He was treated with fluid therapy and hemodialysis. His clinical manifestation improved and he was discharged after hemodialysis
Amino Acid Transport Systems, Basic ; Ammonia ; Brain ; Emergencies ; Fluid Therapy ; Headache ; Humans ; Hyperammonemia ; Metabolism, Inborn Errors ; Nausea ; Ornithine ; Renal Dialysis ; Serologic Tests ; Urea Cycle Disorders, Inborn ; Vomiting