Background: Sympathetic blocks (SBs) have been used widely to relieve the symptoms of sympathetically maintained pain (SMP). The thoracic sympathetic ganglion is not separated from somatic nerves by muscles and connective tissue. The upper thoracic ganglion runs along the posterior surface of the vertebral column in close proximity to the adjacent epidural region. This anatomical difference leads to frequent epidural and intercostal spread in cases of thoracic SBs. The purpose of this study was to investigate the incidence of inadvertent intercostal and epidural injections during thoracic SBs. Methods: Twenty-two patients who were suffering from complex regional pain syndrome or lymphedema after breast cancer surgery were managed with two or three times of thoracic SBs. Therefore, injections of 63 thoracic SBs from 22 patients were enrolled in this study. An investigator who did not attend the procedure evaluated the occurrence of intercostal or epidural spread using anteroposterior fluoroscopic images. Results: The overall incidence of inadvertent intercostal or epidural spread of contrast was 47.5%. Among the inadvertent injections, intercostal spread (34.9%) was more frequent than epidural spread (12.6%). Only 52.5% of the thoracic SBs demonstrated successful contrast spread without any inadvertent spread. The mean difference in skin temperature between the blocked and unblocked sides was 2.5 ± 1.8ºC. Fifty-nine (93.6%) injections demonstrated more than 1.5ºC difference. Conclusions Thoracic SBs showed a high incidence (47.5%) of inadvertent epidural or intercostal injection. Thus, special attention is required for the diagnosis of SMP or the injection of any neurolytic agent around sympathetic ganglion.

Multiple myeloma can usually be identified by non-traumatic vertebral fracture or signs of recurrent infection. Without these clinical signs, detection is unlikely. We briefly report a case of extraosseous multiple myeloma presenting as repeated intracranial bleeding and relapsing high fever. In doing so, we highlight the importance of subtle changes in laboratory findings. A 67-year-old man presented with spontaneous acute epidural hematoma, and hematoma evacuation was performed at the same site 3 times. A radiologic work-up failed to reveal any osseous lesions and he made a gradual recovery. In the meantime, he suffered unexplained fever up to 39oC despite normal chest and abdominal radiograms. Blood chemistry showed mild leukocytosis, high ESR and CRP, and a slightly elevated globulin. On his 15th hospital day, immunoglobulin studies confirmed the diagnosis of multiple myeloma. He was treated in the ICU for difficult breathing and uncontrolled fever. In spite of intensive critical care, his leukocyte count fell to below 2,000 and he died on postoperative day 28. Apparently normal laboratory and radiologic findings can hamper swift discovery and ultimate management of multiple myeloma. When there is unexplained repeated intracranial bleeding and accompanying fever, the possibility of hidden malignancy should be assessed to avoid delaying or missing treatment.
Aged ; Critical Care ; Fever ; Hematoma ; Hemorrhage ; Humans ; Immunoglobulins ; Leukocyte Count ; Leukocytosis ; Multiple Myeloma ; Respiration ; Respiratory Insufficiency ; Thorax

Despite increasing evidence that high-dose chemotherapy and autologous stem cell transplantation (HDCT/auto-SCT) might improve the survival of patients with high-risk or recurrent solid tumors, therapy effectiveness for bone and soft tissue sarcoma treatment remains unclear. This study retrospectively investigated the feasibility and effectiveness of HDCT/auto-SCT for high-risk or recurrent bone and soft tissue sarcoma. A total of 28 patients (18 high-risk and 10 recurrent) underwent single or tandem HDCT/auto-SCT between October 2004 and September 2014. During follow-up of a median 15.3 months, 18 patients exhibited disease progression and 2 died of treatment-related toxicities (1 veno-occlusive disease and 1 sepsis). Overall, 8 patients remained alive and progression-free. The 3-year overall survival (OS) and event-free survival (EFS) rates for all 28 patients were 28.7% and 26.3%, respectively. In the subgroup analysis, OS and EFS rates were higher in patients with complete or partial remission prior to HDCT/auto-SCT than in those with worse responses (OS, 39.1% vs. 0.0%, P = 0.002; EFS, 36.8% vs. 0.0%, P < 0.001). Therefore, careful selection of patients who can benefit from HDCT/auto-SCT and maximal effort to reduce tumor burden prior to treatment will be important to achieve favorable outcomes in patients with high-risk or recurrent bone and soft tissue sarcomas.
Adolescent ; Antineoplastic Combined Chemotherapy Protocols/*therapeutic use ; Bone Neoplasms/mortality/pathology/*therapy ; Child ; Child, Preschool ; Disease-Free Survival ; Female ; Follow-Up Studies ; Humans ; Infant ; Male ; Retrospective Studies ; Sarcoma/mortality/pathology/*therapy ; Soft Tissue Neoplasms/mortality/pathology/*therapy ; *Stem Cell Transplantation ; Survival Rate ; Transplantation, Autologous ; Treatment Outcome ; Young Adult

No abstract available.
Impetigo* ; Pregnancy*

PURPOSE: The detection of epileptogenic lesion plays an important role in the management of patients with partial epilepsy. Although the development of MRI improved the examination of cerebral hemispheres greatly, many patients with neocortical temporal lobe epilepsy (TLE) or extratemporal lobe epilepsy (extra-TLE) still show no lesion in conventional two-dimensional (2D) images. To increase the yield of MRI in those patients, we performed three-dimensional (3D) surface-projection rendering (SPR) of the cerebral hemispheres. METHODS: Conventional 2D MRI (T1, T2, FLAIR, thin slice SPGR) and 3D SPR were performed in 24 patients with neocortical TLE and extra-TLE, and 20 normal subjects. Sulcogyral patterns were evaluated blindly to clinical information. The locations of the epileptogenic zone, ictal onset zone (IOZ) and irritative zone (IRZ) were determined by intracranial EEG monitoring and epilepsy surgery. RESULTS: The 2D MRI identified epileptogenic lesions in five of the 10 neocortical TLE (50%) and five of the 14 extra-TLE (35.7%). 3D SPR revealed abnormal sulcogyral patterns in 9 of the 10 neocortical TLE (90%) and 9 of the 14 extra-TLE (64.3%). Cortical deformation zones with sulcogyral anomalies included the whole area of IOZ in 10 (55.5%) and IRZ in 6 (33.3%), overlapped with IOZ in 7 (38.9%) and IRZ in 11 (61.1%), were connected to IOZ in 1 (5.6%) and IRZ in 1 (5.6%). CONCLUSION: 3D SPR of volumetric MRI data can detect epileptogenic structural lesions of neocortical epilepsy that are not visible in the conventional 2D images.
Brain* ; Cerebrum ; Electroencephalography ; Epilepsies, Partial ; Epilepsy* ; Epilepsy, Temporal Lobe ; Humans ; Magnetic Resonance Imaging*

Intubation of an double-lumen endotracheal tube (DLT) in either a normal or a difficult airway may be more difficult than the intubation of a single-lumen endotracheal tube (ETT). A 72-year-old man undergoing right upper lobectomy could not be intubated with either a 37 Fr or a 35 Fr DLT after induction of anesthesia due to an inability to visualize the glottis. Difficult intubation had not been foreseen, but inspection through the laryngoscope revealed a Cormack grade III condition. Following two attempts to place the DLT, fibroptic bronchoscopy also proved unsuccessful. We intubated a 8.0 mm ETT with OELM (optimal external laryngeal manipulation) and followed this by inserting an infusion set catheter into the ETT as a guiding stylet. The ETT was then withdrawn with the catheter in situ in the trachea, and a 35 Fr DLT successfully introduced. After removing the catheter, the position of the DLT was corrected by fibroptic bronchoscopy. No further complication occurred and surgery was finished satisfactory. We achieved successful DLT intubation using the modified Seldinger technique with an infusion set catheter through an intubated ETT in a patient with an unanticipated difficult airway.
Aged ; Anesthesia ; Bronchoscopy ; Catheters ; Glottis ; Humans ; Intubation* ; Laryngoscopes ; Trachea

BACKGROUND: This study was performed to investigate the relationship between the extent of hippocampal resection and the postsurgical memory outcome in temporal lobe epilepsy (TLE). METHODS: In 36 patients with TLE, the longitudinal distances of pre-surgical hippocampus and post-surgical hippocampal remnant were measured on 3 mm thick coronal MRI images perpendicular to the long axis of hippocampus. Memory tests were performed before and 1 year after the surgery. The relationships of the extent of hippocampal resection (EHR) and the asymmetry index of Wada retention memory scores (WAI) with postsurgical memory outcomes were tested. RESULTS: The ratios of post-surgical/pre-surgical scores in immediate and delayed verbal memory and immediate, delayed and recognition visual memory were not significantly correlated with the EHR. Only verbal recognition memory was positively correlated with the EHR. In TLE of the dominant hemisphere, the ratios of post-surgical/pre-surgical scores of verbal and visual memories were not significantly correlated with the EHR, but the WAIs were significantly correlated with the delayed visual memory changes (p<0.05). In TLE of the non-dominant hemisphere, the ratios of post-surgical/pre-surgical scores of delayed verbal and immediate visual memory (in percentiles) were positively correlated with the EHR (p<0.05). However, a linear regression analysis showed that none of postsurgical memory subtypes were significantly correlated with the EHR. CONCLUSIONS: This study suggests that the extent of hippocampal resection itself does not have a significant relationship with the outcome of postsurgical memory in patients with mesial TLE.
Axis, Cervical Vertebra ; Epilepsy, Temporal Lobe* ; Hippocampus ; Humans ; Linear Models ; Magnetic Resonance Imaging ; Memory* ; Temporal Lobe*

PURPOSE: Hyperphosphatemia and renal osteodystrophy increase the mortality and morbidity in chronic kidney disease. We compared the effects of lanthanum carbonate (LC) and calcium carbonate (CC) on phosphate homeostasis and bone bio-markers in hemodialysis patients. METHODS: The Korean dialysis patients with serum phosphorus more than 5.6 mg/dL were randomized to LC (n=12) or CC (n=11). Serum calcium, phosphorus, intact PTH, bone alkaline phosphatase, and osteocalcin were checked at regular intervals for 6 months. RESULTS: The reduction of serum phosphorus and calcium x phosphorus product at 24-week (wk) from baseline values was similar in LC and CC groups (Phosphorus: baseline, 7.28+/-1.04 mg/dL vs 7.41+/- 1.39 mg/dL, p=NS; at 24-wk, 5.39+/-1.85 mg/dL vs 5.67+/-1.43 mg/dL, p=NS) (Calcium x phosphorus product: baseline, 64.5+/-11.1 mg2/dL2 vs 61.3+/-11.9 mg2/dL2, p=NS; at 24-wk, 47.9+/-14.5 mg2/dL2 vs 51.8+/-14.0 mg2/dL2, p=NS). Despite higher baseline serum calcium levels in LC group, the changes of serum calcium from the baseline at 24-wk were significantly higher in CC group (LC vs CC; 0.23+/-0.38 mg/dL vs 0.94+/-0.87 mg/dL, p<0.05). Bone bio-markers, including iPTH, bone ALP, and osteocalcin, were comparable in 2 groups. However, significant gastrointestinal side effects leading to discontinuing the study were predominantly observed in LC (LC vs CC; n=5/12 vs n=0/11). CONCLUSION: Compared to calcium carbonate, lanthanum carbonate has similar efficacy to reduce serum phosphorus level, but less tendency to increase serum calcium level. However, the high incidence of gastrointestinal side effects in lanthanum carbonate needs further investigation in its correlation to Korean.
Alkaline Phosphatase ; Calcium ; Calcium Carbonate ; Carbon ; Dialysis ; Homeostasis ; Humans ; Hyperphosphatemia ; Incidence ; Lanthanum ; Osteocalcin ; Phosphorus ; Renal Dialysis ; Renal Insufficiency, Chronic ; Renal Osteodystrophy

Distal embolization resulting from carotid angioplasty and stenting (CAS) occurs mainly in the cerebral hemisphere. We report a case of ophthalmic artery occlusion after carotid revascularization. A 75-year old man received emergency CAS for cervical internal carotid artery occlusion. Two months later, the patient was readmitted for decreased visual acuity. We found ophthalmic artery occlusion that was not noticed soon after CAS. Although ophthalmic artery occlusion after CAS is rare, endovascular neurosurgeons should be aware of this potential complication.
Aged ; Angioplasty ; Carotid Artery, Internal ; Cerebrum ; Emergencies ; Humans ; Ophthalmic Artery* ; Stents ; Visual Acuity

PURPOSE: To investigate the various ictal perfusion patterns and find the relationships between clinical factors and different perfusion patterns. MATERIALS AND METHODS: lnterictal and ictal SPECT and SPECT subtraction were performed in 61 patients with partial epilepsy. Bath positive images showing ictal hypoperfusion and negative images revealing ictal hypoperfusion were obtained by SPECT subtraction. The ictal perfusion patterns of subtracted SPECT were classified into focal hypoperfusion, hypoperfusion-plus, combined hypoperfusion-hypoperfusion, and focal hypoperfusion only. RESULTS: The concordance rates with epileptic focus were 91.8% in combined analysis of ictal hypoperfusion and hypoperfusion images of subtracted SPECT, 85.2% in hypoperfusion images only of subtracted SPECT, and 68.9% in conventional ictal SPECT analysis. Ictal hypoperfusion occurred less frequently in temporal lobe epilepsy (TLE) than extratemporal lobe epilepsy. Mesial temporal hypoperfusion alone was seen only in mesial TLE while lateral temporal hypoperfusion alone was observed only in neocortical TLE. Hippocampal sclerosis had much lower incidence of ictal hypoperfusion than any other pathology. Some patients showed ictal hypoperfusion at epileptic focus with ictal hypoperfusion in the neighboring brain regions where ictal discharges propagated. CONCLUSION: Hypoperfusion as well as hypoperfusion in ictal SPECT should be considered for localizing epileptic focus. Although the mechanisrn of ictal hypopertusion could be an intra-ictal early exhaustion of seizure focus or a steal phenomenon by the propagation of ictal discharges to adjacent brain areas, further study is needed to elucidate it.
Baths ; Brain ; Epilepsies, Partial* ; Epilepsy ; Epilepsy, Temporal Lobe ; Humans ; Incidence ; Pathology ; Perfusion* ; Sclerosis ; Seizures ; Tomography, Emission-Computed, Single-Photon*