Optic nerve evulsion is a visually devastating and rare manifestation resulting in sudden visual loss after ocular trauma. The several hypothesis of mechanism include penetrating orbital injury causing a backward pull on the optic nerve, extreme rotation and forward displacement of the globe, and sudden increase in intraocular pressure causing rupture of the lamina cribrosa. The authors report a case of optic nerve evulsion in a 25- year old man who was struck in the right eye with a umbrella. The diagnosis was made by fundoscopic findings, fluorescein angiography, visual evoked potential, electroretinography, orbit computed tomography and magnetic resonance image.
Diagnosis ; Electroretinography ; Evoked Potentials, Visual ; Fluorescein Angiography ; Intraocular Pressure ; Optic Nerve* ; Orbit ; Rupture

PURPOSE: Triage in the emergency departmen (ED) is the preliminary clinical sorting process before full disclosure of patients' problems so that patients with the highest acuity are treated first in the setting of resource constraints. To overcome the inter-rater variability of existing triage tools, the Emergency Severity Index (ESI) was developed and was shown to be both valid and reliable in practice. Because of the disparity in practice patterns and some inappropriate criteria in the original ESI, the authors have modified the ESI and determined its inter-rater reliability. METHODS: We applied the modified ESI to a convenient sample of adults who visited an urban academic ED between July 24, 2001, and August 5, 2001. After completion of a short, 4-hour training course on the modified ESI, an intern and emergency medicine resident pair triaged the patients independently. The inter-rater reliability was measured using a weighted kappa analysis and was categorized as excellent (>or=0.8), good (0.60-0.79), or fair ( Adult ; Disclosure ; Emergencies* ; Emergency Medicine ; Humans ; Triage*

BACKGROUND: The emergence of multidrug-resistant strains of Mycobacterium tuberculosis presents a significant challange to the treatment and control of tuberculosis, and there is an urgent need to understand the mechanisms by which strains acquire multidrug resistance. Recent advances in molecular methods for the detection of M. tuberculosis genetic targets have approached the sensitivity of culture Furthermore the prospect of determining resistance in mycobacteria at the nucleic acid level particulary to first-line drugs like rifampin, isoniazid has provided a glimps of the next generation of sensitivity test for M. tuberculosis. Previous studies in RMP resistant M. tuberculosis have shown that mutation in beta subunit of RNA polymerase is main mechanism of resistance. METHOD: In this study, rpoB gene for the ~3 subunit of RNA polymerase from M. tuberculosis of 42 cultured samples (32 were RMP resistant and 10 were sensitive cases) were isolated and characterised the mutations. Direct sequencing data were compared with the results of INNO-LiPA Line Probe Assay (LiPA, Innogenetics, Belgium), commercial RMP resistance detecting kit using reverse hybridization method. RESULTS: All of the RMP resistant samples were revealed the presence of mutation by LiPA. In 22 samples (68.8%) out of 32 RMP resistant cases, the mutation types were confirmed by the positive signal at one of 4 mutation bands in the strip. The most frequent type was R5 (S53 IL) which were 17 cases (77.3%). Results of direct sequencing were identified the exact characteristics of 8 mutations which were not comfirmed by LiPA. S522W type point mutation and 9 base pair deletion at codon 513-515 were new identified mutations for the first time. CONCLUSION: Mutations in rpoB gene is the main mechanism of RMP resistance in M. tuberculosis and LiPA is a very useful diagnostic tool for the early diagnosis of RMP resistance in M. tuberculosis.
Base Pairing ; Codon ; DNA-Directed RNA Polymerases ; Drug Resistance, Multiple ; Early Diagnosis ; Isoniazid ; Mycobacterium tuberculosis ; Point Mutation ; Rifampin ; RNA Polymerase I ; Tuberculosis*

BACKGROUND: The purpose of this study was to evaluate the preemptive analgesic effect of a single intravenous infusion of low dose ketamine-clonidine. We compared the placebo with low dose ketamine and low dose ketamine-clonidine in patients undergoing an appendectomy. METHODS: Sixty ASA class 1 or 2 patients who received general anesthesia for an appendectomy were allocated randomly to three groups. Group 1 received intravenous normal saline 6 ml and group 2 received ketamine 0.15 mg/kg in normal saline 6 ml and group 3 received ketamine 0.15 mg/kg and clonidine 1microgram/kg in normal saline 6 ml 5 minutes before surgical incision. In the recovery room postoperative analgesia was assessed by the verbal numerical rating scale (VNRS) at 0 min, 15 min, 30 min, 60 min, 90 min and 120 min. Vital signs, sedation score and side effects were also checked. For postoperative analgesia, morphine 2 mg was given intravenously whenever a patient complained of pain, or the VNRS score was above 7. RESULTS: There were no intergroup differences of individual morphine requirements for postoperative pain control among the three groups. VNRS score, blood pressure, heart rate, sedation score and side effects were not significantly different among the three groups. CONCLUSIONS: A single low dose of ketamine-clonidine may not produce a postoperative analgesic effect in the recovery room, and a single low dose of ketamine also may not produce the preemptive effect for at least 2 hours.
Analgesia ; Anesthesia, General ; Appendectomy ; Blood Pressure ; Clonidine ; Heart Rate ; Humans ; Infusions, Intravenous ; Ketamine* ; Morphine ; Pain, Postoperative ; Recovery Room ; Vital Signs

Stroke is defined as a focal neurological deficit lasting more than 24 hours. The complications related to the central nervous system after general surgery is unusual and is difficult to discover the exact causes. We are going to report a case of an unexpected cerebral infarction after a Whipple's operation. The patient was a sixty-three years old female weighing 53 Kg with a diagnosis of cancer of ampulla of Vater scheduled for a Whipple's operation under general anesthesia. Preanesthetic assessment revealed a history of hypertension and hypercholesterolemia. After surgery, she was alert but she appeared to have right hemiparesis, aphasia and right facial palsy. A brain MRI showed a cerebral infarction in the bilateral basal ganglia, left medial temporal lobe and insular cortex. The cause of the cerebral infarction in this patient was unclear. Cerebral thrombosis was first thought of, but we couldn't completely exclude other possible causes e.g., embolism etc. In cases where risk factors of a stroke were found in preoperative evaluation, it is important to correct risk factors preoperatively. Furthermore, it is necessary to prevent hypotension, keep proper hematocrit levels and temperature during an operation, and use hemocoagulase carefully in cases of patients having risk factors of thrombosis and embolism.
Ampulla of Vater ; Anesthesia, General* ; Aphasia ; Basal Ganglia ; Batroxobin ; Brain ; Central Nervous System ; Cerebral Infarction* ; Diagnosis ; Embolism ; Embolism and Thrombosis ; Facial Paralysis ; Female ; Hematocrit ; Humans ; Hypercholesterolemia ; Hypertension ; Hypotension ; Infarction ; Intracranial Thrombosis ; Magnetic Resonance Imaging ; Paresis ; Risk Factors ; Stroke ; Temporal Lobe

BACKGROUND: A postoperative ileus after anesthesia and surgery may be bothersome to recovery and prolong hospitalization periods. The object of this study was to investigate the effect of lidocaine and ketorolac combined to fentanyl IV PCA on the recovery of bowel function after surgery. METHODS: Forty-nine patients undergoing a total abdominal hysterectomy were divided into three groups (F, FT, LFT). All patients received IV PCA for postoperative pain control. PCA contents were fentanyl 1,000 microgram only in saline 100 ml in group F (n = 16) and fentanyl 500 microgram-ketorolac 150 mg in saline 100 ml in group FT (n = 17) and LFT (n = 16). Group LFT received a lidocaine bolus (1.5 mg/kg) before induction and a continuous infusion of lidocaine (2 mg/min) until one hour after surgery. We measured postoperative pain scores (at postoperative 1 hour, 6 hours, 24 hours, and 48 hours) and checked the first flatus time, the first defecation time, and the side effects. RESULTS: The intravenous lidocaine infusion group showed better pain scores at postoperative 1 hour only. The FT and LFT groups provided a more rapid return of bowel function than group F. A combined infusion of lidocaine and ketorolac had no difference in the return of bowel function. There were no significantly different incidences of nausea, vomiting and other side effects. CONCLUSIONS: Ketorolac allowed an earlier recovery of bowel function after surgery. However, an additional infusion of lidocaine was not helpful in the return of bowel function.
Anesthesia ; Defecation ; Fentanyl* ; Flatulence ; Hospitalization ; Humans ; Hysterectomy ; Ileus ; Incidence ; Ketorolac* ; Lidocaine* ; Nausea ; Pain, Postoperative ; Passive Cutaneous Anaphylaxis* ; Vomiting

PURPOSE: Co-morbidity is the presence of co-existing or additional diseases during the initial diagnosis. It may be used as a prognostic indicator for the postoperative outcomes in most cancers, including colorectal cancers. The impact of respective co-morbidities in colorectal cancer surgeries were evaluated to identify their outcomes regarding complications and hospital stay. METHODS: The medical records of 2,242 colorectal cancer patients, who had had curative operations between Jan. 1997 and Dec. 2001, were reviewed to evaluate the prevalence of co-morbidities. All co-morbidities were adequately evaluated and managed preoperatively. RESULTS: Co-morbidities were observed in 789 out of the 2,242 (35.2%) patients. Hypertension was the most frequent (340, 15.2%), with diabetes (210, 9.4%) and cardiovascular diseases (124, 5.5%) following. Early stages (0~II) were more frequently associated with co-morbidities, compared to late stages (III~IV) (P<0.001). Hypertension and cerebrovascular diseases were significantly associated with postoperative complications (P<0.05). Postoperative complications occurred in 578 out of the 2242 (25.8%) patients: e.g., ileus (10.2%), voiding difficulty (4.4%), wound problems (4.3%), etc. Pulmonary complications occurred more often in patients with cerebrovascular diseases, hypertension, and asthma. Wound complications were observed in patients with hypertension, cerebrovascular diseases, chronic obstructive pulmonary disease, and chronic renal failure (P<0.05). Patients with more than one co-morbidity were closely associated with frequent postoperative co-mplications (P<0.05). However, comorbidities did not seem to affect the duration of the postoperative hospital stay. CONCLUSIONS: Postoperative complications frequently occur in colorectal cancer patients with specific co- morbidities, especially in those with more than one. An adequate management of the co-morbidities preoperatively leads to a good outcome.
Asthma ; Cardiovascular Diseases ; Chronic Disease ; Colorectal Neoplasms* ; Comorbidity ; Diagnosis ; Humans ; Hypertension ; Ileus ; Kidney Failure, Chronic ; Length of Stay ; Lung Diseases, Obstructive ; Medical Records ; Postoperative Complications ; Prevalence ; Wounds and Injuries

BACKGROUND: Recent advances of percutaneous coronary intervention (PCI) and transradial coronary intervention (TRI) have made it possible to reduce the local complication rate and the time until a return to ambulation. The aim of this study is to assess the safety and the patient satisfaction of the TRI-based one-day admission program for PCI. METHODS: Total 230 consecutive patients underwent TRI on the day of admission, according to pre-determined inclusion criteria, from May 2001 to October 2003. The subjects were examined for clinical and angiographic characteristics. The patients having a same-day discharge were telephone-interviewed one day and seven days after discharge to assess late complications and the patients' satisfaction. RESULTS: The mean age of the subjects was 59+/-9 years and 77.4% were male patients. 169 (73.4%) had stable angina and 37 (16.1%) had unstable angina. Stents were implanted in 178 cases (69.3%). Of the 230 patients who underwent TRI, 206 patients (89.6%) could discharge on the same day after the procedure. The procedure was successful in 98.5%. The average hospital stay for them was 9.4+/-1.4 hours. Two subjects reported hematoma near the puncture site within 24 hours after discharge, and one reported this problem 7 days after discharge. During the follow-up, there were no cases reporting chest pain needing rehospitalization or such complications as subacute vessel closure. No deaths, myocardial infarctions or revascularization were noted during the follow-up period. The majority of the patients (n=197, 95.6%) were satisfied with the same-day admission and discharge. CONCLUSIONS: Same day admission and discharge after TRI seems to be safe as well as satisfactory for not low-risk patients.
Angina, Stable ; Angina, Unstable ; Angioplasty ; Chest Pain ; Coronary Disease ; Follow-Up Studies ; Hematoma ; Humans ; Length of Stay ; Male ; Myocardial Infarction ; Patient Satisfaction ; Percutaneous Coronary Intervention ; Punctures ; Radial Artery ; Stents ; Walking

Bywaters and beall first reported rhabdomyolysis during World War II; the pigmented casts were found in renal tubules of 4 patients who died of acute renal failure after crushing injury. Since then, several cases of rhabdomyolysis with or without acute renal failure have been reported. The causes such as surgical injuries, excessive exercise, and drug abuse have been suggested as possible etiologies of rhabdomyolysis. Rhabdomyolysis is a clinical syndrome as a result of releasing of myocyte components from the injured striated muscles into blood stream. Clinical manifestations have ranged from asymptomatic elevation of creatinine kinase to acute renal failure which is a life threatening medical emergency. The most common cause of rhabdomyolysis is traumatic muscular injury. The others include alcohol abuse, metabolic disorder, drug, toxins, carbon monoxide poisoning, burn, vascular occlusion, excessive exercise, and bacterial or viral infections and sepsis. Among these, rhabdomyolysis caused by Group A beta-hemolytic streptococcus is very rare. However, rhabdomyolysis due to pharyngitis has not been reported. We report a case of rhabdomyolysis associated with Group A beta-hemolytic streptococcus.
Acute Kidney Injury ; Alcoholism ; Burns ; Carbon Monoxide Poisoning ; Creatinine ; Emergencies ; Humans ; Intraoperative Complications ; Muscle Cells ; Muscle, Striated ; Pharyngitis ; Phosphotransferases ; Rhabdomyolysis* ; Rivers ; Sepsis ; Streptococcus ; Substance-Related Disorders ; World War II

The thrombotic microangiopathy associated with cyclosporine A after kidney transplantation is a detrimental complication that could lead to the loss of transplanted kidney. Although the pathogenesis is still unclear, the decrease in the activity of von Willebrand Factor (VWF)-cleaving metalloprotease that cleaves unusually large von-Willebrand factor (UL-VWF), such as disintegrin-like metalloprotease with thrombospondin type 1 repeats (ADAMTS) 13, and the inhibitory factors of ADAMTS 13 are reported. Therefore, we measured the activity of ADAMTS 13 and the inhibitory factors in a patient with thrombotic microangiopathy after kidney transplantation. A 28 year-old female patient with hemolytic anemia, thrombocytopenia and impaired renal function after the kidney transplantation was diagnosed as thrombotic microangiopathy after renal biopsy. The activity of ADAMTS 13 during the acute stage of thrombotic microangiopathy was reduced to 12%, but when the renal function returned to normal, ADAMTS 13 level returned to 100%. However, the autoantibody of ADAMTS 13 was not detected. The results from this study suggest that the pathogenesis of thrombotic microangiopathy associated with cyclosporine A after the kidney transplantation could be associated with the decrease in the activity of ADAMTS 13.
Adult ; Anemia, Hemolytic ; Biopsy ; Cyclosporine ; Female ; Humans ; Kidney Transplantation ; Kidney* ; Thrombocytopenia ; Thrombospondins ; Thrombotic Microangiopathies* ; von Willebrand Factor