Torsade de pointes is a life-threatening, polymorphic ventricular tachycardia associated with prolongation of the QTc interval. Although torsade de pointes is found in many clinical settings, it is mostly drug induced. Similar problems have been described with nonsedating H1-selective antihistamines like terfenadine and astemizole. The increased risks of both H1-antihistamines were associated with exposure to supratherapeutic doses or concomitant exposure to the cytochrome P-450 inhibitors, ketoconazole, erythromycin and cimetidine. We report a 51-year-old woman with torsade de pointes and a long QTc interval caused by the combined use of terfenadine and itraconazole. After discontinuation of these drugs and treatments with electrical cardioversion and magnesium sulfate, torsade de pointes and prolonged QTc interval were no longer observed and she was discharged in good condition with a normal ECG. In conclusion, physicians should be aware that terfenadine and astemizole can cause torsade de pointes in rare cases.
Astemizole ; Cimetidine ; Cytochrome P-450 Enzyme System ; Electric Countershock ; Electrocardiography ; Erythromycin ; Female ; Histamine Antagonists ; Humans ; Itraconazole* ; Ketoconazole ; Magnesium Sulfate ; Middle Aged ; Tachycardia, Ventricular ; Terfenadine* ; Torsades de Pointes*

BACKGROUND: This study was performed to evaluate the presynaptic effects of depolarizing neuromuscular blocking drugs by using slow and fast frequencies of indirect stimulation on partial twitch depression in vitro. METHODS: A rat phrenic nerve hemidiaphragm was dissected and was mounted in an organ bath containing an oxygenated Krebs solution. The phrenic nerve was stimulated supramaximally and the twitch response (0.1 Hz) was stabilized for at least 30 minutes. T200/T1 ratio (twitch height of the 200th stimuli divided by that of the first stimuli) at frequencies of 0.2, 0.5, 1.0, and 2.0 Hz using a drug concentration which provided approximately 20% twitch depression at 0.1 Hz was calculated. To compare T200/T1 ratios with TOF ratios, a 2.0 Hz TOF response was measured immediately after the 200th stimuli at either frequency of stimulation. RESULTS: T200/T1 ratios produced by succinylcholine (SCC) and decamethonium (C10) were located between alpha-bungarotoxin (ABX) and hexamethonium (C6), however, significant differences among the four drugs were found at 2.0 Hz. The propensity for a decrease in T200/T1 ratios at 2.0 Hz might differ from this study: C6 > C10 > SCC > ABX. T200/T1 ratios at 2.0 Hz were not different from TOF ratios. CONCLUSIONS: It is concluded that small doses of C10 have a greater presynaptic activity than that of SCC, when the observed effects in this study were compared with the result of ABX acting predominantly at postsynaptic receptors and C6 acting predominantly at presynaptic receptors.
Animals ; Baths ; Bungarotoxins ; Depression ; Hexamethonium ; Neuromuscular Blockade* ; Neuromuscular Blocking Agents* ; Oxygen ; Phrenic Nerve ; Rats ; Receptors, Presynaptic ; Succinylcholine

BACKGROUND: Postoperative residual curarization subsequent to the use of neuromuscular blocking drugs can cause respiratory problems. This study examined the incidence of postoperative residual curarization on the arrival of patients in the recovery room. METHODS: Two-hundred-fifty-nine patients were enrolled in the study. The neuromuscular blockade was maintained with vecuronium or rocuronium and all subjects were reversed with pyridostigmine. The train of four ratios (TR) was quantified by acceleromyography immediately upon their arrival in the recovery room. The residual curarization was defined as a TR of < 0.9. RESULTS: The incidence of residual curarization was 32.8% (84 patients). The time from the last dose of muscle relaxants to the TR assessment in the recovery room was significantly different between those with a TR <0.9 (74.9 +/- 35.3 min) and a TR > 0.9 (104.5 +/- 51.1 min) patients. The total dose of muscle relaxants corrected by the ED95 was significantly different between TR < 0.9 and TR > or = 0.9 patients. The total dose of vecuronium or rocuronium, and the dose of pyridostimine was similar in the TR < 0.9 and TR > or = 0.9 patients. CONCLUSIONS: Significant postoperative residual curarization waspresent in the majority of patients, even with the use of intermediate- acting neuromuscular blocking drugs. In addition, the time from the last dose of muscle relaxants to the TR assessment in the recovery room is a major factor that affects the residual curarization.
Humans ; Incidence ; Neuromuscular Blockade ; Pyridostigmine Bromide ; Recovery Room* ; Vecuronium Bromide*

BACKGROUND: Head lift (HL) for 5 seconds and tongue depressor (TD) test have been used for diagnosis of the residual block after using the nondepolarizing muscle relaxants. We investigated validity and reliability of HL, TD, and both of them (HLTD). METHODS: Four-hundred-thirteen patients were enrolled in this study. Neuromuscular blockade was maintained with rocuronium and reversed with pyridostigmine and glycopyrrolate. TOF ratio was quantified by acceleromyograph in the recovery room. HL and TD test were performed in the patients who could respond to verbal command of the investigator. We analyzed the sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio, area under the cure (AUC) from ROC analysis and kappa statistics. RESULTS: Prevalences of residual block were 13%, 32% and 78% at 0.7, 0.9 and 1.0 of TOF ratio cutoff value, respectively. Specificity was good for HL (79.7-86.8%), TD (94.2-97.8%) and HLTD (77.8-85.7%), but sensitivity was not. Positive predictive value was higher in TD than HL and HLTD, and negative predictive value was similar among them. Positive and negative likelihood ratio was higher in TD than HL and HLTD. AUC had no difference among HL, TD and LTD. Kappa statistics were showed minimal or moderate relationship between clinical test and train of four responses. CONCLUSIONS: We concluded that HL, TD and HLTD were not good tools for diagnosis of the residual block in a view of validity and reliability.
Androstanols ; Area Under Curve ; Glycopyrrolate ; Head ; Humans ; Muscles ; Neuromuscular Blockade ; Prevalence ; Pyridostigmine Bromide ; Recovery Room ; Reproducibility of Results ; Research Personnel ; ROC Curve ; Tongue

BACKGROUND: It is well known that sevoflurane anesthesia is associated with emergence agitation (EA) in children, and that fentanyl may reduce its incidence. However, in case of midazolam, there have been conflicting reports. Therefore, we measured the effect of midazolam on EA after sevoflurane anesthesia and compared it with that of fentanyl. METHODS: Sixty pediatric patients receiving sevoflurane anesthesia for tonsillectomy was assigned to 3 groups. Saline 0.1 ml/kg (group P), midazolam 0.1 mg/kg (group M), or fentanyl 1 microgram/kg (group F) was administered intravenously 10 minutes before the end of surgery. The incidences of over-sedation (OS) and EA were checked three times at the postanesthesia care unit. RESULTS: Group M had a tendency to show a high incidence of OS, but its incidence of EA was not different from the other groups. In group F, OS and EA were less frequent than in groups P and M. CONCLUSIONS: After sevoflurane anesthesia for tonsillectomy, fentanyl effectively prevented EA, but midazolam elicited OS and was ineffective at preventing EA.
Anesthesia* ; Child* ; Dihydroergotamine* ; Fentanyl ; Humans ; Incidence* ; Midazolam* ; Tonsillectomy*

Changing patterns of the reemerging Plasmodium vivax malaria in the Republic of Korea (South Korea) during the period 1993 to 2005 are briefly analyzed with emphasis on the control measures used and the effects of meteorological and entomological factors. Data were obtained from the Communicable Diseases Monthly Reports published by the Korea Center for Disease Control and Prevention, and webpages of World Health Organization and United Nations. Meteorological data of Kangwon-do (Province) were obtained from local weather stations. After its first reemergence in 1993, the prevalence of malaria increased exponentially, peaking in 2000, and then decreased. In total, 21,419 cases were reported between 1993 and 2005 in South Korea. In North Korea, a total of 916,225 cases were reported between 1999 and 2004. The occurrence of malaria in high risk areas of South Korea was significantly (P<0.05) correlated with the mosquito population but not with temperature and rainfall. Control programs, including early case detection and treatment, mass chemoprophylaxis of soldiers, and international financial aids to North Korea for malaria control have been instituted. The situation of the reemerging vivax malaria in the Republic of Korea is remarkably improving during the recent years, at least in part, due to the control activities undertaken in South and North Korea.
Seasons ; Plasmodium vivax/drug effects ; Military Personnel/statistics & numerical data ; Malaria, Vivax/*epidemiology/parasitology/*prevention & control ; Korea/epidemiology ; Incidence ; Humans ; Disease Outbreaks/*prevention & control ; Communicable Diseases, Emerging/*epidemiology/parasitology/*prevention & control ; Chloroquine/administration & dosage ; Antimalarials/administration & dosage ; Anopheles/parasitology ; Animals

Zoletil is a non-opioid, non-barbiturate animal anesthetic and proprietary combination of two drugs, a dissociative anesthetic drug, tiletamine, with the benzodiazepine anxiolytic drug, zolazepam. Zoletil has greater potency than ketamine. Zoletil is abused for recreational purposes, especially by people with easy access to medicine. However, in Korea, it is available over-the-counter. Here we report on a case of an 83-year-old woman who received injection of seven vials of "Zoletil 50" by her daughter and presented with an altered mental change. Her mental state was stupor and vital sign was hypotension, bradycardia. Her blood tests indicated metabolic and respiratory acidosis and hyperkalemia. She was treated with intravenous naloxone and flumazenil but was not responsive. She was admitted to the ICU and treated with supportive therapy. Her mental state showed transient recovery, however, her clinical manifestation worsened and she expired.
Acidosis, Respiratory ; Aged, 80 and over ; Animals ; Benzodiazepines ; Bradycardia ; Drug Combinations ; Female ; Flumazenil ; Hematologic Tests ; Humans ; Hyperkalemia ; Hypotension ; Ketamine ; Korea ; Naloxone ; Nuclear Family ; Stupor ; Tiletamine ; Vital Signs ; Zolazepam

OBJECT: The intracellular action of the antidepressant, venlafaxine, was studied in C6-gliomas using heat shock protein 70(HSP70) immunocytochemistry and HSP70 Western blots because HSP70 is associated with stress and depression. METHODS: To examine how the glucocorticoid affects the expression of HSP70 in nerve cells, the rat C6 glioma cell was treated with dexamethasone for 6 hours. In addition, venlafaxine was administered to the experimental groups of C6 glioma cells for 1, 6, 24, and 72 hours each, after which the expression of HSP70 was investigated. Finally, venlafaxine and dexamethasone were simultaneously administered to the experimental groups for 1, 6, 24, and 72 hours, followed by an investigation of the expression of HSP70. RESULTS: The short term(1 hour) venlafaxine treatment significantly increased the level of HSP70 expression. The short term treatment of venlafaxine with dexamethasone also increased the level of HSP70 expression but this reduction was not statistically significant. The long term(72 hours) venlafaxine with dexamethasone treatment significantly reduced the level of HSP70 expression. The long term treatment of venlafaxine also reduced the level of HSP70 expression but this reduction was not statistically significant. Dexamethasone(10uM, 6hours) did not affect the level of HSP70 expression compared with controls. CONCLUSION: Venlafaxine increases the expression of HSP70 at short term treatment, but prolonged treatment with dexamethasone suppresses the expression of HSP70.
Animals ; Blotting, Western ; Depression ; Dexamethasone* ; Glioma* ; Heat-Shock Proteins ; Immunohistochemistry ; Neurons ; Rats* ; Venlafaxine Hydrochloride

Malaria is a reemerging infectious disease in Korea. We experienced a case of asymptomatic P. vivax malaria accompanied by thrombocytopenia, mimicking immune thrombocytopenic purpura. The patient was exposed to mosquito 12 weeks ago. She experienced a characteristic febrile episode lasting for 2 weeks and remained asymptomatic thereafter. It was 7 weeks after the characteristic febrile episode when the diagnosis was established by the parasitemia. Malaria should be considered in the differential diagnosis of thrombocytopenia in Korea, especially in patients with febrile episodes.
Communicable Diseases, Emerging ; Culicidae ; Diagnosis ; Diagnosis, Differential ; Humans ; Korea ; Malaria ; Malaria, Vivax* ; Parasitemia ; Plasmodium vivax* ; Plasmodium* ; Purpura, Thrombocytopenic, Idiopathic* ; Thrombocytopenia

BACKGROUND: Hip replacement arthroplasty (HRA) is highly traumatic and performed in a lateral position for several hours and dead-space ventilation may increase. So, the difference between arterial and end-tidal PCO2 was investigated depending on the changes in the patient's posture during HRA in elderly patients. METHODS: Forty-three patients scheduled for a HRA were divided into two groups; Adult Group (n = 21, A-Group) and Elderly Group (n = 22, E-Group). Mean arterial pressure (MAP), heart rate (HR), PaO2, PaCO2, and end-tidal carbon dioxide tension (P(ET)CO2) were simultaneously measured at 10 min after anesthesia in a supine position (S[10]), at 30 min intervals from 30 min (L[30]) to 180 min (L[180]) in a lateral position and at 10 min in a supine position after the end of surgery (ES[10]) in both groups. The PaCO2-P(ET)CO2 gradient (P[a-ET]CO2) and dead space ventilation (Vd/ Vt) were calculated. RESULTS: At S(10), P(a-ET)CO2 in the A- and E-Groups was 7.0 +/- 5.0 and 7.2 +/- 3.3 mmHg respectively. From L(30) to ES(10), the P(a-ET)CO2 and the ratio of Vd/Vt in both groups increased significantly and progressively (P < 0.05 vs the control value) and the slope in the E-Group rose two times as compared to that in the A-Group. The correlation coefficient between P(a)CO2 and P(ET)CO2 was very significant from S(10) to L(90) and ES(10) in the A-Group, and from S(10) to L (60) in the E-Group (P < 0.01). CONCLUSIONS: For maintaining adequate ventilation of the elderly patient during HRA, PaCO2 should be measured intermittently along with the position changes after anesthesia in addition to the constant monitoring of PETCO2.
Adult ; Aged* ; Anesthesia ; Arterial Pressure ; Arthroplasty, Replacement, Hip* ; Carbon Dioxide ; Heart Rate ; Hip* ; Humans ; Posture ; Supine Position ; Ventilation