The mechanism of chronic pain is very complicated. Memory, pain, and opioid dependence appear to share common mechanism, including synaptic plasticity, and anatomical structures. A 48-yr-old woman with severe pain caused by bone metastasis of breast cancer received epidural block. After local anesthetics were injected, she had a seizure and then went into cardiac arrest. Following cardiopulmonary resuscitation, her cardiac rhythm returned to normal, but her memory had disappeared. Also, her excruciating pain and opioid dependence had disappeared. This complication, although uncommon, gives us a lot to think about a role of memory for chronic pain and opioid dependence.
Amnesia/*diagnosis ; Anesthesia, Local/adverse effects ; Bone Neoplasms/drug therapy/radiotherapy/secondary ; Breast Neoplasms/drug therapy/pathology/radiotherapy ; *Cardiopulmonary Resuscitation ; Electroencephalography ; Female ; Heart Arrest/etiology ; Humans ; Magnetic Resonance Imaging ; Mepivacaine/adverse effects ; Middle Aged ; *Pain Management ; Seizures/etiology ; Tomography, X-Ray Computed

BACKGROUND: Small proportions of all the elderly stroke patients receive recombinant tissue plasminogen activator (r-tPA) therapy, although old age is not a proven contraindication to intravenous thrombolytic therapy for acute ischemic stroke. The purpose of this study was to identify reasons for exclusion from r-tPA therapy and factors associated with the decision of r-tPA use in elderly patients with acute ischemic stroke. METHODS: From the acute stroke registries of 22 domestic university hospitals taking the r-tPA therapy from January 2007 to May 2010, we extracted data of all acute ischemic stroke patients who were aged 80 or over and arrived within onset 3 hours. For all patients, we assessed the eligibility of r-tPA therapy using National Institute of Neurological Disorders and Stroke (NINDS) r-tPA trial criteria. For eligible patients, we compared all clinical variables between patients who were treated with r-tPA and those who were not, and analyzed potential factors related to the decision of r-tPA use. RESULTS: A total of 494 patients were included in this study. 255 patients (51.6%) were excluded by NINDS r-tPA trial criteria and the major reasons for exclusion were minor neurological deficit (53.7%) and clinical improvement (17.3%). Among 239 patients who were eligible for r-tPA, 162 (32.8%) patients received r-tPA and 77 (15.6%) did not. Multivariable analysis showed that younger age, shorter time-delay from onset to admission, non-smoker, no history of prior stroke, good pre-stroke functional status and severe initial neurological deficit were independently associated with the decision of r-tPA use in the elderly stroke patients predictors for r-tPA treatment. CONCLUSION: In very elderly patients, mild neurological deficit on arrival and rapid clinical improvement in neurological symptoms were the main reasons for exclusion from thrombolytic therapy.
Aged ; Hospitals, University ; Humans ; National Institute of Neurological Disorders and Stroke ; Registries ; Stroke ; Thrombolytic Therapy ; Tissue Plasminogen Activator

OBJECTIVE: To investigate the risk factors for poststroke delirium and evaluate its influence on functional recovery after ischemic stroke. METHOD: Risk factors for delirium were investigated retrospectively in three hundred twenty nine acute ischemic stroke patients over 60 years of age. Among the 329 patients, sixty seven developed delirium. Data were analyzed between delirium group (n=22) and control group (n=22) according to age, sex, lesion location and clinical features. Korean modified Barthel index (K-MBI), Korean National Institutes of Health stroke scale (K-NIHSS) and Korean mini-mental state examination (KMMSE) were measured at second and sixth weeks after onset and compared for both groups. RESULTS: Parameters showing statistically significant difference between two groups were age over 80, hyponatremia, sleep deprivation, cognitive impairment and cardiogenic embolism. There was no significant difference in K-MBI, K-NIHSS and K-MMSE scores at second week between the two groups. The delirium group showed significantly less improvement in K-MBI and K-NIHSS scores compared to control group (9.5+/-10.2 vs 18.5+/-11.6, p=0.011; -0.7+/-1.2 vs -1.8+/-1.3, p=0.014). There was no significant improvement in K-MMSE score. CONCLUSION: The possible risk factors for delirium in acute ischemic stroke are age over 80, hyponatremia, sleep deprivation, cognitive impairment and cardiogenic embolism. Stroke patients with comorbid delirium showed poorer functional outcome. Delirium seems to have detrimental effect in functional recovery after stroke.
Delirium ; Embolism ; Humans ; Hyponatremia ; National Institutes of Health (U.S.) ; Prognosis ; Retrospective Studies ; Risk Factors ; Sleep Deprivation ; Stroke

We report the case of a 43-year-old woman with Cushing's syndrome showing bilateral adrenococortical adenomas. We performed bilateral selective adrenal vein samplings. Hypersecretion of cortisol on the left sided adrenal tumor was observed, but no evidence of cortisol hypersecretion from the adrenal tumor on the right side was observed. The left adrenal tumor was resected selectively, but the right adrenal gland was reserved. The left adrenal tumor was histologically diagnosed as a adrenal adenoma without any evidence of nodular hyperplasia. Following the resection of the left adrenal gland, no cortisol hypersecretion from the remaining adrenal tumor on the right side was observed until now, suggesting that a selective adrenalectomy of functioning adenoma may be an acceptable treatment modality.
Adenoma* ; Adrenal Glands ; Adrenalectomy ; Adrenocortical Adenoma* ; Adult ; Cushing Syndrome* ; Female ; Humans ; Hydrocortisone ; Hyperplasia ; Veins

Arterioportal (AP) shunt is related to hepatocellular carcinoma (HCC) with variable frequency but its clinical significance is not well known. We retrospectively studied the prevalence and clinical significance including mortality of the AP shunt combined with HCC. METHODS: The clinical data and radiologic features of HCC patients who were performed hepatic angiography from 1992 to 1997 at St. Mary's Hospital in Korea were reviewed. The data of HCC patients with AP shunt were compared with that of randomized samples of HCC patients without AP shunt. RESULTS: The prevalence of AP shunt in HCC was 7.3%(45/616 HCC patients). There was no significant difference in clinical symptoms and signs such as ascites, encephalopathy, or variceal bleeding and laboratory findings between the HCC patients with AP shunt and those without. The AP shunt was more common in diffuse, poorly demarcated, large HCC. Especially, portal vein thrombosis (PVT) was one of the most common causes of AP shunt. Cumulative survival rate of the HCC patients with AP shunt was lower than that of those without. But only the size of HCC was significantly related with poor prognosis. CONCLUSION: AP shunt occurred in some HCC which was large in size or combined with PVT. AP shunt did not increase the severity of symptoms and signs, but decreased the survival because of its relation to tumor size.
Angiography ; Ascites ; Carcinoma, Hepatocellular* ; Esophageal and Gastric Varices ; Humans ; Korea ; Mortality ; Prevalence ; Prognosis ; Retrospective Studies ; Survival Rate ; Venous Thrombosis

Overcrowding of emergency departments is a growing problem. Delays in admitting patients to inpatient units have been reported as a contributing factor to overcrowding. Overcrowding in ED results in many patients not receiving needed care and impairs the ability of the ED provider to meet the needs of those patients that are treated. The effect of the critically ill patients on the overcrowded emergency department make emergency physicians frustrated. So we created 'the special unit for observation' of critically ill patients and managed them continuously and closely. The special unit for observation have 4 physical beds and monitors and 2 ventilators. One nurse and senior ED residents were asigned to the management of the patients in the special unit. 160 patients(3.4% of all ED visits) admitted to special unit during the period of March 1, 1996 to May 31, 1996. we could continue assessment and management of critically ill patients without psychologic strain or burnout generated by overcrowding. We think that special unit for critically ill patients is a very effective alternative to overcrowded ED.
Critical Illness ; Emergencies ; Emergency Service, Hospital ; Humans ; Inpatients ; Ventilators, Mechanical

No abstract available in English.
Tuberculosis, Spinal

No abstract available in English.
Clinical Study ; Spine ; Tuberculosis ; Tuberculosis, Spinal

We have experienced 11 cases of large bony defect that were treated using microsurgery since 1981. Free vascularized bone transplantation was performed in 8 of them, vascularized bone transposition in 2 cases, and free vascularized joint transplantation in the remaining 1 case. The causes of the large bony defect were primary bone tumor (4 cases), congenital pseudoarthrosis (3 cases), open comminuted fracture (2 cases), sequela of osteomyelitis (1 case), and post-traumatic ankylosis of PIP joint of second finger (1 case). As a donor, fibula was used in 8 cases, iliac crest in 1 case, rib in 1 case and in the remaining 1 case, the second M-P joint of foot was transplanted. In 9 of 11 cases, successful result was obtained and 2 cases were failed because of vascular damage following tibial lengthening in one case and infection on the grafted area in the other one. From the above data and review of articles, following conclusions were obtained. 1. Fibula is thought to be the most appropriate donor for the large bony defect in the extremity, especially in lower extremity, but the donor site must be determined according to the anatomical and physilogical condition of the patient. 2. After mechanical lengthening of the extremity, it is recommened to perform the microvascular surgery after sufficient time for the recovery of vascular damage. But further studies are required for the identification of the change in the vascular tissue following stretching and its recovery time. 3. Progression of the ossification in the epiphysis of transplanted iliac crest was observed and this finding proposed us the idea that the epiphyseal plate injury or leg length discrepancy will be able to be treated with free vascularized epiphyseal plate transplantation and the reconstruction of the destroyed joint of growing children will be possible using free vascularized joint transplantation. 4. As the technique become more popular, the free vascularized bone transplantation is being used for the reconstruction of the extremity more frequently, but it seems to be wise to restrict its indication to cases which are impossible to be treated with more simple methods such as vascularized bone transposition or pedicled bone graft.
Ankylosis ; Bone Transplantation ; Child ; Epiphyses ; Extremities ; Fibula ; Fingers ; Foot ; Fractures, Comminuted ; Growth Plate ; Humans ; Joints ; Leg ; Lower Extremity ; Microsurgery ; Osteomyelitis ; Pseudarthrosis ; Ribs ; Tissue Donors ; Transplants

No abstract available in English.
Arthroscopy ; Knee Joint ; Knee