Zhonghua yi xue za zhi = Chinese medical journal; Free China ed最新文献

Background: Morning serum cortisol examinations and short corticotropin (ACTH) tests are popular screening tests for unstressed patients suspected of having adrenal insufficiency. However, the correlation between morning serum cortisol and the peak cortisol response in the short ACTH test after intravenous injection of ACTH has not been studied before. This retrospective study examined the relationship among the mean basal morning cortisol level, the single random morning cortisol level and the peak cortisol level in the short ACTH test in evaluation of adrenal insufficiency.

Methods: In this retrospective study, we examined the relationship among the mean basal morning cortisol level and the peak cortisol level stimulated by intravenous injection of 250 microg synthetic ACTH in 106 unstressed patients with proven or suspected hypothalamic-pituitary-adrenal disease. Plasma cortisol levels were determined by radioimmunoassay. The correlation of the basal morning cortisol to the short ACTH test was determined by linear regression analysis. The ACTH test was analyzed using the receiver operating characteristic (ROC) curve method, and the cut-off points for various sensitivity and specificity were calculated.

Results: The mean basal is highly correlated to peak cortisol response in the ACTH test (r = 0.7724, p < 0.0001). Iatrogenic Cushing's syndrome, caused by ingestion of herbs with illegal steroid additives, was the most common cause (60%) of adrenal insufficiency in the 52 patients with subnormal result. A mean basal morning serum cortisol of > or = 300 nmol/L excluded the possibility of adrenal insufficiency, and a level of < 110 nmol/L suggested adrenal insufficiency. A mean basal cortisol level of > or = 234 nmol/L predicted a normal cortisol response in the ACTH test with optimal sensitivity (80.6%) and specificity (91.4%).

Conclusions: The mean morning cortisol level is a cost-effective screening test in predicting the results of the ACTH test. A mean morning cortisol level > or = 300 nmol/L in suspicious cases of adrenal insufficiency which are not due to acute central etiologies excludes the possibility of subnormal cortisol response to ACTH; whereas a level < 110 nmol/L is likely to have subnormal cortisol response to ACTH. The short ACTH test or insulin tolerance test should be performed in patients with a morning cortisol level 300 nmol/L or with clinical symptoms highly suggestive of adrenal insufficiency.

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, is a rare disorder characterized by arteriovenous communications in visceral organs. The diagnosis of HHT consists of recurrent epistaxis, mucocutaneous telangiectasis, visceral vascular lesion and familial occurrence. HHT can be definitely diagnosed with the presence of all these three criteria. The prevalence of liver involvement of HHT was reported to range from 8 to 31%. Herein, we present a 75-year-old male who was diagnosed as having HHT with liver involvement, based on the findings of recurrent epistaxis, mucosal telangiectasis on the lower lip and hepatic arteriovenous malformation. The clinical presentations of this patient are discussed, and the literature is reviewed.

Background: Unlike in Western countries, autoimmune hepatitis (AIH) is an infrequent diagnosis in Taiwan. The clinical characteristics of AIH in this area are unclear. The aim of this study was to elucidate the clinical features of AIH in Taiwan.

Methods: All the medical records of in-patients with the diagnosis of chronic hepatitis in our hospital from 1990 to 2001 were reviewed for the possibility of AIH. The clinical features, biochemical data, immunological presentations, treatments and survival of the patients were evaluated.

Results: Twenty-two patients (15 females and 7 males) were diagnosed as having AIH within 11 years. The median age at onset was 64 years (range: 17-77 years). Compared with female patients, male patients had older age (p = 0.001), shorter duration from initial presentation of symptoms to diagnosis (p = 0.015), lower serum levels of alkaline phosphatase (ALK-P, p = 0.022) and albumin (p = 0.043). Five (23%) patients presented with cirrhosis upon diagnosis. Compared with non-cirrhotic patients, cirrhotic patients had lower serum levels of alanine aminotransferase (p = 0.002), aspartate aminotransferase (p = 0.015), gamma-glutamyl transferase (G-GT, p = 0.002), albumin (p = 0.14), white cell counts (p = 0.009) and platelet counts (p = 0.002). Thirteen (59%) patients had concomitant clinico-pathological features of cholestatic liver disease (ALK-P > or = 2 times of upper normal limit or pathologic evidence of cholangiopathy). They had higher serum levels of ALK-P (p < 0.001) and G-GT (p = 0.004) than 9 non-cholestatic patients. There were no significant differences in survival between these groups. The prescribed initial and maintained prednisolone dosages for our patients to control disease activity were 19 +/- 15 mg and 8 +/- 1 mg, respectively, which were lower than those recommended in Western countries. The remission rate to steroid treatment and relapse rate after discontinuing corticosteroids were 87.5% and 50%, respectively.

Conclusions: Compared with Western AIH patients, the AIH patients in Taiwan are older and more likely to develop cholestasis, and need a relatively lower dose of steroid for treatment. Owing to one quarter of the patients already having liver cirrhosis on diagnosis, AIH should be suspected in any Taiwanese patient with cryptogenic hepatitis or cirrhosis.

Background: To evaluate the effects of sphenopalatine artery electrocautery for the treatment of recurrent posterior epistaxis.

Methods: Nine patients were enrolled in the study. Seven patients had hypertension, two had diabetes, two received irradiation for nasopharyngeal carcinoma, one had congestive heart failure and one was a heavy drinker. Three patients needed blood transfusion for profound blood loss. The sphenopalatine artery electrocautery was performed transnasally with endoscope. After the sphenopalatine foramen was identified through dissecting the mucosa of middle meatus posteriorly one centimeter from the choana, the neurovascular bundle in the sphenopalatine foramen was cauterized.

Results: Most operations can be performed within fifty minutes with minimal blood loss under local anesthesia. One patient developed minor epistaxis 2 months after surgery, and the bleeding was controlled with medical treatment. The other patients had no recurrent epistaxis after surgery. Thus, epistaxis was well controlled in all patients without complications. The follow-up duration was 2 to 14 months after surgery, with a mean duration of 10 months.

Conclusions: Transnasal sphenopalatine artery electrocautery is a simple, effective and safe method for the treatment of posterior epistaxis.

This review article summarizes recent studies on myofascial trigger point (MTrP) to further clarify the mechanism of MTrP. MTrP is the major cause of muscle pain (myofascial pain) in clinical practice. There are multiple MTrP loci in an MTrP region. An MTrP locus contains a sensory component (sensitive locus) and a motor component (active locus). A sensitive locus is the site from which pain, referred pain (ReP), and local twitch response (LTR) can be elicited by needle stimulation. Sensitive loci are probably sensitized nociceptors based on a histological study. They are widely distributed in the whole muscle, but are concentrated in the endplate zone. An active locus is the site from which spontaneous electrical activity (SEA) can be recorded. Active loci are dysfunctional endplates since SEA is essentially the same as endplate noise (EPN) recorded from an abnormal endplate as reported by neurophysiologists. Both ReP and LTRs are mediated through spinal cord mechanisms, demonstrated in both human and animal studies. The pathogenesis of MTrPs appears to be related to the integration in the spinal cord (formation of MTrP circuits) in response to the disturbance of the nerve endings and abnormal contractile mechanism at multiple dysfunctional endplates. Methods usually applied to treat MTrPs include stretch, massage, thermotherapy, electrotherapy, laser therapy, MTrP injection, dry needling, and acupuncture. The mechanism of acupuncture is similar to dry needling or MTrP injection. The new technique of MTrP injection can also be used to treat neurogenic spasticity.

Solitary plasmacytomas include extramedullary plasmacytomas and those found in the bone. Seventy percent of patients are male and the median age is 50-55 years, younger than that for plasma cell myeloma. Most solitary plasmacytomas of bone eventually evolve to plasma cell myeloma within 2-10 years, while the extramedullary ones do so infrequently. We present an unusual case of intra-abdominal plasmacytoma in a young woman which was misdiagnosed and treated as T cell lymphoma initially. Typical manifestations of plasma cell myeloma appeared one year later. High dose chemotherapy followed by allogeneic peripheral stem cell blood transplantation (allo-PBSCT) was given. Relapse in skin occurred one year after allo-PBSCT, and was treated with wide excision and local irradiation. The patient was well and alive without evidence of disease 4 years after wide excision of the recurrence of chest wall solitary plasmacytoma and local radiotherapy.

Zafirlukast, a competitive cysteinyl leukotriene receptor antagonist, is a new class of asthma medications. It has shown an adverse event profile similar to that of placebo. Herein, we present a 69-year-old female patient who suffered from general malaise, poor appetite, nausea and jaundice after 3 months of zafirlukast therapy for asthma. She had no past history of liver disease, nor history of alcoholism, herb medication, blood transfusion, acupuncture, tattoo or recent traveling history. Liver biochemistries revealed elevated serum alanine aminotransferase and aspartase aminotransferase levels up to 481 U/L and 212 U/L, respectively. Moreover, peak serum total bilirubin level was elevated to 34.8 mg/dL during admission. Serum viral hepatitis marker, antinuclear antibody, anti-mitochondrial antibody and anti-smooth muscle antibody were all negative. Her general condition and liver biochemistries improved gradually after zafirlukast was discontinued. Roussel Uclaf causality assessment for adverse drug reaction confirmed the diagnosis of drug-induced liver injury. This case reminds us that zafirlukast is a potentially hepato-toxic drug. If clinical manifestations of hepatitis develop, patients should be managed cautiously and closely monitored for liver biochemistries. If drug-induced hepatitis is suspected, medication should be discontinued immediately to prevent further liver injury.