Large Doses Of Methylprednisolone Research Articles

Immune thrombocytopenia in a small cell lung cancer patient treated with atezolizumab: a case report

Immune checkpoint inhibitors (ICIs), an enormous oncological breakthrough in the last 10 years, have become the standard treatments for several types of solid cancers. Although ICIs are generally well tolerated and result in favorable outcomes, they also cause unique immune-related adverse events (irAEs) across bodily systems and organs. Compared to most common irAEs, which occur in the endocrine, skin, pulmonary system, and gastrointestinal tract, haematological irAEs (haem-irAEs) are relatively rare but potentially life-threatening events that are occasionally irreversible and refractory. Currently, haem-irAEs are not sufficiently understood, management, and lack consensus, while other common irAEs have well been characterized and managed. The reports of ICI-related thrombocytopenia in small cell lung cancer (SCLC) are rarely seen. Hence, we reported a rare case of severe steriod-resistant ICI-related thrombocytopenia after received chemotherapy plus anti-PD-L1 inhibitor in SCLC patient. Our case exemplifies the diagnosis, diagnosis of exclusion, treatment, and prognosis of thrombocytopenia in the pattern of combination therapy, meanwhile, the subject of diagnosis, therapies, therapeutic strategies for refractory type and incidence, potential biomarkers, mechanisms and prognosis in ICI-related thrombocytopenia have been fully discussed. Herein, we present a 64-year-old man diagnosed advanced SCLC developed refractory immune-related severe thrombocytopenia, who achieved favorable outcomes of cancer following chemotherapy combined with atezolizumab administrated. Routine blood re-examination on the third day of 6th therapy showed a thrombocyte count of 11×109/L. Combined the medical history and the results of laboratory tests, the diagnosis of ICI-induced thrombocytopenia was confirmed. Despite large doses of methylprednisolone, immunoglobulin, and rituximab, intermittent platelet transfusion, thrombopoietin being administrated to the patient, there were no signs of platelet count and hemoglobin improvement. Currently, this is the first case about atezolizumab induced thrombocytopenia in SCLC patient, while there is extremely rare haem-irAEs reported in SCLC. Although ICI-related severe thrombocytopenia is rare, it may persist or even be fatal. Clinicians should pay more attention to its diagnosis and prompt treatment. Once developed thrombocytopenia, large doses of methylprednisolone, ntermittent platelet transfusion, thrombopoietin should be timely administrated, also plasma exchange or rilzabrutinib, other immunosuppressive drugs, or IL-6 inhibitor warrant apply if steriod-resistant.

Clinical Efficacy and Prognosis of the Large Dose Methylprednisolone Impulse Therapy in Combination with the Surgery in Treatment of the Spine Trauma Complicated with the Spinal Cord Injury

It is aimed to investigate the clinical efficacy and prognosis of large-dose methylprednisolone impulse therapy in combination with the surgery in treatment of the spinal damage complicated with the spinal cord injury. A retrospective analysis was conducted over the clinical data of 90 spine damage patients complicated with the spinal cord injury who underwent the surgical treatment in this hospital between October 2015 and September 2018. In the control group, patients only took the surgical treatment, while those in the observation group adopted the large-dose methylprednisolone impulse therapy. Following treatment, the improvement of vertebral body, Harris score, self-care ability of daily living and the overall effective rate of treatment were evaluated in two groups. In the observation group, the compression height of the anterior vertebral edge was (6.64±2.20) mm, the compression height of the posterior vertebral edge was (5.86±2.63) mm, and the Cobb’s angle was (8.62±2.51), which were significantly improved when compared with those in the control group, and the differences had statistical significance (t=21.75, 11.37 or 12.64; p<0.05). In the observation group, patients also had a higher Harris score (66.11±3.97) points than their counterparts in the control group (5.68±2.26) points (t=83.42; p< 0.05). Besides, the scores of the self- care ability of daily life [Dressing: (8.91±2.33) points; diet: (8.63±2.47) points; walking: (14.33±2.96) points; moving ability of the bed or chair: (13.11±2.97) points; control of defecation: (15.34±4.70) points] in the observation group were all higher than the control group [Dressing: (3.54±2.60) points; diet: (3.16±2.11) points; walking: (1.62±3.11) points; moving ability of the bed or chair: (1.74±3.20) points; control of defecation (2.86±6.12) points] (t=9.69, 10.61, 18.67, 16.42 and 10.22; p< 0.05). In the observation group, the total effective rate of treatment was 95.56 %, also significantly higher than 80.00 % in the control group (e­“2 = 4.113, p<0.05). After the large-dose methylprednisolone impulse therapy in combination with the surgical treatment, spine-damaged patients with the spinal cord injury gain the promising improvement in the vertebra and prognosis, significantly enhancing the self-care ability of daily life, with recovery in the nerve function and muscle strength. Thus, this strategy is worthy of being promoted in clinical practice.

Pulmonary Arterial Hypertension and Fulminant Myocarditis as Initial Manifestation of Systemic Lupus Erythematosus

Severe pulmonary arterial hypertension (PAH) is rarely observed as initial manifestation of systemic lupus erythematosus (SLE). Lupus myocarditis may rarely be initial presentation as a fatal complication of SLE, which mainly involved with the left ventricle. Here, we present a case of an incident PAH woman who had a delivery history 4 months previously. During hospitalization, she suffered from extensive myocardial damage, refractory ventricular tachycardia, and cardiogenic shock. Ultimately, she was diagnosed with SLE, fulminant lupus myocarditis, and PAH associated with connective tissue disease. After a large dose of methylprednisolone and PAH target therapy treatment, she recovered successfully and got a good result. To the best of our knowledge, this is the first case report of PAH and fulminant lupus myocarditis as initial manifestation of SLE in a previously healthy postpartum woman.

Effect of large dose of Methylprednisolone on epilespy combined with electrical status epilepticus during sleep in children

Objective To investigate the clinical effect of large dosage of Methylprednisolone on epilespy combined with electrical status epilepticus during sleep(ESES) in children. Methods Forty-six epielpsy patients with ESES were treated with additive large dosage of Methylprednisolone.The seizures and video electroencephalogram discharges were observed before and after using Methylprednisolone.The Methylprednisolone effect in eliminating the methylprednisolone of ESES and controlling of clinical seizures and improving cognitive function were analyzed. Results Two cases were lost and 44 cases were included, male 30, female 14, the age at onset was (5.37±2.52)(2-9) years old.The duration of follow-up was (4.12±2.00)(1-9) years old.The age at diagnosis of ESES was (8.17±2.09)(4.0-12.5) years old.The efficacy of Methylprednisolone on seizures was 72.7%(32/44 cases), while the efficacy of Methyl prednisolone on electroencephalograph(EEG) was 59.1%(26/44 cases). For patients who were resistant to Levetiracetam or Clonazepam, Methylprednisolone was still effective.Intelligence quotient had no significant changes before and after treatment(P>0.05). The earlier onset age, the worse effect of Methylprednisolone.The efficacy of methylprednisolone for atypical benign epilepsy with cento-temporal spike(BECT) was higher than other syndromes. Conclusions Large dosage of Methyl prednisolone therapy for children with ESES, especially for those resistant to traditional or new antiepileptic drug for ESES, was effective and safe.The onset age and syndrome classification may have a certain value for prognosis and prediction of the effect of Methylprednisolone treatment. Key words: Epilepsy; Electrical status epilepticus during sleep; Methylprednisolone; Spike wave index

Analysis of clinical outcome and treatment of viral encephalitis with bilateral thalamic damage

Objective To investigate the clinical outcome and treatment characteristics of viral encephalitis with bilateral thalamic damage so as to improve its prognosis. Methods Twelve cases of viral encephalitis with bilate-ral thalamic damage were collected during September 2012 to June 2013 by head MRI.These cases were retrospectively studied with the data of medical history, physical examination, laboratory and brain function monitoring and treatment.The relationship between treatment and prognosis was studied during 2 years of follow-up. Results All patients began with the rapid onset, accompanied by fever, coma, and convulsions.Delirium and involuntary movement occurred during the recovery period.Six cases(50.0%) received ventilator assisted ventilation.In the acute phase, electroencephalogram(EEG) showed diffuse slow wave and 4 cases(33.3%) had status epilepticus on EEG.Ten cases discharged from hospital had long-term oral anti epileptic drugs, which lasted 6 months in 3 cases, 1 year in 4 cases, and 2 years in 3 cases for maintaining EEG stability.Head MRI indicated white matter demyelination besides the gray matter damage within the thalamus.All 12 patients underwent methylprednisolone impact treatment and 6 cases had effective reversal within 1 week of onset with better tolerance, and the other 6 cases received treatment in subacute stage and 5 of them accelerated reco-very and 1 case had sense improvement, but died after giving up therapy.After 3 months courses, 8 cases(66.7%) got gross motor and swallowing function recovered to normal, and 3 cases had left unilateral limb movement disorder.After 2 years of follow-up, 11 cases had normal motor, intelligence returned to normal in 9 cases, and 2 cases had mild mental retardation. Conclusions Viral encephalitis complicated with bilateral thalamic damage is characterized by acute onset, serious manifestations, idiopathic progress; in the subacute stage it is most likely to develop white matter demyelination.The key to control the disease is to block the inflammatory immune response quickly, and give patients large dose methylprednisolone treatment can effectively curb the progress of the disease.In the sub acute phase, it can promote the recovery, safe and effective.The long-term prognosis will be good with the reasonable treatment at early stage of the disease. Key words: Thalamus; Encephalitis, viral; Treatment

Clinical characters of rapidly progressive crytogenic organizing pneumonia

To explore the clinical features of rapidly progressive crytogenic organizing pneumonia (COP). Nine cases of rapidly progressive COP with acute respiratory failure confirmed by lung biopsy at First Affiliated Hospital, Nanjing Medical University from October 2003 to March 2014 were retrospectively reviewed. There were 5 males and 4 females with an age range of (52.1 ± 11.4) years. The onset of illness was 7-20 days. The major manifestations included cough (n = 9), dyspnea (n = 9), fever (n = 7), hypodynamia (n = 6), weight loss (n = 3), night sweat (n = 2), hemoptysis (n = 1), cyanosis (n = 9), "velcro" crackles (n = 6) and moist rales (n = 3). Blood tests showed elevated levels of erythrocyte sedimentation rate (n = 8), C-reactive protein (n = 8) and serum ferritin (n = 6). The results of blood gas analysis indicated acute respiratory failure in all 9 patients (PaO2<60 mmHg, 1 mmHg = 0.133 kPa). Chest computed tomography showed bilateral and multiple distribution, patchy areas of alveolar consolidation with air bronchograms (n = 5), diffuse ground-glass opacity (n = 4), tractional bronchiectasis (n = 2), pleural effusion (n = 2) and spontaneous pneumothorax (n = 1). Six cases were cured by conventional dose corticosteroid and another 3 by large-dose methylprednisolone (240 mg/d). Two cases relapsed and then recovered after a second corticosteroid therapy. The clinical manifestations of rapidly progressive COP show severe inflammatory reactions with a fast progression. Chest computed tomography depicts extensive lesions along with pleural effusion and spontaneous pneumothorax. Conventional dose of corticosteroid is the first choice therapy for rapidly progressive COP. Large-dose methylprednisolone is needed when conventional dose of corticosteroid proves ineffective.

Marked improvement of anti-N-methyl-D-aspartate receptor encephalitis by large-dose methylprednisolone and plasmapheresis therapy combined with 18F-fluorodeoxyglucose positron emission tomography imaging: A case report.

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, a recently defined and frequently misdiagnosed disease characterized by psychiatric symptoms, seizures, movement disorders and autonomic dysfunction, has been observed predominantly in young females with ovarian teratoma. Conventional imaging techniques, including computed tomography (CT) and magnetic resonance imaging (MRI), are often ineffective for diagnosis of the disease. If diagnosed early, the initiation of immunotherapy and removal of the tumor (if present) may result in recovery. The current study presents the case of a 38-year-old female with classic clinical symptoms of anti-NMDAR encephalitis. The MRI brain scan results were unremarkable, cerebral spinal fluid (CSF) biochemistry indicated non-specific lymphocytic pleocytosis and the CSF microbiology studies were negative. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) imaging revealed significant generalized asymmetric hypometabolism. The patient demonstrated marked recovery following treatment with a high dose of corticosteroids and plasmapheresis. Accordingly, the follow-up 18F-FDG PET imaging revealed significant improvement.

Trichloroethylene-Induced Hypersensitivity Syndrome: A Disease Caused by Metabolites

Patients suffering from a hypersensitivity syndrome (HS) caused by Trichloroethylene (TCE) have been reported mainly in Asian countries. However, due to its reported extremely low incidence rate, it’s rarely to encounter two patients from the same factory. We hospitalized two male cases who suffered from TCE-induced HS. Both patients developed exfoliative dermatitis, fever and liver dysfunction after unequivocal TCE exposure. Depending on the extent of their rash and liver injury, both patients were administered large doses of methylprednisolone intravenously with a tapering dose every 2 to 5 days. For the follow-up study, Ophthalmic examinations (Tear Breakup Time, Schirmer Test) were abnormal. TCE-induced HS patients can be successfully treated with appropriate glucocorticoid, although xerophthalmia may continue as sequelae. Patch testing was positive for Chloral hydrate, Trichloroethanol and Trichloroacetic acid but not TCE. The positive results suggest that Chloral hydrate, Trichloroethanol and Trichloroacetic acid (metabolites of TCE) are responsible for the hypersensitivity.

Bilateral lung transplantation for bronchiolitis obliterans after allogeneic bone marrow transplantation: a case report and literature review

To explore the feasibility and efficiency of lung transplantation in the treatment of bronchiolitis obliterans (BO) after allogeneic bone marrow transplantation (allo-BMT). We reported one case of bilateral lung transplantation for BO after allo-BMT and reviewed the related literatures. A 23 year-old man diagnosed as BO after allo-BMT underwent a sequential bilateral lung transplantation through bilateral anterolateral thoracotomy without sternal division. The patient suffered from acute rejection on post-operation day (POD) 2, and cured by mechanical ventilation, large dose of methylprednisolone and gamma globulin. The patient was transferred out of the intensive care unit on POD 14 and discharged from the hospital on POD 43. Chest CT scans and pulmonary function tests showed good performance in 3 and 6 months follow-up period. BO is one of the late common non-infectious pulmonary complication after allo-BMT. For patients who have no response to medication, lung transplantation is the only efficient treatment choice so far, which can prolong survival and improve the quality of life. However, limited by small samples, optimal surgery time and appropriate care of postoperative complications still need accumulation of experience by multicenter and large samples studies.

The clinical contrast research of treatment in children of abdominal allergicpurpura

Objective To explore the effective treatment in children of abdominal allergicpurpura.Methods To retrospectively analyze the clinical data of 54 children with abdominal allergicpurpura.54 cases were divided into three groups.Each 18 cases in group Ⅰ,groupⅡ,and group Ⅲ.It was used large doses of methylprednisolone in the group Ⅰ,ranitidine in the groupⅡ,and cimetidine in the groupⅢ,based on conventional treatment.To analyze the effect and adverse effect after the treatment.Results The effect of groupⅠ,and groupⅡ,was significantly higher than group Ⅲ(t=11.775,8.901,7.613,5.786,10.105,12.347,all P＜0.05).There was no significant difference between groupⅠ,and group Ⅱ(P＞0.05).The adverse effect of groupⅠ,was significantly higher than the other groups(x2=4.500,5.017,all P＜0.05).Conclusion The treatment of hormone had obvious effect in children with abdominal allergicpurpura,but it had some risks in the gastrointestinal,so we should close observe the gastrointestinal tract in children.Ranitidine and cimetidine are the drugs of inhibiting gastric acid secretion,but the ranitidine much better than cimetidine. Key words: Purpura,schoenlein-henoch; Methylprednisolone; Ranitidine; Cimetidine; Child

Study on the therapeutic effect and nursing on acute spinal cord injury treatment with large-dose of methylprednisolone

Objective To explore the short-term effect of high dose methylprednisolone (MP) pulse therapy for acute spinal cord injury,to observe its complications,and to summary nursing experience.Method We retrospectively reviewed nursing process of 80 patients who received high-dose MP pulse therapy with acute spinal cord injury in hospital.Results Patients receiving high-dose MP pulse therapy didn't appear any serious complications,at the same time sensory and motor function improved significantly,Conclusions For patients with acute spinal cord injury,the use of high-dose MP pulse therapy can be effective in preventing secondary spinal cord injury and improving spinal function.During the application of MP,close nursing and observation is one of the keys to ensure successful treatment. Key words: Methylprednisolone; Spinal cord injury; Nursing

Clinical Observation of Severe Bronchial Asthma Treated by aerosol inhalation of Pulmicort Respules combined with urbason

Objective To investigate the efficacy of aerosol inhalation of Pulmicort Respules combined with urbason in treating severe bronchial asthma.Methods The clinical data of 40 cases aith severe bronchial asthma treated in our hospital were analyzed retrospectively,among which 20 cases underwent Pulmicort Respules combined with urbason(Tset Group),20 cases underwent urbason( Control Group).Results Compared with the control group,the blood gas analysis in test group had statistically significant difference before treatment (P ＜ 0.05 ).Compared with the control group,the clinical effect and the blood gas analysis in test group had no statistically significant difference after treatment(P ＞ 0.05 ).Compared with the control group,the complications in test group had statistically significant difference( P ＜ 0.05),the complications in test group was less than the control group.Conclusion Aerosol inhalation of Pulmicort Respules can reduce the amount of urbason and lower the incidence d complications.The combination treatment of this two drugs can achieve the same clinical results alike the clinical effect of large doses of methy lprednisolone. Key words: Asthma; Pulmicort respules ; Urbason

Extracorooreal membrane oxvgenation treatment of a child with fulminant myocarditis

Objective To report the clinical experience of extracorporeal membrane oxygenation (ECMO)in the emergency management of fulminant myocarditis.Methods The patient,an 11 year-old boy,had fever for 4 day and abdominal pain,vomiting for 1 day and anuria for 12 hours.Electrocardiogram showed Ⅲ atrial-ventricular block,multifocal ventricular rhythm,bundle branch block,convulsivum multifocal ventricular tachycardia,extensive low voltage,ST-T elevation at lead Ⅰ,AVR,V1,V2,V3;and there were ST-T intrusion,T wave inversion at lead Ⅱ,Ⅲ,AVR,AVF,V4～5.Blood creatine kinase was 2 161 U/L,reatine kinase isoenzyme 109 U/L,α-hydroxybutyrate dehydrogenase 612 U/L,lactate dehydrogenase 696 U/L,troponin Ⅰ 22.1 U/L.Echocardiogram showed right atrium 4.4 mm,right ventricular 2.3 mm,severe tricuspid valve regurgitation,left ejection fraction 33％,left ventricular fractional shortening 15％,ventricular wall motion dyssynchrony.Blood lactate was 4.0 mmol/L.The patient's condition was still unstable after using dobutamin,dopamine,milrinone,furosemide,large dose methylprednisolone,intravenous human immunoglobin,phosphocreatine and so on.ECMO was used for cardio-pulmonary support.It is necessary to monitoring the consciousness,temperature,heart rate,respiration,blood pression,SaO2,urinary volume,ariterial blood gas,blood electrolytes,blood lactate,blood glucose,liver function,renal function,blood routine,activated clotting time(ACT),lower extremity blood supply and so on.ACT was maintained at 160～200 s.Heparin was used persistently[5～10 U/(kg·min)].Results ECMO system had been successfully used for 7 days.The cardiac function of the patient was improved significantly.There was no complication,such as hemorrhage,infection,and embolism.Heart arrest in the patient occurred three times,ventricular fibrillation and ventricular flutter occurred one time respectively during ECMO.The rhythm was recovered by electric defibrillation and antiarrhythmic drugs.On day 20,the patient was discharged.At the time of hospital discharge,the patient demonstrated good activity,with normal myocardial enzymes.The echocardiogram showed the size of the cardiac chambers and the contractile function of the myocardia were normal.Electrocardiogram showed Ⅰ degree atrial-ventricular block,complete right bundle branch block.Two weeks later,the electrocardiogram demonstrated complete right bundle branch block.Echocardiogram showed septal thickening(0.9 cm).Two months later,the electrocardiogram was just as that of two weeks before.Echocardiogram showed septal thickening(0.7 cm).The children had no symptom after he was discharged and acted without limitation.Conclusion ECMO is a kind of effective treatment for fulminant myocarditis.The key to desirable therapeutic effect is the timing of its application. Key words: Extracorporeal membrane oxygenation ; Fulminant myocarditis ; Children

Methylprednisolone and tetrandrine in combination with direct current electrical field for treating acute spinal cord injury

Abstract Background The direct current electrical field can effectively promote the regeneration of the spinal cord; moreover, methylprednisolone (MP) can relieve secondary edema after spinal cord injury. Tetrandrine (Tet) is an effective component of hanfangji and can protect the effect of spinal cord and axis-cylinder. Whether direct current electrical field combining with MP or Tet has synergic or strengthening effect on treating complete spinal cord injury or not should be studied further. Objective To study the effect of direct current electrical field assisted by MP and Tet on treating spinal cord injury. Desing Randomized controlled animal study. Setting People's Hospital of Hainan Province. Materials A total of 45 healthy hybrid dogs, of both genders, weighing 10–12 kg, aged 1.5–2 years, were provided by Animal Center of Hainan Province. Somatosensory evoked potential meter (DANTEC Company), IBAS-2.0 imaging analysis meter (Germany), and self-made electronic stimulator. Methods The experiment was carried out in Hainan People's Hospital from May 2001 to June 2004. All experimental dogs were randomly divided into 4 groups: control group (n =9), electrostimulating group ( n =12), MP + electrostimulating group ( n =12) and Tet + electrostimulating group ( n =12). After anesthesia, Allen WD method was used to induce complete spinal cord injury. The metal bar, which was 10 cm in height fell freely and vertically hit the spinal cord to provide a complete spinal cord injury. Dogs in control group and electrostimulating group were implanted electrical stimulators 6 hours after spinal cord injury (no electricity in control group); dogs in MP + electrostimulating group were injected 30 mg/kg MP for 15 minutes at 2 hours after spinal cord injury and electrical stimulators implanted at 6 hours after injury; dogs in Tet + electrostimulating group were intravenously injected with 7.5 mg/kg Tet at 2 hours after spinal cord injury and electrical stimulators implanted at 6 hours after injury; and then, 7.5 mg/kg Tet injected at days 2 and 3 after injury. Specimens were taken from control group from three dogs of every month; from the injured segments of spinal cords at 1 month, 2 months and 3 months; and from electrostimulating group, MP + electrostimulating group and Tet + electrostimulating group of 4 dogs for histological examinations. Detection of neurological function: Neurological function was evaluated with the functional 10 grading system. The scores ranged from 0 to 10 (0: complete paraplegia; 10: normality). Detection of cortical somatosensory evoked potential (CSEP): According to the scheme formulated by the International Electroencephalographical Association, the patterns of the fundamental waves were P1–N1–P1 waves. The latency of the P1 wave and the amplitude of P1–N1 waves were mainly observed individually at 1, 2 and 3 months after the injury. Histological detection: All spinal cord specimens of the injuried segment were harvested at 1, 2 and 3 months after injury. They were stained with hematoxylin and Nissl staining methods, and then were observed under an optical microscope, and the neurons were counted. The sectional areas of the neurons and the density of the Nissl bodies were measured by a system image pattern analysis (IBAS-2.0, Germany). Main outcome measures The neurological function, cortical somatosensory evoked potential, neuronal amount, sectional area of neurons and Nissl body density at 1 to 3 months after injury. Results All 45 experimental dogs were involved in the final analysis. Detection of neurological function: One month later, the dogs in MP + electrostimulating group could walk, but the dogs in electrostimulating group and Tet + electrostimulating group could stand. Two months after injury, the dogs in MP + electrostimulating group almost recovered to normal, but the dogs in electrostimulating group could walk and those in Tet + electrostimulating group could run. Those in control group had no parent recovery. Detection of P1 latency and P1–N1 amplitude: Changes of P1 latency in control group were long and P1–N1 amplitude was very low at 1 month later. Compared to electrostimulating group, MP + electrostimulating group and Tet + electrostimulating group, there were significant differences ( P P Sectional areas of neurons and Nissl body density: At 1–3 months after injury, sectional areas of neurons were larger in electrostimulating group [(170.14±7.45), (209.60±14.80), (312.47±12.63) μm 2 ], MP + electrostimulating group [(282.18±15.25), (418.18±16.27), (515.25±15.10) μm 2 ] and Tet + electrostimulating group [(231.81±7.38), (322.67±8.45), (386.82±10.42) μm 2 ] than control group[(98.12±4.93), (113.50±6.74), (122.59±8.03) μm 2 , P P Conclusion The direct current electrical field can effectively promote spinal cord regeneration. The combination of direct current electrical field with large dose MP or Tet has synergistic effects for treating spinal cord injury. The curative effects of direct current electrical field with large dose MP are much better than those with Tet.

Propofol Infusion Syndrome???A Fatal Case at a Low Infusion Rate

To the Editor: We report the case of a 24-year-old male athlete who sustained a spinal injury, while competing in a Swiss wrestling contest. His third cervical vertebra was fractured, producing incomplete sensory and motor paraplegia. Upon admission to a regional hospital, the patient was treated with IV large-dose methylprednisolone (1). He unfortunately suffered from massive aspiration during initial magnetic resonance imaging, followed by acute respiratory distress syndrome (ARDS) and systemic inflammatory reaction syndrome (SIRS). The patient's trachea was intubated and his lungs were mechanically ventilated. He was sedated with propofol at a maximum infusion rate of 2.6 mg·kg−1· h−1. He required moderate adrenergic support. Cardiac troponin I (Trop I) and creatine kinase (CK) were increased 14 and 52 h after initiation of propofol sedation. (Fig. 1) The patient developed acute renal failure and was transferred to our hospital, a tertiary referral center, for further therapy. Before dialysis could be started, he suffered from pulseless bradycardia because of hyperkalemia, followed by massive cerebral edema. Further therapy was withheld, and the patient died.Figure 1.: Course of CK and Trop I levels and timing of medication. Immediately upon admission to the primary care hospital, steroids were given as an initial bolus infusion of 30 mg/kg followed by an infusion of 5.4 mg· kg−1 · h−1 for 23 h (1). Four hours after admission, sedation with propofol at a maximum infusion rate of 2.6 mg·kg−1 · h−1 (mean 1.9 mg· kg−1 · h−1) was started after tracheal intubation because of aspiration. The patient developed ARDS with an increasing need of catecholamine support 24 h after admission (dopamine: maximum 3.5 μg/min, norepinephrine: maximum 12 μg/min). Elevated CK was measured initially after 52 h (830 U/L) and increased Trop I after 14 h (3.56 ng/mL), after initializing sedation. Sedation with propofol was stopped upon admission to the tertiary referral hospital. Maximum level of CK and Trop I was 486,900 U/L and 6.3 ng/mL, respectively, on Day 6. The bars denote the timing of medication.Propofol infusion syndrome is defined by severe metabolic acidosis, rhabdomyolysis, renal failure, and cardiac failure in association with a prolonged propofol infusion, critical illness, and concurrent administration of catecholamines and steroids (2). Evidence for dose-dependent association between propofol use and propofol infusion syndrome (3) has led to guidelines recommending maximum propofol infusion rates of 4.8 mg· kg−1·h−1 (4) for long-term sedation in intensive care unit patients. Recent case reports describe propofol infusion syndrome after short-term (3–6 h) infusions, if infusion rates are high (5–7). Our patient presented with the features of propofol infusion syndrome. We have no other explanation for his rhabdomyolysis and cardiac failure. He received markedly less propofol than the maximum doses currently considered safe. To our knowledge, this is the first case of suspected propofol infusion syndrome in a patient receiving such low propofol infusion rates. We suggest considering alternative sedation regimes when risk factors for propofol infusion syndrome are present: ARDS, SIRS, and treatment with large-dose steroids or catecholamines. Tobias M. Merz, MD Bruno Regli, MD Hans-Ulrich Rothen, MD, PhD Clinic of Intensive Care Medicine University Hospital Bern Bern, Switzerland [email protected] Peter Felleiter, MD Intensive Care Unit Swiss Paraplegic Centre Nottwil Nottwil, Switzerland

Liver Transplantation in a Patient With Sitosterolemia and Cirrhosis

Sitosterolemia (MIM 210250) is a rare genetic disorder caused by disruption of the normal mechanisms that regulate dietary cholesterol absorption and prevent the accumulation of noncholesterol sterols. As a result of this defect, affected individuals accumulate high concentrations of plant sterols in plasma and tissues. They present clinically with tendon or tuberoeruptive xanthomas, premature coronary artery disease, and/or hemolytic anemia. Two genes, ABCG5 and ABCG8, compose the STSL locus, and complete mutation in either, but not both, results in disease. The expression of these genes is confined to the intestine and liver. They are thought to function as sterol efflux pumps. It is not clear which organ, liver or intestine, is of greater importance in maintaining sterol balance with respect to noncholesterol sterols. We report here a case of a patient who presented with "chronic active liver disease" and was found to have sitosterolemia by chance and subsequently underwent orthotopic liver transplantation. Following transplantation, the grossly elevated pretransplantation serum plant sterol levels decreased to values only slightly higher than those of the patient's heterozygous father. This case highlights 2 important features: (1) The liver functions as the predominant organ for maintaining noncholesterol sterol balance (because the intestinal defect was not altered), and (2) a new clinical feature of undiagnosed sitosterolemia may be "idiopathic" liver disease. Because the diagnosis of sitosterolemia is based on specialized plasma analyses, we would propose that some consideration to this diagnosis should be given in appropriate cases.

Large-Dose Pretreatment with Methylprednisolone Fails to Attenuate Neuronal Injury After Deep Hypothermic Circulatory Arrest in a Neonatal Piglet Model

Conflicting results have been reported with regard to the neuroprotective effects of steroid treatment with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). We evaluated the mode and severity of neuronal cell injury in neonatal piglets after prolonged DHCA and the possible neuroprotective effect of systemic pretreatment (>6 h before surgery) with large-dose methylprednisolone (MP). Nineteen neonatal piglets (age, <10 days; weight, 2.1 +/- 0.5 kg) were randomly assigned to 2 groups: 7 animals were pretreated with large-dose systemic MP (30 mg/kg) 24 h before surgery, and 12 animals without pharmacological pretreatment (saline) served as control groups. All animals were connected to full-flow CPB with cooling to 15 degrees C and 120 min of DHCA. After rewarming to 38.5 degrees C with CPB, animals were weaned from CPB and survived 6 h before they were killed, and the brain was prepared for light and electron microscopy, immunohistochemistry, and TUNEL-staining. Quantitative histological studies were performed in hippocampus, cortex, cerebellum, and caudate nucleus. Systemic pretreatment with large-dose MP lead to persistent hyperglycemia but no significant changes of cerebral perfusion. Necrotic and apoptotic neuronal cell death were detected in all analyzed brain regions after 120 min of DHCA. In comparison to the control group, large-dose pretreatment with systemic MP lead to an increase of necrotic neuronal cell death and induced significant neuronal apoptosis in the dentate gyrus of the hippocampus (P = 0.001). In conclusion, systemic pretreatment with large-dose MP fails to attenuate neuronal cell injury after prolonged DHCA and induces regional neuronal apoptosis in the dentate gyrus.

Observation and Nursing of Spinal Injury Treatment with Large Dose Methylprednisolone

目的 观察大剂量甲基强的松龙两种给药法治疗脊髓损伤的疗效和护理,探讨用药特点及护理对策.方法78例脊髓损伤手术后的患者,按治疗方法的先后分为常规法(34例),改良法(44例),根据脊髓损伤的神经功能评分标准,评定脊髓损伤程度并比较疗效,记录用药特点及用药后临床表现.结果两种方法治疗后感觉及运动功能均有改善,但改良法对感觉、运动功能的改善明显优于常规法(P＜0.01).结论甲基强地松龙可改善脊髓损伤患者的运动及感觉功能,采取改良给药方法,加强护理和观察,能使甲基强的松龙发挥最大的药理作用和疗效.减少并发症的发生。

Using Methylprednisolone to Supplement Direct Current Electrical Field in Promoting Spinal-Cord Regeneration

In order to compensate for the fact that direct current electrical fields could not reduce or correct spinal-cord edema after trauma, methylprednisolone was used 2 hr after spinal-cord injury to promote the efficacy of the direct current electrical field. Thirty-three dogs were randomly divided into three groups and their spinal cords were injured with the Allen method (weight-dropping technique). Group A, a control group; Group B, implantation of an electrical stimulator 6 hr after spinal-cord injury; and Group C, given an injection of a large dose of methylprednisolone 2 hr after injury. Electric stimulators were implanted into the dogs' bodies 6 hr post-injury. The nerve functions, evoked potential cortical somatosensory and three kinds of nerve morphometric changes, were observed 1 to 3 months after injury. The indexes of Groups B and C were much better than Group A (p<0.05). The results in Group C were better than in Group B. Differences were statistically significant. The combination of direct current electrical field and an injection of a large dose of methylpredwisolone could effectively treat spinal cord injury, promoting earlier recovery of nerve function.

PNEUMOMEDIASTINUM, SUBCUTANEOUS EMPHYSEMA, AND PULMONARY FIBROSIS IN A PATIENT WITH IDIOPATHIC PNEUMONIA SYNDROME AFTER BONE MARROW TRANSPLANTATION

An adolescent female underwent bone marrow transplantation for relapsed leukemia and developed acute and chronic graft-versus-host disease and idiopathic pneumonia syndrome. Her lung disease responded to large doses of methylprednisolone but evolved to pulmonary fibrosis and pneumomediastinum and subcutaneous emphysema in the convalescent period. Pulmonary function tests revealed a restrictive pattern. Pneumomediastinum and subcutaneous emphysema are complications not only of obstructive but also of restrictive lung disease and vary with respect to time of onset.