Targeted temperature management in brain edema

Targeted temperature management is a treatment strategy to lower core body temperature to achieve neuroprotection or reduce elevated intracranial pressure. Therefore, it has been increasingly used in the neurointensive care unit to manage various types of acute neurologic injuries.Current Concepts: Targeted temperature management can be divided into three distinct phases, including induction, maintenance, and rewarming, and each phase has risks and predictable complications. In patients with acute neurocritical illnesses, including traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, and ischemic stroke, brain edema is a potentially life-threatening complication as it raises the intracranial pressure, leading to brain herniation and permanent neurological damage. In this sense, targeted temperature management can be considered the final strategy for medical treatment for controlling an intracranial pressure crisis in patients with severe brain injury.Discussion and Conclusion: In the neurointensive care unit, applying targeted temperature management to patients with severe brain injuries may be challenging. Targeted temperature management in critically ill neurological patients is associated with an increased risk of systemic complications, as hypothermia is prolonged, requiring a comprehensive patient-by-patient assessment of the advantages and disadvantages of treatment. Except for cerebral pressure management, analyses of targeted temperature management in patients with traumatic brain injury and subarachnoid hemorrhage remain controversial regarding its effect on prognosis. Targeted temperature management should be reserved for selective patients, and further studies are needed to improve the efficacy of hypothermia for individual conditions, including intracerebral hemorrhage and ischemic stroke.

Explanatory Power and Prognostic Implications of Factors Associated with Troponin Elevation in Acute Ischemic Stroke / 대한뇌졸중학회지

Background@#and Purpose We investigated the impact of comorbidity burden on troponin elevation, with separate consideration of neurological conditions, in patients with acute ischemic stroke (AIS). @*Methods@#This prospective, observational cohort study consecutively enrolled patients with AIS for 2 years. Serum cardiac troponin I was repeatedly measured, and disease-related biomarkers were collected for diagnosis of preassigned comorbidities, including atrial fibrillation (AF), ischemic heart disease (IHD), myocardial hypertrophy (MH), heart failure (HF), renal insufficiency (RI), and active cancer. The severity of neurological deficits and insular cortical ischemic lesions were assessed as neurological conditions. Adjusted associations between these factors and troponin elevation were determined using a multivariate ordinal logistic regression model and area under the receiver operating characteristic curve (AUC). Cox proportional hazards model was used to determine the prognostic significance of comorbidity beyond neurological conditions. @*Results@#Among 1,092 patients (66.5±12.4 years, 63.3% male), 145 (13.3%) and 335 (30.7%) had elevated (≥0.040 ng/mL) and minimally-elevated (0.040–0.010 ng/mL) troponin, respectively. In the adjusted analysis, AF, MH, HF, RI, active cancer, and neurological deficits were associated with troponin elevation. The multivariate model with six comorbidities and two neurological conditions exhibited an AUC of 0.729 (95% confidence interval [CI], 0.698–0.759). In Cox regression, AF, IHD, and HF were associated with adverse cardio-cerebrovascular events, whereas HF and active cancer were associated with mortality. @*Conclusion@#Troponin elevation in patients with AIS can be explained by the burden of comorbidities in combination with neurological status, which explains the prognostic significance of troponin assay.

Recurrent Cerebral Infarction Associated with Uterine Adenomyosis

Uterine adenomyosis, which is known as a benign gynecological disease, can induce hypercoagulable state and be an uncommon cause of cerebral thromboembolism, as cerebral infarction is common in patients with malignant neoplasm. We report a woman with uterine adenomyosis who shows several episodes of cerebral infarction and discuss the stoke mechanism and treatment of this under-recognized etiology of stroke.

Relationship of Low Density Lipoprotein Cholesterol Level and Interest Nutrition on Nutrition Label in Korean Adults: 2008–2011 Korea National Health and Nutrition Examination Survey

Background@#Low density lipoprotein (LDL) cholesterol is an important metabolic marker, and it is suggested to be closely related with dietary habits.The use of nutrition labels is beneficial for making healthier food choices. In addition, dietary habits and nutrients of interest vary among nutrient label users. This study investigated the association between different nutrients of interest and LDL cholesterol levels in Korean adults. @*Methods@#This cross-sectional study included 21,870 adults from the 2008–2011 Korea National Health and Nutrition Examination Survey (KNHANES). Participants were divided into five groups according to the nutrients they were most interested in: 1) total calories, 2) carbohydrates, 3) protein, 4) fat, and 5) non-users of nutrition label. LDL cholesterol target level was set according to individual cardiovascular risk level. Multivariate logistic regression analysis was used to verify which nutrient of interest is related to the achievement of LDL cholesterol target level. @*Results@#Participants who were interested in total calories consumed lesser total calories and carbohydrates daily than those in the other groups did. Moreover, compared with the “not reading nutrition label” group, the odds ratios (95% confidence intervals) for achieving LDL cholesterol target level was 1.29 (1.05–1.58, P=0.015) in the “total calories” group after adjusting for confounding variables. @*Conclusion@#Participants who were interested in total calories were more likely to achieve optimal LDL cholesterol levels than those who did not read nutrition labels. Therefore, reading nutrition labels, especially focusing on total calories, can be helpful for reducing cardiovascular risk.

Phylogenetic Positioning of a Strongyloides stercoralis Isolate Recovered from a Korean Patient and Comparison with Other Asian Isolates

Strongyloidiasis is caused by Strongyloides stercoralis and is one of the most neglected tropical diseases in tropical and subtropical regions. Although several strongyloidiasis cases have been reported in Korea, genetic analysis of Korean isolates is still incomplete. In this study, a parasite was isolated from a 61-year-old man diagnosed with strongyloidiasis during the treatment of lymphoma on his retroperitoneal lymph node. Diffuse symmetric wall thickening from the ascending to descending colon and a nematode-infected intestine was observed following microscopic examination. Genomic DNA was isolated from a patient tissue block, and S. stercoralis was identified by PCR and sequencing (18S rDNA). In order to determine phylogenetic location of a Korean isolate (named KS1), we analyzed cox1 gene (500-bp) and compared it with that from 47 previous S. stercoralis isolates (28 human isolates and 19 canid isolates) from Asian countries. Our results showed that phylogenetic tree could clearly be divided into 5 different groups according to hosts and regions. KS1 was most closely related with the Chinese isolates in terms of genetic distance.

Phylogenetic Positioning of a Strongyloides stercoralis Isolate Recovered from a Korean Patient and Comparison with Other Asian Isolates

Strongyloidiasis is caused by Strongyloides stercoralis and is one of the most neglected tropical diseases in tropical and subtropical regions. Although several strongyloidiasis cases have been reported in Korea, genetic analysis of Korean isolates is still incomplete. In this study, a parasite was isolated from a 61-year-old man diagnosed with strongyloidiasis during the treatment of lymphoma on his retroperitoneal lymph node. Diffuse symmetric wall thickening from the ascending to descending colon and a nematode-infected intestine was observed following microscopic examination. Genomic DNA was isolated from a patient tissue block, and S. stercoralis was identified by PCR and sequencing (18S rDNA). In order to determine phylogenetic location of a Korean isolate (named KS1), we analyzed cox1 gene (500-bp) and compared it with that from 47 previous S. stercoralis isolates (28 human isolates and 19 canid isolates) from Asian countries. Our results showed that phylogenetic tree could clearly be divided into 5 different groups according to hosts and regions. KS1 was most closely related with the Chinese isolates in terms of genetic distance.

Assessment of Preterm Infants Using the Bayley-III Scales in Korea

OBJECTIVE: To assess the well-being of preterm newborns using the Bayley-III scales in a Korean-based population, and to evaluate the perinatal risk factors influencing developmental outcome. METHODS: Using the Bayley-III scales, we assessed 120 preterm infants who were referred for evaluation of neurodevelopmental performance. We subdivided them into an extremely preterm group (n=18) and a very/moderate to late preterm group (n=102). Bayley-III mean scores and the rate of infants showing a delay were compared for both groups. The relationship between perinatal risk factors and Bayley-III scores was analyzed. The risk factors were considered as very low birth weight, history of neonatal medical problems, and abnormal radiologic findings in brain magnetic resonance images (MRIs). RESULTS: Although no significant differences in mean scores were observed between the extremely preterm group and the very/moderate to late preterm group, the rate of babies showing developmental delay in motor composite scores was significantly higher in the extremely preterm group. The proportions of preterm infants with cognitive, language, and motor delays were 38.3%, 26.7%, and 35.0%, respectively. Very low birth weight was a significant risk factor for low cognitive, language, and motor composite scores. Also, abnormal radiologic findings on brain MRI were significant indicators of lower motor composite scores. CONCLUSION: Cognitive development was the most frequently delayed domain in preterm infants and motor development was more frequently delayed in the extremely preterm group. The very low birth weight and abnormal radiologic findings in brain MRI were predictive factors for neurodevelopmental outcome.

Prognostic Significance of Troponin Elevation for Long-Term Mortality after Ischemic Stroke / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Troponin, a marker of myocardial injury, frequently increases and is related with poor outcome in ischemic stroke patients. However, the long-term outcome of this elevation remains uncertain. We, therefore, investigated the prognostic significance of troponin elevation for long-term mortality, and explored factors affecting troponin elevation after ischemic stroke. METHODS: We retrospectively analyzed the medical data of stroke patients who were admitted within 24 hours of symptom onset and underwent a serum cardiac troponin I test at admission during a five-year period. Information on mortality as the outcome was obtained from the National Death Certificate system. RESULTS: A total of 1,692 patients were eligible for inclusion with 33 months of median follow-up. Troponin elevation that exceeded the 99th percentile (>0.04 ng/mL) of values was detected in 166 patients (9.8%). After adjusting for baseline characteristics, troponin elevation was associated with previous ischemic heart disease and congestive heart failure, comorbid atrial fibrillation and active cancer, and increased National Institutes of Health Stroke Scale score. Patients with troponin elevation had a high risk of overall death (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.40–2.40), including stroke-related (HR 1.71, 95% CI 1.14–2.55), cardiac-related (HR 3.17, 95% CI 1.49–6.74), and cancer-related (HR 1.98, 95% CI 1.14–3.45) death than those without troponin elevation. CONCLUSIONS: Troponin elevation in the acute stage of ischemic stroke was associated with long-term mortality, mainly due to increased stroke- and cancer-related death in the first year and cardiacrelated death in the later period.

Role of Perfusion-Weighted Imaging in a Diffusion-Weighted-Imaging-Negative Transient Ischemic Attack

BACKGROUND AND PURPOSE: The absence of acute ischemic lesions in diffusion-weighted imaging (DWI) in transient ischemic attack (TIA) patients makes it difficult to diagnose the true vascular etiologies. Among patients with DWI-negative TIA, we investigated whether the presence of a perfusion-weighted imaging (PWI) abnormality implied a true vascular event by identifying new acute ischemic lesions in follow-up magnetic resonance imaging (MRI) in areas corresponding to the initial PWI abnormality. METHODS: The included patients underwent DWI and PWI within 72 hours of TIA and also follow-up DWI at 3 days after the initial MRI. These patients had visited the emergency room between July 2009 and May 2015. Patients who demonstrated initial DWI lesions were excluded. The initial PWI abnormalities in the corresponding vascular territory were visually classified into three patterns: no abnormality, focal abnormality, and territorial abnormality. RESULTS: No DWI lesions were evident in initial MRI in 345 of the 443 TIA patients. Follow-up DWI was applied to 87 of these 345 DWI-negative TIA patients. Initial PWI abnormalities were significantly associated with follow-up DWI abnormalities: 8 of 43 patients with no PWI abnormalities (18.6%) had new ischemic lesions, whereas 13 of 16 patients with focal perfusion abnormalities (81.2%) had new ischemic lesions in the areas of initial PWI abnormalities [odds ratio (OR)=15.1, 95% confidence interval (CI)=3.6–62.9], and 14 of 28 patients with territorial perfusion abnormalities (50%) had new lesions (OR=3.7, 95% CI=1.2–11.5). CONCLUSIONS: PWI is useful in defining whether or not the transient neurological symptoms in DWI-negative TIA are true vascular events, and will help to improve the understanding of the pathomechanism of TIA.

A Comprehensive Rehabilitation Approach in a Patient With Serious Neuropsychiatric Systemic Lupus Erythematosus

Neuropsychiatric systemic lupus erythematosus (NPSLE) involves the central and peripheral nervous system in patients with systemic lupus erythematosus (SLE). It is essential to specify the problems faced by patients with NPSLE because it causes diverse disabilities and impairs quality of life. After performing a comprehensive evaluation, tailored management should be provided for the patient's specific problems. We report here the case of a 30-year-old female with SLE who experienced serious neuropsychiatric symptoms cerebral infarction followed by posterior reversible encephalopathy syndrome and peripheral polyneuropathy. We systemically assessed the patient using the International Classification of Functioning, Disability and Health model as a clinical problem-solving tool and provided comprehensive rehabilitation by focusing on her problems.

Magnetic Resonance Imaging in Acute Ischemic Stroke Treatment / 대한뇌졸중학회지

Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis.

Clinical Features of Parricide in Patients with Schizophrenia / 신경정신의학

OBJECTIVES: This study aimed to describe the demographic, clinical and offense characteristics of the patients with schizophrenia who committed parricide. This study also investigated the risk factors of parricide by comparing with characteristics of stranger killers to prevent the tragic offense. METHODS: The sample consisted of 88 schizophrenic patients who committed homicide, 59 of them committed parricide and 29 of them killed strangers. Medical chart review regarding demographic and clinical characteristics as well as offense characteristics was conducted. The information that was difficult to be obtained through chart review was acquired by direct interview. RESULTS: Parricide group had earlier age of onset, more conflicts with the victims, more violence history toward victims and more offense provoking events than stranger killing group. Parricide group showed higher rate of past treatment than that of stranger killing group. However drug compliance at the time of offense was low in both groups. Offense provoking events in the parricide group included blaming, threatening a forced hospitalization or medication toward patients. The most common psychiatric symptoms associated with homicide were threat/control override (TCO) symptoms, delusional perception, commanding auditory hallucination and especially with parricide, Capgras syndrome (CS). CONCLUSION: Interaction between psychotic symptoms such as TCO, CS and underlying emotion toward victims are likely to be associated with parricide. Mental health professionals are expected to play an important role in preventing this tragic offense by active history taking of the violence and effective management with active caregiver education/intervention of intrafamilial conflicts.

Segmental Zoster Paresis Showing Spinal Nerve Roots Involvement on Gadolinium-Enhanced MRI

Segmental zoster paresis is a focal, asymmetric limb weakness caused by a herpes zoster infection. It is a rare complication of herpes zoster and the exact pathogenesis is uncertain. However, the most likely cause is the direct spread of the virus from the sensory ganglia to the anterior horn cells or anterior spinal nerve roots. We experienced two patients with segmental zoster paresis who showed both anterior and posterior root involvement on a gadolinium-enhanced MRI, supporting this hypothesis.

A Case of Peripartum Cardiomyopathy / 대한산부인과학회잡지

Peripartum cardiomyopathy is relatively uncommon form of heart failure that occurs from one month before, to 5 months after delivery. The causes of this disease are unknown and mortality rate may be as high as 20-50%. We recently experienced one case of this disease and summarized here with brief review of literatures.

Vero Cell Co-culture Counteracts the Detrimental Effects of Hydrosalpinx Fluid on the Development of Mouse Embryos in vitro

Recent studies have suggested that the hydrosalpinx has a negative effect on pregnancy outcome, with markedly diminished implantation and increased early pregnancy loss. Fluid from the hydrosalpinx may leak into and accumulate in the uterine cavity. It is not clear, however if this creates a hostile local environment in the uterus for embryo implantation or exerts a direct embryotoxic effect. This study was conducted to investigate the detrimental effects of hydrosalpinx fluid (HSF) on the development of mouse embryos in vitro and to demonstrate whether Vero cells overcome these adverse effects. HSF was collected from three women with bilateral hydrosalpinx at the time of laparoscopic surgery. Collected fluid was centrifuged and the supernatant was frozen at -20degrees C. For co-culture, Vero cells were commercially obtained in a frozen state and cultured using Ham's F10 medium. Single-cell mouse embryos (B6CBAF1) were cultured for 5 days in 0, 0.4, 0.8, and 1.2% of HSF in media with and without Vero cells and examined daily to record the number of embryos reaching expanded blastocyst and hatching stage. Co-culture of mouse embryos with Vero cells at 0.8% HSF concentration significantly enhanced embryo development, but not at 1.2% hydrosalpinx fluid concentration. These results suggest that HSF is highly embryotoxic and Vero cells are likely to overcome these detrimental effects to some degree.

Studies on Pregnanacy Rate of Controlled Ovarian Hyperstimulation before Intrauterine Insemination in the Treatment of Unexplained Infertility / 대한산부인과학회잡지

OBJECTIVE: To determine which regimen for controlled ovarian hyperstimulation is the most effective in achieving pregnancy after intrauterine insemination in the treatment of unexplained infertility. MATERIALS AND METHODS: From March 1996 to February 2000, a total of 67 cycles of intrauterine insemination after controlled ovarian hyperstimulation were treated in 39 patients under 40 years old who diagnosed as unexplained infertility. Two methods of controlled ovarian hyperstimulation were used. The one is clomiphene citrate/hMG and the other is hMG only. These were compared the pregnancy rate respectively. RESULTS: Mean age of study group was 32+/-2.7 years old (28-38 years old) and mean duration of infertility was 46+/-17.8 months (15-96 months). The overall clinical pregnancy rate was 17.9% (12/67 cycle) per cycle and 30.7% (12/39 patient) per patient. According to the methods of controlled ovarian hyperstimulation, pregnancy rate was 16.7% (8/48 cycle) after clomiphene citrate/hMG used, 21.1% (4/19 cycle) after hMG only used. 4 cases of ovarian hyperstimulation syndrome developed (clomiphene citrate/hMG 1 case, hMG only 3 cases) and all of them were self-regressed. CONCLUSION: Compared with using hMG only as controlled ovarian hyperstimulation before intrauterine insemination, using clomiphene citrate/hMG was more effective regimen and considered as the first choice in the treatment of unexplained infertility.

Two Cases of Primary Peritoneal Serous Papillary Carcinoma / 대한산부인과학회잡지

Primary peritoneal serous papillary carcinoma (PPSPC) is very rare and not well identified. Because of developmental, biological and histologic similarity to papillary serous carcinoma of ovary its diagnosis and treatment, prognosis and post treatment follow up schedule is similar that of epithelial ovarian cancer. We have experienced two cases of primary peritoneal serous papillary carcinoma and report this with brief review of the concerned literatures.

Two Cases of Primary Peritoneal Serous Papillary Carcinoma / 대한산부인과학회잡지

Primary peritoneal serous papillary carcinoma (PPSPC) is very rare and not well identified. Because of developmental, biological and histologic similarity to papillary serous carcinoma of ovary its diagnosis and treatment, prognosis and post treatment follow up schedule is similar that of epithelial ovarian cancer. We have experienced two cases of primary peritoneal serous papillary carcinoma and report this with brief review of the concerned literatures.