Quality of Acute Stroke Care within Emergency Medical Service System in Korea: Proposal for Severe Emergency Medical Center

Background@#Korea recently established 70 emergency medical service areas. However, there are many concerns that medical resources for stroke could not be evenly distributed through the country. We aimed to compare the treatment quality and outcomes of acute stroke among the emergency medical service areas. @*Methods@#This study analyzed the data of 28,800 patients admitted in 248 hospitals which participated in the 8th acute stroke quality assessment by Health Insurance Review and Assessment Service. Individual hospitals were regrouped into emergency service areas according to the address of the location. Assessment indicators and fatality were compared by the service areas. We defined the appropriate hospital by the performance of intravenous thrombolysis. @*Results@#In seven service areas, there were no hospitals which received more than 10 stroke patients for 6 months. In nine service areas, there were no patients who underwent intravenous thrombolysis (IVT). Among 167 designated emergency medical centers, 50 hospitals (29.9%) responded that IVT was impossible 24 hours a day. There are 97 (39.1%) hospitals that meet the definitions of appropriate hospital. In 23 service areas (32.9%) had no appropriate or feasible hospitals. The fatality of service areas with stroke centers were 6.9% within 30 days and 15.6% within 1 year from stroke onset than those without stroke centers (7.7%, 16.9%, respectively). @*Conclusions@#There was a wide regional gap in the medical resource and the quality of treatments for acute stroke among emergency medical service areas in Korea. The poststroke fatality rate of the service areas which have stroke centers or appropriate hospitals were significantly low.

Atypical parkinsonism with marked asymmetry due to a superimposed developmental venous anomaly

@#Intracranial developmental venous anomalies (DVAs) are the most common cerebral vascular malformation and are usually asymptomatic. Movement disorders are rarely associated with DVAs within basal ganglia regions. We report a case of markedly asymmetric parkinsonism due to unilateral DVA in the basal ganglia, which occurred together with symmetrical nigrostriatal dopaminergic deficits. A 57-year-old woman presented with resting tremor in the right hand lasting for 6 months. She also experienced problems with gait and started falling while walking one month ago. The neurological examination found a resting tremor in the right hand and moderate rigidity and bradykinesia in the right extremities. She reported light headedness on standing up. The patient displayed minimal response to treatment with 300 mg levodopa. The FP-CIT PET scan revealed symmetrical decrease of radiotracer uptake in bilateral basal ganglia. Brain MRI and cerebral angiography identified a large DVA draining the basal ganglia, thalamus, and surrounding deep white matter in the left side. Conclusion: A DVA may contribute to the prominent asymmetrical manifestation in our patient, in combination with symmetrical dopaminergic loss from neurodegenerative Parkinsonian syndrome. A marked asymmetry in patients with signs of atypical Parkinsonism can be a clue for further imaging investigation to exclude superimposed structural lesions such as DVAs.

The Effect of Pulsatility Index on Infarct Volume in Acute Lacunar Stroke

PURPOSE: Lacunar stroke, in the context of small vessel disease, is a type of cerebral infarction caused by occlusion of a penetrating artery. Pulsatility index (PI) is an easily measurable parameter in Transcranial Doppler ultrasound (TCD) study. PI reflects distal cerebral vascular resistance and has been interpreted as a surrogate marker of small vessel disease. We hypothesized that an increased PI, a marker of small vessel disease, might be associated with a larger infarct volume in acute lacunar stroke. MATERIALS AND METHODS: This study included 64 patients with acute lacunar stroke who underwent TCD and brain MRI. We evaluated the association between the mean PI value of bilateral middle cerebral arteries and infarct volume on diffusion-weighted MRI using univariate and multivariate linear regression. RESULTS: The mean infarct volume and PI were 482.18±406.40 mm3 and 0.86±0.18, respectively. On univariate linear regression, there was a significant positive association between PI and infarct volume (p=0.001). In the multivariate model, a single standard deviation increase of PI (per 0.18) was associated with an increase of 139.05 mm3 in infarct volume (95% confidence interval, 21.25 to 256.85; p=0.022). CONCLUSION: We demonstrated that PI was an independent determinant of infarct volume in acute lacunar stroke. The PI value measured in acute stroke may be a surrogate marker of the extent of ischemic injury.

Acute Cerebral Infarction Associated with Inherited Protein S Deficiency

Coagulopathies are a relatively common cause of young-age stroke. We present herein a 15-year-old male who was admitted for acute cerebral infarction with dysarthria and weakness of the right side. He had previously been diagnosed with autosomal dominant protein-S deficiency. His left internal carotid artery was totally occluded. Emergency mechanical thrombolysis resulted in recanalization of that occluded artery and consequent improvement in symptoms. The patient was discharged with an oral anticoagulant.

Relationship between Metabolic Syndrome and Gallbladder Stone / 가정의학회지

BACKGROUND: The prevalence of metabolic syndrome is increasing in Korea. The aim of this study was to establish if there is an association between the presence of metabolic syndrome and the development of gallbladder stones in Koreans. METHODS: Among the subjects who visited a health promotion center of a general hospital from January 2001 to December 2005, a total of 34,574 adults was examined. Among them, the final 34,470 adults (males 20,277, females 14,193) were included. Metabolic syndrome was defined if they fell under the three conditions of BMI > or = 25 kg/m2, blood pressure > or = 130/85 mmHg, fasting glucose 110 mg/dL, triglyceride > or = 150 mmHg and low HDL-cholesterol (< 40 mg/dL in men, < 50 mg/dL in women). After adjusting for age and sex, logistic regression analysis was done to evaluate the relationship between metabolic syndrome and gallstones. RESULTS: This study showed that the prevalence of metabolic syndrome was 17.6% (males 21.1%, females 12.4%). Gallbladder stone risk was increased according to BMI, high blood pressure, high fasting blood glucose and low HDL. Gallbladder stone risk was increased according to clustering of components of metabolic syndrome after adjustment for age and sex (1 criterion: OR = 1.42, 95% CI, 1.20-1.69, P = 0.000; 2 criterion: OR = 1.86, 95% CI, 1.57-2.21, P = 0.000; 3 criterion: OR = 2.02, 95% CI, 1.66-2.45, P = 0.000; 4 criterion: OR = 2.17, 95% CI, 1.66-2.85, P = 0.000; 5 criterion: OR = 2.17, 95% CI, 1.17-4.02, P < 0.014). CONCLUSION: Gallbladder stone risk was increased according to BMI, and increased with people who had combination of more metabolic syndrome components.

Correlations of C-reactive Protein Levels with Obesity Index and Metabolic Risk Factors in Healthy Adults

BACKGROUND: C-reactive protein (CRP) is one of the increasing plasma proteins in inflammatory diseases and tissue necrosis and recent evidence show that increased elevated levels of CRP are associated with an increased risk of coronary heart disease (CHD) and obesity. To investigate the relationship of obesity and CRP, we evaluated the correlation of CRP with obesity index in healthy adults. METHODS: The subjects included 1,926 healthy adults (1,168 men and 758 women) who visited the Health Promotion Center of a general hospital from May to December 2004. We excluded subjects who had inflammatory diseases, and investigated based on age, physical examination, blood pressure, fasting plasma glucose, serum lipid profile, percentage of body fat, and body mass index (BMI). CRP was analyzed by method of Turbid Immuno Assay (TIA) which has high sensitivity-CRP. We evaluated serum level of CRP in relation to %body fat, BMI, and clustering of metabolic risk factors. RESULTS: Comparing the median CRP with the percentage of body fat, BMI, clustering of metabolic risk factors the value of CRP significantly increased according to increase in %body fat BMI and metabolic risk fakfor (P or =0.22 mg/dL) was increased as %body fat, BMI, and clustering of metabolic risk factor increased. The Odds Ratios for elevated levels of CRP were 1.5 (95% CI 1.0~2.1) in men and 2.9 (95% CI 1.7~4.8) in women for subjects with obesity (BMI> or =25 kg/m2), 2.0 (95% CI 1.3~2.9) in men with more than 25% %body fat, and 2.5 (95% CI 1.4~4.1) in women with more than 30% %body fat. CONCLUSION: As %body fat increased, the proportion of elevated CRP (> or =0.22 mg/dL) level increased in men and women. We conclude that obesity is related with CRP.