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.

The association between urinary bisphenol A levels and nonalcoholic fatty liver disease in Korean adults: Korean National Environmental Health Survey (KoNEHS) 2015-2017

BACKGROUND@#Nonalcoholic fatty liver disease (NAFLD) is becoming a global health problem. Bisphenol A (BPA), one of most widely used environmental chemicals, is suspected to be a contributor to the development NAFLD. This study was performed to examine the relationship between human BPA levels and risk of NAFLD.@*METHODS@#The data (n = 3476 adults: 1474 men and 2002 women) used in this study were obtained from the Korean National Environmental Health Survey III (2015-2017). BPA levels were measured in urine samples. NAFLD was defined using hepatic steatosis index after exclusion of other causes of hepatic diseases.@*RESULTS@#There was a significant linear relationship between the elevated urinary BPA concentrations and risk of NAFLD. In a univariate analysis, odds ratio (OR) of the highest quartile of urinary BPA level was 1.47 [95% confidence interval (CI) 1.11-1.94] compared to the lowest quartile. After adjusted with covariates, the ORs for NAFLD in the third and fourth quartiles were 1.31 [95% CI 1.03-1.67] and 1.32 [95% CI 1.03-1.70], respectively.@*CONCLUSIONS@#Urinary BPA levels are positively associated with the risk of NAFLD in adults. Further experimental studies are needed to understand the molecular mechanisms of BPA on NAFLD prevalence.

Association between Obesity and Infection

Obesity and infection are interacting with each other. Infection causes obesity, and obesity contributes to the occurrence and deterioration of infection. The sources of infection that cause obesity include viruses such as adenovirus, intestinal viruses, bacteria such as intestinal microbes, parasites, and the antibiotics that cause these microbes to change. The above risk factors cause chronic inflammatory reactions in the body, and in addition, obesity is further accelerated when bad eating habits are accompanied. Among the infections that occur often in obese people and worsen their condition are various viral infections such as influenza viruses and coronavirus, bacterial infections that cause urinary tract infections or periodontal infections, respiratory infections such as bronchitis, pneumonia, floor infections and infections in surgical areas. Infection in obesity increases complications, and reduces the effectiveness of antibiotics and vaccines. The mechanism between obesity and infection is a decrease in immunity resulting from increased chronic inflammation. Based on the evidence that obesity and infection cause and effect each other and interact with each other, it can be used for prevention and treatment of obesity. Studies related to the development of obesity vaccines and the maintenance of healthy intestinal microbes are under way, which is expected to reduce obesity and prevent future prevention. As a result, reducing obesity will reduce the risk and deterioration of infection.

Symptomatic Retinal Artery Occlusion after Angioplasty and Stenting of the Carotid Artery: Incidence and Related Risk Factors

OBJECTIVE: Retinal artery occlusion (RAO) is rarely seen as a complication in patients undergoing carotid artery stenting (CAS); hence, its characteristics have not been documented in detail. This study aimed to investigate the incidence of this complication and the related risk factors, focusing on differences in ophthalmic artery (OA) supply (whether by the external or internal carotid artery [ECA or ICA]) prior to CAS procedures. MATERIALS AND METHODS: We retrospectively examined 342 patients who underwent CAS for severe and/or symptomatic carotid artery stenosis between January 2009 and December 2017. Cumulative medical records and radiologic data were assessed. RAO was confirmed by photography and fluorescent angiography of the fundus, which were performed by an ophthalmologist. In all patients, distal filter systems of various types were applied as cerebral protection devices (CPDs) during procedures. Univariate and multivariate analyses were conducted to identify the risk factors for RAO after CAS. RESULTS: Symptomatic RAO was observed in six patients (1.8%), of which five (6.8%) were ECA-dominant group members (n = 74). In a binary logistic regression analysis, OA supply by the ECA (odds ratio [OR], 9.705; 95% confidence interval [CI], 1.519–62.017; p = 0.016) and older age (OR, 1.159; 95% CI, 1.005–1.336; p = 0.041) were identified as significant risk factors in patients with RAO after CAS. ECA-supplied OA was also associated with the severity of ipsilateral ICA stenosis (p = 0.001) and ulcerative plaque (p = 0.021). CONCLUSION: In procedures performed using ICA distal filtering CPD systems, RAO as a complication of CAS (performed for severe stenosis) showed a relationship to ECA-supplied OA. For older patients, simultaneous use of ICA-ECA CPDs might help prevent such complications.

Current Treatments on Obesity

Recently, the number of obesity and diabetes mellitus have increased rapidly not only in Korea but also around the world. It is even called the new pandemic of the 21st century. In Korea, the diabetes growth rate, which exceeds the obesity growth rate, is a bigger problem. Accordingly, the simultaneous treatment of diabetes and obesity has become a global issue. In this article, we will review various obesity treatments to help diabetes remission and take a look at meaningful previous study about dietary methods for obesity. This overview includes the update of medications for obesity and the practical method for clinicians in field of obesity treatment in Korea.

Current Treatments on Obesity

Recently, the number of obesity and diabetes mellitus have increased rapidly not only in Korea but also around the world. It is even called the new pandemic of the 21st century. In Korea, the diabetes growth rate, which exceeds the obesity growth rate, is a bigger problem. Accordingly, the simultaneous treatment of diabetes and obesity has become a global issue. In this article, we will review various obesity treatments to help diabetes remission and take a look at meaningful previous study about dietary methods for obesity. This overview includes the update of medications for obesity and the practical method for clinicians in field of obesity treatment in Korea.

Intracranial Mirror Aneurysms: Anatomic Characteristics and Treatment Options

OBJECTIVE: Mirror aneurysms are generally considered as a subset of multiple aneurysms, defined as aneurysms occurring bilaterally and symmetrically on the same-named vessels. Although not infrequent, the characteristics of mirror aneurysms are not well studied. This investigation was conducted to elucidate the anatomic features of such lesions and examine treatment options. MATERIALS AND METHODS: A retrospective review was conducted, aimed at 172 patients treated for 344 mirror aneurysms between January 2007 and December 2015. Aneurysms of similar nature but in asymmetric locations on the same-named vessels were excluded. All available records were examined and lesion characteristics, as well as treatment outcomes were assessed. RESULTS: In study subjects (n = 172), mirror aneurysms most often involved middle cerebral artery bifurcation (n = 83), followed by a paraclinoid internal carotid artery (n = 50) and posterior communicating artery (n = 21). Most of the lesions (95.3%) measured ≤ 10 mm, and in 126 patients (74.6%), the size ratios were > 50%. Of the 344 aneurysms studied, coil embolization was undertaken in 217, surgical clipping in 62, and observation alone (no treatment) in 65. Coil embolization and surgical clipping were done bilaterally in 83 and 12 patients, respectively. In 12 patients, combined coiling and clipping were implemented on each side. Single-stage coil embolization of both the aneurysms was performed in 73 patients, with excellent post-procedural (85.6%) and follow-up (86.8%) occlusive results. There was no procedure-related morbidity or mortality. CONCLUSION: By adopting different treatment strategies to different configurations and vascular sources, mirror aneurysms can be safely and effectively treated. If feasible, single-stage coil embolization should be considered as a reasonable treatment option for mirror aneurysms.

Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update / 대한뇌졸중학회지

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke and a critical disease usually leading to severe disability or death. ICH is more common in Asians, advanced age, male sex, and low- and middle-income countries. The case fatality rate of ICH is high (40% at 1 month and 54% at 1 year), and only 12% to 39% of survivors can achieve long-term functional independence. Risk factors of ICH are hypertension, current smoking, excessive alcohol consumption, hypocholesterolemia, and drugs. Old age, male sex, Asian ethnicity, chronic kidney disease, cerebral amyloid angiopathy (CAA), and cerebral microbleeds (CMBs) increase the risk of ICH. Clinical presentation varies according to the size and location of hematoma, and intraventricular extension of hemorrhage. Patients with CAA-related ICH frequently have concomitant cognitive impairment. Anticoagulation related ICH is increasing recently as the elderly population who have atrial fibrillation is increasing. As non-vitamin K antagonist oral anticoagulants (NOACs) are currently replacing warfarin, management of NOAC-associated ICH has become an emerging issue.

Prospective Study for Evaluating Therapeutic Efficacy of Obese Patients of Low Socioeconomic Status in Korea

BACKGROUND: Recently, the prevalence of obesity and socioeconomic costs stemming from obesity are increasing steeply. Obesity, in particular, has a highly polarization caused by income levels. Obesity in low-income patients is expected to become a serious social problem in the future. This study aims to observe the effects of consistent consultation and drug therapy during a six months period, and to develop the treatment process of obesity for low-income people. METHODS: The body weight, waist circumference, body mass index (BMI), and blood pressure (BP) was measured every 2 weeks, and laboratory blood tests with a survey including Beck Depression Inventory (BDI) and eating behavior index was checked at 0, 3, and 6 months. Paired t-test and linear mixed model was done to evaluate the difference between pre-treatment data and post-treatment data. RESULTS: Twenty-one patients (2 males, median age [interquartile range] of 39 years [29-46]) were analyzed. There were statistically significant reductions of body weight (P<0.01), BMI (P<0.01), waist circumference (P<0.01), low-density lipoprotein (P=0.01), BDI-I (P<0.01), eating behavior index (P<0.01). There was no statistically significant difference of safety outcome of the BP and blood tests. CONCLUSIONS: Proper obesity treatment of obese patients of low socioeconomic status was meaningful enough to affect depression and eating patterns as well as reducing body weight and decreased waist circumference.

Intracerebral Hemorrhage related to Phentermine as an Appetite Suppressant

We present a case report indicating that the administration of phentermine, an appetite suppressant with sympathomimetic activity, can provoke an intracerebral hemorrhage. A 48-year-old woman with no previously established cerebrovascular risk fa ctors and who had taken phentermine for 30 days developed sudden-onset left hemiparesis. Brain magnetic resonance imaging revealed an acute intracerebral hemorrhage involving the right thalamus. This case indicates that physicians should be aware of the relevant cause of medication history including appetite suppressants in young patients with an acute intracerebral hemorrhage.

Bilateral Periodic Limb Movement Disorder Developed after Anterior Cerebral Artery Infarction

Previous reports on the lesions causing stroke-related periodic limb movement in sleep (PLMS) have involved subcortical structures such as the basal ganglia/corona radiata or pons. We report a case of an 81-year-old female patient who presented with bilateral, right-side-predominant PLMS that developed after a left cortical infarction. The right-side PLMS may be attributable to the loss of cortical inhibition following a pyramidal tract lesion, while the left-side PLMS may be caused by activation of the contralateral motor cortex due to dysfunction of interhemispheric inhibition.

Cerebral Venous Angioma Complicated by Non-hemorrhagic Venous Infarction

Venous angioma is normally asymptomatic, but it can present with clinical presentations such as seizures, headache, and focal neurological deficits. Brain hemorrhage is known to be the most common complication, with nonhemorrhagic brain infarction due to venous angioma being very rare. We report the first case of supratentorial venous angioma complicated by nonhemorrhagic venous infarction. This case occurred in a 49-year-old female, and was confirmed by magnetic resonance (MR) imaging including contrast-enhanced MR venography and perfusion imaging.