Chulho Kim

Paradoxical longevity in obese patients with intracerebral hemorrhage

Background: The paradoxical phenomenon of relative longevity among obese patients with established diseases has been reported for various disease conditions. The authors sought to investigate whether the obesity paradox also applies to intracerebral hemorrhage (ICH) survivors. Methods: A total of 1,604 patients with ICH from 33 centers with nationwide coverage were prospectively enrolled to this cohort between October 2002 and March 2004. Baseline information including body mass index (BMI) was collected at admission, and mortality status was ascertained from the governmental mortality archive on December 2006. Associations between obesity and 30-day mortality or long-term risk of death were analyzed. Results: Among the 1,356 patients with ICH included, the 30-day mortality rate was 7.2% and the long-term mortality rate was 26.9% after a mean follow-up of 33.6 ± 15.5 months. Neither BMI nor obesity status were associated with 30-day mortality after ICH. However, BMI was independently associated with a lower risk of long-term mortality (hazard ratio [HR] 0.91 per 1-kg/m2 increase; 95% confidence interval [CI] 0.87–0.95). As compared with patients of normal weight, underweight subjects had a higher risk of death (HR 1.64; 95% CI 1.11–2.40), and conversely, overweight (HR 0.69; 95% CI 0.49–0.96) or obese (HR 0.61; 95% CI 0.43–0.88) subjects showed a lower risk of post-ICH death. Conclusion: In our study, obesity was associated with a lower risk of long-term death but not with 30-day mortality after ICH. Thus, it may be considered that an obesity status in a patient with ICH be treated as an indication of metabolic reservoir capacity and an increased likelihood of survival.

Increased serum alkaline phosphatase as a predictor of long-term mortality after stroke

Background: Although the critical role of alkaline phosphatase in bone mineralization is clearly understood, the potentially adverse effect of high alkaline phosphatase levels on the cardiovascular system was only recently suggested. In this study, we hypothesized that increased levels of serum alkaline phosphatase may be associated with poor outcome after stroke in terms of mortality. Methods: We prospectively included patients with acute stroke admitted consecutively to our hospital, from October 2002 to September 2008. A total of 2,029 patients were selected for the analyses. In the analyses of mortality, the patients were divided by baseline measurements into quintiles of alkaline phosphatase levels (<57, 57–69, 70–81, 82–97, >97 IU/L). Results: In the Cox proportional hazard models, compared with the first alkaline phosphatase quintile, adjusted hazard ratios of the third, fourth, and fifth quintiles for all-cause death were 1.67 (95% confidence interval 1.12–2.49), 1.79 (1.20–2.67), and 2.83 (1.95–4.10). When we divided the patients into ischemic and hemorrhagic stroke, the association was also significant for both subtypes of stroke. In terms of vascular death, compared to the first alkaline phosphatase quintile, the adjusted hazard ratios of the fourth and fifth quintiles of alkaline phosphatase were 1.81 (95% confidence interval 1.14–2.86) and 2.78 (1.87–4.15). Conclusion: Our study demonstrated that increased serum levels of alkaline phosphatase are an independent predictor of all-cause and vascular death after either ischemic or hemorrhagic stroke.

Clinical features of headache associated with mobile phone use: a cross-sectional study in university students.

BackgroundHeadache has been reported to be associated with mobile phone (MP) use in some individuals. The causal relationship between headache associated with MP use (HAMP) and MP use is currently undetermined. Identifying the clinical features of HAMP may help in clarifying the pathophysiology of HAMP and in managing symptoms of individuals with HAMP. The aim of the present study is to describe the clinical features of HAMP.MethodsA 14-item questionnaire investigating MP use and headache was administered to 247 medical students at Hallym University, Korea. Individual telephone interviews were subsequently conducted with those participants who reported HAMP more than 10 times during the last 1 year on the clinical features of HAMP. We defined HAMP as a headache attack during MP use or within 1 hour after MP use.ResultsIn total, 214 (86.6%) students completed and returned the questionnaire. Forty (18.9%) students experienced HAMP more than 10 times during the last 1 year in the questionnaire survey. In subsequent telephone interviews, 37 (97.4%) interviewed participants reported that HAMP was triggered by prolonged MP use. HAMP was usually dull or pressing in quality (30 of 38, 79.0%), localised ipsilateral to the side of MP use (32 of 38, 84.2%), and associated with a burning sensation (24 of 38, 63.2%).ConclusionWe found that HAMP usually showed stereotyped clinical features including mild intensity, a dull or pressing quality, localisation ipsilateral to the side of MP use, provocation by prolonged MP use and often accompanied by a burning sensation.

Aspirin resistance is associated with increased stroke severity and infarct volume

Objectives: To investigate whether aspirin resistance is associated with initial stroke severity and infarct volume, using diffusion-weighted imaging (DWI) in patients with acute ischemic stroke that occurred while taking aspirin. Methods: We studied a total of 310 patients who were admitted within 48 hours of acute ischemic stroke onset. All patients had been taking aspirin for at least 7 days before stroke onset. Aspirin resistance, defined as high residual platelet reactivity (HRPR) on aspirin treatment, was measured using the VerifyNow assay and defined as an aspirin reaction unit ≥550. Initial stroke severity was assessed using the NIH Stroke Scale (NIHSS) score. Infarct volume was measured using DWI. Results: HRPR occurred in 86 patients (27.7%). The initial NIHSS score (median [interquartile range]) was higher in patients with HRPR than in the non-HRPR group (6 [3–15] vs 3 [1–8], p < 0.001). DWI infarct volumes were also larger in the HRPR group compared to the non-HRPR group (5.4 [0.8–43.2] vs 1.7 [0.4–10.3], p = 0.002). A multivariable median regression analysis showed that HRPR was significantly associated with an increase of 2.1 points on the NIHSS (95% confidence interval 0.8–4.0, p < 0.001) and an increase of 2.3 cm3 in DWI infarct volume (95% confidence interval 0.4–3.9, p < 0.001). Conclusions: Aspirin resistance is associated with an increased risk of severe stroke and large infarct volume in patients taking aspirin before stroke onset.

Differences in cognitive function between patients with viral and alcoholic compensated liver cirrhosis

As alcohol induces change in frontal cortex primarily involved in cognition, cognitive function may be different between viral and alcoholic liver cirrhosis (LC). This study aimed to determine the differences of cognitive function between viral and alcoholic compensated LC. From October 2011 to March 2013, 80 patients (viral: 37; alcohol: 43) with compensated LC were prospectively enrolled. Neuropsychological functions including attention, language, visuospatial, verbal memory, visual memory, and frontal/executive function were evaluated between two groups and compared with age-matched normal group (nxa0=xa01000). Cumulative incidence rate of overt hepatic encephalopathy (HE) was calculated. In the comparison with normal group, both two groups showed decreased memory function, frontal/executive function, and Korea-Mini Mental Status Examination. In the analysis of two groups, memory function by Verbal Learning Test (recognition: 20.1xa0±xa03.6 and 17.8xa0±xa04.8, pxa0=xa00.022), visuospatial function by Ray-Complex Figure Copy Test (recognition: 19.0xa0±xa02.6 and 17.3xa0±xa04.0, pxa0=xa00.043), frontal/executive function by Controlled Oral Ward Association (semantic: 17.1xa0±xa06.9 and 12.7xa0±xa06.9, pxa0=xa00.004), and the Korea-Mini Mental Status Examination (27.5xa0±xa01.9 and 26.2xa0±xa03.1, pxa0=xa00.03) showed low scores in alcoholic compensated LC patients. The 1-, 2-, and 3-year cumulative incidence rates of overt HE were 23xa0%, 26xa0%, and 26xa0% and 33xa0%, 43xa0%, and 49xa0% in the viral and alcoholic compensated LC group, respectively (pxa0=xa00.033). Impaired memory and frontal lobe executive functions and early development of overt HE were more common in patients with alcoholic LC. For patients with alcoholic LC, more integrated tests for early detection of minimal HE and intensive treatment should be considered to prevent overt HE.

Smoking is Not a Good Prognostic Factor following First-Ever Acute Ischemic Stroke

Background and Purpose There is evidence that smoking increases stroke risk; however, the effect of smoking on functional outcome after stroke is unclear. The aim of this study was to explore the effect of smoking status on outcome following acute ischemic stroke. Methods We assessed 1,117 patients with first-ever acute cerebral infarction and no prestroke disability whose functional outcome was measured after three months. A poor outcome was defined as a modified Rankin Scale score of ≥2. Smoking within one month prior to admission was defined as current smoking. Our analysis included demographics, vascular risk factors, initial National Institutes of Health Stroke Scale (NIHSS) score, stroke subtype, onset-to-admission time, thrombolytic therapy, initial blood pressure, and prognostic blood parameters as covariates. Results At baseline, current smokers were predominantly male, approximately 10 years younger than non-smokers (mean age, 58.6 vs. 68.3 years), and less likely to have hypertension and atrial fibrillation (53.9% vs. 65.4% and 8.7% vs. 25.9%, respectively), with a lower mean NIHSS score (4.6 vs. 5.7). The univariate analyses revealed that current smokers had a better functional outcome and significantly fewer deaths at three months follow-up when compared with non-smokers (functional outcome: 64.0% vs. 58.4%, P=0.082; deaths: 3.0% vs. 8.4%, P=0.001); however, these effects disappeared after adjusting for covariates (P=0.168 and P=0.627, respectively). Conclusions In this study, smoking was not associated with a good functional outcome, which does not support the paradoxical benefit of smoking on functional outcome following acute ischemic stroke.

Prediction of persistent hemodynamic depression after carotid angioplasty and stenting using artificial neural network model

OBJECTIVESnTo assess and compare predictive factors for persistent hemodynamic depression (PHD) after carotid artery angioplasty and stenting (CAS) using artificial neural network (ANN) and multiple logistic regression (MLR) or support vector machines (SVM) models.nnnPATIENTS AND METHODSnA retrospective data set of patients (n=76) who underwent CAS from 2007 to 2014 was used as input (training cohort) to a back-propagation ANN using TensorFlow platform. PHD was defined when systolic blood pressure was less than 90mmHg or heart rate was less 50 beats/min that lasted for more than one hour. The resulting ANN was prospectively tested in 33 patients (test cohort) and compared with MLR or SVM models according to accuracy and receiver operating characteristics (ROC) curve analysis.nnnRESULTSnNo significant difference in baseline characteristics between the training cohort and the test cohort was observed. PHD was observed in 21 (27.6%) patients in the training cohort and 10 (30.3%) patients in the test cohort. In the training cohort, the accuracy of ANN for the prediction of PHD was 98.7% and the area under the ROC curve (AUROC) was 0.961. In the test cohort, the number of correctly classified instances was 32 (97.0%) using the ANN model. In contrast, the accuracy rate of MLR or SVM model was both 75.8%. ANN (AUROC: 0.950; 95% CI [confidence interval]: 0.813-0.996) showed superior predictive performance compared to MLR model (AUROC: 0.796; 95% CI: 0.620-0.915, p<0.001) or SVM model (AUROC: 0.885; 95% CI: 0.725-0.969, p<0.001).nnnCONCLUSIONSnThe ANN model seems to have more powerful prediction capabilities than MLR or SVM model for persistent hemodynamic depression after CAS. External validation with a large cohort is needed to confirm our results.

Effects of glycemic variability and hyperglycemia in acute ischemic stroke on post-stroke cognitive impairments

AIMSnWe aimed to investigate the effect of glycemic variability in the acute stage of stroke on the development of post-stroke cognitive impairment (PSCI).nnnMETHODSnPatients who underwent blood glucose tests at least five times within 7u202fdays after acute ischemic stroke were included. Factors related to glycemic variability (standard deviation (SD), coefficient of variance (CV), and mean absolute glucose (MAG)) were calculated; neuropsychological assessments were administered 3u202fmonths after stroke. PSCI was defined as a score of less than -2 SDs for age-, sex-, and education-adjusted means in at least one cognitive domain.nnnRESULTSnA total of 354 patients were enrolled. PSCI was identified in 74 (20.9%) subjects. In the diabetic group (n =u202f87), MAG was a significant predictor for PSCI (adjusted OR, 1.94; 95% CI, 1.11-3.42); however, it was not significant in the non-diabetic group, although PSCI exhibited an increasing tendency within higher SD and MAG tertiles. Moreover, hyperglycemia demonstrated a detrimental effect on PSCI, regardless of diabetes status; this effect did not appear in poorly-controlled diabetic patients with HbA1cu202f≥u202f8.0%.nnnCONCLUSIONSnGlycemic variability and hyperglycemia during acute ischemic stroke were identified as novel predictors for PSCI. Although this result is not evidence of a causal relationship, our study suggests that monitoring glycemic index and controlling its variability during the acute phase of ischemic stroke may help to prevent poor cognitive outcomes.

Blood Pressure Variability and Outcome in Patients with Acute Nonlobar Intracerebral Hemorrhage following Intensive Antihypertensive Treatment

Background: Blood pressure (BP) variability has been associated with stroke risk. We elucidated the association between systolic BP (SBP) variation and outcomes in patients with nonlobar intracerebral hemorrhage (ICH) following intensive antihypertensive treatment upfront. Methods: We screened consecutive patients with spontaneous ICH who underwent intensive antihypertensive treatments targeting BP <140 mmHg between 2008 and 2016. SBPs were monitored hourly during the acute period (⩽7 days after symptom onset) in the intensive care unit. SBP variability was determined in terms of range, standard deviation (SD), coefficient of variation (CoV), and mean absolute change (MAC). The primary outcomes included hematoma growth and poor clinical outcome at 3 months (modified Rankin Scale [mRS] score ≥3. The secondary outcome was an ordinal shift in mRS at 3 months. Results: A total of 104 individuals (mean age, 63.0 ± 13.5 years; male, 57.7%) were included in this study. In multivariable model, MAC (adjusted odds ratio [OR], 1.11; 95% confidence interval [CI]: 1.02–1.21; P = 0.012) rather than the range of SD or CoV, was significantly associated with hematoma growth even after adjusting for mean SBP level. Sixty-eight out of 104 patients (65.4%) had a poor clinical outcome at 3 months. SD and CoV of SBP were significantly associated with a 3-month poor clinical outcome even after adjusting for mean SBP. In addition, in multivariable ordinal logistic models, the MAC of SBP was significantly associated with higher shift of mRS at 3 months (adjusted OR, 1.08; 95% CI: 1.02–1.15; P = 0.008). Conclusions: The MAC of SBP is associated with hematoma growth, and SD and COV are correlated with 3-month poor outcome in patients with supratentorial nonlobar ICH. Therefore, sustained SBP control, with a reduction in SBP variability is essential to reinforce the beneficial effect of intensive antihypertensive treatment.

Association of SOX17 Gene Polymorphisms and Intracranial Aneurysm: A Case-Control Study and Meta-Analysis

BACKGROUNDnGenome-wide association studies have revealed an association between SRY-box 17 (SOX17) gene and intracranial aneurysm (IA) formation. However, results were mainly derived from European and Japanese populations. We investigated the association between SOX17 gene polymorphisms and IA in a homogeneous Korean population. We performed a meta-analysis to assess these results in East-Asian populations.nnnMETHODSnThis cross-sectional study included 187 age- and sex-matched patients with IA and 372 control subjects. Genetic association analysis was performed in the generalized linear model to identify associations between 4xa0single nucleotide polymorphisms and IA, including 95xa0patients with ruptured aneurysms and 92 with unruptured aneurysms. The East-Asian meta-analysis of 5100 IA cases and 7930 control cases was conducted under an inverse variance model.nnnRESULTSnAmong 4 single nucleotide polymorphisms that passed quality control tests, the minor C allele of rs1072737 was significantly associated with IA (odds ratio 0.69, 95% confidence interval 0.49-0.96, Pxa0= 0.03). None of the 4 single nucleotide polymorphisms showed a significant association between patients with ruptured and unruptured aneurysms. Meta-analysis revealed that Gxa0alleles of rs10958409 and rs9298506 were significantly associated with IA in the East-Asian population after removing study heterogeneity (odds ratio 1.11, 95% confidence interval 1.04-1.19, Pxa0= 0.0023 and odds ratio 1.19, 95% confidence interval 1.07-1.32, Pxa0= 0.0016).nnnCONCLUSIONSnIdentification of genetic variants located near SOX17 is likely to be clinically significant for IA formation. rs10958409 and rs9298506 may increase risk of IA in East-Asian populations. Our findings may help in the identification of IA pathogenesis.