Seung-Han Suk

Effect of cilostazol in acute lacunar infarction based on pulsatility index of transcranial Doppler (ECLIPse): a multicenter, randomized, double-blind, placebo-controlled trial.

Background: This study is intended to evaluate the propensities of cilostazol to reduce the pulsatility index (PI) in patients with acute lacunar infarction using the serial transcranial Doppler (TCD) examinations. Methods: In a multicenter, randomized, double-blind, placebo-controlled trial, patients were randomly assigned to receive either placebo or 100 mg cilostazol twice a day as well as aspirin 100 mg a day. The primary outcomes were the changes of middle cerebral artery (MCA) and basilar artery (BA) PIs at 14 and 90 days from the baseline TCD study. This study is registered with ClinicalTrials.gov (NCT00741286). Results: Trial medication was given to 203 patients, with 100 receiving cilostazol and 103 receiving placebo, and 164 were included in the per-protocol analysis of the primary outcome. Results from the linear mixed model showed that significant effects were obtained for time-by-group interactions (p = 0.008 in right MCA, p = 0.015 in left MCA, p = 0.002 in BA), suggesting that changes of PIs from the baseline to the 90-day study were different across the groups. Conclusions: Cilostazol further decreased TCD PIs at 90 days from baseline compared to placebo in acute lacunar infarction. This result may be related to pleiotropic effects, such as vasodilation, beyond its antiplatelet activity.

Tooth Loss May Predict Poor Cognitive Function in Community- Dwelling Adults without Dementia or Stroke: The PRESENT Project

Periodontal disease is a potential predictor of stroke and cognitive impairment. However, this association is unclear in adults aged 50 yr and above without a history of stroke or dementia. We evaluated the association between the number of teeth lost, indicating periodontal disease, and cognitive impairment in community-dwelling adults without any history of dementia or stroke. Dental examinations were performed on 438 adults older than 50 yr (315 females, mean age 63±7.8 yr; 123 males, mean age 61.5±8.5 yr) between January 2009 and December 2010. In the unadjusted analysis, odds ratios (OR) of cognitive impairment based on MMSE score were 2.46 (95% CI, 1.38-4.39) and 2.7 (95% CI, 1.57-4.64) for subjects who had lost 6-10 teeth and those who had lost more than 10 teeth, respectively, when compared with subjects who had lost 0-5 teeth. After adjusting for age, education level, hypertension, diabetes, hyperlipidemia, and smoking, the relationship remained significant (OR, 2.0; 95% CI, 1.08-3.69, P=0.027 for those with 6-10 teeth lost; OR, 2.26; 95% CI, 1.27-4.02, P=0.006 for those with more than 10 teeth lost). The number of teeth lost is correlated with cognitive impairment among community-dwelling adults aged 50 and above without any medical history of stroke or dementia.

Associated conditions and clinical significance of awake bruxism.

Background:  Awake bruxism is defined as an oral parafunctional activity that includes clenching and grinding of teeth during wakefulness. Confirming the possible related anatomy and the clinical significance of awake bruxism in geriatric hospitals is the aim of this study.

Induction of apoptosis signal-regulating kinase 1 and oxidative stress mediate age-dependent vulnerability to 3-nitropropionic acid in the mouse striatum

The mitochondrial toxin, 3-nitropropionic acid (3-NP), produces age-dependent oxidative stress and selective striatal damage, which may simulate Huntingtons disease starting in middle age. Recent reports showed that apoptosis signal-regulating kinase 1 (Ask1) activated by oxidative stress triggers a cell death signaling pathway. 3-NP was injected to the striatum in C57BL/6J mice. We have confirmed that striatal lesion volume and DNA fragmentation were age-dependent after 3-NP treatment. In the non-injured striatum of the middle-aged group, the protein levels of Ask1 and its active form, phosphorylated Ask1 (pAsk1), were significantly higher than in the young group. Ask1 increased more in the 3-NP injured striatum of the middle-aged group than in the non-injured striatum, and subsequently the activity of pAsk1 was significantly higher than in the young group. However, middle-aged SOD1Tg mice showed significant reductions of Ask1 and pAsk1 in the injured and the non-injured striatum compared to the middle-aged group. In particular, apoptosis signal transduction and cell death were significantly inhibited by the reduction of Ask1 expression using siRNA. Present results suggest that age-related upregulation of Ask1 and oxidative stress may mediate age-dependent striatal vulnerability to 3-NP.

Toxic encephalopathy after taking dried seeds of Datura stramonium in two elderly subjects.

An altered mentality, or delirium, is a common medical condition of the elderly in emergency medicine or neurology clinics. Among causes of this, toxic etiology due to an anticholinergic agent is not rare. The authors present two elderly women who were brought to an emergency room because of anticholinergic syndrome. The patients displayed agitative behavior, confusion, urinary retention, dry mouth and dilated pupils within 3 h of ingesting the dried seeds of Datura stramonium which has been used as a herbal medicine or as a traditional folk remedy for relieving coughing and asthma in Korea. They were discharged with a complete recovery after receiving conservative therapy for 5 days. Physicians of emergency medicine should be mindful of anticholinergic syndrome due to herbal medicine when the elderly with a history of delirium come to a hospital.

Cilostazol decreases cerebral arterial pulsatility in patients with mild white matter hyperintensities: subgroup analysis from the Effect of Cilostazol in Acute Lacunar Infarction Based on Pulsatility Index of Transcranial Doppler (ECLIPse) study.

Background: The Effect of Cilostazol in Acute Lacunar Infarction Based on Pulsatility Index of the Transcranial Doppler (ECLIPse) study showed a significant decrease in the transcranial Doppler (TCD) pulsatility index (PI) with cilostazol treatment at 90 days after acute lacunar infarction. The aim of the present study was to perform a subgroup analysis of the ECLIPse study in order to explore the effect of cilostazol in acute lacunar infarction based on cerebral white matter hyperintensities (WMH) volume. Methods: The ECLIPse study was a multicenter, randomized, double-blind, placebo-controlled trial that evaluated the difference between the efficacy of cilostazol and a placebo to reduce the PI in patients with acute lacunar infarction using serial TCD examinations. The primary outcome was changes in the PIs of the middle cerebral artery (MCA) and basilar artery at 14 and 90 days from the baseline TCD study. For this subgroup analysis, using semi-automated computerized software, the WMH volume was measured for those subjects for whom fluid-attenuated inversion recovery (FLAIR) images were available. Results: Of the 203 patients in eight hospitals in the ECLIPse study, 130 participants from six hospitals were included in this subgroup analysis. Cilostazol was given to 63 patients (48.5%) and placebo to 67 patients (51.5%). All baseline characteristics were well balanced across the two groups, and there were no significant differences in these characteristics except in the changes of PI from the baseline to the 90-day point. There was a significant decrease of TCD PIs at 90-day study from baseline in the cilostazol group (p = 0.02). The mean WMH volume was 11.57 cm3 (0.13-68.45, median 4.86) and the mean MCA PI was 0.95 (0.62-1.50). The changes in PIs from the baseline to 14 days and to 90 days were 0.09 (-0.21 to 0.33) and 0.10 (-0.22 to 0.36). While there were no significant correlations between WMH volume and the changes in PIs, a trend of inverse correlation was observed between the WMH volume and the changes in PIs from the baseline to the 90-day point. For the subgroup analysis, the WMH volume was dichotomized based on its median value (4.90 cm3). Cilostazol decreased the TCD PIs significantly at the 90-day point in patients with WMH volumes ≤4.9 cm3 (p = 0.002). Significant treatment effects were observed in the cilostazol group. Conclusions: This study showed that cilostazol decreased cerebral arterial pulsatility in patients with WMH. Our findings indicate the unique effect of cilostazol in small vessel disease (SVD), especially in patients with mild WMH changes. Further clinical trials focusing on WMH volume and clinical outcomes are required to assess the unique efficacy of cilostazol in SVD.

Two cases of discontinuation syndrome following cessation of memantine

Although memantine is widely used and generally considered safe, an abrupt cessation of memantine may result in discontinuation syndrome that can be distressing and result in decline of natural course. We report two patients who developed significant behavior disturbance after abrupt cessation of memantine. Although re‐trial of memantine improves these symptoms, more additional drugs may be required to achieve previous status. Therefore, abrupt cessation of memantine should be prudent and require cautious follow up.

Aseptic Meningitis in Kikuchi's Disease

The involvement of the nervous system in Kikuchis disease (KD) is rare. Although some reports of meningeal involvement in KD were described in the literature from Japan, it has rarely been reported in Korea. A 23-year-old man presented with severe headache, fever, and vomiting. Cerebrospinal fluid (CSF) analysis revealed an opening pressure 300 mmH2O, WBC 283/mm3, glucose 44 mg/dl and protein 86 mg/dl. Multiple tender lymph nodes on the left anterior neck were found on the 9th day of his hospital stay. The lymph node biopsy disclosed histopathologic features typical of KD. We report a patient with KD accompanied by aseptic meningitis, emphasizing the importance of recognizing this disorder in diagnosing patients with meningitis.

Higher skeletal muscle mass may protect against ischemic stroke in community-dwelling adults without stroke and dementia: The PRESENT project

BackgroundIt is well known that a low skeletal muscle mass (SMM) is associated with stroke. However, it is unknown whether increasing muscle mass can prevent stroke.MethodsThis community-based cross-sectional study was supported by the regional government. SMM measurements and brain computed tomography was performed in 722 stroke-free and dementia-free subjects (aged 50–75 years). Subjects were divided into quartiles (Q) by SMM, checked using the bioelectrical impedance analysis method (InBody 770, InBody, Seoul, Korea). Odds ratios (ORs) of brain white matter changes/silent infarction (WMC/SI) were calculated. The subjects were then divided into two groups by sex and evaluated.ResultsIn the analysis of the four groups, the unadjusted ORs of Q2–Q4 were 0.616 (95% confidence interval [CI], 0.372–1.022; P = 0.061), 0.290 (CI, 0.159–0.530; P < 0.001), and 0.209 (CI, 0.108–0.403; P < 0.001) for the risk of WMC/SI. Adjusted ORs for age, hypertension, diabetes mellitus, education, hypercholesterolemia, and smoking were 0.994 (CI, 0.513–1.740; P = 0.085), 0.669 (CI, 0.329–1.362; P = 0.268), and 0.464 (CI, 0.219–0.984; P = 0.045). In the two–group (dichotomized) analysis, the unadjusted OR for the higher muscle mass groups (Q3 + Q4) was 0.313 (CI, 0.200–0.491; P < 0.001). The adjusted OR was 0.577 (CI, 0.340–0.979; P = 0.042). Considering sex, the adjusted OR were 0.351 (CI, 0.141–0.869; P = 0.024) in men and 0.771 (CI, 0.391–1.519; P = 0.452) in women.ConclusionsOur findings suggest that increased SMM may protect against WMC/SI, especially in men.

Impact of Healthcare Accreditation Using a Systematic Review: Balanced Score Card Perspective

Original Articles 의료기관인증의 효과에 대한 체계적 문헌고찰: Balanced Score Card 관점으로 2 Purpose: The purpose of this study was to analyze the impact of healthcare accreditation and to provide empirical evidence to validate positive effectiveness. Methods: Six electronic databases (KERIS, KoreaMed, NDSL, Ovid-medline, Embase, Cochrane library) were accessed in May 2016.