Hyperattenuating lesions after mechanical thrombectomy in acute ischaemic stroke: factors predicting symptomatic haemorrhage and clinical outcomes

AIM

To evaluate the clinical significance of hyperattenuating lesions on CT after mechanical thrombectomy for acute ischaemic stroke, and to identify imaging factors that predict symptomatic haemorrhage and unfavourable outcomes.

MATERIALS AND METHODS

Seventy-eight patients with acute ischaemic stroke in the anterior circulation who underwent mechanical thrombectomy were evaluated. All patients underwent post-interventional unenhanced computed tomography (CT) within 24 h and follow-up CT or magnetic resonance imaging (MRI) within 7 days. Baseline characteristics and clinical outcomes were compared between patients with and without hyperattenuating lesions. In patients with hyperattenuating lesions, clinical and imaging factors that predict symptomatic haemorrhage and unfavourable outcomes were determined.

RESULTS

Fifty-six of 78 patients (71.8%) demonstrated hyperattenuating lesions on post-interventional CT. Patients with hyperattenuating lesions showed lower Alberta Stroke Program Early CT score (ASPECTS), persistent/symptomatic haemorrhage, and unfavourable outcomes than those without. In patients with hyperattenuating lesions, larger hyperattenuating lesion volume (>21.3 ml; OR, 55.60, p<0.001) and perilesional oedema (OR, 46.04, p=0.015) were independent factors predicting symptomatic haemorrhage. Older age (OR, 1.2, p=0.006) and lower ASPECTS (OR, 0.45, p=0.046) were independent factors predicting unfavourable outcomes in patients with hyperattenuating lesions. Adding the volume of the hyperattenuating lesion to age and ASPECTS increased the predictive performance of unfavourable outcomes (area under the curve 0.874 versus 0.934, p=0.043).

CONCLUSIONS

Hyperattenuating lesions on post-interventional CT are associated with increased risk of symptomatic haemorrhage and unfavourable outcomes. Larger hyperattenuating lesion volume is an independent factor of symptomatic haemorrhage and it has added predictive value for unfavourable outcomes.

Association between body mass index and stroke severity in acute ischaemic stroke with non-valvular atrial fibrillation

BACKGROUND AND PURPOSE

The objective of this study was to investigate the association between body mass index (BMI) and both initial stroke severity at presentation and functional outcomes after acute ischaemic stroke (AIS) in patients with non-valvular atrial fibrillation (NVAF).

METHODS

Patients were categorized on the basis of their BMI into underweight (BMI <18.5, n = 111), normal (18.5 ≤ BMI <25, n = 1036) and overweight to obese (BMI ≥25, n = 472) groups. Initial stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score and functional outcomes were assessed using the modified Rankin Scale score at discharge. The differences in stroke severity and functional outcomes were compared between groups using robust log-linear regression with a Poisson distribution and binary logistic regression analysis.

RESULTS

A total of 1619 AIS patients with NVAF from six hospitals were included. Compared with the NIHSS scores [median 5, interquartile range (IQR) 2-14] of normal-weight patients, the NIHSS scores (median 9, IQR 4-19) of underweight patients were more likely to be higher, whereas those of overweight to obese patients were lower (median 4, IQR 1-12) (P < 0.001). In terms of functional outcomes after stroke, underweight patients had a higher risk of poor functional outcomes (odds ratio 1.78, 95% confidence interval 1.09-2.56, P = 0.01) but overweight to obese patients had no significant difference in functional outcomes compared with normal-weight patients.

CONCLUSION

An inverse association was found between BMI and stroke severity in AIS patients with NVAF. This suggests the presence of an obesity paradox for short-term outcomes in patients with NVAF.

Differential impact of unrecognised brain infarction on stroke outcome in non-valvular atrial fibrillation

There has been little information regarding the impact of unrecognised brain infarctions (UBIs) on stroke outcome in patients with non-valvular atrial fibrillation (NVAF). By using volumetric analysis of ischaemic lesions, we evaluated the potential impact of UBIs on clinical outcome according to their presence and categorised type. This study enrolled 631 patients with NVAF having no clinical stroke history. UBIs were categorised into three types as territorial, lacunar, or subcortical. We collected stroke severity, functional outcome at three months, and the total volume of UBIs and acute infarction lesions. We investigated the association between clinical outcome and the type or volume of UBI, using a linear mixed model and logistic regression analysis. UBIs were detected in 285 (45.2 %) patients; territorial UBIs were observed in 24.4 % of patients (154/631), lacunar UBIs in 25 % (158/631), and subcortical UBIs in 15.7 % (99/631). Although initial stroke severity was not different between patients with UBIs and those without, those with UBIs had less improvement during hospitalisation, leading to poorer outcome at three months. Among the three types of UBIs, only territorial UBIs were associated with poor outcome, especially in patients with relatively smaller acute infarction volume. UBIs, in particular, territorial UBIs, may be considered as predictors for poor outcome after ischaemic stroke in patients with NVAF. Our results suggest that the impact of UBIs on clinical outcome differs according to the type of UBIs and the acute stroke severity.

Comparison of stent retriever and intra-arterial fibrinolysis in patients with acute ischaemic stroke

BACKGROUND AND PURPOSE

Although the stent retriever (SR) has shown a better reperfusion rate and clinical outcome than the older generation mechanical clot retrieval device, it is uncertain whether the SR is superior to intra-arterial fibrinolysis (IAF).

METHODS

Ischaemic stroke patients who were treated with SR or IAF as initial endovascular treatment modality for unilateral arterial occlusion in the anterior circulation were included. Successful reperfusion was defined as Thrombolysis in Cerebral Infarction grade ≥2b. A favourable clinical outcome was defined as a modified Rankin Score ≤2 at 3 months.

RESULTS

Between January 2009 and May 2012, 55 patients were treated with SR and 50 patients were treated with IAF. The baseline characteristics were similar between the two groups except for the occlusion site and rescue treatment. In binary logistic regression analysis adjusted for the occlusion site and rescue treatment, SR was independently associated with increased successful reperfusion [82.0% vs. 47.3%; odds ratio (OR) 5.21; 95% confidence interval (CI) 1.92-14.14) and a more favourable clinical outcome at 3 months (54.0% vs. 43.6%; OR 3.40; 95% CI 1.31-8.84). The frequency of symptomatic intracranial haemorrhage and mortality at 3 months was not different between the two groups.

CONCLUSIONS

Stent retriever was as safe as and more effective than IAF. Our findings suggest that SR may be considered as an initial modality rather than IAF in acute stroke patients who undergo endovascular treatment.

The association between asymptomatic coronary artery disease and CHADS2 and CHA2 DS2 -VASc scores in patients with stroke

BACKGROUND AND PURPOSE

CHADS2 and CHA2 DS2 -VASc scores are measurement tools that stratify thromboembolic risk in patients with non-valvular atrial fibrillation, and are predictive of cerebral atherosclerosis, fatal stroke and ischaemic heart disease. Patients with higher CHADS2 and CHA2 DS2 -VASc scores are more likely to have had an akinetic/hypokinetic left ventricular segment or a recent myocardial infarction, all of which are associated with coronary artery disease (CAD). Most of the CHADS2 score components are also risk factors for atherosclerosis. Thus, CHADS2 and CHA2 DS2 -VASc scores may be predictive of CAD.

METHODS

In all, 1733 consecutive patients with acute ischaemic stroke who underwent multi-slice computed tomography coronary angiography were enrolled. The association of CHADS2 and CHA2 DS2 -VASc scores with the presence and severity of CAD was investigated.

RESULTS

Of the 1733 patients, 1220 patients (70.4%) had any degree of CAD and 576 (33.3%) had significant CAD (≥ 50% stenosis in at least one coronary artery). As the CHADS2 and CHA2 DS2 -VASc scores increased, the presence of CAD also increased (P < 0.001). The severity of CAD was correlated with CHADS2 score (Spearman coefficient 0.229, P < 0.001) and CHA2 DS2 -VASc score (Spearman coefficient 0.261, P < 0.001). In multivariate analysis, after adjusting for confounding factors, CHADS2 and CHA2 DS2 -VASc scores ≥2 were independently associated with CAD. The CHA2 DS2 -VASc score was a better predictor of the presence of CAD than the CHADS2 score on area under the curve analysis.

CONCLUSION

CHADS2 and CHA2 DS2 -VASc scores were predictive of the presence and severity of CAD in patients with stroke. When a patient has high CHADS2 or CHA2 DS2 -VASc scores, physicians should consider coronary artery evaluation.

The frequency of cerebral microbleeds increases with CHADS(2) scores in stroke patients with non-valvular atrial fibrillation

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMBs) are extravasations of blood from lipohyalinized or amyloid angiopathic cerebral arterioles, and the presence and numbers of CMBs are significantly associated with the development of oral anticoagulation (OA)-related intracranial haemorrhage (ICH). The aim of this study was to investigate whether there is a difference in CMBs burden according to CHADS(2) scores or CHA(2) DS(2) -VASc scores in non-valvular atrial fibrillation (NVAF) patients.

METHODS

We included 550 ischaemic stroke patients who had NVAF and who had undergone brain magnetic resonance imaging (MRI) with gradient-recalled echo (GRE) T2 sequences from our prospective stroke registry between January 2005 and November 2011. We calculated CHADS(2) scores and CHA(2) DS(2) -VASc scores for all patients based on their underlying cardiovascular diseases. The presence, location and number of CMBs were assessed in each patient. We also investigated whether the CMBs were actually associated with the development of ICH during follow-up.

RESULTS

The mean patient age was 70.4 ± 10.5 years, and 324 (58.9%) patients were men. One-hundred and seventy-three patients (31.5%) had CMBs detected on GRE MRI. Higher CHADS(2) scores or CHA(2) DS(2) -VASc scores were strongly associated with the presence and number of CMBs. During follow-up of median 3.1 ± 1.6 years, the presence of CMBs was independently associated with the development of ICH, whilst the CHADS(2) scores or CHA(2) DS(2) -VASc scores were not.

CONCLUSIONS

Considering the positive association between the presence of CMBs and OA-related ICH, our results suggest that the increase in ICH in high-risk groups during OA may be related to an increased burden of CMBs.

Proteins involved in DNA damage response pathways and survival of stage I non-small-cell lung cancer patients

BACKGROUND

Biological complexity leads to significant variation in the survival of patients with stage I non-small-cell lung cancer (NSCLC). DNA damage response (DDR) pathways play a critical role in maintaining genomic stability and in the progression of NSCLC. Therefore, the development of a prognostic biomarker focusing on DDR pathways is an intriguing issue.

PATIENTS AND METHODS

Expression of several proteins (ATM, ATMpS1981, γH2AX, 53BP1, 53BP1pS25, Chk2, Chk2pT68, MDC1, MDC1pS964, BRCA1pS1423, and ERCC1) and overall survival were investigated in 889 pathological stage I NSCLC patients.

RESULTS

Low expression of BRCA1pS1423 or ERCC1 was significantly associated with worse survival in the whole cohort of patients. Analysis performed based on histology revealed that low expression of γH2AX, Chk2pT68, or ERCC1 was a poor prognostic factor in squamous cell carcinoma patients [adjusted hazard ratio (aHR), Cox P: 1.544, 0.012 for γH2AX; 1.624, 0.010 for Chk2pT68; 1.569, 0.011 for ERCC1]. The analysis of the interaction between two proteins showed that this effect was more pronounced in squamous cell carcinoma patients. However, these effects were not detected in adenocarcinoma patients.

CONCLUSIONS

The proteins involved in DDR pathways exhibited differential expression between squamous cell carcinoma and adenocarcinoma and were important determinants of survival in stage I squamous cell carcinoma patients.

Use of a handheld, computerized device as a decision support tool for stroke classification

BACKGROUND

The Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification has been widely used to determine etiology of ischemic stroke. However, interrater reliability is known to be modest. The complexity of abstraction and the interpretation of various clinical and laboratory data might limit the accuracy of the TOAST classification. In this study, we developed a computerized clinical decision support system for stroke classification that can be used in a handheld device and tested whether this system can improve diagnostic accuracy and reliability.

METHODS

Based on the TOAST classification, a logical algorithm was developed and implemented on a handheld device, named iTOAST. After answering six questions using the touch interface, the stroke subtype result is displayed on the screen. Four neurology residents were randomly assigned to classify stroke subtypes using iTOAST or the conventional method (cTOAST). Using a crossover design, they classified the stroke subtypes of 70 patients. The standard subtypes were determined by three stroke experts. Correlated kappa coefficients using iTOAST compared with cTOAST were determined.

RESULTS

The kappa (SE) value of iTOAST [0.790 (0.041), 95% CI: 0.707-0.870] was higher than that of cTOAST [0.692 (0.046), 95% CI: 0.600-0.782] (P<0.001). Neither sequence (P=0.857) nor period effect (P=0.999) was observed.

CONCLUSIONS

The stroke classification tool using a handheld, computerized device was easy, accurate, and reliable over the conventional method. It may have additional benefit because a handheld, computerized device is accessible anytime and anywhere.

Early neurological outcomes according to CHADS2 score in stroke patients with non-valvular atrial fibrillation

BACKGROUND AND PURPOSE

A higher CHADS(2) score or CHA(2)DS(2)-VASc score is associated with an increased risk of ischaemic stroke in patients with non-valvular atrial fibrillation (NVAF). However, there are no data regarding early neurological outcomes after stroke according to the risk levels.

METHODS

In this study, a total of 649 stroke patients with NVAF were enrolled and categorized into three groups: low-risk (CHADS(2) score of 0-1), moderate-risk (CHADS(2) score 2-3), or high-risk group (CHADS(2) score ≥4). CHA(2)DS(2)-VASc score was divided into four groups including 0-1, 2-3, 4-5, and ≥6. We investigated whether there were differences in initial stroke severity, early neurological outcome, and infarct size according to CHADS(2) score or CHA(2)DS(2)-VASc score in stroke patients with NVAF.

RESULTS

The initial National Institutes of Health Stroke Scale (NIHSS) score was highest in high-risk group [9.5, interquartile range (IQR) 4-18], followed by moderate-risk (8, IQR 2-17) and low-risk group (6, IQR 2-15) (P=0.012). Likewise, initial stroke severity increased in a positive fashion with increasing the CHA(2)DS(2)-VASc score. During hospitalization, those in the high-risk group or higher CHA(2)DS(2)-VASc score had less improvement in their NIHSS score. Furthermore, early neurological deterioration (END) developed more frequently as CHADS(2) score or CHA(2)DS(2)-VASc score increased. Multivariate analysis showed being in the high-risk group was independently associated with END (OR 2.129, 95% CI 1.013-4.477).

CONCLUSIONS

Our data indicate that patients with NVAF and higher CHADS(2) score or CHA(2)DS(2)-VASc score are more likely to develop severe stroke and a worse clinical course is expected in these patients after stroke presentation.

Expression of RUNX3 in skin cancers

BACKGROUND

Expression of Runt-related transcription factor 3 (RUNX3) is reduced in a large number of cancers. However, a few studies have reported higher expression of RUNX3 in several cancers, including basal cell carcinoma (BCC). In light of this, we explored the expression of RUNX3 in skin cancers generally, to determine whether it acts as an oncogene or a tumour-suppressor gene in skin tumours.

AIM

To investigate the expression of RUNX3 in normal skin and malignant skin tumours.

METHODS

RUNX3 expression was evaluated by western blotting in 24 specimens, comprising 6 malignant melanoma (MM), 6 squamous cell carcinoma (SCC), 6 BCC and 6 normal skin specimens. Immunohistochemical staining was carried out to analyse RUNX3 expression in 16 MM, 16 SCC and 16 BCC specimens. To identify where the protein was expressed, the cytoplasmic and nuclear protein expression of RUNX3 in skin cancer tissues was determined. A cell-proliferation study was performed on an MM line (G361) by small interfering (si)RNA transfection.

RESULTS

The western blotting experiments showed that RUNX3 was not expressed in normal skin tissues, but it was overexpressed in all MM and SCC samples, and in five of the six BCC samples. Using immunochemistry, RUNX3 was found to be overexpressed in all cancer tissues analysed. Subcellular fraction analysis revealed that RUNX3 was expressed in the nuclei but not the cytoplasm of all the skin cancer tissues analysed, and RUNX3 silencing by siRNA in G361 cells resulted in a decrease in proliferation.

CONCLUSIONS

Based on these results, we suggest that RUNX3 has an oncogenic potential and does not act as a tumour suppressor in skin cancers.

Effect of warfarin withdrawal on thrombolytic treatment in patients with ischaemic stroke

BACKGROUND AND PURPOSE

  Abruptly discontinuing warfarin may induce a rebound prothrombotic state. Thrombolytic agents may also paradoxically induce prothrombotic conditions, which include platelet activation and thrombin generation. Therefore, prothrombotic states may be enhanced by withdrawing warfarin in patients under thrombolytic treatment. This study was aimed to determine whether patients with warfarin withdrawal have different clinical outcomes from those without warfarin use after thrombolytic treatment.

METHODS

  A total of 148 consecutive patients with atrial fibrillation who were not on anticoagulants at admission and who received thrombolysis were included in this study. We compared the outcomes between a warfarin withdrawal group and a no-warfarin group.

RESULTS

  Fourteen patients (9.5%) were included in the warfarin withdrawal group. Although baseline National Institute of Health Stroke Scale (NIHSS) scores, recanalization rates, and hemorrhage frequencies did not differ between the groups, the warfarin withdrawal group showed poorer outcomes. Increased NIHSS scores during the first 7days were more frequent in the warfarin withdrawal group (57.1% vs. 26.9%, P=0.029). The median percent improvement in NIHSS scores at 24h after thrombolysis was also lower in the warfarin withdrawal group. After adjusting for covariates, warfarin withdrawal was a strong predictor of poor functional outcome at 3months (modified Rankin score≥3) (odds ratio, 17.067, 95% CI 2.703-107.748).

CONCLUSIONS

  Discontinuing warfarin was associated with early neurologic deterioration and poor long-term outcomes after thrombolytic treatment.

Failure of complete recanalization is associated with poor outcome after cardioembolic stroke

BACKGROUND

  Recanalization is strongly associated with outcomes after thrombolytic treatment. Cardiac emboli are known as better response to fibrinolytic agents because they are fibrin-rich; however, cardioembolic stroke itself is associated with poor outcomes and high mortality. Completeness of recanalization may therefore affect the outcome of cardioembolic stroke. We investigated whether degree of recanalization influences outcomes following fibrinolytic therapy in cardioembolic stroke.

METHODS

  Consecutive stroke patients with relevant artery occlusions on baseline CT angiography who had received thrombolytic treatment were enrolled. Completeness of recanalization was assessed by the Thrombolysis in Myocardial Infarction (TIMI) grade, which was compared between patients with and without cardiac sources of embolism (CSE). We also investigated independent predictors of poor outcome (modified Rankin scale score 3-6) at 3 months.

RESULTS

  Of the 127 patients enrolled, 65 (51%) had one or more CSE. Although the overall recanalization rates (TIMI 2 or 3) in patients with CSE (65%) and patients without CSE (68%) were similar (P=0.710), patients with CSE were less likely to show complete recanalization (TIMI 3) compared with those without CSE (19% vs. 39%, P=0.011). Multivariate analysis revealed that CSE was associated with failure of complete recanalization (OR 2.809, 95% CI 1.097-7.192) and was an independent predictor of poor outcome at 3months (OR 3.629, 95% CI 1.205-8.869).

CONCLUSIONS

  In cardioembolic strokes, failure of complete recanalization following thrombolytic therapy was frequent and was associated with poor outcome after thrombolysis.

Identification of oxidized serum albumin in the cerebrospinal fluid of ischaemic stroke patients

BACKGROUND AND PURPOSE

  Extensive evidence has shown that oxidative stress mediates neuronal death in animal models of hypoxic-ischaemia. Brain biomarkers of oxidative stress need to be identified in order to better understand and treat brain damage in human stroke patients. The present study was conducted to identify potential target proteins of oxidative stress in the cerebrospinal fluid (CSF) of stroke patients with acute ischaemic brain injury.

METHODS

  We performed two-dimensional polyacrylamide gel electrophoresis to separate protein samples obtained from the CSF of control and stroke patients. To determine protein oxidation levels, oxyblot was then used to detect protein carbonyls that were determined by formation of a stable 2,4-dinitrophenylhydrazine (DNP) product using an anti-DNP antibody.

RESULTS

  We found that oxidation of serum albumin was increased in the CSF from stroke patients as well as rats who underwent permanent middle cerebral artery occlusion (6.5%, 23%, respectively). In stroke patients, oxidized albumin levels correlated to neurologic indications.

CONCLUSIONS

  The present study suggests that oxidized albumin in CSF can be utilized as an oxidative stress marker in human stroke patients.

The different infarct patterns between adulthood-onset and childhood-onset moyamoya disease

BACKGROUND AND PURPOSE

The pattern of infarctions based on the findings of diffusion-weighted image was assessed, and it was also investigated whether there are any age-specific differences in patients with moyamoya disease (MMD).

METHODS

The subjects were 66 consecutive patients with MMD who had an acute cerebral infarction. Each ischaemic lesion was categorised into one of seven patterns (gyral, atypical territorial, honeycomb, classic territorial, multiple-dot, borderzone, deep lacunar) based on diffusion-weighted image findings. The patterns were compared between adulthood-onset MMD (A-MMD, ≥20 years old, 34 patients) and childhood/adolescent-onset MMD (C-MMD, <20 years old, 32 patients) according to their ages of infarct presentation.

RESULTS

A total of 91 infarct patterns were observed from 66 patients. The gyral, atypical territorial, and honeycomb patterns, which are not usually seen in conventional stroke patients, were common in MMD (68.1%). Among all patterns, a gyral pattern was most common (40/91, 44.0%). Borderzone and deep lacunar patterns were infrequent. Gyral and borderzone patterns were more frequently seen in the C-MMD group, whereas a honeycomb pattern was not seen in young patients. Honeycomb pattern was more common at advanced vascular stages. Infarctions confined to the cortex were more common in the C-MMD group (26/32, 75.0%) than in A-MMD patients (14/34, 41.2%).

CONCLUSIONS

Moyamoya disease showed various characteristic and age-specific infarct patterns. Different infarct patterns between the A-MMD and C-MMD groups may be associated with age-specific vulnerability of the brain to ischaemia, stage of arteriopathy or changes of abnormal collateral pathways.

Self-expanding stent for recanalization of acute embolic or dissecting intracranial artery occlusion

BACKGROUND AND PURPOSE

Stent placement may be an effective and last resort method for recanalization of recalcitrant intracranial artery occlusion. The purpose of this study was to evaluate the safety and efficacy of a self-expanding stent for the recanalization of acute embolic or dissecting intracranial artery occlusion.

MATERIALS AND METHODS

Nine patients (mean age, 66 years; NIHSS score, 10-23) with acute embolic (n = 8) or dissecting occlusion (n = 1) of the intracranial arteries (ICA terminus in 5, MCA in 3, and BA in 1) were treated with a recapturable self-expanding stent. The safety and efficacy of the stent for recanalization were evaluated retrospectively.

RESULTS

The emboli were entrapped against the vessel wall by the stent, resulting in immediate recanalization (TIMI 2) in all embolic occlusions. The dissecting occlusion was recanalized completely (TIMI 3). Adjunctive thrombolytics (n = 8, urokinase, 100,000-300,000 U) and/or GP IIb/IIIa antagonist (n = 7, tirofiban, 0.5-1 mg) were administered intra-arterially, and the degree of recanalization further improved in 4 embolic occlusions (TIMI 3). Acute in-stent thrombosis occurred in 2 patients, who received only urokinase without GP IIb/IIIa antagonist. Both of the reoccluded arteries were reopened, by stent recapture in 1 and by intra-arterial administration of GP IIb/IIIa antagonist in the other. Recapture was attempted in 7 cases, of which there were 3 successful outcomes. There was 1 asymptomatic hemorrhagic conversion at the infarction site. The mean improvement of the NIHSS score between baseline and discharge was 12.3 (range, 3-22).

CONCLUSIONS

Preliminary results of this study suggest that a self-expanding stent may be safe and efficient for recanalization of acute embolic or dissecting intracranial artery occlusion.

Risk-factors for human infection with Orientia tsutsugamushi: a case-control study in Korea

A case-control study was conducted involving 156 patients with scrub typhus and 130 controls. Three factors were associated significantly with the risk of developing scrub typhus: engaging in fruit farming (OR 2.44; 95% CI 1.04-5.69), gathering chestnuts (OR 2.05; 95% CI 1.09-3.87) and taking breaks in areas adjacent to agricultural operations (OR 3.06; 95% CI 1.50-6.22). In contrast, receiving information or educational materials concerning the prevention of scrub typhus had a protective effect (OR 0.45; 95% CI 0.24-0.83). These results suggest that a health education programme will lower the risk of developing scrub typhus when applied to high-risk groups.

Mutation in the edd gene encoding the 6-phosphogluconate dehydratase of Pseudomonas chlororaphis O6 impairs root colonization and is correlated with reduced induction of systemic resistance

AIMS

The primary objective of this study was to determine the role of 6-phosphogluconate dehydratase in root colonization and the induction of systemic resistance by the rhizobacterium, Pseudomonas chlororaphis O6.

METHODS AND RESULTS

The edd gene encoding for 6-phosphogluconate dehydratase, which is one of the key enzymes in glucose utilization, was cloned. Transcription of the gene was higher in medium containing sugars than with organic acids. An edd mutant failed to grow on glucose but grew on organic acids. The edd mutant colonized tobacco roots at wild-type levels early after inoculation, but levels were lower by 12 days. The edd mutant failed to induce the systemic resistance in tobacco to a soft-rot pathogen at wild-type level.

CONCLUSIONS

6-Phosphogluconate dehydratase in P. chlororaphis O6 contributes to root colonization and induction of systemic resistance presumably as the consequence of its essential role in the Entner-Doudoroff (ED) pathway.

SIGNIFICANCE AND IMPACT OF THE STUDY

Metabolism of sugars through the ED pathway in P. chlororaphis O6 may be important because it facilitates the production of inducers of systemic resistance including butanediol.

Simulation and sensitivity analysis of phosphorylation of EGFR signal transduction pathway in PC12 cell model

The epidermal growth factor receptor (EGFR) signalling pathway is a complex signalling process with a wide network of interactions. The activation of the mitogen-activated protein kinases (MAPKs) cascade by this activated EGFR has been well studied. MAPKs form a highly integrated network, which is essential for certain specialised cell functions. This paper presents a kinetic model for the MAPK pathway downstream of the EGFR using a biochemical simulator. The model includes 30 signalling events and 29 signalling molecules. The time course data were examined for the activation of each signalling component. The simulation provides a large volume of data, by monitoring the kinetics of the signalling components, which were compared experimentally using the PC12 cell line. The kinetic model corresponded well with the experimental results observed in the EGFR induced activation of proteins. An examination of the kinetic analysis of the multiple signalling events provides a quantitative framework for representing the EGFR signalling network.

Association of aortic plaque with intracranial atherosclerosis in patients with stroke

OBJECTIVE

To determine whether there is a relationship between aortic plaques and intracranial (IC) atherosclerosis.

METHODS

We reviewed 922 patients with stroke who had both transesophageal echocardiography and cerebral angiography. The plaques of these patients were classified as either complex aortic plaques (CAP), which protruded > or =4 mm or were present as mobile lesions in the proximal aorta, or simple aortic plaques (SAP), which were <4 mm or present in the descending aorta. Cerebral artery atherosclerosis was classified as either an IC or extracranial (EC) atherosclerosis.

RESULTS

Among the 922 patients, we found aortic plaques in 237 patients (26%). There were 111 (47%) patients of SAP, 74 (31%) patients with CAP, and 52 (22%) patients that had both SAP and CAP. Angiography showed IC or EC atherosclerosis in 511 patients (55%). The presence of aortic plaques was significantly associated with IC or EC atherosclerosis. The significance appeared to be due to the strong association between the presence of SAP and IC atherosclerosis (51% SAP vs 35% no plaques; odds ratio = 1.94, 95% CI: 1.17 to 3.21). In the multiple logistic regression analysis, SAP were independent predictors of IC atherosclerosis

CONCLUSIONS

The presence of simple aortic plaques may be a marker of advanced vascular disease. Detection of simple aortic plaques during transesophageal echocardiography may have clinical implications because patients with these plaques frequently had concomitant intracranial atherosclerosis, a risk factor for stroke.

Yonsei Stroke Registry. Analysis of 1,000 patients with acute cerebral infarctions

BACKGROUND AND PURPOSE

The hospital-based stroke registry is a well-established method useful for understanding diverse clinical characteristics of stroke related to geographical, racial or environmental differences. We analyzed the data from 1,000 patients with acute cerebral infarctions registered with the Yonsei Stroke Registry (YSR) which is the first prospective hospital-based observational study in Korea.

METHODS

All patients had cerebral infarctions and presented within 7 days of onset. CT or MRI was performed in all patients and a vascular imaging study (digital subtraction or magnetic resonance angiography) was conducted in 53.9% of the patients. Subtype classification was made through a consensus approach based on the strict application of TOAST criteria.

RESULTS

The mean age of patients was 62 +/- 12 years, and 60.8% were males. Undetermined cause (UD) was the most frequent subtype (40.6%), which was followed by lacunar stroke (LS 21.5%), cardiac embolism (CE 18.3%), large-artery atherosclerosis (LAA 16.5%) and other determined causes (3.1%). Hypertension was found in 64.3%, smoking in 35.2%, diabetes mellitus in 26.9%, hypercholesterolemia in 24.1%, high hematocrit (> or = 50%) in 21.8%, clinically identified potential cardiac sources of embolism in 18.3%, a history of previous stroke in 22.0% and a history of previous transient ischemic attack in 4.7%. Recurrent stroke was associated with a higher number of risk factors (p < 0.001) and a higher incidence of LAA (p = 0.003) than the first stroke. Vertebrobasilar artery territorial infarction was found in 39.8%, which was associated with higher incidences of LAA and LS and a lower incidence of CE than carotid artery territorial lesions (p = 0.001). The 30-day mortality rate was 5.3% and cerebral herniation caused early death in 52%.

CONCLUSION

The distribution of stroke subtypes in the YSR was largely comparable with that of western registries. The highest incidence of UD might be related to the strict application of TOAST criteria.

Competitive immunoassay for recombinant hirudin using capillary electrophoresis with laser-induced fluorescence detection

A competitive immunoassay based on capillary electrophoresis (CE) with laser-induced fluorescence (LIF) has been developed for the determination of recombinant hirudin (r-hirudin) in biological mixtures. Hirudin, a thrombin inhibitor, is a polypeptide of 65 amino acids. To check purity levels and perform pharmacokinetic studies of (r-hirudin), specific and reproducible analysis methods are demanded. The work involved the development of separation conditions allowing for routine analysis of plasma samples. In this study, r-hirudin was labeled with fluorescein isothiocyanate (FITC), and FITC-labeled r-hirudin was purified using high-performance liquid chromatography. The purified product was then mixed with the sample followed with the addition of anti-hirudin antibody. Free, antibody-bound, and tagged r-hirudin could be separated within 5 min by CE analysis using uncoated fused-silica capillary with high reproducibility. The developed method can be used to determine r-hirudin with good precision and a detection limit lower than 20 nM. This result demonstrates the feasibility of the CE-LIF immunoassay method for the determination of r-hirudin in plasma samples.

Altered expression of the fragile histidine triad gene in primary gastric adenocarcinomas

Genomic alterations and abnormal expression of the fragile histidine triad (FHIT) gene in gastric carcinomas were examined to determine whether the FHIT gene is actually a frequent target for alteration during gastric carcinogenesis. To correlate DNA and RNA lesions of the FHIT gene with the effect on FHIT protein expression, we have investigated the FHIT gene for loss of heterozygosity (LOH), aberrant transcripts, point mutations, and protein expression in 35 gastric adenocarcinomas. Allelic loss at D3S1300 was detected in 7 of 33 (21%) informative cases. Aberrant transcripts, with deletions and/or insertions, were observed in 20 of 35 (57.1%) cases and resulted from alternative splicing through exon skipping and/or insertion of the FHIT intron 5 sequence or activation of the cryptic splice site. Point mutations were not found in the FHIT coding region but detected in noncoding exon 2, 3, 4, or 5 of eight aberrant transcripts. Significant reduction of FHIT protein expression was observed in 22 of 35 (62.9%) cases. Aberrant FHIT transcription was shown to be associated with loss of FHIT protein expression. However, aberrant FHIT transcripts themselves were not associated with any clinicopathological parameters, such as age, sex, tumor site, or clinical stage. Moreover, there was no association between the presence of LOH at D3S1300 and the expression of aberrant FHIT transcripts. Nevertheless, high frequency of aberrant FHIT transcripts, significant rate of LOH at D3S1300, and altered expression of the FHIT protein indicate that alterations of the FHIT gene can play an important role in gastric carcinogenesis.

Prevalence of arthropod antibodies in Korean patients with allergic rhinitis

Arthropod antigens are main causative agents which induce allergic responses in humans. However, little information is known about the prevalence of specific arthropod allergens in Koreans with allergic diseases. The current study was designed to determine the positive rates of arthropod antibodies by the Korean inhalant panel of MAST-CLA. One hundred sixty patients, who were diagnosed with allergic rhinitis from an out-patient center at the Soonchunhyang University Chunan Hospital, were studied between August 1998 to July 2000. The overall positive rate, at least more than one specific antibody of arthropods such as Dermatophagoides farinae (Df), Dermatophagoides pteronyssinus (Dp), and cockroach mix (Cm), was 46.9%. Each positive rate of Df, Dp, and Cm was 45.0%, 43.1%, and 8.8%, respectively. A significant agreement among arthropod allergens was observed (Df and Dp: 95.6%, Kappa = 0.911, P < 0.001). Our data supported the fact that arthropods were the most common allergens in Korean patients with allergic rhinitis; however, the MAST-CLA should be modified to increase specificity of arthropod allergens.

His-His-Leu, an angiotensin I converting enzyme inhibitory peptide derived from Korean soybean paste, exerts antihypertensive activity in vivo

It has been reported that soybean peptide fractions isolated from Korean fermented soybean paste exert angiotensin I converting enzyme (ACE) inhibitory activity in vitro. In this study, further purification and identification of the most active fraction inhibiting ACE activity were performed, and its antihypertensive activity in vivo was confirmed. Subsequently, a novel ACE inhibitory peptide was isolated by preparative HPLC. The amino acid sequence of the isolated peptide was identified as His-His-Leu (HHL) by Edman degradation. The IC(50) value of the HHL for ACE activity was 2.2 microg/mL in vitro. Moreover, the synthetic tripeptide HHL (spHHL) resulted in a significant decrease of ACE activity in the aorta and led to lowered systolic blood pressure (SBP) in spontaneously hypertensive (SH) rats compared to control. Triple injections of spHHL, 5 mg/kg of body weight/injection resulted in a significant decrease of SBP by 61 mmHg (p < 0.01) after the third injection. These results demonstrated that the ACE inhibitory peptide HHL derived from Korean fermented soybean paste exerted antihypertensive activity in vivo.

Aroma extract dilution analysis of a beeflike process flavor from extruded enzyme-hydrolyzed soybean protein

Aroma-active compounds from a beeflike process flavor, produced by extrusion of enzyme-hydrolyzed vegetable protein (E-HVP), were analyzed using aroma extract dilution analysis. The number of aroma-active compounds and the aroma intensity were increased by the addition of aroma precursors prior to extrusion. The most intense compound was 2-methyl-3-furanthiol having a cooked rice/vitamin-like/meaty aroma note. Several sulfur-containing furans, such as 2-methyl-3-(methylthio)furan, 2-methyl-3-(methyldithio)furan, and bis(2-methylfuryl)disulfide, were detected with high flavor dilution (FD) factors. Some pyrazines, such as 2-ethyl-3,5-dimethylpyrazine, 2,6-diethylpyrazine, and 3,5-diethyl-2-methylpyrazine, also had high FD factors. It is hypothesized that sulfur-containing amino acids and thiamin were important precursors in aroma formation in process flavor from E-HVP.

MRI features of infarcts with potential cardiac source of embolism in the Yonsei Stroke Registry (YSR), Korea

The determination of the embolic source is crucial to understanding the pathogenesis of ischemic stroke, the initiation of appropriate therapy, and the prevention of recurrent infarctions. In this study we undertook to identify the characteristic features on magnetic resonance images of patients who had suffered from stroke due to cardiac embolism (CE), as classified by TOAST (possible and probable). We retrospectively studied magnetic resonance imaging (MRI) findings of patients with ischemic stroke from the Yonsei Stroke Registry (YSR). On the basis of the TOAST classification, 92 patients were identified to have a potential cardiac source of embolism (PCSE), in which 69 patients were found to have high-risk PCSE and 23 patients medium-risk PCSE. To compare their imaging characteristics, another group of 49 patients who were found to have had a stroke due to large artery-to-artery (ATA) embolism-common or internal carotid artery (CCA, ICA)-were identified. Involvement of the simultaneous superficial and deep territories (58.7%; 6.1%, p < 0.001), and combined new anterior and old posterior circulation (15.2%; 2.0%, p = 0.016) were more frequent in PCSE than ATA embolism. Bilateral anterior hemispheric involvement was also more frequent in the PCSE group, but it did not reach statistical significance (13.0%; 4.1%, p = 0.090). ATA embolism tended to involve only superficial territories compared to PCSE (71.4%; 28.3%, p < 0.001). There were no topographic differences between the high-risk and medium-risk groups. With respect to the etiology of PCSE in our population, atrial fibrillation was the most common. Characteristic MRI features of patients with PCSE, which were not documented previously by computed tomography (CT) included: old and new, involvement of multiple different vascular territories, bilateral anterior hemisphere, as well as anterior and posterior circulation. These MRI features, together with simultaneous superficial and deep territorial involvement, help to differentiate the underlying embolic sources, whether they are cardiac or ATA in origin.

Infection status with trematode metacercariae in pond smelts, Hypomesus olidus

Many Koreans usually eat raw pond smelts, Hypomesus olidus, in the winter. This study was performed to evaluate the infection status with trematode metacercariae in pond smelts from January 1998 through February 1999. Among 1,305 fish collected, 459 were purchased from wholesale dealers in Chinchon-gun, Chungchongbuk-do, and the rest of them were caught with a casting net in Soyangho (Lake), Taehoman (Bay) and Paekkokchosuchi (Pond). Seven species of trematode metacercariae including two unidentified ones were detected from 1,305 pond smelts. The number of detected trematode metacercariae according to the species are as follow: Clonorchis sinensis 8, Holostephanus nipponicus 7, Cyathocotyle orientalis 24, Diplostomum sp. 14, and Metorchis orientalis 7. From the above results, it was confirmed that H. olidus plays a role as the second intermediate host of some kinds of trematode including C. sinensis in Korea. Our report shows possible clonorchiasis caused by eating raw pond smelts.

Serial brain SPECT images in a case of Sydenham chorea

BACKGROUND

The pathophysiological nature of Sydenham chorea (SC) has been presumed to be an autoimmune-mediated inflammatory process. Positron emission tomography in SC has revealed a striatal hypermetabolism that might explain the transient neuronal dysfunction. However, any focal hyperperfusion in the striatum or its related structures has not been demonstrated in previous single photon emission computed tomographic (SPECT) imaging studies, which raised a concern about the pathogenesis of the striatal hypermetabolism.

OBJECTIVE

To investigate the cerebral perfusion patterns of the subcortical structures by using serial technetium Tc 99m-ethyl cysteinate dimer SPECT in a case of SC, which may provide a clue for the pathophysiological mechanisms.

DESIGN

A case report and serial SPECT studies.

CASE PRESENTATION

A girl aged 4 years 3 months showed severe generalized choreic movements with concomitant signs of acute pharyngitis. Results of a laboratory study taken 7 days after the onset of chorea showed elevated antistreptolysin O titer, C-reactive protein levels, and erythrocyte sedimentation rate. Other laboratory data, throat culture, echocardiography, brain magnetic resonance imaging, and electroencephalography did not reveal any abnormalities. Five days after treatment with haloperidol and penicillin, the chorea began to improve slowly, and completely resolved in 2 months.

RESULTS

Three serial SPECT images and semiquantitative analysis of cerebral perfusion were obtained. Cerebral perfusion in the striatum and thalamus was markedly increased bilaterally during the stage of active chorea and then returned nearly to its baseline level during the convalescent phase. These cerebral perfusion patterns were concordant with semiquantitative analysis.

CONCLUSIONS

Hyperperfusion in both the striatum and thalamus in our patient may reflect the subcortical inflammatory processes in SC. The unequivocal SPECT findings in our patient are difficult to reconcile with the negative findings of previous SPECT studies but may suggest the heterogeneity of the perfusion patterns in SC.

Heterodimeric aminopeptidase A from Bacillus licheniformis NS115

An aminopeptidase A (EC 3.4.11.7) was purified to homogeneity from Bacillus licheniformis NS115 and its enzymatic properties were characterized. The enzyme had an apparent molecular mass of 64 kDa, consisting of heterodimeric 42 kDa and 22 kDa subunits, and is a new enzyme from N-terminal analysis of heavy and light subunits. The light subunit had no catalytic activity against the substrate and apparent K(m) values of heavy and whole enzyme were 0.26 and 0.087 mM of gamma-glutamyl-p-nitroanilide, respectively.

New scoring system using tumor markers in diagnosing patients with moderate pericardial effusions

We performed diagnostic and therapeutic pericardiostomy with drainage and biopsy in 51 patients with moderate to large pericardial effusions of different etiologies from August 1991 to July 1995. Patients were divided into 4 groups (group 1, tuberculous pericarditis; group 2, suspected tuberculous pericarditis; group 3, acute pericarditis; group 4, malignancy). The pericardial fluid adenosine deaminase level in tuberculosis (87 +/- 10 U/l) was significantly higher than that in malignancy or acute pericarditis (21 +/- 4 U/l, 23 +/- 7 U/l, respectively) (P = 0.0001). The mean pericardial fluid carcinoembryonic antigen level (1.8 +/- 0.3 ng/ml) in benign disease was significantly lower than that (170.7 +/- 46.4 ng/ml) in malignant disease (P = 0.0001). Follow-up study has been done. With a new scoring system (each score 1 for adenosine deaminase > or = 40 U/l, or carcinoembryonic antigen < or = 5 ng/ml) in 25 patients since November 1993, we could diagnose 5 among 7 patients (71%) with tuberculosis, 11 among 13 patients (85%) with malignancy (adenosine deaminase < or = 40 U/l, or carcinoembryonic antigen > or = 5 ng/ml) and 5 among 5 patients (100%) with acute pericarditis (adenosine deaminase < or = 40 U/l, or carcinoembryonic antigen < or = 5 ng/ml), respectively. Our long-term follow-up study suggests that with the new scoring system we can decrease complications or avoid unnecessary procedures or treatments of patients.

[ELISA of rat sera infected with Paragonimus iloktsuenensis]

Enzyme-linked immunosorbent assay (ELISA) of paragonimiasis iloktsuenensis rat sera was performed using crude antigens of Paragonimus iloktsuenensis (PIA), P. westermani (PWA) and Clonorchis sinensis (CSA). Three crude antigens (PIA, PWA, CSA) were prepared to saline homogenated supernatants of whole adult worms. Infected rat sera were obtained biweekly from the albino rats fed 50-80 metacercariae of P. iloktsuenensis through gastric catheter. Experimental groups were divided into 4 groups: GI (controls), GII, GIII and GIV according to 1-7 worms as GII, 10-19 worms as GIII and 22-40 worms as GIV, respectively. In ELISA, the mean OD values of each group for the homologous antigen (PIA) were increased significantly compared to the control sera at the 4th week of infection. With the progress of duration of infection, the mean OD values of infected sera of GII & GIV continuously increased up to the 12th week (last week), but in GIII the mean OD value increased until the 10th week. No significance was noted among the infection dose groups (GII, GIII and GIV), after the 6th week of infection. Also, the OD values of all infected rats did not show any proportional relationships to the number of worms recovered. In brief, the antibody productivity of individual rats were strongly different. The rat sera infected with P. iloktsuenensis cross-reacted with those infected with P. westermani or C. sinensis, as identified by OD values.