It has been reported that embolic signal (ES) detected by transcranial Doppler (TCD) has clinical significance, especially in patients with recent stroke attributable to arterial or cardiac embolism. Therefore, we conducted this study to determine whether the prevalence of ES is high in ischemic stroke patients with cancer and related to hypercoagulopathy.We prospectively studied cancer patients with acute ischemic stroke within the middle cerebral artery (MCA) distribution on diffusion-weighted imaging. Conventional stroke mechanisms (CSMs) were determined using cardiologic and vascular studies. Additionally, the coagulation status was assessed based on the serum D-dimer levels, and TCD monitoring was performed on both MCAs for 30 minutes to detect ES. Clinical features including vascular risk factors, characteristics of ischemic stroke, and cancer and laboratory findings associated with the presence of ES were evaluated.A total of 74 patients were finally included in this study. ES was more commonly observed in patients without CSMs (22 of 38 patients, 57.9%) than in those with CSMs (12 of 36 patients, 33.3%) (p = 0.034). Moreover, ES was more commonly detected in patients with high D-dimer levels (p < 0.001), and D-dimer levels were significantly correlated with the number of ESs in patients without CSMs (r = 0.732, p < 0.001), but were poorly correlated in patients with CSMs (r = 0.152, p = 0.375). Higher levels of D-dimer (odds ratio [OR], 1.082 per 1 microg/ml increase; 95% confidence interval [CI], 1.014-1.154) and adenocarcinoma (OR, 3.829; 95% CI, 1.23-13.052) were independently associated with the presence of ES. The use of anticoagulants dramatically decreased the D-dimer levels.A high prevalence of ES was observed in cancer patients with ischemic stroke, especially in those without CSMs. Elevated D-dimer levels were independently associated with ES, and decreased dramatically with the use of anticoagulants. ANN NEUROL 2010;68:213-219.
Intravenous thrombolysis for acute ischemic stroke has been investigated in several clinical trials without enough information on collateral blood flow and perfusion deficit in the ischemic areas. The therapeutic time window varies from patient to patient depending on these factors. Triphasic perfusion computed tomography (TPCT) can provide this information as reliably as conventional angiography.To assess the safety and efficacy of thrombolysis within 3 or 7 hours of stroke onset according to the extent of perfusion deficit on TPCT.In 46 patients with acute middle cerebral artery (MCA) territory stroke, TPCT was performed with power injector-controlled, intravenous administration of contrast media after taking precontrast CT scans. Sequential scans of early, middle, and late phases were performed. The entire procedure took 5 minutes. Depending on collateral blood flow, the perfusion deficit on TPCT was graded as "severe perfusion deficit" or "moderate perfusion deficit." Twenty-nine patients were excluded based on clinical, laboratory, and TPCT findings. Seventeen patients were treated with an intravenous recombinant tissue-type plasminogen activator, 0.9 mg/kg. The 17 treated patients were divided into 2 groups: group 1 with small severe perfusion deficit (33% but
Patients with active cancer are at an increased risk for stroke. Hypercoagulability plays an important role in cancer-related stroke. We aimed to test whether 1) hypercoagulability is a predictor of survival, and 2) correction of the hypercoagulable state leads to better survival in patients with stroke and active cancer.We recruited consecutive patients with acute ischemic stroke and active systemic cancer between January 2006 and July 2015. Hypercoagulability was assessed using plasma D-dimer levels before and after 7 days of anticoagulation treatment. The study outcomes included overall and 1-year survival. Plasma D-dimer levels before and after treatment were tested in univariate and multivariate Cox regression models. We controlled for systemic metastasis, stroke mechanism, age, stroke severity, primary cancer type, histology, and atrial fibrillation using the forward stepwise method.A total of 268 patients were included in the analysis. Patients with high (3rd-4th quartiles) pre-treatment plasma D-dimer levels showed decreased overall and 1-year survival (adjusted HR, 2.19 [95% CI, 1.46-3.31] and 2.70 [1.68-4.35], respectively). After anticoagulation treatment, post-treatment D-dimer level was significantly reduced and independently associated with poor 1-year survival (adjusted HR, 1.03 [95% CI, 1.01-1.05] per 1 μg/mL increase, P=0.015). The successful correction of hypercoagulability was a protective factor for 1-year survival (adjusted HR 0.26 [CI 0.10-0.68], P=0.006).Hypercoagulability is associated with poor survival after stroke in patients with active cancer. Effective correction of hypercoagulability may play a protective role for survival in these patients.
Objectives : The aim of this study is to evaluate the effect of Paljeong-san pharmacopuncture(PJS) on the rat model of benign prostatic hyperplasia(BPH). Methods : Rats were divided into 5 groups, with 6 rats in each group. The 5 groups included sham-operated group(sham group), BPH model group(BPH group), finasteride-treated group (fina group), PJS-treated groups(PJS 10 and PJS 100 group). Testosterone was injected subcutaneously to the castrated rats except sham group for BPH model. During 4-week experimental period, finasteride(5 mg/kg) was administrated orally once daily in fina group, PJS in PJS 10(10 mg/kg) and PJS 100(100 mg/kg) group and normal saline in sham and BPH group were injected subcutaneously once daily at Jungwan(CV12). We checked prostate weights, serum concentration of dihydrotestosterone(DHT), morphologic changes of the prostate, and the amount of expression of the proliferating cell nuclear antigen(PCNA) and 5α-reductase gene to evaluate the effect of PJS after 4-week experimental period. Results : 1. PJS and finasteride treatment reduced prostate weights comparing with BPH group, but PJS-treated groups showed no significant changes, unlikely fina group. 2. PJS-treated groups showed significant degreases in concentration of DHT. 3. PJS-treated groups showed significant degreases concentration-dependently in the amount of expression of the PCNA and 5α-reductase gene. 4. PJS treatment showed shrinking of thickness in the prostatic epithelial tissue. Conclusions : PJS has the effects that improve the symptoms of BPH through inhibiting proliferation of the prostatic tissues.
Due to the global warming and air pollution, interest in renewable energies has increased in recent years. In particular, the crisis of the depletion of fossil energy resources in the near future has accelerated the renewable energy technologies. Among the renewable energy resources, oceans covering almost three-fourths of earth's surface have an enormous amount of energy. For this reason, various approaches have been made to harness the tremendous energy potential. In order to achieve two purposes: to improve harbor water quality and to use wave energy, this study proposed a sea water exchange structure applying an Oscillating Water Column (OWC) wave generation system that utilizes the air flow velocity induced by the vertical motion of water column in the air chamber as a driving force of turbine. In particular, the airflow velocity in the air chamber was estimated from the time variations of water surface profile computed by using 3D-NIT model based on the 3-dimensional irregular numerical wave tank. The relationship of the frequency spectrums between the computed airflow velocities and the incident waves was analyzed. This study also discussed the characteristics of frequency spectrums in the air chamber according to the presence of the structure, wave deformations by the structure, and the power of the water and air flows were also investigated. It is found that the phase difference exists in the time series data of water level fluctuations and air flow in the air chamber and the air flow power is superior to the fluid flow power. 핵심용어: Oscillating Water Column (OWC) wave generation system, water exchange, 3D-NIT model, airflow, water level fluctuation, 진동수주형 파력발전시스템, 해수교환, 3D-NIT모델, 공기흐름, 수위변동
Thyroid storm is characterized by rapidly increased circulation of T3, T4, or both with worsened hyperthyroidism, hyperthermia, tachycardia, and hypertension. Although many case reports have been presented on thyroid storm, which occurs during surgery [1], case reports on thyroid storm that occurs prior to the induction of anesthesia are rare [2]. We present a case where a patient underwent a thyroid storm during anesthesia induction, even though she had neither a history of hyperthyroidism, nor abnormal findings in the preoperative evaluation.
A 50 year-old female patient (height 156 cm, weight 59 kg) was diagnosed with a humerus fracture, and was, therefore, admitted for an open reduction and internal fixation. The examination findings upon being admitted were normal. Preoperative electrocardiogram showed tachycardia with a heart rate of 90-100 beats/min. Her past history showed no diagnosis of hypertension, diabetes mellitus, or thyroid disease. However, the patient had experienced 6 kg weight loss, intermittent palpitation, and hand tremors for the past 1 year. There were no abnormal laboratory findings. The patient had no history of past surgeries or experience with anesthesia.
Upon arriving on the operating table, her blood pressure was 125/85 mmHg, body temperature was 36.5℃ and her heart rate was about 90-100 beats/min. She did not complain of anxiety or discomfort. The patient did not receive premedication in the ward. While performing ECG and pulse oximetry monitoring, glycopyrrolate 0.2 mg was intravenously administered before general anesthesia induction. After injection of glycopyrrolate, her blood pressure increased from 120/80 mmHg to 200-220/110 mmHg, her heart rate also elevated from 100 beats/min to 170-190 beats/min, and a severe diaphoresis was observed. Respiration also weakened, and the patient was losing consciousness. Therefore, 100% oxygen was administered and assisted ventilation was performed, followed by an endotracheal intubation without muscle relaxants. Her body temperature increased to 39℃. At first, we suspected malignant hyperthermia. To reduce body temperature, ice packs were applied on the neck, axillar, and groin sites, and cooled lactated Ringer's solution was infused. Esmolol and labetalol were, intravenously, administered to reduce high blood pressure. In the pulse oxymetry, oxygen saturation was maintained at 97-100%. The end-tidal carbon dioxide level was maintained at around 40 mmHg. Physical examination showed no findings of muscle rigidity, including in the masseter muscle. We finally made an impression of the thyroid storm. After a 40 minute adjustment of blood pressure and heart rate, with labetalol and esmolol, the patient's consciousness returned and blood pressure was stable at 110-130/80-90 mmHg. The patient's body temperature stabilized at around 37.5℃.
The surgery was postponed. A thyroid hormone test showed TSH 6.64 ng/ml (normal: 0.60-1.81 ng/ml), and free T4 5.48 ng/dl (normal: 0.83-1.76 ng/dl). Anti-thyroid antibodies, thyroglobulin in Ab, were 1,116 IU/ml (normal < 115 IU/ml). These patterns corresponded to a thyroid storm. Anti-thyroid antibodies were positive and Graves' disease was confirmed with a thyroid function test. Thus, antithyroid drug, methimazole was administered to the patient. Euthyroid state was achieved and the patient received operation for humerus fracture after 1 month later.
In the past, thyroid surgery was the most common cause of thyroid storm and when a thyroid storm occurs with surgery, it commonly occurs 6-18 hr post-surgery [3,4]. However, recent preoperative medication creates a euthyroid state before performing surgery, although its occurrence is low [3]. The clinical sign of the thyroid storm, due to the abrupt release of T4 and T3 into the circulation. In this case, T3 and T4 levels abruptly increased. When surgery is performed, without the awareness of the patient having hyperthyroidism, the likelihood of a thyroid storm occurrence increases. To reduce the occurrence of thyroid storm, adequate premedication is needed, when performing anesthesia. Barbiturates or benzodiazepines should be administered to adequately sedate the patient. Anticholinergic drugs, especially atropine, are usually not administered because atropine deter the normal heat control mechanism and cause tachycardia.
In this case, the electrocardiogram from 6 months prior showed a heart rate of 70-80 beats/min, and in the tests after the patient was admitted into the hospital, the blood pressure was normal, the body temperature was 36.5℃, and the electrolytes test and blood test appeared normal. Therefore, the surgery was expected to be uneventful. However, the preoperative electrocardiogram showed tachycardia of 90-100 beats/min. Although the patient had no past history of a thyroid disease, it was confirmed that in the past 1 year, the patient had experienced a 6 kg weight loss, intermittent palpitation, and hand tremors. Therefore, although hyperthyroidism was not diagnosed, if there had been more appropriate history-taking, hyperthyroidism could have been suspected.
There has not been a case report of considering glycopyrrolate, as an etiologic factor of thyroid storm. Psychological stress, among many other initiating factors, is considered to have another significant role in causing the thyroid storm. Even though the patient's heart rate was 90-100 beats/min on the operating table, the administration of glycopyrrolate, without premedication in the general ward, was not appropriate because it is an anticholinergic drug, which further increases the heart rate by stimulating the sympathetic nervous system. In conclusion, if abnormal findings, such as tachycardia, weight loss, and tremors are found, or if hyperthyroidism is suspected even though a patient does not have a history of hyperthyroidism, a preoperative thyroid function test should be performed. Also, an anesthesiologist should consider potential thyroid storm, due to intravenous glycopyrrolate administration in patient with hyperthyroidism or hyperthyroidism like symptoms.
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