High Levels of Remnant Lipoprotein Cholesterol Is a Risk Factor for Large Artery Atherosclerotic Stroke

Background and Purpose

Remnant lipoproteins (RLPs) are products of partially catabolized chylomicrons and very-low-density lipoprotein, from which some triglycerides have been removed. These particles are smaller and denser than the parent particles and are believed to be strongly atherogenic. We explored the association between RLP cholesterol (RLP-C) and ischemic stroke, including stroke subtypes.

Methods

A cohort of 142 ischemic stroke patients (90 men and 52 women; age, 65.2±12.8 years, mean±SD) was enrolled; all had acute infarcts confirmed by diffusion-weighted MRI, and had fasting lipograms. A full stroke-related evaluation was conducted on each patient. An outpatient population of 88 subjects without a history of cerebrovascular or cardiovascular disease served as a control group. Serum RLP fractions were isolated using an immunoaffinity gel containing specific antiapolipoprotein (anti-apo)B-100 and anti-apoA-I antibodies. RLP-C values were considered to be high when they were in the highest quartile of all values in the study.

Results

High RLP-C values were more common in stroke patients than in control patients (31.0% vs. 14.8%, p=0.01), when 5.6 mg/dL (>75th percentile) was used as the cutoff value. Multivariable analyses indicated that RLP-C was a risk factor for stroke, with an odds ratio of 2.54 (p=0.045). The RLP-C level was higher in the large artery atherosclerosis subgroup (5.7±3.9 mg/dL) than in any other stroke subgroup (small vessel occlusion, 4.9±5.9 mg/dL; cardioembolism, 1.8±2.3 mg/dL; stroke of undetermined etiology, 3.1±2.9 mg/dL).

Conclusions

We have found an association between high RLP-C levels and ischemic stroke, and in particular large artery atherosclerotic stroke.     

A randomized controlled clinical trial to compare the safety and efficacy of edaravone in acute ischemic stroke

Background and Objective:

Edaravone has potent antioxidant and free radical scavenger properties. Few Japanese studies had demonstrated its neuroprotective role in acute ischemic stroke (AIS). This study aims to evaluate the efficacy of edaravone in terms of functional outcome in a group of Indian patients of AIS.

Materials and Methods:

Fifty patients of AIS were randomly divided into two groups. The study group received 30 mg of edaravone twice daily for 14 days by infusion, while control group received normal saline infusion as placebo. Outcome assessment was done by the Modified Rankin Scale (MRS). MRS score ≤2 at 90 days was considered as a favorable outcome.

Results:

Of 25 patients, 18 (72%) had favorable outcomes (MRS ≤2) at 90 days in edaravone group, while 10 (40%) of 25 patients in placebo group had favorable outcome (P < 0.005). Two patients expired (one in each group) during treatment. The mean Barthel index increased from 41.20 ± 32.70 at baseline to 82.40 ± 18.32 at day 90 in edaravone group as compared with placebo group in which scores were 44.20 ± 22.76 at baseline and 68.20 ± 21.30 at day 90 (P < 0.005).

Conclusions:

We therefore conclude that edaravone effectively improves functional outcome in AIS.     

Transferrin in korean children with attention deficit hyperactivity disorder

Objective

The aim of the present study was to investigate the relationship between iron, ferritin, transferrin, total iron binding capacity (TIBC), hemoglobin, mean corpuscular volume (MCV) mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) in children with ADHD.

Methods

MethodsaaThe sample consisted of 48 ADHD children and sex and age matched control children (a couple of 28 boys, 22 girls; age 6-8 years; mean±SD, 6.98±0.39). We diagnosed ADHD according to DSM-IV. ADHD symptoms were evaluated subjectively with Conners'' Parent Rating Scales, Dupaul Parent ADHD Rating Scales. Subjects with ADHD and control were evaluated the hematology test including the iron, transferrin, MCV etc. Paired t test were used to evaluate the relation of a lot of hematology findings between ADHD and control group.

Results

The serum iron, ferritin, transferrin, TIBC, hemoglobin, MCV, MCH, and MCHC of ADHD group were respectively 80.92±33.33 ug/dL, 35.81±16.59 ng/mL, 248.42±44.15 mg/dL, 351.69±102.13 ug/dL, 12.78±0.71 g/dL, 82.94±2.58 fL, 27.18±1.12 uug, 32.79±1.12%. Otherwise the serum iron, ferritin, transferrin, TIBC, hemoglobin, MCV, MCH, and MCHC of control group were respectively 82.04±28.14 ug/dL, 37.05±18.28 ng/mL, 266.27±25.40 mg/dL, 352.77±89.54 ug/dL, 12.77±0.70 g/dL, 81.81±2.96 fL, 26.69±0.99 uug, 32.66±0.96%. A significant difference were found in the transferrin(t=2.63, p=0.011), MCV (t=2.19, p=0.034), and MCH (t=2.18, p=0.034).

Conclusion

These results suggested that lower transferrin levels might be related with ADHD symptoms.     

Neuroprotective Effect of Anthocyanin on Experimental Traumatic Spinal Cord Injury

Objective

We investigated the neuroprotective effect of anthocyanin, oxygen radical scavenger extracted from raspberries, after traumatic spinal cord injury (SCI) in rats.

Methods

The animals were divided into two groups : the vehicle-treated group (control group, n=20) received an oral administration of normal saline via stomach intubation immediately after SCI, and the anthocyanin-treated group (AT group, n=20) received 400 mg/kg of cyanidin 3-O-β-glucoside (C3G) in the same way. We compared the neurological functions, superoxide expressions and lesion volumes in two groups.

Results

At 14 days after SCI, the AT group showed significant improvement of the BBB score by 16.7±3.4%, platform hang by 40.0±9.1% and hind foot bar grab by 30.8±8.4% (p<0.05 in all outcomes). The degree of superoxide expression, represented by the ratio of red fluorescence intensity, was significantly lower in the AT group (0.98±0.38) than the control group (1.34±0.24) (p<0.05). The lesion volume in lesion periphery was 32.1±2.4 µL in the control and 24.5±2.3 µL in the AT group, respectively (p<0.05), and the motor neuron cell number of the anterior horn in lesion periphery was 8.3±5.1 cells/HPF in the control and 13.4±6.3 cells/HPF in the AT group, respectively (p<0.05).

Conclusion

Anthocyanin seemed to reduce lesion volume and neuronal loss by its antioxidant effect and these resulted in improved functional recovery.     

Normobaric oxygen therapy in acute ischemic stroke: A pilot study in Indian patients

Purpose:

Clinical and radiological assessment of effects of normobaric high-flow oxygen therapy in patients with acute ischemic stroke (AIS).

Materials and Methods:

Patients with anterior circulation ischemic strokes presenting within 12 h of onset, ineligible for intravenous thrombolysis, an National Institute of Health Stroke Scale (NIHSS) score of >4, a mean transit time (MTT) lesion larger than diffusion-weighted image (DWI) (perfusiondiffusion mismatch), and an evidence of cortical hypoperfusion on magnetic resonance imaging (MRI) were included into the trial. Active chronic obstructive pulmonary disease (COPD), requirement of >3/L min oxygen delivery to maintain SaO2 > 95%, rapidly improving neurological deficits, pregnancy, contraindications to MRI, or unstable medical conditions were excluded. The experimental group received humidified oxygen at flow rates of 10 L/min for 12 h. The NIHSS, modified Rankin Score (mRS), Barthel Index (BI) were measured at 0, 1, 7 day of admission and at 3 months follow-up. MRI with DWI/PWI was performed at admission, 24 h later and at 3 months follow-up.

Results:

Of 40 patients (mean age = 55.8 years ± 13.2) (range, 26–82), 20 patients were randomized to normobaric oxygen (NBO). The mean NIHSS in NBO and control groups were 14.25 and 12.7 at admission which decreased to 11.6 and 9.5 on the seventh day, and 9.4 and 9.05 at 3 months, respectively. The mean mRS (3.7/3.7) and BI (58.2/53.9) in NBO and control groups improved to 2/2.2 and 73.05/73.8 at the end of 3 months, respectively.

Conclusions:

NBO did not improve the clinical scores of stroke outcome in Indian patients with AIS.     

Time course of inflammatory cytokines in acute ischemic stroke patients and their relation to inter-alfa trypsin inhibitor heavy chain 4 and outcome

Background:

Biomarker for prognosis of stroke is urgently needed for the management of acute ischemic stroke (AIS) patients.

Objective:

To evaluate the course of inflammatory cytokines in AIS patients and its comparison with inter-alfa trypsin inhibitor heavy chain 4 (ITIH4) and outcome after AIS.

Materials and Methods:

A panel of 12 inflammatory cytokines and ITIH4 were estimated in serial blood samples collected at admission, 24 h, 48 h, 72 h, 144 h and at discharge of AIS patients (n = 5).

Results:

Out of the 12 cytokines, only interleukin (IL)-2, tumor necrosis factor-alfa (TNF-α), IL-10, IL-6, IL-1B and IL-8 were in the measurable range of the kit (10 pg/mL). We found high IL-2 at admission, which decreased (P < 0.05) in the follow-up samples. TNF-α initially increases (P < 0.05) at 24 h followed by gradual decrease (P < 0.05) after 72 h. IL-10 decreases initially (P < 0.05) till 72 h as compared with its level at admission and then increases (P < 0.05) after 144 h. Similarly, ITIH4 was down-regulated in the early 72 h followed by further increase with improvement of the patient. ITIH4 correlates with IL-10 and computed tomography scan infarct volume. Serum IL-6, IL-1B and IL-8 increased in the AIS patients, but did not show any pattern.

Conclusions:

Serial measurement of IL-10, IL-2 and TNF-α and ITIH4 may be useful for the follow-up of clinical outcome after AIS.     

Accumulated Mannitol and Aggravated Cerebral Edema in a Rat Model of Middle Cerebral Artery Infarction

Objective

Repeated administration of mannitol in the setting of large hemispheric infarction is a controversial and poorly defined therapeutic intervention. This study was performed to examine the effects of multiple-dose mannitol on a brain edema after large hemispheric infarction.

Methods

A middle cerebral artery was occluded with the rat suture model for 6 hours and reperfused in 22 rats. The rats were randomly assigned to either control (n=10) or the mannitol-treated group (n=12) in which intravenous mannitol infusions (0.8 g/kg) were performed six times every four hours. After staining a brain slice with 2,3,5-triphenyltetrazolium chloride, the weight of hemispheres, infarcted (IH) and contralateral (CH), and the IH/CH weight ratio were examined, and then hemispheric accumulation of mannitol was photometrically evaluated based on formation of NADH catalyzed by mannitol dehydrogenase.

Results

Mannitol administration produced changes in body weight of -7.6±1.1%, increased plasma osmolality to 312±8 mOsm/L. It remarkably increased weight of IH (0.77±0.06 gm versus 0.68±0.03 gm : p<0.01) and the IH/CH weight ratio (1.23±0.07 versus 1.12±0.05 : p<0.01). The photometric absorption at 340 nm of the cerebral tissue in the mannitol-treated group was increased to 0.375±0.071 and 0.239±0.051 in the IH and CH, respectively from 0.167±0.082 and 0.162±0.091 in the IH and CH of the control group (p<0.01).

Conclusion

Multiple-dose mannitol is likely to aggravate cerebral edema due to parenchymal accumulation of mannitol in the infarcted brain tissue.     

Prognostic Value of Serum S100 Protein by Elecsys S100 Immunoassay in Patients with Spontaneous Subarachnoid and Intracerebral Hemorrhages

Objective

The serum S100 protein has been known to reflect the severity of neuronal damage. The purpose of this study was to assess the prognostic value of the serum S100 protein by Elecsys S100 immunoassay in patients with subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) and to establish reference value for this new method.

Methods

Serum S100 protein value was measured at admission, day 3 and 7 after bleeding in 42 consecutive patients (SAH : 20, ICH : 22) and 74 healthy controls, prospectively. Admission Glasgow coma scale (GCS) score, Hunt & Hess grade and Fisher grade for SAH, presence of intraventricular hemorrhage, ICH volume, and outcome at discharge were evaluated. Degrees of serum S100 elevation and their effect on outcomes were compared between two groups.

Results

Median S100 levels in SAH and ICH groups were elevated at admission (0.092 versus 0.283 µg/L) and at day 3 (0.110 versus 0.099 µg/L) compared to healthy controls (0.05 µg/L; p<0001). At day 7, however, these levels were normalized in both groups. Time course of S100 level in SAH patient was relatively steady at least during the first 3 days, whereas in ICH patient it showed abrupt S100 surge on admission and then decreased rapidly during the next 7 days, suggesting severe brain damage at the time of bleeding. In ICH patient, S100 level on admission correlated well with GCS score (r=-0.859; p=0.0001) and ICH volume (r=0.663; p=0.001). A baseline S100 level more than 0.199 µg/L predicted poor outcome with 92% sensitivity and 90% specificity. Logistic regression analyses showed Ln (S100) on admission as the only independent predictor of poor outcome (odd ratio 36.1; 95% CI, 1.98 to 656.3).

Conclusion

Brain damage in ICH patient seems to develop immediately after bleeding, whereas in SAH patients it seems to be sustained for few days. Degree of brain damage is more severe in ICH compared to SAH group based on the S100 level. S100 level is considered an independent predictor of poor outcome in patient with spontaneous ICH, but not in SAH. Further study with large population is required to confirm this result.     

Predictors of Poor Outcome in Patients with Acute Cerebral Infarction

Background and Purpose

Plasma D-dimer levels are elevated during the acute phase of cerebral infarction (CI). We investigated whether the D-dimer level on admission and other clinical characteristics could be used to predict the poor outcome of patients with acute CI.

Methods

The clinical characteristics and plasma D-dimer levels measured within 3 days of onset were compared according to outcome among patients with acute CI.

Results

In total, 359 consecutive patients (mean age, 71.8 years) were examined, of which 174 had a poor outcome [score on the modified Rankin scale (mRS) ≥3] at 30 days after hospitalization. The mean mRS score was higher and a poor outcome was observed more frequently among women than among men (p<0.001 for each). The proportions of women, cardioembolism, atrial fibrillation, advanced age (≥75 years), prior history of CI or transient ischemic attack, and elevated D-dimer level (≥1.0 µg/mL) were significantly higher among patients with a poor outcome than among those with a good outcome. A multivariate analysis showed that elevated D-dimer level [≥1.0 µg/mL; odds ratio (OR), 2.45; 95% confidence interval (95% CI), 1.52-3.89; p<0.01], advanced age (OR, 1.93; 95% CI, 1.21-3.07; p<0.01), and female gender (OR, 1.75; 95% CI, 1.08-2.83; p=0.02) were independent predictors of a poor outcome.

Conclusions

Certain clinical characteristics (gender and advanced age) and an elevated D-dimer level upon admission can be used to predict the outcome of patients with acute CI at 30 days after hospitalization.     

Differences in Clinical Features and Disability according to the Frequency of Medication Use in Patients with Chronic Migraine

Background and Purpose

Chronic migraine (CM) has a significant impact on daily activities, and analgesic overuse is a major contributing factor to migraine transformation. Limited information is available on the functional consequences of CM stemming from analgesic overuse. This study evaluated the impact of the frequency of analgesic medication use on headache-related disability and clinical features in patients with CM.

Methods

Patients with CM were enrolled consecutively and classified into two groups according to their frequency of medication use: <15 days/month (CM-ML, n=52) and ≥15 days/month (CM-MH, n=68). All patients completed a structured questionnaire concerning the clinical features of their migraine, a validated version of the Migraine Disability Assessment questionnaire (MIDAS), and the Headache Impact Test-6 (HIT-6).

Results

The pain intensity, as measured by a visual analog scale, was greater in the CM-MH group than in the CM-ML group (8.5±0.2 vs. 7.7±0.3, mean±SD; p<0.05). In the disability domain, the MIDAS scores were significantly higher for CM-MH patients than for CM-ML patients (47.6±4.8 vs. 26.8±4.5, p<0.01). The impact from migraine, as measured by the HIT-6, was greater for CM-MH patients than for CM-ML patients (65.6±1.0 vs. 62.1±1.0, p<0.05).

Conclusions

Our results indicate that the headache pain intensity and disability are greater in patients with CM who use medication frequently.     

Effect of Dietary Calcium on Spinal Bone Fusion in an Ovariectomized Rat Model

Objective

To evaluate the effect of calcium supplementation on spinal bone fusion in ovariectomized (OVX) rats.

Methods

Sixteen female Sprague Dawley rats underwent bilateral ovariectomy at 12 weeks of age to induce osteoporosis and were randomly assigned to two groups : control group (n=8) and calcium-supplemented group (OVX-Ca, n=8). Autologous spinal bone fusion surgery was performed on both groups 8 weeks later. After fusion surgery, the OVX-Ca group was supplemented with calcium in drinking water for 8 weeks. Blood was obtained 4 and 8 weeks after fusion surgery. Eight weeks after fusion surgery, the rats were euthanized and the L4-5 spine removed. Bone fusion status and fusion volume were evaluated by manual palpation and three-dimensional computed tomography.

Results

The mean fusion volume in the L4-5 spine was significantly greater in the OVX-Ca group (71.80±8.06 mm³) than in controls (35.34±8.24 mm³) (p<0.01). The level of osteocalcin, a bone formation marker, was higher in OVX-Ca rats than in controls 4 weeks (610.08±10.41 vs. 551.61±12.34 ng/mL) and 8 weeks (552.05±19.67 vs. 502.98±22.76 ng/mL) after fusion surgery (p<0.05). The level of C-terminal telopeptide fragment of type I collagen, a bone resorption marker, was significantly lower in OVX-Ca rats than in controls 4 weeks (77.07±12.57 vs. 101.75±7.20 ng/mL) and 8 weeks (69.58±2.45 vs. 77.15±4.10 ng/mL) after fusion surgery (p<0.05). A mechanical strength test showed that the L4-5 vertebrae in the OVX-Ca group withstood a 50% higher maximal load compared with the controls (p<0.01).

Conclusion

Dietary calcium given to OVX rats after lumbar fusion surgery improved fusion volume and mechanical strength in an ovariectomized rat model.     

Cilostazol Reduces PAC-1 Expression on Platelets in Ischemic Stroke

Background and Purpose

Cilostazol, a phosphodiesterase III inhibitor, is known to be a useful antiplatelet agent that inhibits the progression of atherosclerosis in ischemic stroke. This study investigated the effects of combining cilostazol with aspirin on the expressions of P-selectin and PAC-1 on activated platelets in acute ischemic stroke.

Methods

We analyzed 70 patients with acute ischemic stroke (<72 hrs of an ischemic event). The daily intake was 100 mg of aspirin in 37 patients and 100 mg of aspirin plus 200 mg of cilostazol in 33 patients. The expressions of P-selectin and PAC-1 on activated platelets were measured on the day of admission and 5 days later. We also evaluated the clinical progression using the National Institutes of Health Stroke Scale (NIHSS) at the same times.

Results

After 5 days the extent of PAC-1 expression on activated platelets was significantly lower for combined aspirin and cilostazol treatment (61.0±19.3%, p=0.008; mean±standard deviation) than the baseline level (70.9±12.9%), but did not differ between aspirin alone (66.0 ±19.0%) and baseline (70.1±15.7%). The expression of P-selectin did not differ between combined aspirin and cilostazol treatment and baseline. The clinical progression did not differ between the two groups, as indicated by the absence of significant changes on the NIHSS in the acute period.

Conclusions

This study found that the combined regimen of aspirin and cilostazol exerts the beneficial effect of reducing PAC-1 activity on activated platelets in acute ischemic stroke. However, the clinical outcome of this regimen was no better than that of the aspirin-only regimen. Therefore, further detailed studies of the possible clinical benefits of cilostazol in acute ischemic stroke are needed.     

Simple Decompression of the Ulnar Nerve for Cubital Tunnel Syndrome

Objective

Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper extremity. Although many different operative techniques have been introduced, none of them have been proven superior to others. Simple cubital tunnel decompression has numerous advantages, including simplicity and safety. We present our experience of treating cubital tunnel syndrome with simple decompression in 15 patients.

Methods

According to Dellon''s criteria, one patient was classified as grade 1, eight as grade 2, and six as grade 3. Preoperative electrodiagnostic studies were performed in all patients and 7 of them were rechecked postoperatively. Five patients of 15 underwent simple decompression using a small skin incision (2 cm or less).

Results

Preoperative mean value of motor conduction velocity (MCV) within the segment (above the elbow-below the elbow) was 41.8±15.2 m/s and this result showed a decrease compared to the result of MCV in the below the elbow-wrist segment (57.8±6.9 m/s) with statistical significance (p<0.05). Postoperative mean values of MCV were improved in 6 of 7 patients from 39.8±12.1 m/s to 47.8±12.1 m/s (p<0.05). After an average follow-up of 4.8±5.3 months, 14 patients of 15 (93%) reported good or excellent clinical outcomes according to a modified Bishop scoring system. Five patients who had been treated using a small skin incision achieved good or excellent outcomes. There were no complications, recurrences, or subluxation of the ulnar nerve.

Conclusion

Simple decompression of the ulnar nerve is an effective and successful minimally invasive technique for patients with cubital tunnel syndrome.     

The association of obesity with insulin resistance in male patients with obstructive sleep apnea syndrome in Korea

Objective

Obstructive sleep apnea syndrome (OSAS) has been associated with cardiovascular complications and insulin resistance has been implicated in the pathogenesis and progression of atherosclerosis. We investigated whether insulin resistance is associated with OSAS independent of obesity.

Methods

A total of 183 male patients with OSAS and 52 healthy controls were assessed by nocturnal polysomnography (NPSG). After NPSG, serum concentrations of total cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, glucose and insulin were measured. Insulin resistance was determined by calculating the homeostasis model assessment for insulin resistance (HOMA-IR).

Results

Subjects were divided into normal control, mild-to-moderate OSA group (n=96) and severe OSA group (n=87). There were no significant differences among groups in age, body mass index (BMI), neck circumference or waist circumference. Serum concentrations of total cholesterol, LDL cholesterol, triglycerides, glucose, insulin and HOMA-IR scores of normal controls did not differ from those of the mild-to-moderate or severe OSAS groups. HOMA-IR significantly correlated with anthropometric variables, oxygen desaturation index, triglyceride and LDL cholesterol. Stepwise multiple linear regression analysis showed that waist circumference (β=0.35) and triglycerides (β=0.27) were significant determinants of HOMA-IR (adjusted R²=20%, p<0.01).

Conclusion

Insulin resistance was related to obesity itself rather than OSAS severity or nocturnal hypoxemia-related variables. In preventing cardiovascular complications in OSAS patients, weight reduction should be considered.     

Antipsychotic Effects of Quetiapine in Naturalistic Long Term Follow Up Study

Objective

This study aimed to examine the effectiveness of quetiapine and the effects of dosage relates to its effectiveness on schizophrenia and schizoaffective disorder in a naturalistic setting in Korean people.

Methods

This study was a 24-week, open-label, non-comparative, naturalistic study of quetiapine in patients diagnosed with schizophrenia and schizoaffective disorder according to DSM-IV. We stratified the patients into mild [(clinical global impression severity (CGI-S) <4 at baseline)] and severe groups (CGI-S ≥4 at baseline). We investigated the response rate, defined as clinical global impression improvement (CGI-I) ≤2, in the severe group and the aggravation rate in the mild group using the last-observation-carried-forward (LOCF) and the Kaplan-Meier method (K-M).

Results

During the 24 weeks, 151 (18.4%) of the participants dropped out of the study. There was a significant decrease in the mean CGI-S score, from 4.5±1.1 at baseline to 2.8±1.1 at 24 weeks. The response rate of severe group was 54.5% (estimated by LOCF) and 73.3% (K-M estimated) at 24 weeks. All patients who completed the study had taken a mean quetiapine dosage of 507.9±245.9 mg daily. The decrease of CGI-S score in high-dose group (the maximum dose was 750 mg/d or above) was statistically significant than that in recommended-dose group (the maximum dose was less than 750 mg/d).

Conclusion

This study demonstrated the long-term effectiveness of quetiapine in the treatment of schizophrenia and schizoaffective disorder in a naturalistic setting in Korean people. This study suggests that higher than recommended quetiapine dosages could be more effective in some patients.     

Remifentanil-Propofol Sedation as an Ambulatory Anesthesia for Carpal Tunnel Release

Objective

This prospective study evaluated the use of continuous sedation using propofol and remifentanil when carpal tunnel release (CTR) was performed under local anesthesia.

Methods

We sedated 60 patients undergoing CTR using local anesthesia with remifentanil at loading and continuous doses of 0.5 µg kg^-1 and 0.05 µg kg^-1min^-1, respectively, and propofol, using a target controlled infusion (TCI) pump set to a target of 2 µg mL^-1 (group A), or with the same drug doses except that the continuous remifentanil dose was 0.07 µg kg^-1min^-1 (group B) or 0.1 µg kg^-1min^-1 (group C).

Results

In group B, the levels of pain when local anesthetics were administered (p = 0.001), intraoperative pain (p < 0.001) and anxiety (p = 0.001) were significantly lower than those of group A. Furthermore, the incidence of adverse events, including desaturation (p < 0.001) and vomiting (p = 0.043), was significantly lower in group B than in group C.

Conclusion

Continuous sedation using an appropriate dose of remifentanil and propofol can be used as safe, efficacious ambulatory anesthesia in cases of CTR under local anesthesia, performed using only 2 mL of local anesthetic, with a high degree of patient satisfaction.     

Changes in the Cross-Sectional Area of Multifidus and Psoas in Unilateral Sciatica Caused by Lumbar Disc Herniation

Objective

To quantitatively evaluate the asymmetry of the multifidus and psoas muscles in unilateral sciatica caused by lumbar disc herniation using magnetic resonance imaging (MRI).

Methods

Seventy-six patients who underwent open microdiscectomy for unilateral L5 radiculopathy caused by disc herniation at the L4-5 level were enrolled, of which 39 patients (51.3%) had a symptom duration of 1 month or less (group A), and 37 (48.7%) had a symptom duration of 3 months or more (group B). The cross-sectional areas (CSAs) of the multifidus and psoas muscles were measured at the mid-portion of the L4-5 disc level on axial MRI, and compared between the diseased and normal sides in each group.

Results

The mean symptom duration was 0.6±0.4 months and 5.4±2.7 months for groups A and B, respectively (p<0.001). There were no differences in the demographics between the 2 groups. There was a significant difference in the CSA of the multifidus muscle between the diseased and normal sides (p<0.01) in group B. In contrast, no significant multifidus muscle asymmetry was found in group A. The CSA of the psoas muscle was not affected by disc herniation in either group.

Conclusion

The CSA of the multifidus muscle was reduced by lumbar disc herniation when symptom duration was 3 months or more.     

Short Segment Anterior Correction of Adolescent Idiopathic Scoliosis

Objective

The purpose of this study was to introduce our surgical experiences of scoliosis and to evaluate the effectiveness of anterior correction and fusion in adolescent idiopathic scoliosis (AIS).

Methods

Between August 2004 and August 2007, four patients with AIS were treated with anterior segmental fusion and fixation at our hospital. Mean follow-up period was 9 (6-12) months. The average age was 14.0 (13-15) years. According to Lenke classification, three patients showed Lenke 1 curve and one patient with Lenke 5 curve. Single rod instrumentation was performed in one patient, dual rod instrumentation in one patient and combined rod instrumentation in two patients. Coronal Cobb measurements were performed on all curves in thoracic, thoracolumbar and, lumbar spine and the angle of hump was measured by a scoliometer pre- and postoperatively.

Results

The average operative time was 394 minutes (255-525) with an average intraoperative blood loss of 1,225 ml (1,000-1,700). The mean period of hospital stay was 19.3 days and there was no complication related to the surgery. The mean Cobb angle was reduced from 43.3° to 14.8° (65.8% correction) postoperatively and the rib hump corrected less than 5°. All patients and their parents were satisfied with the deformity correction.

Conclusion

Anterior spinal correction and fusion of AIS with Lenke 1 and 5 curve showed excellent deformity correction without any complications. In particular, we recommend anterior dual rod instrumentation because of mechanical stability, better control of kyphosis, and a higher fusion rate.     

Prognostic Role of Serum Levels of Uric Acid in Amyotrophic Lateral Sclerosis

Background and Purpose

It has been suggested that oxidative stress is one of the pathomechanisms underlying amyotrophic lateral sclerosis (ALS), and thus antioxidants such as uric acid (UA) that could reduce oxidative stress might be beneficial in the prevention or treatment of this disease. The objective of this study was to prospectively investigate serum UA levels in Korean ALS patients and to relate them to disease progression.

Methods

ALS patients and healthy controls who were individually well-matched for sex, age, and body mass index (BMI) underwent blood testing for serum UA levels, and analyzed whether UA levels were correlated with the disease status of the patients, as defined by the ALS Functional Rating Scale-Revised (ALSFRS-R).

Results

The study included 136 ALS patients and 136 matched controls. The UA level was lower in the ALS patients (4.50±1.17 mg/dL, mean±SD) than in the controls (5.51±1.22 mg/dL; p<0.001). Among the ALS patients, the level of UA acid was inversely correlated with the rate of disease progression (decrease in ALSFRS-R score). Kaplan-Meier analysis revealed that a better survival rate was more strongly correlated with top-tertile levels of serum UA than with bottom-tertile levels (log-rank test: p=0.035).

Conclusions

ALS patients had lower serum UA levels than did healthy individuals. UA levels in ALS were negatively correlated with the rate of disease progression and positively associated with survival, suggesting that UA levels contribute to the progression of ALS. UA levels could be considered a biomarker of disease progression in the early phase in ALS patients.     

Posterior Cervical Fixation with Nitinol Shape Memory Loop in the Anterior-Posterior Combined Approach for the Patients with Three Column Injury of the Cervical Spine : Preliminary Report

Objective

The authors reviewed clinical and radiological outcomes in patients with three column injury of the cervical spine who had undergone posterior cervical fixation using Nitinol shape memory alloy loop in the anterior-posterior combined approach.

Materials

Nine patients were surgically treated with anterior cervical fusion using an iliac bone graft and dynamic plate-screw system, and the posterior cervical fixation using Nitinol shape memory loop (Davydov™) at the same time. A retrospective review was performed. Clinical outcomes were assessed using the Frankel grading method. We reviewed the radiological parameters such as bony fusion rate, height of iliac bone graft strut, graft subsidence, cervical lordotic angle, and instrument related complication.

Results

Single-level fusion was performed in five patients, and two-level fusion in four. Solid bone fusion was presented in all cases after surgery. The mean height of graft strut was significantly decreased from 20.46±9.97 mm at immediate postoperative state to 18.87±8.60 mm at the final follow-up period (p<0.05). The mean cervical lordotic angle decreased from 13.83±11.84° to 11.37±6.03° at the immediate postoperative state but then, increased to 24.39±9.83° at the final follow-up period (p<0.05). There were no instrument related complications.

Conclusion

We suggest that the posterior cervical fixation using Nitinol shape memory alloy loop may be a simple and useful method, and be one of treatment options in anterior-posterior combined approach for the patients with the three column injury of the cervical spine.