Factors associated with use of emergency medical services in patients with acute stroke

Purposes

The aim of this study was to investigate the factors associated with use of emergency medical services (EMS) in patients with acute stroke.

Methods

Prospective data on consecutive patients with acute stroke who presented to the emergency department of a university medical center from January 1, 2010, to July 31, 2011, were analyzed. Patients were excluded if they had an unknown residence, had onset of stroke at a nursing home or hospital, or were transferred from another hospital. Variables for all patients with stroke and ischemic stroke who did and did not use EMS were compared.

Results

In total, 1344 patients (60% male; mean age, 68.7 years) were included. Use of EMS (n = 409; 30.4%) was significantly associated with a higher level of education (≧ 6 years vs < 6 years; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.25-2.29), a higher National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.05-1.11), altered consciousness (OR, 1.88; 95% CI, 1.25-2.84), and atrial fibrillation (OR, 2.43; 95% CI, 1.71-3.44) after adjustment. For patients with ischemic stroke, use of EMS was significantly higher in cases of cardioembolism (OR, 3.04; 95% CI, 1.40-6.60) and large artery atherothrombosis (OR, 2.10; 95% CI, 1.22-3.62) than lacunar infarction.

Conclusion

Patients with stroke who have altered consciousness, a higher level of education, a higher National Institutes of Health Stroke Scale score, atrial fibrillation, and cardioembolic stroke were more likely to use EMS.     

The Evaluation of Atherosclerosis in Migraine Patients

Abstract A potential association might exist between atherosclerosis and migraine. Carotid intima‐media thickness (CIMT) is a marker of generalized atherosclerosis; hence, we aimed to assess CIMT in migraine patients. This study included 30 patients and 60 healthy controls aged between 20 and 40 years. Episodic migraine diagnosis was made according to the criteria of International Headache Society (IHS). Healthy controls who do not suffer any headache problems were selected from among hospital and laboratory staffs. All subjects were evaluated regarding some parameters and features known to be associated with migraine and vascular changes, that is, gender, age, body mass index, blood pressure, cholesterol, smoking habits, used hormonal contraceptives, and history of disease. The left common carotid arteries of the subjects were examined, and CIMT was measured with real‐time gray‐scale sonography. Mean values and standard deviations were calculated. All measurements were made in migraine‐free periods. Migraine patients and control subjects were well matched for those parameters known to be associated with vascular changes, that is, gender, age, BMI, blood pressure, and cholesterol. CIMT values were higher in patients. The results showed that the mean CCA IMT values were 0.493 ± 0.074 mm and 0.409 ± 0.053 mm in migraine patients and controls, respectively (P < 0.001). There is a relationship between atherosclerosis and inflammation in migraine patients. The risk of cranial inflammatory arteriopathy increases in repeated attacks of migraine. Our study also supports that high number of attacks and attack duration are important in the development of atherosclerosis.     

Updated spirometric reference values for adult Chinese in Hong Kong and implications on clinical utilization

STUDY OBJECTIVES: The accuracy of reference values of lung function is important for assessment of severity and functional impairment of respiratory diseases. The aim of the study was to establish updated prediction formulae of spirometric parameters for Hong Kong Chinese and to compare the reference values with those derived from other studies in white and Chinese subjects. DESIGN: Cross-sectional multicenter study. SETTING: Lung function laboratories of eight regional hospitals in Hong Kong. PARTICIPANTS: Subjects were recruited by random-digit dialing. One thousand one hundred seventy-six subjects who fulfilled recruitment criteria underwent spirometry. MEASUREMENTS: Spirometry was performed according to American Thoracic Society recommendations, and the technique was standardized among the eight participating lung function laboratories. RESULTS: Evaluable data of 1,089 (494 men and 595 women) healthy nonsmokers aged 18 to 80 years were analyzed. Age and height were found to be the major determinants of FEV1 and FVC, with a linear decline of height-adjusted values with age in both sexes. Spirometric values of this population have increased compared to Chinese populations of similar sex, age, and height two decades ago. Reference values derived from white populations were higher than our values by 5 to 19%, and the degree of overestimation varied with age, sex, and lung function parameter. We also demonstrated that the blanket application of correction factors for Asian populations may not be appropriate. In this study cohort, the distribution-free estimation of age-related centiles was more appropriate for the determination of lower limits of normal. CONCLUSIONS: Our findings underscore the need to use reference values based on updated data derived from local populations or those matched for ethnicity and other sociodemographic characteristics.     

Disseminated tuberculosis following reduced-intensity cord blood transplantation for adult patients with hematological diseases

Allogeneic hematopoietic stem cell transplantation (allo-SCT) recipients are prone to infections. The incidences of mycobacterial infections after allo-SCT in several case series vary from less than 0.1-5.5%. However, no study has been published on tuberculosis following unrelated cord blood transplantation (UCBT). We retrospectively reviewed medical records of 113 adult patients with a median age of 54 years who underwent reduced-intensity UCBT (RI-UCBT) at Toranomon Hospital from March 2002 to May 2004. Mycobacterium tuberculosis infections were diagnosed in three patients (2.7%), of these two patients developed primary infection and one patient developed reactivation of latent tuberculosis. The interval between RI-UCBT and the diagnosis of tuberculosis was 34, 41 and 61 days. All the patients had disseminated disease at diagnosis. Histological examination showed the lack of granuloma in caseous necrosis. Combination antituberculous treatments showed limited efficacy, and two patients died immediately after diagnosis. M. tuberculosis caused life-threatening illness, rapidly progressing in RI-UCBT recipients. The lack of granuloma in caseous necrosis suggests the impaired T-cell function in early post transplant phase of RI-UCBT. We should consider M. tuberculosis in the differential diagnoses of fever of unknown source after RI-UCBT.     

Resection of liver metastasis after a pancreatoduodenectomy for pancreatic cancer: a case report

A case of resected liver metastasis from pancreatic cancer, in a 69-year-old woman who obtained a relatively long survival, is presented. Primary pancreatic cancer was found in a patient presenting with obstructive jaundice and a loss of appetite. A pylorus-preserving pancreatoduodenectomy was carried out on December 2, 1996. Eleven months later, a 1.5-cm mass was found in the right posterior segment of the liver. Although the tumor size had increased to 2.5 cm 5 months later, no other metastases were observed. Therefore, the right posterior segment of the liver was resected. Eleven months after the second operation, recurrence was found in the cut surface of the liver and the left caudate lobe. She died on May 1, 1999. This case demonstrated a relatively favorable prognosis in comparison to other common type of liver metastasis from pancreatic cancer. This study discusses the peculiarities of this case and emphasizes the necessity to carefully select the patients before attempting to resect the liver metastasis from pancreatic cancer.     

Bone loss in men with prostate cancer treated with gonadotropin-releasing hormone agonists

Prostate cancer is the most common visceral malignancy in men. As the tumor is testosterone dependent, a frequent treatment modality involves therapy with GnRH agonists (GnRH-a) resulting in hypogonadism. Because testosterone is essential for the maintenance of bone mass in men, we postulated that GnRH-a therapy would negatively impact skeletal integrity. We compared bone mineral density (BMD), biochemical markers of bone turnover, and body composition in 60 men with prostate cancer (19 men receiving GnRH-a therapy and 41 eugonadal men) and BMD in 197 community-living healthy controls of similar age. BMD was assessed by dual energy x-ray absorptiometry and ultrasound. Biochemical markers of bone turnover, included markers of bone resorption (urinary N-telopeptide) and bone formation markers (bone-specific alkaline phosphatase and osteocalcin). Body composition (total body fat and lean body mass) was assessed by dual energy x-ray absorptiometry. Significantly lower BMD was found at the lateral spine (0.69 +/- 0.17 vs. 0.83 +/- 0.20 g/cm(2); P < 0.01), total hip (0.94 +/- 0.14 vs. 1.05 +/- 0.16 g/cm(2); P < 0.05), and forearm (0.67 +/- 0.11 vs. 0.78 +/- 0.07 g/cm(2); P < 0.01) in men receiving GnRH-a compared with the eugonadal men with prostate cancer. Significant differences were also seen at the total body, finger, and calcaneus (all P < 0.01). BMD values in eugonadal men with prostate cancer and healthy controls were similar. Markers of bone resorption (urinary N-telopeptide) and bone formation (bone-specific alkaline phosphatase) were elevated in men receiving GnRH-a therapy compared with those in eugonadal men with prostate cancer. Men receiving GnRH-a also had a higher percent total body fat (29 +/- 5% vs. 25 +/- 5%; P < 0.01) and lower percent lean body weight (71 +/- 5% vs. 75 +/- 5%; P < 0.01) compared with eugonadal men with prostate cancer. In conclusion, men with prostate cancer receiving androgen deprivation therapy have a significant decrease in bone mass and increase in bone turnover, thus placing them at increased risk of fracture.     

Global structural changes of an ion channel during its gating are followed by ion mobility mass spectrometry

Mechanosensitive ion channels are sensors probing membrane tension in all species; despite their importance and vital role in many cell functions, their gating mechanism remains to be elucidated. Here, we determined the conditions for releasing intact mechanosensitive channel of large conductance (MscL) proteins from their detergents in the gas phase using native ion mobility–mass spectrometry (IM-MS). By using IM-MS, we could detect the native mass of MscL from Escherichia coli, determine various global structural changes during its gating by measuring the rotationally averaged collision cross-sections, and show that it can function in the absence of a lipid bilayer. We could detect global conformational changes during MscL gating as small as 3%. Our findings will allow studying native structure of many other membrane proteins.One of the best candidates to explore the gating of mechanosensitive channels is the mechanosensitive channel of large conductance (MscL) from Escherichia coli. The crystal structure of MscL in its closed/nearly closed state from Mycobacterium tuberculosis revealed this channel as a homopentamer (1). Each subunit has a cytoplasmic N- and C-terminal domain as well as two α-helical transmembrane (TM) domains, TM1 and TM2, which are connected by a periplasmic loop. The five TM1 helices form the pore and the more peripheral TM2 helices interact with the lipid bilayer.MscL detects changes in membrane tension invoked by a hypoosmotic shock and couples the tension sensing directly to large conformational changes (1, 2). On the basis of a large body of structural and theoretical data, numerous gating models of MscL have been proposed (3–9). These models agree upon (i) the hydrophobic pore constriction of the channel and (ii) the channel opens by an iris-like rotation—i.e., a tilting and outward movement of transmembrane helices that make the channel wider and shorter (5). This mechanism is supported by patch-clamp (10), disulfide cross-linking (11), FRET spectroscopy (12), and site-directed spin labeling EPR experiments (6, 7), as well as computational studies (13–15). So far, direct experimental results have only been observed for short-range local structural changes, and no measure of the overall global structural changes during channel gating have been reported. Because there is no crystal structure available for the open MscL channel, elucidating overall global structural changes from the onset of channel activation is of utmost importance for our understanding of the gating mechanism of mechanosensitive channels. Here, we provide direct experimental evidence for the key areal changes occurring during channel gating by combining our ability to activate MscL in a controlled manner to different subopen states (16) with a native ion mobility-mass spectrometry (IM-MS) approach.     

A case of pulmonary adenocarcinoma accompanied by minimal change nephrotic syndrome, antiphospholipid syndrome and warm-type autoimmune hemolytic anemia]

A 49-year-old man was urgently admitted due to edema in both leg and left toe pain. A chest radiograph revealed a solitary nodule in the right lung field. Detailed investigations including bronchoscopy and renal biopsy led to a simultaneous diagnosis of clinical stage IIIB pulmonary adenocarcinoma, minimal change nephrotic syndrome, antiphospholipid syndrome, and warm-type autoimmune hemolytic anemia. Prednisolone was administered for nephrotic syndrome, antiphospholipid syndrome and warm-type autoimmune hemolytic anemia, and 6 courses of chemotherapy with 70Gy radio-therapy were performed. The pulmonary nodule significantly decreased in size and the other three autoimmune diseases appeared to be well-controlled. Thirteen months after admission, multiple brain metastases developed along with worsening antiphospholipid syndrome symptoms including lupus anticoagulant. Following whole-brain irradiation, the brain metastases decreased in size and antiphospholipid syndrome symptoms improved. Thirty-nine months after the initial visit, the primary lung cancer, its brain metastasis and the 3 other autoimmune diseases appeared to be well-controlled. The temporal correlation of the lung cancer and the three autoimmune diseases suggests the latter may be paraneoplastic syndrome.     

Typhoid fever complicated by multiple organ involvement: report of two cases

Typhoid fever complicated by multiple organ involvement has been rarely mentioned in the literature. We reported two cases of typhoid fever with several unusual manifestations, including acute renal failure, acute hepatitis, acute pancreatitis, disseminated intravascular coagulation, and lower gastrointestinal bleeding. A renal biopsy in the first case showed no pathological change. Bone marrow biopsy showed focal necrosis of matrix, which might have been due to severe illness. A liver biopsy in the second case showed a predominantly histiocytic proliferation with occasional neutrophilic infiltration in the portal areas and hepatic sinusoids. Focal necrosis, bile duct injury, and multiple eosinophilic bodies were also noted. After appropriate antimicrobial therapy, both patients recovered without any sequelae. The potential of multiple organ involvement is highlighted in typhoid fever, which, on rare occasions, may occur simultaneously in the same patient.