관상동맥질환 의심 환자에서 관상동맥 조영 CT와 심근 SPECT를 통해 살펴본 허혈성 뇌경색의 위험도

학위논문 (석사)-- 서울대학교 대학원 : 의학과, 2015. 2. 김용진.Background: Coronary artery disease (CAD) is considered an important cause of morbidity and mortality in patients with ischemic stroke. However, risk for ischemic stroke in patients with CAD remains unclear. We evaluated the risk of ischemic stroke according to the presence, severity, and extent of CAD evidenced by coronary computed tomographic angiography (CCTA) and single-photon emission computed tomography (SPECT) in patients with suspected CAD. Methods: We studied 1137 patients with suspected CAD, but without a history of CAD or stroke, who underwent both CCTA and SPECT for the evaluation of CAD between 2004 and 2011. Results: During a median follow-up period of 26 months, ischemic stroke was observed in 25 of 1137 patients (2.2%). The presence of coronary atherosclerotic plaque on CCTA was associated with a > 4-fold hazard increase for ischemic stroke (unadjusted hazard ration [HR] 4.3895% confidence interval [CI] 1.03–18.64p = 0.046). Plaque in ≥ 2 vessels was associated with a >3-fold further increase in the risk of ischemic stroke compared with plaque only in one vessel (unadjusted HR 3.6895% CI 1.57–8.62p = 0.003), whereas plaque of ≥ 50% diameter stenosis was not associated with increased risk compared with plaque of < 50% diameter stenosis (unadjusted HR 1.0395% CI 0.43–2.46p = 0.943). The presence and extent of perfusion defect, and summed stress score on SPECT were not associated with ischemic stroke. Conclusions: The risk of ischemic stroke was associated with the presence and extent of coronary atherosclerosis evidenced by CCTA, but not with the presence and extent of myocardial ischemia evidenced by SPECT. CCTA may provide additional information with regard to the risk of ischemic stroke in patients with suspected CAD.Figure 1. Flow chart of the study population 2 Figure 2. Kaplan–Meier survival curves according to coronary computed tomographic angiography findings 9 Figure 3. Kaplan–Meier survival curves according to single-photon emission computed tomography findings 10 Figure 4. Coronary CT angiography and SPECT images in a 62-year-old man with chest pain who experienced ischemic stroke 1 year after coronary evaluation 11 Table 1. Baseline characteristics of patients with coronary artery disease 13 Table 2. The occurrence of ischemic stroke 14 Table 3. Univariate analysis of factors associated with ischemic stroke 15~16Maste

소아 천식에서 기도염증 및 기도재형성을 반영하는 지표로써 유도객담 내 pentraxin 3 농도의 의의

의과대학/석사Pentraxin 3 (PTX3)는 패턴인식수용체에 속하는 급성기 반응 단백의 일종이며, 조직의 손상 및 염증 반응을 나타내는 표지인자로서의 역할에 대한 연구가 최근 들어 활발해지고 있다. 본 연구에서 저자는 소아천식 환자들의 유도객담을 분석하여 PTX3의 농도가 증가되어 있는지를 확인하고자 하였다. 또한, 유도객담 내 PTX3 농도와 소아의 기도 염증 및 과민성, 폐기능 등과의 연관성을 확인하고자 하였다. 총 260명의 소아들을 대상으로 연구를 진행하였으며 이들 중 천식환자 140명, 대조군 120명이었다. 모든 대상 소아들에게 폐기능검사와 메타콜린 기관지유발검사를 시행하였으며, 혈액을 채취하여 총 호산구 수, 총 IgE 농도, 혈청 호산구 양이온 단백의 농도를 측정하였다. 유도객담 내 PTX3의 농도는 천식환자군이(mean ± SE, 1094.55 ± 224.65 pg/mL) 대조군에 비해(177.36 ± 30.00 pg/mL, p < 0.001) 유의하게 높은 수치를 나타내었다. 또한, 중등도 및 중증 지속성 천식 환아들이(median, 1190.63 pg/mL; IQR, 302.70 to 2619.84 pg/mL) 경증 지속성 천식과(median, 391.72 pg/mL; IQR, 73.77 to 1352.35 pg/mL, p = 0.044) 간헐성 천식 환아들에 비해(median, 188.15 pg/mL; IQR, 80.41 to 745.08 pg/mL, p = 0.006) 유의하게 높은 PTX3 농도를 보였다. 유도객담 내 PTX3 농도는 폐기능검사에서 기관지확장제 반응 결과와 유의한 양의 상관관계를 보였으며(r = 0.25, p = 0.013), FEV1 (r = -0.30, p = 0.001), FEV1/FVC (r = -0.27, p = 0.002), FEF25-75 (r = -0.392, p < 0.001)와는 유의하게 음의 상관관계를 나타내었다. 또한 기관지확장제 흡입 후 FEV1 (r = -0.25, p < 0.001) 및 FEV1/FVC (r = -0.25, p < 0.001)와 역시 유의한 음의 상관관계를 보였다. 유도객담 내 PTX3의 농도는 소아천식에서 기도염증 및 기도재형성을 반영하는 지표로써 역할을 기대할 수 있을 것으로 생각된다.ope

Sputum pentraxin 3 as a candidate to assess airway inflammation and remodeling in childhood asthma

Pentraxin 3 (PTX3) is a soluble pattern recognition receptor and an acute-phase protein. It has gained attention as a new biomarker reflecting tissue inflammation and damage in a variety of diseases. Aim of this study is to investigate the role of PTX3 in childhood asthma.In total, 260 children (140 patients with asthma and 120 controls) were enrolled. PTX3 levels were measured in sputum supernatants using enzyme-linked immunosorbent assay test. We performed spirometry and methacholine challenge tests and measured the total eosinophil count and the serum levels of total IgE and eosinophil cationic protein (ECP) in all subjects.Sputum PTX3 concentration was significantly higher in children with asthma than in control subjects (P?<?0.001). Furthermore, sputum PTX3 levels correlated with atopic status and disease severity among patients with asthma. A positive significant correlation was found between sputum PTX3 and the bronchodilator response (r?=?0.25, P?=?0.013). Sputum PTX3 levels were negatively correlated with forced expiratory volume in 1?second (FEV1) (r?=?-0.30, P?=?0.001), FEV1/forced vital capacity (FVC) (r?=?-0.27, P?=?0.002), and FEF25-75 (r?=?-0.392, P?<?0.001), which are indicators of airway obstruction and inflammation. In addition, the PTX3 concentration in sputum showed negative correlations with post-bronchodilator (BD) FEV1 (r?=?-0.25, P?<?0.001) and post-BD FEV1/FVC (r?=?-0.25, P?<?0.001), which are parameters of persistent airflow limitation reflecting airway remodeling.Sputum PTX3 levels increased in children with asthma, suggesting that PTX3 in sputum could be a candidate molecule to evaluate airway inflammation and remodeling in childhood asthma.ope

A case of eosinophilic fasciitis presenting as pitting edema of the lower extremities

Eosinophilic fasciitis is a rare disease characterized by diffuse fasciitis with peripheral eosinophilia and progressive induration and thickening of the skin and soft tissues. We report a 19-year-old female who presented with pitting edema in both lower extremities. She had a history of excessive physical activity before her symptoms developed. Physical examination revealed 2+ pitting edema in both lower legs. She complained of mild pain in both knee joints and feet, with no tenderness or heating sensations. Laboratory results were unremarkable except for severe eosinophilia. Parasite infection, venous thrombosis, and cardiac and renal problems were excluded. A magnetic resonance imaging study of both lower extremities revealed increased signal intensity in the subcutaneous lesions, consistent with superficial inflammation of the fascia. Mixed perivenular lymphoplasmacytic and eosinophilic infiltration in the subcutaneous lesion were observed on biopsy. The patient was treated with corticosteroids, resulting in remarkable improvement in both edema and eosinophilia.ope

Prognostic Usefulness of Eosinopenia in the Pediatric Intensive Care Unit

Eosinopenia, a biomarker for infection, has recently been shown to be a predictor of adult mortality in the intensive care unit (ICU). Our study assessed the usefulness of eosinopenia as a mortality and an infection biomarker in the pediatric ICU (PICU). We compared the PICU mortality scores, eosinophil count and percentage at ICU admission between children who survived and those who did not survive and between children with infection and those without infection. A total of 150 patients were evaluated. The initial eosinophil count and percentage were significantly lower in the group that did not survive when compared to those that did survive (P < 0.001; P < 0.001). However, there was no significant difference in the eosinophil count and percentage seen in patients with and without infection. Eosinopenia, defined as an eosinophil count < 15 cells/µL and an eosinophil percentage < 0.25%, (hazard ratio [HR]: 2.96; P = 0.008) along with a Pediatric Index of Mortality (PIM) 2 (HR: 1.03; P = 0.004) were both determined to be independent predictors of mortality in the PICU. The presence of eosinopenia at the ICU admission can be a useful biomarker for mortality in children, but is not useful as a biomarker for infection.ope

Fractional Exhaled Nitric Oxide and Impulse Oscillometry in Children With Allergic Rhinitis

PURPOSE: Airway inflammation, bronchial hyper-responsiveness (BHR), and bronchodilator response (BDR) are representative characteristics of asthma. Because allergic rhinitis (AR) is a risk factor for asthma development, we evaluated these 3 characteristics in AR using measurement of fractional exhaled nitric oxide (FeNO), a methacholine challenge test (MCT), and impulse oscillometry (IOS). METHODS: This study included 112 children with asthma (asthma group), 196 children with AR (AR group), and 32 control subjects (control group). We compared pulmonary function parameters and FeNO levels among the 3 groups. The AR group was subdivided into 2 categories: the AR group with BHR and the AR group without, and again pulmonary function and FeNO levels were compared between the 2 subgroups. RESULTS: FeNO levels were more increased in the AR and asthma groups than in the control group; within the AR group, FeNO was higher in the AR group with BHR than in the AR group without. The BDR was more increased in the AR group than in the control group when percent changes in reactance at 5 Hz (Δ X5) and reactance area (Δ AX) were compared. In the AR group, however, there was no difference in Δ X5 and Δ AX between the AR group with BHR and the AR group without. CONCLUSIONS: Reversible airway obstruction on IOS and elevated FeNO levels were observed in children with AR. Because elevated FeNO levels can indicate airway inflammation and because chronic inflammation may lead to BHR, FeNO levels may be associated with BHR in AR. IOS can be a useful tool for detecting lower airway involvement of AR independent of BHR assessed in the MCT.ope

Usefulness of Thrombocytopenia and Changes in Platelet Counts as Prognostic Markers in Pediatric Intensive Care Units

Background : Thrombocytopenia has been shown to be a useful predictor of mortality in adult intensive care units (ICUs). The aim of this study is to assess whether the level of platelet count at ICU admission and the changes in platelet counts can predict mortality in the pediatric ICU (PICU). Methods : Platelet counts were checked daily for at least 4 days in a total of 303 children who were admitted to the ICU. We compared the initial platelet counts and changes in platelet counts between survivors and non-survivors. A multivariable logistic regression model, a receiver operating characteristic curve and a linear mixed model were used. Results : The initial platelet count was significantly lower in non-survivors when compared to survivors. Multivariate analysis demonstrated that platelet count <120 × 109/L (Odds ratio, 4.913; 95% confidence interval 2.451-9.851; p < 0.0001) was an independent predictor of mortality. In the case of children with thrombocytopenia (<120 × 109/L) at admission to the ICU, the platelet counts increased serially in survivors, whereas non-survivors maintained their decreased platelet counts. In the case of children without thrombocytopenia, the platelet counts decreased most on day 3 in non-survivors. Conclusions : At admission to the ICU, thrombocytopenia defined as a platelet count <120 × 109/L can be a useful predictor of mortality in children. In children who had initial thrombocytopenia, the serial increase of platelet counts can be related to increased survival, whereas in children who did not have initial thrombocytopenia, more than a 10% decrease of platelet counts on day 3 can be related to mortality.ope

Utility of tools for the assessment of asthma control in childhood asthma

Purpose : The goal of asthma control is to maintain well-controlled state. In this study, we investigated whether childhood asthma control test (C-ACT) may reflect lung function and whether fractional exhaled nitric oxide (FeNO) can be used to improve the accuracy of C-ACT in reflecting the asthma control level. Methods : We reviewed the medical records of 155 patients with asthma underwent lung function tests and C-ACT upon visiting our outpatient clinic. We compared lung function test results according to the C-ACT score stratified by atopy and also examined FeNO according to C-ACT and the Global Initiative for Asthma (GINA) guidelines. The diagnostic accuracy of well-controlled asthma by C-ACT, FeNO, and C-ACT+FeNO was examined. We also calculated the cutoff value of FeNO and C-ACT for well-controlled asthma. Results : Peak expiratory flow (PEF) showed a significant correlation with the C-ACT score. Stratified by atopy, PEF, and forced expiration in one second (FEV1) showed significant correlations with the C-ACT score in the atopic asthma group. There was no difference in FeNO between subjects with C-ACT≥20 and <20, but FeNO was significantly higher in the uncontrolled asthma according to the GINA guidelines. The diagnostic accuracy of well-controlled asthma was higher when FeNO was combined with the C-ACT score than C-ACT or FeNO. Our study showed that the cutoff values of C-ACT and FeNO 19 and 18.3 ppb (parts per billion), respectively, for well-controlled asthma. Conclusion : C-ACT showed a significant correlation with PEF, and atopic asthma group showed significant correlations with PEF and FEV1. A combination of C-ACT with FeNO might reflect asthma control status more accurately.ope

Forced expiratory flow between 25% and 75% of vital capacity as a predictor for bronchial hyperresponsiveness in children with allergic rhinitis

Purpose Allergic rhinitis (AR) is regarded as a risk factor for asthma and bronchial hyperresponsiveness (BHR) is frequently observed in patients with AR. The purpose of this study is to analyze the characteristics of AR patients with BHR and identify factors that contribute to the incidence of BHR. Methods The medical records of a total of 176 children with AR were analyzed retrospectively. All patients were evaluated by performing spirometry and a methacholine challenge test. Results One hundred and fifty-five patients (88%) were classified as the BHR-negative group and 21 patients (12%) were classified as the BHR-positive group. Forced expiratory flow between 25% and 75% of vital capacity (FEF25-75 %predicted) was reduced, and total eosinphil counts, total immunoglobulin E (IgE) level, and serum specific IgE levels of Dermatophagoides pteronyssinus and Dermatophagoides farinae were higher in the BHR-positive group compared to the BHR-negative group. However, FEF25-75 was the only statistically significant predictor for the presence of BHR on multivariate logistic regression analysis. The cutoff value to distinguish BHR-positive subjects obtained from a receiver operating characteristics curve of FEF25-75 was 88.4%. A higher frequency of BHR was found in the group with a FEF25-75 less than 88.4%, and the sensitivity, specificity, positive predictive value and negative predictive value were 57.1%, 80.6%, 28.6%, and 93.3%, respectively. Conclusion Reduced FEF25-75 values in children with AR can be helpful in predicting BHR. Children with low FEF25-75 in spirometric tests should be followed closely for apparent onset of clinical symptoms of asthma.ope

Hypersensitivity reaction to aspirin accompanied by severe eosinophilia in a child with history of Kawasaki disease

Drug hypersensitivity is one of drug adverse reactions that develop in susceptible patients following exposure to certain drugs and cannot be predicted from the known pharmacology of a drug. Severe hypersensitivity is associated with high morbidity and mortality. Although the issue of hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) has been largely investigated in adults, data related to NSAIDs hypersensitivity is insufficient in childhood. And in spite of the recommendation to avoid use of aspirin due to Reye syndrome in children, aspirin is one of major treatment along with intravenous immunoglobulin in Kawasaki disease. We report a case of a 10-month-old boy who underwent intravenous immunoglobulin and aspirin treatment for Kawasaki disease, and subsequently revealed severe leukocytosis and eosinophilia. To our knowledge, there have been no previous reports of aspirin-induced eosinophilia in Korea.ope