Comparison between early and late carotid endarterectomy for symptomatic carotid stenosis in relation to oxidized low-density lipoprotein and plaque vulnerability

ObjectiveAlthough carotid endarterectomy (CEA), the gold standard in stroke prevention, has been performed in the late stage after the insult, its optimal timing remains unclear. Using biomarkers in plaque and plasma, we evaluated oxidative stress and plaque vulnerability between early and late CEA in symptomatic patients.MethodsWe compared symptomatic stroke patients who underwent early CEA within 4 weeks of the last insult (group A; n = 15) with those who received CEA in the late stage beyond 4 weeks from the last symptom (group B; n = 57). They were divided into vulnerable (group Av, n = 13; group Bv, n = 33) and stable (group As, n = 2; group Bs, n = 24) subgroups according to the pathologic findings on their plaques. We studied the relationships among their primary symptoms, clinical findings, oxidized low-density lipoprotein levels, and gelatinase A (matrix metalloproteinase [MMP]-9) activity in their plaques and plasma.ResultsGroup A had a variety of symptoms; there was no difference in the outcome of CEA between groups A and B. The plaque and plasma oxidized low-density lipoprotein levels were higher in group A than in group B (P < .05). The incidence of pathologically vulnerable plaque was higher in group A than in group B. Plaque oxidized low-density lipoprotein levels and MMP-9 activity were similar in group Av and group Bv and were higher in those groups than in group As and Bs.ConclusionsWe first demonstrated that vulnerable plaques in patients subjected to early CEA manifested a remarkable increase in oxidized low-density lipoprotein and MMP-9 activation. Our findings suggest that early CEA may be beneficial in the aspect of oxidative stress

フィリピンにおける公衆衛生に関する留学記

As a second-year resident at the University of Tokushima Hospital, I report on my experience of overseas training in the Philippines under the training program of the National Institute of Health Sciences. The National Institute of Health Sciences is an institution that conducts education, investigation, and research related to health, medical care, and welfare, and I trained for two months in the Department of Clinical Training in Community Health, Specialty Course III. In addition to the out-of-hospital training at the Ministry of Health, Labour and Welfare, Chiba Prefectural Government, and National Institute of Infectious Diseases, the one week overseas training in the Philippines（Manila） consisted mainly of lectures and training on mosquito-borne infectious diseases, zoonosis, and parasites at the University of the Philippines, Philippine General Hospital, Suburban Health Center, and WHO Western Pacific Office. Infectious diseases are very different from those in Japan. The actual observation made us understand that rabies and parasitic infections are raging in the Philippines due to the sanitary conditions of the living environment, which is very different from that of Japan. By learning about the medical system at overseas medical facilities, we were able to rethink deeply about the merits of the Japanese medical system and the direction it should take in the future from various perspectives

トクシマ ダイガク ビョウイン ノウソッチュウ センター デノ ナイケイドウミャク キュウセイ ヘイソク ニ タイスル チリョウ センリャク

Objective : Strokes related to acute internal carotid artery （ICA） occlusion are associated with extremely poor prognosis. Recently, some studies have reported that the prognosis has been getting better by treating with intra-arterial endovascular therapy. We sought to evaluate clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intraarterial endovascular therapy or otherwise. Methods : We reviewed ４４ patients who underwent treatment with intra-arterial endovascular therapy or otherwise in our stroke care unit （SCU） from January, ２０１１ to May, ２０１４. We compared the prognosis of patients in the ２ treatment groups （endovascular group, n＝２３ vs nonendovascular group, n＝２１）. Results : The rate of good prognosis （modified Rankin Score of ≦２） was significantly higher in the endovascular group than non-endovascular group （１７．４％ vs０％，p＝０．０４５）. The rate of patients who had extreme improvements of National Institutes of Health Stroke Scale （NIHSS） ≧８ was higher in the endovascular group than non-endovascular group （３０．４％ vs１４．３％）. Concerning the improvement of NIHSS ≧８, recombinant tissue-type plasminogen activator （rt-PA） or the left side ICA occlusion were associated significantly （p＝０．０１９, p＝０．０４２, respectively）. Although the hypothesis that endovascular therapy could contribute to extreme improvements of NIHSS wasn’t proved （p＝０．２０２）, there was one case that NIHSS was dramatically improved from ２２ to ０ by endovascular therapy. Conclusions : Intra-arterial endovascular therapy of ICA occlusion might result in improved clinical outcomes for indicated cases

ノウソッチュウ シンダン ノ サイゼンセン

Stroke Care Unit （SCU） in Tokushima University Hospital has been opened since November １９９９. Patients with acute stroke in SCU were diagnosed by stroke MRI and biomarker immediately after their admission. Diffusion MRI could diagnose the ultra-acute ischemic and hemorrhagic lesion except brainstem ischemic lesion within ３ hrs after onset. Diffusion-Perfusion mismatch was useful to indicate intra-arterial thrombolytic therapy. ３T-MRI was introduced since March ２００４，and it can measured functional MR spectroscopy and tractography more quickly compared to １．５T-MRI. Plasma oxidized LDL in patients with acute cerebral infarction was significantly higher than that in healthy control and it became peak level during ３‐５ day after stroke onset. In conclusion, stroke MRI and plasma oxidized LDL are useful diagnostic tools for acute stroke

トクシマ ダイガク ビョウイン ノウソッチュウ センター ニオケル インナイ ハッショウ ノウソッチュウ ノ ケントウ

We assessed the current status of patients with acute in-hospital stroke. 63 patients with acute in-hospital stroke were enrolled. The most prevalent subtype of stroke was embolism（n＝24）. The main cause of hospitalization were malignant neoplasms in15. Only 5 patients were treated with rt-PA, 8 patients received endovascular interventions. In-hospital stroke is a sever complication of in-patients and is associated with an unfavorable prognosis, but endovascular interventions offer safe and feasible therapeutic treatment options

Usefulness of a novel higher brain dysfunction screening test for evaluating higher brain function in healthy persons

To accurately and rapidly screen for higher brain dysfunction, we developed a screening test named the “higher brain dysfunction screening test” (HIBRID-ST). Previous studies have reported a decrease in higher brain function with age. However, whether HIBRID-ST can detect a decrease in higher brain function in healthy persons remains unclear.We aimed to assess the usefulness of HIBRID-ST for evaluating higher brain function in healthy persons. We recruited 60 persons without physiological abnormalities and divided them into six equal groups based on their age (20s−70s). HIBRID-ST addresses orientation, short-term memory, word recall, situational awareness, visual short-term memory, and graphic replication and includes the Trail Making and Kanahiroi tests. There was a significant negative correlation between the participants’ age and their total HIBRID-ST score (ρ= −0.68, p<0.01). The total HIBRID-ST score of participants in their 70s was significantly lower than that of participants in their 20s−60s ; the total HIBRID-ST score of participants in their 60s was significantly lower than that of participants in their 20s−50s. Our findings show that HIBRID-ST accurately detects an age-related decline in higher brain function. Further studies are needed to examine the usefulness of HIBRID-ST in patients with higher brain dysfunction

クモマクカ シュッケツ ニ ゾクハツ シタ ジュウショウ ノ Neurogenic stress cardiomyopathy ノ ケントウ

Neurogenic stress cardiomyopathy（NSC）is caused by catecholamine excess and／or sympathetic nerve activation, presented as a transient cardiac wall motion abnormality. It is reported to occur in ４‐１５％ of patients suffering from subarachnoid hemorrhage（SAH）. Of particular concern, severe NSC leading to cardiac dysfunction is especially important to consider when treating SAH patients in the acute stage because it could affect the prognosis of SAH and the timing of surgery. Currently, the incidence of severe NSC and risk factors are not well characterized. In the present study, we reviewed the medical records of８５patients（２０men,６５women）who were admitted and treated for ruptured cerebral aneurysms at Tokushima University Hospital during the period from January ２０１０ to May ２０１２. NSC occurred in five patients（５．９％）, and three of those patients（３．５％）showed severe NSC with cardiac dysfunction. NSC was observed only in patients with poor SAH-grade, and those resulting in severe cardiac dysfunction were all in women. Notably, the incidence of severe NSC was particularly high in female patients with poor SAH-grades （１７．６％）. We reported the morbidity of severe NSC in patients with SAH. It is important to pay special attention to severe NSC in female patients, particular those with poor SAH-grades