Objective: The purpose of this study was to analyze treatment outcomes according to treatment modality for elderly patients over 75 years with unruptured intracranial aneurysm. Methods: Fifty-four elderly patients treated in a single tertiary institute between January 2010 and December 2018 were retrospectively reviewed. We compared clinical outcome, radiological results, and complications between the coiling and clipping groups. Results: A total of 55 procedures were performed in 54 patients. Of 55 aneurysms, 44 were treated endovascularly and 11 were treated surgically. There was no significant difference in patient baseline characteristics including mean age, sex, and preexisting co-morbidity between the two groups. Even though there was no significant difference (p=0.373), procedure-related symptomatic complication occurred only in coiling group (3 out of 44 patients, 6.6%). Mortality rate was significantly higher in clipping group (1 out of 11 patients, 9.1%) than in coiling group (0%, p=0.044). Good clinical outcome (modified Rankin Scale 0-2) at 90 days was achieved in 43 cases treated with coiling (97.7%), and 10 cases with clipping (90.9%, p=0.154). Conclusions Clipping is more invasive procedure and takes longer operation time, which might lead to unpredictable mortality in elderly patients. Coiling might have high procedure-related stroke rate due to tortuous vessels with atherosclerosis. Therefore, aggressive treatment of elderly patients should be carefully considered based on patient’s medical condition and angiographic findings.

PURPOSE: Acute kidney injury (AKI) is common in critically ill patients. Serum cystatin C has emerged as a reliable marker of AKI. We sought to assess the value of serum cystatin C for early detection and prediction of renal function recovery in patients with sepsis. MATERIALS AND METHODS: Sepsis patients (113 AKI patients and 49 non-AKI patients) admitted to the intensive care unit (ICU) were included. Serum creatinine and cystatin C levels and glomerular filtration rate were measured on days 0, 1, 3, and 7. RESULTS: Serum cystatin C levels were significantly higher in AKI patients than in non-AKI patients at all time points. Multivariate analysis showed that only serum cystatin C levels on day 0 were associated with AKI development [odds ratio (OR)=19.30; 95% confidence interval (CI)= 2.58–144.50, p<0.001]. Linear mixed model analysis showed significant variation in cystatin C levels between the recovery and non-recovery groups over time (p=0.001). High levels of serum cystatin C at day 0 (OR=1.64; 95% CI=1.00–2.68, p=0.048) were associated with recovery of AKI. CONCLUSION: Serum cystatin C level was found to be associated with the development and worsening of AKI in ICU patients with sepsis.
Acute Kidney Injury ; Creatinine ; Critical Illness ; Cystatin C* ; Diagnosis* ; Glomerular Filtration Rate ; Humans ; Intensive Care Units ; Kidney* ; Multivariate Analysis ; Recovery of Function* ; Sepsis

BACKGROUND: The renin-angiotensin-aldosterone system is closely associated with volume status and vascular tone in septic shock. The present study aimed to assess whether plasma renin activity (PRA) and plasma aldosterone concentration (PAC) measurements compared with conventional severity indicators are associated with mortality in patients with septic shock. METHODS: We evaluated 105 patients who were admitted for septic shock. Plasma levels of the biomarkers PRA and PAC, the PAC/PRA ratio, C-reactive protein (CRP) level, and cortisol level on days 1, 3, and 7 were serially measured. During the intensive care unit stay, relevant clinical information and laboratory results were recorded. RESULTS: Patients were divided into two groups according to 28-day mortality: survivors (n = 59) and non-survivors (n = 46). The survivor group showed lower PRA, PAC, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and Sequential Organ Failure Assessment (SOFA) score than did the non-survivor group (all P < 0.05). The SOFA score was positively correlated with PRA (r = 0.373, P < 0.001) and PAC (r = 0.316, P = 0.001). According to receiver operating characteristic analysis, the areas under the curve of PRA and PAC to predict 28-day mortality were 0.69 (95% confidence interval [CI], 0.58 to 0.79; P = 0.001) and 0.67 (95% CI, 0.56 to 0.77; P = 0.003), respectively, similar to the APACHE II scores and SOFA scores. In particular, the group with PRA value ≥3.5 ng ml⁻¹ h⁻¹ on day 1 showed significantly greater mortality than did the group with PRA value <3.5 ng ml⁻¹ h⁻¹ (log-rank test, P < 0.001). According to multivariate analysis, SOFA score (hazard ratio, 1.11; 95% CI, 1.01 to 1.22), PRA value ≥3.5 ng ml⁻¹ h⁻¹ (hazard ratio, 3.25; 95% CI, 1.60 to 6.60), previous history of cancer (hazard ratio, 3.44; 95% CI, 1.72 to 6.90), and coronary arterial occlusive disease (hazard ratio, 2.99; 95% CI, 1.26 to 7.08) were predictors of 28-day mortality. CONCLUSIONS: Elevated PRA is a useful biomarker to stratify the risk of critically ill patients with septic shock and is a prognostic predictor of 28-day mortality.
Aldosterone* ; APACHE ; Arterial Occlusive Diseases ; Biomarkers ; C-Reactive Protein ; Critical Illness* ; Humans ; Hydrocortisone ; Intensive Care Units ; Mortality ; Multivariate Analysis ; Plasma* ; Renin* ; Renin-Angiotensin System ; ROC Curve ; Shock, Septic* ; Survivors

BACKGROUND: The renin-angiotensin-aldosterone system is closely associated with volume status and vascular tone in septic shock. The present study aimed to assess whether plasma renin activity (PRA) and plasma aldosterone concentration (PAC) measurements compared with conventional severity indicators are associated with mortality in patients with septic shock. METHODS: We evaluated 105 patients who were admitted for septic shock. Plasma levels of the biomarkers PRA and PAC, the PAC/PRA ratio, C-reactive protein (CRP) level, and cortisol level on days 1, 3, and 7 were serially measured. During the intensive care unit stay, relevant clinical information and laboratory results were recorded. RESULTS: Patients were divided into two groups according to 28-day mortality: survivors (n = 59) and non-survivors (n = 46). The survivor group showed lower PRA, PAC, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and Sequential Organ Failure Assessment (SOFA) score than did the non-survivor group (all P < 0.05). The SOFA score was positively correlated with PRA (r = 0.373, P < 0.001) and PAC (r = 0.316, P = 0.001). According to receiver operating characteristic analysis, the areas under the curve of PRA and PAC to predict 28-day mortality were 0.69 (95% confidence interval [CI], 0.58 to 0.79; P = 0.001) and 0.67 (95% CI, 0.56 to 0.77; P = 0.003), respectively, similar to the APACHE II scores and SOFA scores. In particular, the group with PRA value ≥3.5 ng ml⁻¹ h⁻¹ on day 1 showed significantly greater mortality than did the group with PRA value <3.5 ng ml⁻¹ h⁻¹ (log-rank test, P < 0.001). According to multivariate analysis, SOFA score (hazard ratio, 1.11; 95% CI, 1.01 to 1.22), PRA value ≥3.5 ng ml⁻¹ h⁻¹ (hazard ratio, 3.25; 95% CI, 1.60 to 6.60), previous history of cancer (hazard ratio, 3.44; 95% CI, 1.72 to 6.90), and coronary arterial occlusive disease (hazard ratio, 2.99; 95% CI, 1.26 to 7.08) were predictors of 28-day mortality. CONCLUSIONS: Elevated PRA is a useful biomarker to stratify the risk of critically ill patients with septic shock and is a prognostic predictor of 28-day mortality.
Aldosterone ; APACHE ; Arterial Occlusive Diseases ; Biomarkers ; C-Reactive Protein ; Critical Illness ; Humans ; Hydrocortisone ; Intensive Care Units ; Mortality ; Multivariate Analysis ; Plasma ; Renin ; Renin-Angiotensin System ; ROC Curve ; Shock, Septic ; Survivors

OBJECTIVE: Although middle cerebral artery (MCA) aneurysms are less amenable to coil embolization, an increasing number of studies support favorable endovascular treatment for them. The purpose of this study is to compare the outcomes of two different treatments (surgery versus coiling) and evaluate the benefits of surgical clipping for MCA aneurysms. METHODS: Here we retrospectively analyzed the outcomes of 178 ruptured and unruptured MCA aneurysms treated in patients between September 2008 and April 2012. Parameters assessing treatment outcomes include degree of aneurysm occlusion, presence of regrowth, clinical status, and complications. RESULTS: Among 178 MCA aneurysms, 153 were treated surgically. After a mean follow-up of 12 months, the surgery group showed a clinically significant complete occlusion rate (98%) compared with the coiling group (56%) (p<0.001). Follow-up radiologic evaluation showed a higher regrowth rate (four of 16 cases) in the coiling group than in the surgery group (one of 49 cases) (p=0.003). There was no statistically significant difference in favorable clinical outcome rate between the two groups. The procedure-related permanent morbidity and mortality rates were 2% (three of 153 cases) in the surgery group and 0% (0 of 25 cases) in the coiling group. CONCLUSION: Compared to endovascular treatment, surgical neck clipping for both ruptured and unruptured MCA aneurysms results in a significantly higher complete obliteration rate and less regrowth. Therefore, even in this endovascular era, we still recommend surgical clipping as the primary treatment option for MCA aneurysms rather than coil embolization.
Aneurysm* ; Embolization, Therapeutic ; Follow-Up Studies ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery* ; Mortality ; Neck* ; Retrospective Studies ; Surgical Instruments

PURPOSE: Methicillin-resistant Staphylococcus aureus (MRSA) is recognized as an important cause of not only healthcare-associated pneumonia (HCAP) but also community-acquired pneumonia (CAP). We determined the impact of MRSA on differences in clinical characteristics, courses, and outcomes between CAP and HCAP. MATERIALS AND METHODS: We conducted a retrospective observational study on 78 adult patients admitted with MRSA pneumonia at a university-affiliated tertiary hospital between January 2008 and December 2011. We compared baseline characteristics, chest radiographs, treatment outcomes, and drug resistance patterns between the CAP and HCAP groups. RESULTS: Of the 78 patients with MRSA pneumonia, 57 (73.1%) were HCAP and 21 (26.9%) were CAP. MRSA infection history in the previous year (29.8% vs. 14.3%, p=0.244) tended to be more common in HCAP than in CAP. Despite similar Pneumonia Severity Index scores (151 in CAP vs. 142 in HCAP), intubation rates (38.1% vs. 17.5%; p=0.072) and intensive care unit admission (42.9% vs. 22.8%; p=0.095) tended to be higher in the CAP group, while 28-day mortality was higher in the HCAP group (14.3% vs. 26.3%; p=0.368), although without statistical significance. All patients showed sensitivity to vancomycin and linezolid; meanwhile, HCAP patients showed greater resistance to gentamicin than CAP patients (58.3% vs. 16.6%; p=0.037). The median total hospital charges were 6899 American dollars for CAP and 5715 American dollars for HCAP (p=0.161). CONCLUSION: MRSA pneumonia showed significantly differences in baseline characteristics, chest radiographs, treatment outcomes, and medical expenses between HCAP and CAP groups.
Aged ; Community-Acquired Infections/*microbiology ; Female ; Humans ; Male ; Methicillin-Resistant Staphylococcus aureus/*pathogenicity ; Middle Aged ; Pneumonia/*microbiology ; Retrospective Studies

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a technique developed to allow mediastinal staging of lung cancer and also to evaluate intrathoracic lymphadenopathy. In a tuberculosis-endemic area, tuberculosis should be considered as an etiology of mediastinal lymphadenopathy. The aim of this study was to investigate the utility of the routine culture for tuberculosis from specimens of EBUS-TBNA. METHODS: We prospectively performed routine culture for tuberculosis from aspiration or core biopsy specimens got from 86 patients who had undergone EBUS-TBNA due to mediastinal lymphadenopathy between March 2010 and March 2011. RESULTS: A total of 135 lymph node aspiration and 118 core biopsy specimens were included in this analysis. We confirmed the malignancy in 62 (72.9%), tuberculosis in 7 (8.1%), sarcoidosis in 7 (8.1%), asperogillosis in 2 (2.3%) and pneumoconiosis in 2 (2.3%) patients. One lung cancer patient had pulmonary tuberculosis coincidentally and 5 patients had unknown lymphadenopathy. The number of positive culture for Mycobacterium tuberculsosis by EBUS-TBNA is 2 (1.5%) from 135 lymph node aspiration specimens and 2 (1.7%) from 118 core biopsy specimens. Out of eight patients confirmed with tuberculosis, only one patient had positive mycobacterial culture of aspiration specimen from EBUS-TBNA without histopathologic diagnosis. CONCLUSION: These results propose that routine culture for tuberculosis from EBUS-TBNA may not provide additional information for the diagnosis of coincident tuberculous lymphadenitis. However, if there is any possibility of tuberculous lymphadenopathy or pulmonary tuberculosis, it should be considered to perform EBUS-TBNA in patients who have negative sputum AFB smears or no sputum production.
Biopsy ; Biopsy, Fine-Needle ; Bronchoscopy ; Humans ; Lung Neoplasms ; Lymph Nodes ; Lymphatic Diseases ; Mycobacterium ; Needles ; Pneumoconiosis ; Prospective Studies ; Sarcoidosis ; Sputum ; Tuberculosis ; Tuberculosis, Lymph Node ; Tuberculosis, Pulmonary