Subarachnoid hemorrhage (SAH) is a stroke subtype with high mortality and poor functional outcomes. Prompt occlusion of a ruptured aneurysm at an early stage is crucial to prevent rebleeding, which can result in even higher mortality and more severe disabilities. The most critical initial decision in SAH management is the choice of treatment method with surgical clipping or endovascular coiling. We aimed to develop an evidence-based clinical guideline to select the optimal initial treatment in patients with SAH. We developed this guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted across four databases (MEDLINE, Embase, Cochrane, and KoreaMed) to answer two population, intervention, comparison, outcome questions comparing clipping and coiling. The risk of bias was assessed using ROB 2.0 and the Newcastle-Ottawa Scale. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams and meta-analyses were generated for functional outcome and mortality. We included six randomized control trials (RCTs) and 58 observational studies. Meta-analysis of RCTs showed that coiling improved functional outcomes compared to clipping (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.86–0.97). No significant mortality difference was observed in RCTs (OR, 1.38; 95% CI, 0.91–2.09), but non-RCTs favored clipping for reduced mortality (OR, 0.77; 95% CI, 0.69–0.86). However, it is difficult to generalize these findings to all clinical situations, as patients with SAH have a highly variable clinical course. Final treatment decision should be tailored to the individual patient’s status, including aneurysm location, morphology, and the expertise available at the treatment center. Such decisions are best made by specialists such as a board-certified physician and should be explained to the patient and their caregivers, along with the rationale for selecting the most appropriate treatment at the given hospital. Korea has many certified endovascular neurosurgeons, cerebrovascular surgeons, and certified cerebrovascular centers. Proper selection of the most suitable treatment method by certified physicians and centers would greatly benefit patient outcomes and healthcare professionals.

Accurate and early identification of stroke and large vessel occlusion (LVO) in emergency settings is essential for improving patient outcomes and ensuring the efficient allocation of medical resources. This clinical practice guideline systematically reviews domestic and international literature and conducts meta-analyses to evaluate the utility and diagnostic accuracy of stroke assessment tools used in prehospital emergency medical services (EMS). We developed a guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted to evaluate the usefulness of diagnostic EMS assessment tools for diagnosing stroke and LVO. Overall, 70 non-randomized control studies were selected for this study. A meta-analysis was conducted with a subgroup analysis to distinguish between patients with stroke and those with LVO. EMS tools demonstrated high sensitivity but low specificity for diagnosing stroke. In the prehospital setting, using validated EMS stroke assessment tools is recommended for the early identification of stroke and LVO. Upon hospital arrival, stroke specialists should conduct further evaluation and triage to confirm the diagnosis and guide appropriate management. Delays in diagnosing LVO are frequently unacceptable. While experts advocate for the use of EMS assessment tools to facilitate early identification of LVO, these tools alone lack adequate sensitivity. Therefore, further diagnostic evaluations and consultation with stroke specialists upon hospital arrival are recommended.

The mothership (MS) model, where patients are directly transferred to a thrombectomy-capable center, and the drip-and-ship (DS) model, where thrombolysis is initiated at the nearest primary stroke center before transfer for thrombectomy, are the primary transport modes for patients with stroke. We aimed to establish guidelines for selecting the appropriate transfer strategy based on emergent large vessel occlusion (LVO). We developed this guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted across four databases (MEDLINE, Embase, Cochrane, and KoreaMed) to answer three Population, Intervention, Comparison, and Outcome questions comparing MS and DS models. The risk of bias was assessed using the Newcastle-Ottawa Scale. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams and meta-analyses were generated for functional outcomes, mortality, and successful recanalization. Twenty-six non-randomized controlled studies showed that the MS model improved good functional outcomes by approximately 14% compared with the DS model (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.00–1.30). Fifteen studies reported that mortality in the MS and DS models showed no significant differences (OR, 0.97; 95% CI, 0.84–1.11). Twenty-four studies revealed no significant difference in successful recanalization between the MS and DS models (OR, 0.87; 95% CI, 0.68–1.10). The MS model should be considered first to improve the functional outcome of patients with LVO. However, if thrombectomy cannot be performed immediately after thrombolysis, or if a thrombectomy-enabled hospital is not nearby, the DS model should be considered by stroke specialists depending on transportation time and regional factors. We suggest a mixed approach with the DS model based on specific circumstances or regions to ensure the optimum treatment of patients with acute ischemic stroke (AIS). Appropriate transport for patients with LVO improves the prognosis of AIS.

Ethylene glycol (EG) poisoning is highly lethal and difficult to diagnose. EG is metabolized through enzymatic reactions, producing glycolic acid, leading to high anion gap acidosis. The authors report a case wherein EG poisoning produced a large lactate gap between the two measuring methods. A 33-year-old male presented to the emergency department with an altered level of consciousness. The lactate levels measured using a point-of-care test (POCT) revealed severe lactic acidosis. The POCT lactate level corresponded to the amount of anion gap. Follow-up tests in the intensive care unit revealed a serum lactate level of 1.91 mmol/L, while the arterial POCT test yielded 28.1 mmol/L. Based on the lactate gap observed between the two methods, the possibility of EG poisoning was re-considered. EG poisoning was later confirmed by detecting EG in the patient’s system. Thus, EG poisoning should be considered when there is a severe lactate gap between the measuring methods.

Absorptiometry, Photon ; Adult ; Bone Density ; Bone Diseases, Metabolic ; Calcium ; Confounding Factors (Epidemiology) ; Cross-Sectional Studies ; Epidemiology ; Female ; Femur ; Femur Neck ; Hip ; Humans ; Logistic Models ; Male ; Methods ; Nutrition Surveys ; Osteoporosis ; Population Surveillance ; Potassium ; Potassium, Dietary ; Prevalence ; Retrospective Studies ; Spine ; Vitamin D

Pulmonary nocardiosis is a rare opportunistic infection that commonly affects immunocompromised hosts, such as patients with organ transplants, acquired immunodeficiency syndrome, or prolonged immunosuppression. Recently, we encountered a case of pulmonary nocardiosis with empyema that progressed to severe sepsis. The patient was treated in the intensive care unit. Thereafter, medical thoracoscopy was performed to improve drainage of the pleural fluid. Nocardia was identified in the culture of the pleural fluid.
Acquired Immunodeficiency Syndrome ; Drainage ; Empyema* ; Humans ; Immunocompromised Host ; Immunosuppression ; Intensive Care Units ; Nocardia Infections ; Nocardia* ; Opportunistic Infections ; Sepsis* ; Thoracoscopy ; Transplants

Smoking is the major risk factor for lung squamous cell carcinoma (SCC), although a small number of lung SCCs occurs in never-smokers. The purpose of this study was to compare 50 hotspot mutations of lung SCCs between never-smokers and smokers. We retrospectively reviewed the medical records of patients newly diagnosed with lung SCC between January 1, 2011 and December 31, 2013 in the Seoul National University Hospital. Formalin-fixed, paraffin-embedded tumor samples were used for analysis of hotspot mutations. Fifty cancer-related genes in never-smokers were compared to those in ever-smokers. Of 379 lung SCC patients, 19 (5.0%) were never-smokers. The median age of these 19 patients was 67 years (interquartile range 57–73 years), and 10 of these patients were women (52.5%). The incidence rates of stage I, II, III, and IV disease in this group were 26.4%, 5.3%, 31.6%, and 36.8%, respectively, and sequencing was performed successfully in 14 cases. In the 26 lung SCC tumor samples (12 from never-smokers and 14 from ever-smokers) sequenced using personal genome machine, the most common mutations were in TP53 (75.0%), RAS (66.7%), and STK11 (33.3%), but mutations were also found in EGFR, KIT, and PTEN. The distribution of hotspot mutations in never-smokers was similar to that in ever-smokers. There was no significant difference in overall survival between the 2 groups. The 50 hotspot mutations of lung SCC in never-smokers were similar to those of ever-smokers.
Carcinoma, Squamous Cell* ; Epithelial Cells* ; Female ; Genome ; Humans ; Incidence ; Lung Neoplasms ; Lung* ; Medical Records ; Retrospective Studies ; Risk Factors ; Seoul ; Smoke ; Smoking

Xanthohumol (XH), the principal prenylflavonoid of the hop plant (Humulus lupulus L.), dose-dependently inhibited isobutylmethylxanthine (IBMX)-induced melanogenesis in B16 melanoma cells, with little cytotoxicity at the effective concentrations. Decreased melanin content was accompanied by reduced tyrosinase enzyme activity, protein and mRNA expression. The levels of tyrosinase-related protein 1 and 2 mRNAs were decreased by XH. XH also inhibited alpha-melanocyte stimulating hormone- or forskolin-induced increases in melanogenesis, suggesting an action on the cAMP-dependent melanogenic pathway. XH downregulated the protein and mRNA expression of microphthalmia-associated transcription factor (MITF), a master transcriptional regulator of key melanogenic enzymes. These results suggest that XH might act as a hypo-pigmenting agent through the downregulation of MITF in the cAMP-dependent melanogenic pathway.
1-Methyl-3-isobutylxanthine/pharmacology ; Animals ; Cell Line ; Cell Survival/drug effects ; Dose-Response Relationship, Drug ; Down-Regulation ; Drug Antagonism ; Forskolin/pharmacology ; *Humulus ; Intramolecular Oxidoreductases/antagonists & inhibitors/biosynthesis ; Melanins/antagonists & inhibitors/*biosynthesis ; Melanocytes/*drug effects/*metabolism ; Melanoma, Experimental ; Membrane Glycoproteins/antagonists & inhibitors/biosynthesis ; Mice ; Microphthalmia-Associated Transcription Factor/antagonists & inhibitors ; Monophenol Monooxygenase/antagonists & inhibitors/biosynthesis/genetics ; Oxidoreductases/antagonists & inhibitors/biosynthesis ; Propiophenones/*pharmacology ; Signal Transduction/drug effects ; alpha-MSH/metabolism

BACKGROUND: Numerous reports suggest the role of oxygen in melanogenesis. However, little has been reported on the effect of a hypoxic environment on cellular melanogenesis. OBJECTIVE: The effect of low oxygen tension on cellular melanogenesis was investigated in B16 murine melanoma cells. METHODS: Using cells cultured under an ambient (21% O2) or hypoxic (5% O2) condition, melanin content and tyrosinase activity were measured spectrophotometrically. The expression of tyrosinase, tyrosinase-related protein (TRP)- 1, and TRP-2 were analyzed by RT-PCR and Western blot. RESULTS: Culture of cells under hypoxic conditions caused significant inhibition of isobutylmethylxanthine (IBMX)- induced increase of melanin content. No cytotoxicity was observed during the hypoxic culture periods. Decreased melanin content occurred through the decrease of tyrosinase protein and activity (p<0.01). The mRNA levels of tyrosinase and TRP-2 were also decreased by hypoxia, while that of TRP-1 was unchanged. Similar inhibitions of melanin content and tyrosinase activity were observed in the cells stimulated with dibutyryl-cAMP. CONCLUSION: IBMX-induced melanogenesis in B16 cells was significantly inhibited under hypoxic culture conditions, suggesting the important role of oxygen tension in cellular melanogenesis.
Anoxia* ; Blotting, Western ; Melanins ; Melanoma ; Melanoma, Experimental* ; Monophenol Monooxygenase ; Oxygen ; RNA, Messenger