The procedure room should be spacious enough to easily accommodate the patient, entire staff, and equipment needed for the operation [1]. A sterile field and careful adherence to aseptic practices are vital elements of the procedure room [2]. The special instruments required for the procedures described in this book are detailed in the chapters covering specific procedures, and this section focuses on the basic equipment required for all interventional fluoroscopy operations (Fig. 2.1).

Background: This study was to investigate the cancellation rate and trend of orthopedic surgeries during the novel coronavirus disease 2019 (COVID-19) pandemic. Moreover, we assessed the psychologic status of orthopedic healthcare workers, and investigated the details of the preventive surgeries underwent in COVID-19-positive patients.Methods: For 3 months after January 20, 2020, cancellation rates of elective surgeries were investigated, and the number of elective surgeries conducted in the same period over the last two years was compared. Four different questionnaires were used to investigate psychologic status among the orthopedic health care workers. We compared the outcomes according to occupation (physician or nurse), and type of work (faculty staff or resident physician). Outcomes according to occupation and type of work were compared. Preventive surgeries underwent in patients who could not wait for the results of the COVID-19 diagnosis were investigated.Results: Spine and hip surgery had relatively lower cancellation rates, and elective surgeries were significantly reduced. During the initial pandemic, the cancellation rate of orthopedic elective surgeries was significantly higher than in the same period of the previous year and was different for each subdivision depending on the degree of pain or disability. The psychological outcomes were within the normal range and there were no significant differences between groups. After preventive surgery, all medical staff involved in the operation tested negative.Conclusion: During the COVID-19 pandemic, the cancellation rate of orthopedic elective surgeries was significantly higher than in the same period of the previous year. Orthopedic health care workers did not seem to have significant psychological distress. As a result of the preventive surgery in specialized facilities, all the medical staff who participated in the operation tested negative.

Abstract To investigate prognosis prediction of motor outcome in anterior choroidal artery (AChA) infarction patients using radiologic and transcranial magnetic stimulation (TMS) studies. Twenty six patients with complete weakness of the affected hand were recruited. The Motricity Index (MI), Medical Research Council (MRC) scores for the affected finger extensors, Modified Brunnstrom classification (MBC) and Functional Ambulation Category (FAC) were evaluated twice: at onset and the chronic stage (3–4 months after onset). Patients were assigned according to the presence of infarction at the corona radiata (CR); the CR-positive group (infarct presence at the CR and posterior limb of internal capsule [PLIC], 11 patients) and CR-negative group (infarct presence at the PLIC, 15 patients), and the presence of motor evoked potentials at the affected hand muscle: the TMS-positive group (11 patients) and the TMS-negative group (15 patients). At the second evaluation, the MI scores were significantly different between the CR-positive (45.10 ± 7.06) and CR-negative groups (57.90 ± 11.56), and between the TMS-positive (60.37 ± 11.53) and TMS-negative groups (46.70 ± 7.99) (P < .05). The MRC scores for the finger extensors were also significantly different between the CR-positive (0.95 ± 1.01) and CR-negative (2.57 ± 1.33) groups and between the TMS-positive (3.05 ± 0.88) and TMS-negative (1.03 ± 1.14) groups (P < .05). Fourteen (53.85%) of the 26 patients recovered to have a functional hand score (MBC ≥5) and 19 (73.07%) of the 26 patients recovered to have an independent gait score (FAC ≥3) on their second evaluation. The results show that CR involvement in addition to the presence of a PLIC lesion and a TMS-negative response were related to poor motor outcomes in patients with an AChA infarction. Consequently, radiologic and TMS studies can be considered for motor outcome prognosis prediction in patients with an AChA infarction.

Active and prompt scale-up screening tests are essential to efficiently control the coronavirus disease 2019 (COVID-19) outbreak. The goal of this work was to identify shortcomings in the conventional screening system (CSS) implemented in the beginning of the outbreak. To overcome these shortcomings, we then introduced a novel, independently developed system called the Yeungnam University type drive-through (YU-Thru), and distributed it nationwide in Korea. This system is similar to the drive-throughs utilized by fast food restaurants. YU-Thru system has shortened the time taken to test a single person to 2-4 minutes, by completely eliminating the time required to clean and ventilate the specimen collection room. This time requirement was a major drawback of the CSS. YU-Thru system also reduced the risk of subjects and medical staff infecting one another by using a separate and closed examination system. On average, 50 to 60 tests were conducted per day when using the CSS, while now up to 350 tests per day are conducted with the YU-Thru system. We believe that the YU-Thru system has made an important contribution to the rapid detection of COVID-19 in Daegu, South Korea. Here, we will describe the YU-Thru system in detail so that other countries experiencing COVID-19 outbreaks can take advantage of this system.

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic infection associated with high morbidity and mortality. The Korean city of Daegu endured the first large COVID-19 outbreak outside of China. Since the report of the first confirmed case in Daegu on February 18, 2020, a total of 6,880 patients have been reported until May 29, 2020. We experienced five patients with ischemic stroke and COVID-19 during this period in four tertiary hospitals in Daegu. The D-dimer levels were high in all three patients in whom D-dimer blood testing was performed. Multiple embolic infarctions were observed in three patients and suspected in one. The mean time from stroke symptom onset to emergency room arrival was 22 hours. As a result, acute treatment for ischemic stroke was delayed. The present case series report raises the possibility that the coronavirus responsible for COVID-19 causes or worsens stroke, perhaps by inducing inflammation. The control of COVID-19 is very important; however, early and proper management of stroke should not be neglected during the epidemic.

Serum Homocysteine (Hcy) level is known to be one of the risk factors of stroke. However, whether serum Hcy levels are related to stroke-subtypes still remains controversial. The aim of this study was to explore the association between Hcy and stroke subtypes. A total of 3240 patients with acute ischemic stroke were registered. Patients with recurred ischemic stroke, undetermined or other determined etiology, pre-mRS > 1 were excluded. Out of 1868 eligible patients, 574 additional patients were excluded due to loss of either follow up or serum homocysteine level. Hcy level was divided into 3 groups according to tertiles. Age, creatinine, serum high-density lipoprotein, serum low-density lipoprotein were significantly different among 3 groups. There was a tendency that the LDL level decreased as the Hcy level increased (p for trend=0.02). In binary logistic regression, highest Hcy level was significantly related to large artery disease compared to small vessel occlusion. (OR 1.44, 95% CI 1.04–1.99) The present study suggested that high serum Hcy level is associated with large artery disease compared to small vessel occlusion. In those mechanisms, LDL-cholesterol might have been involved in atherosclerotic pathway in acute ischemic status.

Introduction: Although platelet reactivity on clopidogrel is related to outcomes in patients with acute coronary syndromes, few studies have investigated its relation to clinical outcomes in acute ischemic stroke. Hypothesis: This study evaluated the association between clopidogrel resistance and early neurological outcomes in patients diagnosed with acute large artery atherosclerotic stroke. Methods: 1067 consecutive patients with onset within 7 days and stroke classification of large artery atherosclerosis were included. Platelet reactivity on clopidogrel was assessed using VeryfyNow P2Y12 assay at least 72 hours after the time of first clopidogrel dosage. Optimal cutoff value of clopidogrel resistance was obtained by using receiver-operating characteristic curve. Early neurological deterioration was defined as an increment of motor NIHSS score ≥1 before P2Y12 assay. We assessed any hemorrhagic transformation on 5-day MRI. Results: A total of 235 patients who met inclusion criteria were analyzed. The median initial dose of clopidogrel was 300 mg, and their median P2Y12 % inhibition was 26.3. P2Y12 % inhibition <29 was the significant discriminator of clopidogrel resistance with an AUC of 0.632 (95% CI 0.48-0.67; p=0.048). A multivariate analysis revealed that clopidogrel resistance is an independent risk factor even after adjustment for the variables that may affect the outcome (OR 2.75; 95% CI 1.11 to 6.83; p=0.029). Hemorrhagic transformation was not influenced by clopidogrel resistance (OR 0.60, 95% CI 0.14 to 2.540; P=0.484). Conclusion: In conclusion, high platelet reactivity with clopidogrel is an independent risk factor of early neurological worsening in acute large artery atherosclerotic stroke. Evaluation of ischemic stroke patients regarding antiplatelet resistance might be of clinical importance and alternative pharmacological strategies could be investigated in patients with high platelet reactivity.

Introduction: Although white matter hyperintensities (WMH) on brain MRIs are associated with common vascular risk factors, the mechanisms underlying progression of WMH are still poorly understood. Hypothesis: We aim to investigate the association between common vascular risk factors and the severity of WMH according to the subtypes of ischemic stroke. Methods: Consecutive patients admitted due to ischemic stroke or TIA were included (n=841). Large artery disease (LAD) and small vessel occlusion (SVO) were defined according to the SSS-TOAST classification. WMH were categorized into two groups: no/mild and moderate/severe using Fazekas scale. Demographics, vascular risk factors and laboratory results were compared between the two groups (LAD vs SVO) in total and separately. Results: A total of 228 patients who underwent brain MRI within seven days after onset were eligible (n=170 in LAD, n=58 in SVO). Patients with LAD were older than those with SVO (mean age 67 years vs. 60 years, p<0.001), but the proportion of patients with moderate/severe WMH did not significantly differ between the two groups (28.2% vs 29.3%, p=0.876). Older age and hypertension were independent risk factors of moderate/severe WMH (OR=3.94 [2.46-6.30] with an increased age of 10 years; OR=5.14 [1.70-15.56], P=0.004 for hypertension) after adjustment of common cardiovascular risk factors. In patients with LAD, independent risk factors of moderate/severe WMH were age (OR=3.86 [1.83-8.12] for every ten-year increase, P<0.001) and hypertension (OR=5.64 [1.51-21.1], P=0.01). On the other hand, age was the only independent risk factor in patients with SVO (OR=3.03 [1.28-7.19] for every ten-year increase, P=0.012). Conclusion: In conclusion, this study showed that there is a different association between hypertension and severity of WMH in each stroke subtype. Other potential mechanisms of WMH, those not associated with traditional vascular risk factors, may be associated with progression of WMH.

OBJECTIVE: Stent-assisted coil embolization (SAC) is one of the treatment options for patients with intracranial aneurysms. The purpose of this study was to assess clinical outcomes of patients who underwent coil embolization for acutely ruptured aneurysms without antiplatelet premedication. METHODS: A total of 449 patients with acutely ruptured aneurysms underwent endovascular treatment without antiplatelet premedication between April 2006 and October 2015. Among them, 55 patients underwent SAC (SAC group) and 394 underwent coiling without stent assistance (non-SAC group). Periprocedural complications and clinical outcomes at postictal 6 months were compared between the 2 groups. RESULTS: The rate of hemorrhagic complications showed no significant difference (SAC group vs. non-SAC group, 9.1% vs. 4.8%). Although procedural thromboembolism occurred more frequently in the SAC group (25.5% vs. 12.4%; P = 0.01), poor clinical outcomes (modified Rankin scale score >= 3) were comparable (30.9% vs. 22.1%). In the multivariate analysis, Hunt-Hess grade (odds ratio [OR] = 4.22; P < 0.001), hemorrhagic complications (OR = 4.01; P = 0.018), and age (OR = 1.04, P = 0.001) were independent predictors of poor clinical outcomes, but stent-assisted coil embolization and procedural thromboembolism were not. CONCLUSIONS: Although procedure-related thrombo-embolism occurred more frequently, comparable treatment outcomes could be achieved with antiplatelet premedication-free SAC in patients with acutely ruptured aneurysms. The use of stents and thromboembolic complications were not significant risk factors for poor clinical outcome.

【Objectives】We investigated the angiographic outcomes and prognostic factors for imaging features of acute cervicocerebral artery dissection.

Introduction: The features of vascular images and risk factors might be different according to the location of the cervicocerebral artery dissection. Hypothesis: We investigate whether the risk factors, neuroimaging features, and imaging outcomes differ according to the dissection site (anterior vs. posterior circulation). Methods: Consecutive patients who presented with ischemic symptoms and underwent brain vascular imaging within seven days after the onset of symptoms were enrolled. Demographic characteristics, putative risk factors, imaging findings, and types of antithrombotic medication were assessed between anterior circulation dissection (ACD) and posterior circulation dissection (PCD). The baseline and follow-up vascular images (6 months or 1 year after the onset of symptoms) were compared to determine the prognostic difference in the reverse of the lesion. Results: A total of 117 patients (n=32 with ACD and n=85 with PCD) were eligible for these analysis. The median delay from symptom onset to baseline vascular imaging was a day (IQR 1, 2). Patients with PCD were older (OR=1.5 by increasing 10 years old [1.02-2.03], p=0.038) and had a dissection associated with exercise or neck manipulation more frequently (OR=4.8 [1.2-18.1], p=0.019) compared to patients with ACD. Arterial stenosis or occlusion was the most common imaging feature (94% in ACD vs. 86% in PCD, p= 0.345). Aneurysm or pseudoaneurysm was identified in 9.4% of ACD and 24.7% of PCD (p=0.067). Among patients with PCD, vertebral artery was the most common lesion site (65% [53-74%]). The complete reverse on the follow-up images at the 6 months or 1 year was identified in 9 patients with ACD and 11 patients with PCD (45% vs. 22%, p=0.054). Neither anticoagulation nor antiplatelet demonstrated significant differences between the frequency of the complete reverse on the follow-up vascular images in patients with ACD and PCD (33% vs. 21%, p=0.613 for anticoagulation; 44% vs. 23%, p=0.087 for antiplatelet). Conclusions: These results substantiate the difference in the risk factors and radiologic features according to the dissection site. There was no difference in efficacy of antiplatelet and anticoagulant drugs at complete reverse of the lesion after cervicocerebral artery dissection.

Background: Although DWI-positive patients who present with transient symptoms have higher day-7 stroke rates than DWI-negative cohorts, little is known about the outcomes of TIA patients with focal perfusion lesions. The aim of the current study is to determine the day-7 recurrent stroke rate in TIA/minor stroke patients who have perfusion lesions on baseline MRI. Methods: Consecutive TIA and minor stroke (NIHSS < 4) patients who underwent baseline DWI and perfusion imaging as well as day-7 follow-up MRI with DWI and FLAIR at Yeungnam University Stroke Center in Korea were enrolled. Two perfusion parameters (Time to Peak and Mean Transit Time), DWI, ADC and FLAIR sequences were reviewed by 2 raters blinded to clinical outcomes. New brain infarction was defined by the presence of a new lesion on day-7 DWI and FLAIR. Symptomatic carotid and intracranial stenosis was assessed on baseline MRA. New neurological symptoms that occurred within 7 days were recorded. Results: Sixty-four patients met the inclusion criteria. Mean age was 64±13 years. Median ABCD2 was 4 (IQR: 3-5). At baseline, perfusion lesions were identified in 30 (47%), DWI lesions in 24 (38%) and symptomatic carotid and/or intracranial stenosis in 22 (34%) patients. Nine patients (14%) developed a new brain infarction on day-7 MRI, and all 9 patients had a baseline perfusion lesion. Thus, the rate of new brain infarction in patients with perfusion lesions at baseline was 30% (9/30). Of the 9 patients with new infarcts, 7 (78%) were clinically symptomatic, 5 (56%) had a negative baseline DWI, and 6 (67%) had normal vessel imaging. Conclusion: Our data suggest that the identification of a focal perfusion lesion during the imaging evaluation of TIA or minor stroke predicts a high rate of recurrent stroke within 1 week, even in the absence of identifiable vessel stenosis or DWI positivity on initial MRI.

Background & Significance: Echocardiographic left ventricular hypertrophy (LVH) and left atrial enlargement (LAE) reflect mortality and morbidity from cardiovascular disease. We aimed to investigate the association between echocardiographic findings and stroke subtypes and its implication in acute ischemic stroke. Methods: We retrospectively reviewed the records of 1692 patients with acute ischemic stroke, who were admitted within 7 days after symptom onset. Stroke subtypes were categorized according to the SSS-TOAST classification. LVH was defined as left ventricular mass index (LVMI) >115 g/m2 in men and >95 g/m2 in women, and moderate to severe LAE was defined as left ventricular volume index (LAVi) ≥34 ml/m2 in both gender. The demographic data and echocardiographic findings [LVMI, LAVi, and left atrial anterior-posterior diameter (LAD) and presence of LVH or LAE] were compared in each stroke subtype. Results: A total of 1002 patients who were classified as patients with large-artery atherosclerosis (LAA, n=525), patients with cardioembolism (CE, n=296), and patients with small vessel occlusion (SVO, n=181) were included. Echocardiographic variables showed trends in which larger LVMI, LAD, and LAVi in CE group compared with two other groups. Multivariate analysis was performed as comparison with SVO after adjusting for age, gender, hyperlipidemia, diabetes mellitus, and history of smoking. LVH and LVMI were significant independent predictors of LAA (OR 1.6, 95%CI 1.0-2.5, p=0.04 in LVH and OR 1.1, 95%CI 1.0-1.2 by increased LVMI 10g/m2, p=0.036), and all of moderate-to-severe LAE, LVH, LVMI, LAD and LAVi were significant independent predictors of CE (OR 16.7, 95%CI 8.3-33.7, p<0.001 in LAE; OR 2.4, 95%CI 1.5-3.8, p<0.001 in LVH; OR 1.2, 95%CI 1.11-1.3 by increased LVMI 10g/m2, p<0.001; OR 1.2, 95%CI 1.1-1.2 by increased LAD 1 mm, p<0.001; OR 1.2, 95%CI 1.1-1.2 by increased LAVi 1 ml/m2, p<0.001). Conclusions: Our studies demonstrate echocardiographic LVMI, LAD and LAVi are linked to specific stroke subtypes even after adjusting for established cardiovascular risk. These results suggest that consideration of echocardiographic indices is helpful to understand the pathomechanism in the ischemic stroke.

Background: Vitamin deficiency increase the risk of cardiovascular disease. Objective: We determined whether vitamin D deficiency is associated with 3 month functional outcome in acute ischemic stroke patients. Material and Methods: We retrospectively analyzed 328 consecutive patients with first-ever transient ischemic attack and acute ischemic stroke using prospective stroke registry. Serum 25-hydroxyvitamin D [25(OH)D] was obtained within 24 hours of hospital admission. Vitamin D deficiency was defined as serum 25(OH)D level of less than 10 ng/ml. Poor 3 month functional outcome was defined as modified Rankin Scale (mRS) 3-6. Multivariable logistic regression analysis was used to test whether Vitamin D deficiency is an independent predictor of poor 3 month functional outcome. Results: Mean age was 67.4 (±13.2) years, and 59.1% of patients were men. Mean level of 25(OH)D was 11.5 ± 6.1 ng/mL and 48.2% of patients were vitamin D-deficient. On bivariate analysis, vitamin D deficiency was associated with 4 seasonal variation (Pearson's X2, p = 0.008) and severe NIH Stroke Scale (NIHSS) score (Mann-Whitney U, p Conclusion: Vitamin D deficiency is highly prevalent in Korea, and associated with poor 3 month functional outcome in patients with acute ischemic stroke. Future trials should be designed to determine whether optimal vitamin D supplementation could improve functional outcomes of stroke patients.

Background and Objectives MUC5AC and MUC5B are representative secretory mucin genes in the human airway. MUC5AC and MUC5B expression are increased by a variety of inflammatory mediators. Betulinic acid, a naturally occurring pentacyclic triterpenoid, is known to have an anti-inflammatory property. However, the effects of betulinic acid on mucin secretion of airway epithelial cells still have not been reported. Therefore, in this study, the effect of betulinic acid on inflammatory mediators-induced MUC5AC and MUC5B expression was investigated in human airway epithelial cells. Materials and Method In the mucin-producing human NCI-H292 airway epithelial cells, the effects of betulinic acid on interleukin-1β (IL-1β)-, lipopolysaccharide (LPS)-, and phorbol myristate acetate (PMA)-induced MUC5AC and MUC5B expression were analyzed by reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay. Results Betulinic acid attenuated IL-1β-, LPS- and PMA-induced MUC5B mRNA and glycoprotein expression in NCI-H292 cells. Betulinic acid did not attenuate IL-1β-, LPS- and PMA-induced MUC5AC mRNA and glycoprotein expression in NCI-H292 cells. Conclusion These results suggest that betulinic acid attenuates IL-1β-, LPS- and PMA-induced MUC5B expression in airway epithelial cells. Therefore, betulinic acid may modulate a control of mucus-hypersecretion in airway inflammatory disease. Korean J Otorhinolaryngol-Head Neck Surg 2014;57(8):526-32

Background and ObjectivesZZNaringenin and delphinidin are types of anthocyanidin, which are flavonoids and thus have anti-inflammatory property.Moderate consumption of natural dietary naringenin and delphinidin is believed to do anti-inflammatory action, but the action mechanism is unclear.Therefore, this study aimed to investigate the effects of naringenin and delphinidin on interleukin-1β (IL-1β)and lipopolysaccharide (LPS)-induced MUC5AC and MUC5B expressions in airway epithelial cells.Materials and MethodZZIn NCI-H292 cells and cultured nasal polyp epithelial cells, the effects of naringenin and delphinidin on IL-1β-and LPS-induced MUC5AC and MUC5B expressions were analyzed by real-time polymerase chain reaction and enzyme-linked immunosorbent assay.ResultsZZDelphinidin attenuated IL-1β-and LPS-induced MUC5AC and MUC5B mRNA and glycoprotein expression in a dose-dependent pattern in NCI-H292 cells and in cultured nasal polyp epithelial cells.Naringenin partially attenuated IL-1β-and LPS-induced MUC5AC and MUC5B mRNA and glycoprotein expression at a high dose.ConclusionZZThese results suggest that delphinidin attenuates MUC5AC and MUC5B expressions in the airway epithelial cells.Between anthocyanidin and delphinidin, delphinidin exhibits greater potential as an ideal therapeutic agent for the control of mucus-hypersecretion in the treatment of airway inflammatory diseases.