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ABSTRACT: Febrile neutropenia caused by chemotherapy is a frequent medical emergency associated with severe complications in the emergency department (ED). Timely administration of antibiotics is believed to improve patient outcomes for several infectious diseases such as pneumonia and sepsis but has not been thoroughly evaluated for reducing risk of complications in chemotherapy-induced febrile neutropenia. The aim of this study was to evaluate associations between the risk factors and serious complications in patients presenting to the ED with febrile neutropenia. We reviewed the health information system database to identify a retrospective cohort of patients with febrile neutropenia who visited the ED of a tertiary medical hospital from January to December 2008. Only episodes of febrile neutropenia caused by chemotherapy for underlying cancer were included. Serious complications during hospitalization were defined as unstable hemodynamic status, respiratory distress, altered mental status, newly developed arrhythmia that required intervention, and death during hospitalization. Univariate and multivariate logistic regression analysis was performed to determine potential factors associated with serious complications. We further use decision tree approach to help analyze variables. Among a total of 81 febrile neutropenic episodes in 78 patients, 25 (30.8%) episodes of serious complications were identified. Latency of the first dose of antibiotics, pneumonia and platelet counts ≤ 50,000/mm(3) were identified as independent factors associated with serious complications of febrile neutropenia. Earlier administration of antibiotics is associated with fewer complications in patients presenting to the ED with febrile neutropenia. Copyright © 2013 John Wiley & Sons, Ltd.
Hematological Oncology 01/2013; · 2.47 Impact Factor
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ABSTRACT: Background: Heat shock proteins (HSPs) act as chaperones and have a protective function in cardiovascular diseases. The clinical association of a novel small HSPB7 with cardiovascular disease, however, has not been reported. The aim of this study was to investigate the potential biological functions of HSPB7 and its relationship with acute coronary syndrome (ACS). Methods and Results: A mouse myocardial infarction (MI) model and samples from clinical human subjects were used to determine plasma HSPB7 concentration after acute MI. The associations of plasma HSPB7 concentration with ACS and other risk factors of coronary artery disease were analyzed. Plasma HSPB7 concentration was found to be rapidly elevated in mice after coronary artery ligation. In addition, plasma HSPB7 concentration was significantly higher in patients with ACS than in control patients with non-cardiac chest pain (5.1ng/ml vs. 2.9ng/ml, P<0.001). Plasma HSPB7 was detected as early as 1-3h after the onset of symptoms and remained detectable up to 24h. Furthermore, in patients presenting to the emergency department with acute chest pain, HSPB7 level was an independent risk factor of ACS (adjusted odds ratio, 7.44; 95% confidence interval: 1.91-28.93, P<0.01). Conclusions: HSPB7 is a potential early biomarker after MI and serves as an independent risk factor of ACS in patients with acute chest pain. (Circ J 2012; 76: 2226-2233).
Circulation Journal 06/2012; 76(9):2226-33. · 3.77 Impact Factor
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ABSTRACT: The purpose of this trial was to establish whether changes in resting oxygen saturation (Spo(2)) during ascent of Jade Mountain is useful in predicting acute mountain sickness (AMS). AMS-risk factors were also assessed.
A prospective trial was conducted on Jade Mountain, Taiwan from October 18 to October 27, 2008. Resting oxygen saturation (Spo(2)) and heart rate (HR) were measured in subjects at the trail entrance (2610 m), on arrival at Paiyun Lodge (3402 m) on day 1, and at Paiyun Lodge after reaching the summit (3952 m) the next day (day 2). AMS was diagnosed with Lake Louise criteria (AMS score ≥4). A total of 787 subjects were eligible for analysis; 286 (32.2%) met the criteria for AMS.
Subjects who developed AMS had significantly lower Spo(2) than those who did not at the trail entrance (93.1% ± 2.1% vs 93.5% ± 2.3%; P = .023), on arrival at Paiyun Lodge on day 1 (86.2% ± 4.7% vs 87.6% ± 4.3%; P < .001), and on the return back to the Paiyun Lodge after a summit attempt on day 2 (85.5% ± 3.5% vs 89.6% ± 3.2%; P < .001), respectively. Trekkers with AMS were significantly younger (40.0 vs 43.2 years; P < .001), and had less high altitude (>3000 m) travel in the previous 3 months (29.9% vs 37.1%; P = .004).
Subjects with AMS had a lower Spo(2) than those without AMS; however, the differences between the 2 groups were not clinically significant. The results of this study do not support the use of pulse oximetry in predicting AMS on Jade Mountain.
Wilderness and Environmental Medicine 06/2012; 23(2):122-7. · 0.94 Impact Factor
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ABSTRACT: Tuberculosis infection caused by Mycobacterium tuberculosis or other Mycobacterium species is a major communicable disease worldwide.
We evaluated the epidemiology of tuberculous peritonitis to determine diagnostic features and factors related to late diagnosis.
We retrospectively reviewed 211 tuberculous peritonitis cases diagnosed between January 1999 and December 2009. Clinical features, laboratory data, and diagnostic methods were analysed.
Subjects included 115 males (54.5%) and 96 females (45.5%) with median age 61.0 years (range 43-72) and 29.2 days mean duration from symptoms to diagnosis. Disease histories included end-stage renal disease (20.9%), pulmonary tuberculosis (36.0%) and liver cirrhosis (23.7%). Most common symptoms were abdominal distension (80.1%), abdominal pain (68.7%) and weight loss (45.5%). Most common signs were ascites (62.6%) and fever (55.5%). One-year survival rate was 89.9%; 21 patients died during follow-up. Mortality risk was higher in patients with more concomitant diseases, including liver cirrhosis, AIDS, chronic steroid use, alcoholism, GI bleeding, haemoptysis, period from symptom presentation to treatment, secondary bacterial peritonitis requiring emergent operation.
Increased duration between symptoms and definitive diagnosis increases mortality risk. Early diagnosis and prompt initiation of anti-tuberculosis therapy improve prognosis. Neutrophil-predominant ascites influences poor prognosis when correlated with secondary bacterial peritonitis.
Digestive and Liver Disease 09/2011; 44(2):111-7. · 3.05 Impact Factor
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ABSTRACT: Medical simulation has been used to teach critical illness in a variety of settings. This study examined the effect of didactic lectures compared with simulated case scenario in a medical simulation course on the early management of severe sepsis.
A prospective multicentre randomised study was performed enrolling resident physicians in emergency medicine from four hospitals in Asia. Participants were randomly assigned to a course that included didactic lectures followed by a skills workshop and simulated case scenario (lecture-first) or to a course that included a skills workshop and simulated case scenario followed by didactic lectures (simulation-first). A pre-test was given to the participants at the beginning of the course, post-test 1 was given after the didactic lectures or simulated case scenario depending on the study group assignment, then a final post-test 2 was given at the end of the course. Performance on the simulated case scenario was evaluated with a performance task checklist.
98 participants were enrolled in the study. Post-test 2 scores were significantly higher than pre-test scores in all participants (80.8 ± 12.0% vs 65.4 ± 12.2%, p<0.01). There was no difference in pre-test scores between the two study groups. The lecture-first group had significantly higher post-test 1 scores than the simulation-first group (78.8 ± 10.6% vs 71.6 ± 12.6%, p<0.01). There was no difference in post-test 2 scores between the two groups. The simulated case scenario task performance completion was 90.8% (95% CI 86.6% to 95.0%) in the lecture-first group compared with 83.8% (95% CI 79.5% to 88.1%) in the simulation-first group (p=0.02).
A medical simulation course can improve resident physician knowledge in the early management of severe sepsis. Such a course should include a comprehensive curriculum that includes didactic lectures followed by simulation experience.
Emergency Medicine Journal 07/2011; 29(7):559-64. · 1.44 Impact Factor
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The American journal of emergency medicine 07/2011; 29(6):696.e3-4. · 1.54 Impact Factor
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ABSTRACT: The objective of this study is to investigate the role of sympathovagal balance in predicting inhospital mortality by assessing power spectral analysis of heart rate variability (HRV) among patients with nontraumatic subarachnoid hemorrhage (SAH) in an emergency department (ED).
A cohort of 132 adult patients with spontaneous SAH in an ED was prospectively enrolled. A continuous 10-minute electrocardiography for off-line power spectral analysis of the HRV was recorded. Using the inhospital mortality, the patients were classified into 2 groups: nonsurvivors (n=38) and survivors (n=94). The HRV measures were compared between these 2 groups of patients.
Having compared the various measurements, the very low-frequency component, low-frequency component, normalized low-frequency component (LF%), and low-/high-frequency component ratio (LF/HF) were significantly lower, whereas the normalized high-frequency component was significantly higher among the nonsurvivors than among the survivors. A multiple logistic regression model identified LF/HF (odds ratio, 2.16; 95% confidence interval [CI], 1.18-3.97; P=.013) and LF% (odds ratio, 0.78; 95% CI, 0.69-0.88; P<.001) as independent variables that were able to predict inhospital mortality for patients with SAH in an ED. The receiver operating characteristic area for LF/HF in predicting inhospital mortality was 0.957 (95% CI, 0.914-1.000; P<.001), and the best cutoff points was 0.8 (sensitivity, 92.1%; specificity, 90.4%).
Power spectral analysis of the HRV is able to predict inhospital mortality for patients after SAH in an ED. A tilt in the sympathovagal balance toward depressed sympathovagal balance, as indicated by HRV analysis, might contribute to the poor outcome among these patients.
The American journal of emergency medicine 05/2011; 30(5):651-6. · 1.54 Impact Factor
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ABSTRACT: The objective was to determine the diagnostic accuracy of procalcitonin measurement for bacterial infections in patients with all causes of liver cirrhosis.
The authors conducted a cross-sectional study of 98 patients with cirrhosis treated in the emergency department (ED) of Chang-Gung Memorial Hospital, Taiwan. Serum procalcitonin levels and other clinical information were obtained concurrently. Patients were assigned to a sepsis or nonsepsis group after the medical records were reviewed by two emergency physicians blinded to the study. Receiver operating characteristic (ROC) curve analysis was conducted to determine the sensitivity, specificity, likelihood ratio, and suggested cutoff values. The diagnostic accuracy of the C-reactive protein (CRP) level was also determined for comparison.
A total of 98 patients were enrolled for analysis in 1 year. Twenty-seven patients (27.6%) were assigned to the sepsis group. Eleven patients (11.2%) had positive blood cultures. The areas under the ROC curves for procalcitonin and CRP in predicting sepsis were 0.89 (95% confidence interval [CI] = 0.77 to 0.92) and 0.81 (95% CI = 0.72 to 0.89), respectively (p = 0.11). The cutoff that maximized Youden's index was 0.49 ng/mL for procalcitonin and 24.7 mg/L for CRP. At these cutoffs, the sensitivity and specificity were 81.5 and 87.3% for procalcitonin and 80.0 and 80.3% for CRP. These results suggest that procalcitonin measurement shows at least an equivalent diagnostic accuracy to CRP measurement.
Procalcitonin provided satisfactory diagnostic accuracy in differentiating bacterial infections in patients with all causes of liver cirrhosis in the ED. A cutoff value of 0.5 ng/mL is suggested for clinical use.
Academic Emergency Medicine 02/2011; 18(2):121-6. · 1.86 Impact Factor
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ABSTRACT: Since the implementation of National Health Insurance in Taiwan, Emergency Department (ED) volume has progressively increased, and the current triage system is insufficient and needs modification. This study compared the prioritization and resource utilization differences between the four-level Taiwan Triage System (TTS) and the standardized five-level Canadian Triage and Acuity Scale (CTAS) among ED patients.
This was a prospective observational study. All adult ED patients who presented to three different medical centers during the study period were included. Patients were independently triaged by the duty triage nurse using TTS, and a single trained research nurse using CTAS with a computer support software system. Hospitalization, length of stay (LOS), and medical resource consumption were analyzed by comparing TTS and CTAS by acuity levels.
There was significant disparity in patient prioritization between TTS and CTAS among the 1851 enrolled patients. With TTS, 7.8%, 46.1%, 45.9% and 0.2% were assigned to levels 1, 2, 3, and 4, respectively. With CTAS, 3.5%, 24.4%, 44.3%, 22.4% and 5.5% were assigned to levels 1, 2, 3, 4, and 5, respectively. The hospitalization rate, LOS, and medical resource consumption differed significantly between the two triage systems and correlated better with CTAS.
CTAS provided better discrimination for ED patient triage, and also showed greater validity when predicting hospitalization, LOS, and medical resource consumption. An accurate five-level triage scale appeared superior in predicting patient acuity and resource utilization.
Journal of the Formosan Medical Association 11/2010; 109(11):828-37. · 1.13 Impact Factor
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ABSTRACT: We sought to determine the diagnostic value of a D-dimer test for myocardial infarction (MI). The prospective cohort study was carried in the ED of a university hospital. All included patients were tested for D-dimer and cardiac troponin I (cTnI) on ED admission and additional cTnI 6 h later. AMI was retrospectively confirmed by employing the ESC-ACC-AHA-WHF 2007 universal definition. The discriminative value of D-dimer test was assessed by ROC curve analysis. Multivariate analysis was used to identify independent risk factors associated with D-dimer elevation other than MI. A total of 178 patients were included in this study. Median D-dimer levels were significantly higher in MI patients. A D-dimer value greater than 200 ng/ml was significantly associated with MI. When used alone, the test has a high sensitivity of 91.8% but a low specificity of 23.9%. Combined use of cTnI and D-dimer tests raised the sensitivity to 98.4% and helped early triage a subgroup of low risk patients. However, the test had the downside of 58% false positives. High false positives could be partly explained by the high prevalence of underlying hypercoagulable comorbidities. Diabetes mellitus with chronic renal insufficiency was identified as the strongest risk factor associated with D-dimer elevation in patients without MI. D-dimer test alone has a low diagnostic value for MI. Co-existing hypercoagulable conditions may confound the results. Combining cTnI and D-dimer tests enables early identification a low risk group of patients for MI at the cost of high false positives.
Journal of Thrombosis and Thrombolysis 04/2010; 30(4):472-8. · 1.48 Impact Factor
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ABSTRACT: Acute mountain sickness (AMS) is a pathophysiological symptom complex that occurs in high altitude areas. The AMS prevalence is reportedly 28% on Jade Mountain, the highest mountain (3952 m) in Taiwan. We conducted this study owing to the lack of annual epidemiological data on AMS in Taiwan. Between April 2007 and March 2008, 1066 questionnaires were completed by trekkers visiting Paiyun Lodge on Jade Mountain. Information in the questionnaire included demographic data, mountaineering experience, AMS history, and trekking schedule. Weather data were obtained from the Central Weather Bureau of Taiwan. The Lake Louise AMS score was used to record symptoms and diagnose AMS. The chi-square test or the Student t test was used to evaluate associations between variables and AMS. In our study, the AMS prevalence was 36%. It increased significantly at different rates at different locations on the Jade Mountain trail and varied significantly in different months. Rainy weather tended to slightly increase the incidence of AMS. A lower incidence of AMS was correlated with hig-altitude trekking experience or preexposure (p < 0.05), whereas a higher incidence of AMS was correlated with a prior history of AMS (p < 0.05). The trekkers with AMS were significantly younger, ascended faster from their residence to the entrance or to Paiyun Lodge, and ascended slower from the entrance to the Paiyun Lodge (p < 0.05), but the differences lacked clinical significance. No differences in the incidence of AMS based on blood type, gender, or obesity were observed. The most common symptom among all trekkers was headache, followed by difficulty sleeping, fatigue or weakness, gastrointestinal (GI) symptoms, and dizziness or lightheadedness. In conclusion, the AMS prevalence on Jade Mountain was 36%, varied by month, and correlated with trekking experience, preexposure, and a prior history of AMS. The overall presentation of AMS was similar to that on other major world mountains.
High altitude medicine & biology 01/2010; 11(1):43-9. · 1.58 Impact Factor
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Journal of Emergency Medicine 12/2009; 42(3):299-300. · 1.31 Impact Factor
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ABSTRACT: A 28-year-old woman presented at the emergency department (ED) with acute bilateral leg weakness and lost the ability to walk 1 day after noticing bilateral leg numbness and intermittent pleuritic pain for 3 weeks. Physical examination revealed bilateral decreased muscle strength with score 4 symmetrically in the legs and decreased deep tendon reflex. Laboratory tests indicated lymphopenia but no other grossly remarkable findings. Cerebrospinal fluid analysis demonstrated albuminocytologic dissociation. Electrophysiologic survey also indicated sensory-motor demyelinating polyneuropathy. The clinical picture was compatible with acute inflammatory demyelinating polyneuropathy (AIDP), the most prevalent form of Guillain-Barré syndrome (GBS). Plasma exchange was immediately arranged. After serial examination, pleuritic pain, persistent lymphopenia, positive immunologic findings of anti-DNA, and antinuclear antibodies led to a diagnosis of systemic lupus erythematosus (SLE). Prednisolone was added along with plasma exchange. The patient was able to walk after 2 weeks of therapy. Acute inflammatory demyelinating polyneuropathy presenting as the initial manifestation of SLE is rather rare. The precise mechanism of SLE-related AIDP remains unclear but is probably immune related. Although steroids are not recommended in the management of AIDP or GBS, patients with SLE-related AIDP may benefit from steroid therapy. This case highlights that early initiation of evaluation for SLE by ED physicians may facilitate correct diagnosis and better outcomes in patients presenting with GBS or AIDP in the ED.
The American journal of emergency medicine 10/2009; 27(7):900.e3-5. · 1.54 Impact Factor
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ABSTRACT: To compare the effectiveness of ice packs and hot water immersion for the treatment of centipede envenomations.
Sixty patients envenomated by centipedes were randomized into three groups and were treated with ice packs, hot water immersion, or analgesia injection. The visual analog score (VAS) for pain was measured before the treatment and 15 min afterward. Demographic data and data on local and systemic effects after centipede bites were collected. The VAS scores and the pain decrease (DeltaVAS) were compared between the three groups.
All patients suffered from pain at the affected sites; other local effects included redness (n = 49, 81.7%), swelling (n = 32, 53.3%), heat (n = 14, 23.3%), itchiness (n = 5, 8.3), and bullae formation (n = 3, 5.0%). Rare systemic effects were reported. All three groups had similar VAS scores before and after treatment. They also had similar effectiveness in reducing pain caused by centipedes bites (DeltaVAS = 2.55 +/- 1.88, 2.33 +/- 1.78, and 1.55 +/- 1.68, with ice packs, analgesia, and hot water immersion, respectively, p = 0.165).
Ice packs, hot water immersion, and analgesics all improved the pain from centipede envenomation. Ice pack treatment is a safe, inexpensive, and non-invasive method for pre-hospital management in patients with centipede envenomation.
Clinical Toxicology 08/2009; 47(7):659-62. · 2.22 Impact Factor
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Journal of Emergency Medicine 04/2009; 40(6):e123-4. · 1.31 Impact Factor
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ABSTRACT: Hemothorax is defined as collection of blood in the pleural cavity. Massive hemothorax may result in severe respiratory distress. We present an extremely rare cause of non-traumatic hemothorax in a 3 1/2-year-old girl by Bochdalek diaphragmatic hernia (BDH), and that was initially misdiagnosed as pneumonia with massive pleural effusion. Hemothorax masks the clinical and X-ray findings of BDH that makes the diagnosis even more difficult. Delayed or incorrect diagnosis of BDH complicated with respiratory distress leads to the wrong decision-making and the subsequent management, which may result in significant morbidity and mortality. Accordingly, emergency physicians need to be aware of this extremely rare etiology when evaluating pediatric hemothorax in a busy emergency department.
The American journal of emergency medicine 03/2009; 27(2):252.e1-2. · 1.54 Impact Factor
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ABSTRACT: Cyanosis is a bluish skin due to deoxygenated hemoglobin or methomoglobin in the arterial blood.Central cyanosis mostly results from cardiovascular or pulmonary shunts. Tet spell is an episodic central cyanosis due to total occlusion of right ventricle outflow in a patient with a congenital heart disease, such as Tetralogy of Fallot (TOF). There are limited cases of patients who lived with untreated TOF until adulthood. Tet spell in an adult is rarely seen in an emergency department. Early recognition of this condition, along with proper disposition andmanagement, can prevent majormorbidity or mortality. We report a 29-year-old man who presented with cyanotic spell and in whom a diagnosis of TOF was later confirmed. This case reminds us of TOF as a differential diagnosis of hypercyanotic crises and its unique manifestations and management.
The American journal of emergency medicine 02/2009; 27(1):130.e3-5. · 1.54 Impact Factor
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ABSTRACT: Wallenberg syndrome is also called lateral medullary syndrome or posterior inferior cerebellar artery syndrome. The clinical presentations include ipsilateral Horner syndrome, ipsilateral cerebellar signs, and the hypalgesia of ipsilateral face and contralateral body. A considerable number of cases of Wallenberg syndrome were reported to be associated with vertebral artery dissection (VAD). Nowadays, the preferred imaging tool comes down to magnetic resonance imaging because it provides high spatial resolution, which is especially important for assessment of lesions in posterior fossa. The optimal treatment of VAD remains controversial. Most patients receive conservative treatments with anticoagulants or antiplatelet drugs. Overall, most cases have good prognosis. However, the rarity and various presentations of VAD may challenge emergency physicians in making correct diagnosis in the emergency department. Hence, maintaining a high index of suspicion is needed for an early diagnosis, especially in young people without risk factors attributing to cerebrovascular accident.
The American journal of emergency medicine 02/2009; 27(1):131.e1-3. · 1.54 Impact Factor
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ABSTRACT: Wang, Shih-Hao(1,2) Tai-Yi Hsu,(1,2) Jen-Tse Kuan,(1,2) Jih-Chang Chen,(1,2) Wei-Fong Kao,(3) Te-Fa Chiu,(1,2) Yu-Cheng Chen,(1,2) and Hang-Cheng Chen.(1,2) Medical problems requiring mountain rescues from 1985 to 2007 in Yu-Shan National Park, Taiwan. High Alt. Med Biol. 10:77-82, 2009.-Medical problems requiring mountain rescue in densely populated and low-latitude locations like Taiwan have rarely been studied or discussed. The purpose of this research was to examine mountain-rescue operations that occurred in Yu-Shan National Park Taiwan from 1985 to 2007. Of 186 mountain-rescue operations, 128 involved medical problems (illnesses or injuries). Of the medical problems, 62% involved trauma and 41% involved illness. Ninety-nine ground rescues, 14 helicopter rescues, 38 combination ground and helicopter rescues, and 20 rescues using unclear methods were conducted, and the remaining 15 rescue operations did not involve visitors. In the 186 rescue operations, 330 visitors were rescued, 240 of them survived, 66 were dead, and 24 had an unclear outcome. Factors that affected the type of injury or the probability of survival included the activity, altitude, composition of the visitor group, weather, and occurrence of natural disasters. Mountain-rescue operations in which both ground and helicopter rescue were utilized were more successful. Our retrospective findings indicate that wilderness emergency services should have the capability of performing rescues in rugged terrain and be flexible in their approach to any situation arising in mountainous regions; proper training of onboard helicopter medical personnel is also necessary. In conclusion, we recommend setting up a standard system for reporting mountain- rescue operations, with statistics compiled annually.
High altitude medicine & biology 02/2009; 10(1):77-82. · 1.58 Impact Factor
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ABSTRACT: The content of the second edition of "Guideline for General Management of Patients with Acute Ischemic Stroke" was amended from the first edition of that of the Taiwan Stroke Society in 2002. The format of the guideline followed the common unified instruction for the project of "The establishment of clinical guidelines for the top 10 payments diseases of the National Health Insurance at the departments of inpatients, emergency and outpatients" as recommended by the National Health Research Institutes (NHRI). The guideline was revised after several official meetings of local experts, as well as citation from the latest updated guidelines of the United States and the European Stroke academic groups. Before editing notice, the final evaluation was performed by the review team of the NHRI. Application of the guideline is dedicated or designated to the patients with acute ischemic stroke, and which is applied only limited to the general management. Guidelines for subacute or chronic phase, or the specific treatment for ischemic stroke patients will be published in separated articles. Management of most of the needs for patients with acute ischemic stroke must be completed in a very short period of time. It is recommended that hospitals providing stroke service to set up stroke unit, and to organize an integrated stroke team consisting of specialists from multiple disciplines. Upon arrival to the hospitals, patients should undergo the brain computed tomography, and related examinations and assessment as soon as possible to guide the choice of treatment reference for acute intervention. Intravenous recombinant tissue plasminogen activator treatment within three hours is effective in reducing disability for patients with acute ischemic stroke. Ischemic stroke patients with or without persistent symptoms should start antiplatelet therapy immediately, generally aspirin. Dose-adjusted warfarin (INR range of 2.0-3.0) is recommended for ischemic stroke patients with persistent or paroxysmal atrial fibrillation to prevent secondary embolism. The routine use ofheparin and drugs theoretically preventing further brain injury, including steroids, neuroprotectants, plasma volume expanders, barbiturates, and streptokinase, has not been proven benefits for recommendation.
Acta neurologica Taiwanica 01/2009; 17(4):275-94.
