Predictive Value of Multimodal Evoked Potentials in Comatose Survivors after Cardiac Arrest

PURPOSE: To evaluate the prognostic value of multimodal evoked potentials in predicting both awakening and failure to awake from coma due to cardiac arrest. METHODS: Multimodal evoked potentials composed of somatosensory evoked potentials (SEPs), visual evoked potentials (VEPs) and brainstem auditory evoked potentials (BAEPs) were recorded for 46 patients with anoxicischemic encephalopathy who had coma duration>24 h. Patients with trauma, stroke, malignancy, or age<14 y were excluded. Outcomes were categorized as awakening (GOS 3-5) vs. vegetative state or death (GOS 1-2). RESULTS: Forty-one percent of patients regained consciousness, and 59% died or remained vegetative. Bilaterally absent SEP N20 peaks predicted non-awakening with a sensitivity of 52% and a specificity of 100%. Unilaterally or bilaterally absent BAEP III-V predicted non-awakening with a sensitivity of 12% and a specificity of 100%. Using bilaterally absent SEP N20 peaks, unilaterally or bilaterally absent BAEP III-V, or both of the above predicted non-awakening with a sensitivity of 56% and a specificity of 100%. Bilaterally present SEP N20 peaks predicted awakening with a sensitivity of 100% and a specificity of 63%. However, the combination of bilateral presence of SEP N20 and VEP P100 in predicting awakening increased the specificity to 74%, reaching a sensitivity of 89%, a PPV of 71% and a NPV of 91%. CONCLUSION: Non-awakening in postanoxic coma can be reliably predicted with SEPs and BAEPs. Bilaterally preserved SEPs and VEPs predicted awakening with an accuracy of 80% at 1~4 days after cardiopulmonary resuscitation.

Multicenter Investigation on Clinical Characteristics, Cognitive Impairments, Behavioral and Psychological Symptoms of Demented Elderly in Busan-Gyeongnam Province

OBJECTIVES: The purpose of this study is to examine the state of demographic findings with clinical characteristics, cognitive impairment and behavioral psychological symptoms of demented elderly in Busan-Gyeongnam Province. METHODS: Patients with dementia who were registered at nine medical centers in Busan Metropolitan City and Gyeongnam Province were the major subjects of this study. Data was collected by face-to-face interview. The final sample consisted of 144 cases after eliminating several incomplete questionnaires. Based on the collected data, the authors evaluated demographic findings, clinical characteristics, and cognitive impairment and behavioral psychological symptoms of the patients with dementia using statistical analyses. All of the patients were taken the Korean version of Mini-Mental State Examination(K-MMSE), the Clinical Dementia Rating Scale(CDR) and the the Korean version of Neuropsychiatric Inventory(K-NPI). RESULTS: Approximately 61% of the patients with dementia in Busan-Gyeongnam Province were women, and their mean age was 72.9(SD=8.3) years old. Their average education level was 2.3(SD=1.3) years. Among the demented elderly, Alzheimer's disease accounted for 68% compared with vascular dementia(32%) and the proportion of mild stage of dementia was above 50%. The mean K-MMSE score was 16.7(SD=6.2), the mean CDR score was 1.3(SD=0.8), and the Barthel Index with K-IADL score were 16.7(SD=5.4) and 1.5(SD=0.9). The average score of K-NPI was 22.6(SD=22.5) and the number of manifested K-NPI was 4.9(SD=2.8). The K-NPI score has increased in demented elderly as the severity of dementia getting worse according to the CDR score. The number of manifested K-NPI was significantly more prevalent in patients with AD than that of patients with VD. CONCLUSION: This study is a meaningful approach to the state of demographic findings, clinical characteristics, cognitive impairment and behavioral psychological symptoms associated with the dementied elderly who were comprehensively examined in Busan-Gyeongnam Province. Based on this study, we found that the demographic information was comparable with other epidemiologic study in Korea and our study patients were relatively mild stage of demenitia according to the assessment of cognition and behavioral symptom scales.

The Differences of Clinical Features between Alzheimer's Disease and Vascular Dementia According to Progression

BACKGROUND: The differences in clinical features are important when differentiating between Alzheimer's disease (AD) and vascular dementia (VD). There have been many studies comparing the severity of progression in both diseases. They have assessed individual symptoms but have not explained the differences and global change of progression comprehensively. We have evaluated the cognitive and non-cognitive functions at the same time and evaluated the differences between AD and VD. METHODS: One hundred and thirty-eight dementia patients from Busan?Gyeongnam Dementia Association outpatient clinics were analyzed. All of the patients underwent the Korean version of the Mini-Mental State Examination (K-MMSE), the expanded version of the Korean Clinical Dementia Rating Scale (CDR), the Korean version of the Neuropsychiatric Inventory (K-NPI), the scales for activity of daily living, and the Short form of the Samsung Dementia Questionnaire (S-SDQ). RESULTS: There were 93 patients with AD and 45 with VD. VD patients revealed more severe Barthel Index of Activity of Daily Living (B-ADL) deficits. AD patients had more severe memory and orientation deficiency in CDR 1 and CDR 2. VD patients revealed much faster decline of K-MMSE score between CDR 2 and CDR 3. CONCLUSIONS: These results suggest that VD patients display more severe B-ADL difficulty, while AD patients display more severe memory difficulty and disorientation. B-ADL progresses in the earlier stages in VD and in the later stages in AD. Global cognitive dysfunction progression is the opposite: in the earlier stages in AD and in the later stages in VD.

The Differences of Behavioral and Psychological Symptoms in the Patients of Alzheimer's Disease and Vascular Dementia

BACKGROUND: Behavioral and psychological symptoms (BPSD) are common in dementia. These may be helpful for clinical differentiation between Alzheimer's disease (AD) and vascular dementia (VD). Most previous studies have reported the prevalence and severity of BPSD regardless of severity of progression. However, we evaluated the differences of BPSD by grading dementia progression and including severe cases only. METHODS: 141 dementia outpatients from clinics of Busan-Gyeongnam Dementia Association in Korea were analyzed. All patients were administered the Korean version of the Neuropsychiatric Inventory (K-NPI), the expanded version of Korean Clinical Dementia Rating Scale (CDR), and the Korean version of Mini-Mental State Examination (K-MMSE). RESULTS: There were 95 patients with AD and 46 patients with VD. AD patients revealed higher frequency of manifested BPSD symptoms and most of subscales showed higher composite scores also. But apathy was more severely and frequently manifested in VD. AD patients had more frequent night-time behavior and aberrant motor symptoms above 3 point in CDR 0.5 and VD patients had more frequent apathy symptom above 3 point in CDR 1. CONCLUSIONS: These results suggest that generally AD patients revealed more frequent and severe BPSDs than VD patients. Apathy was a more dominant symptom in VD. It seemed that some of the symptoms were valuable clues for the differential diagnosis even though a better designed study was required.

Factors Affecting Depression and Life Satisfaction in Family Caregivers of Patients with Dementia

BACKGROUND: The purposes of this study were to examine the state of depression and life satisfaction of family caregivers and to find out which factors would be significant in determining depression and life satisfaction of caregivers for the elderly with dementia. METHODS: Caregivers of patients with dementia who were registered at nine medical centers in Busan Metropolitan City and Gyeongnam Province were the major subjects of this study. Data was collected by face-to-face interviews. The final sample consisted of 144 cases after eliminating several incomplete questionnaires. Based on the collected data, the authors evaluated demographic findings, general characteristics, and factors influencing depression and life satisfaction of the caregivers using statistical analyses. RESULTS: The severity of depression and the degree of life satisfaction in family caregivers were low. We found that caregiver's anxiety, monthly income, caregiver burden, non-relative network, self-confidence of caregiving, and the degree of the Barthel index of activity of daily living (B-ADL) were significant factors in determining depression of the caregivers (p<0.05). The following two variables were significant factors in determining the caregiver's level of life satisfaction: burden of caregiving costs and patient's Korean mini-mental state examination (K-MMSE) score (p<0.05). CONCLUSIONS: Our results showed that the level of anxiety, caregiver burden and social support, rather than the conditions of dementia patients, influenced depression and life satisfaction for the caregivers of patients with dementia. Therefore, in order to improve the quality of life for caregivers, we should consider psychosocial factors as well as patient's medical factors in influencing depression and life satisfaction.

The Effect of Semen Contamination on the Urine Dipsticks / 임상검사와정도관리

BACKGROUND: The dipstick methodology is the most fundamental urinalysis but interfered by many factors. We evaluated the effect of semen contamination on the urine dipsticks. METHODS: Thirty-two specimens for semen analysis were enrolled. After semen was directly applied on urine dipsticks, residual samples were diluted in pooled normal urine. Urine dipsticks were performed at each dilution titer. Seminal plasma separated by centrifugation of semen were also tested in the same manner. RESULTS: All semen showed positive results for blood, protein and leukocytes. The intensities of reaction for blood and leukocytes were correlated with sperm concentration. The negative conversion of blood and protein occurred at 1:100, and that of leukocytes occurred at 1:50. Seminal plasma showed nearly the same findings. CONCLUSIONS: Semen contamination of urine may cause false positive reaction especially for blood and protein on the urine dipsticks. It should therefore be considered when assessing unexplained, transient hematuria or proteinuria.

The Difference of Caregiver Burden in Patients with Alzheimer's Disease and Vascular Dementia

BACKGROUND: The burden on caregivers of patients with dementia has an impact on medical, economic, and social areas. However, not enough attention is given to this burden in Korea. There are also very few reports comparing the burden experienced by caregivers of patients with Alzheimer's disease (AD) and vascular dementia (VD). METHODS: One hundred and forty four Alzheimer's and vascular dementia patients were recruited by nine medical centers in the metropolitan city of Busan and the Gyeongnam province. We evaluated the global dementia state of patients in terms of cognitive functions, behavioral and psychological symptoms of dementia, and the activity of daily living along with caregiver burden with the length of care time per day. The Burden Interview, Caregiver Burden Inventory (CBI), Life Satisfaction Index-Z, Beck Depression Inventory, and Beck Anxiety Inventory were conducted by face-to-face interviews with the caregivers. We compared the differences of caregiver burden related to the cause of dementia and according to dementia severity. RESULTS: There were 98 AD patients (68.1%) and 46 VD patients (31.9%). There were 89 females (61.8%) and 55 males (38.2%). Most of the global dementia states did not differ between AD and VD except for the Barthel index (p<0.05). Most of the caregiver burden tests were scored worse in VD. The differences of CBI-time dependent burden and CBI-developmental burden were statistically significant in all the patients (p<0.05). CONCLUSIONS: Our study suggests that VD patients have more caregiver burden than AD patients and that the physical activity of daily living influences caregiver burden.

The Change of Cognitive Function and Prognostic Factor in Alzheimer's Disease: 1-Year Follow-up Study

BACKGROUND: The rate of cognitive change and prognostic factor in Alzheimer's disease are important for clinical management, but little is known in Korea. We report a one year follow-up study of comprehensive evaluation including cognitive functions, behavioral and psychological symptoms of dementia (BPSD) and activity of daily living (ADL). METHODS: 43 patients with Alzheimer's disease were enrolled. All subjects received the Korean version of Mini-Mental State Examination (K-MMSE), the Severe Dementia Scale (SDS), the extended version of Korean Clinical Dementia Rating Scale (CDR) and Sum of Box (CDR-SB), the Barthel index of Activity of Daily Living (B-ADL), the Korean Instrumental Activity of Daily Living (K-IADL) and the Korean version of the Neuropsychiatric Inventory (K-NPI). We retested each scale after 1 year and evaluated the changes. RESULTS: The mean change rates of K-MMSE, SDS, CDR, CDR-SB and B-ADL scores were 2.0 +/- 3.2 (-7~8) mean +/- SD (range), 3.5 +/- 4.9 (-7~14), -0.4 +/- 0.7 (-2~1), -0.8 +/- 4.4 (-10~9) and 1.5 +/- 3.7 (-7~9). The change of K-MMSE and B-ADLscore according to CDR were significantly different. The annual rates of changes of scores on K-MMSE, B-ADL and CDR were largest in CDR 1 group (K-MMSE: 4.0 +/- 2.7, B-ADL: 3.4 +/- 2.8, CDR: -1 +/- 0.7). The change rate of SDS was largest in CDR 4 (7.2 +/- 4.3). There were not any significant factors that affected the change of K-MMSE, SDS, B-ADL or CDR. CONCLUSIONS: These results suggest that K-MMSE is sensitive to the early stage and SDS is sensitive to the later stage. The deterioration rate of cognitive function in Alzheimer's disease is large at middle stage.

Which is the Treatment of Choice for Acute Acetaminophen Overdose in a Situation Where a Serum Level Determination is Not Available Within 8 Hours: Oral or Intravenous N-Acetylcysteine Treatment?

PURPOSE: The purpose of this study was to develop therapeutic decision guidelines on N-acetylcysteine (NAC) treatment for acetaminophen (AAP) overdose in a situation where a serum level determination is not available within 8 hours. METHODS: We reviewed retrospectively the medical records of patients admitted for AAP overdose from January 2001 to February 2004. Forty-nine patients met inclusion criteria; patients with acute AAP overdose who were exposed to 7.5 g or 140 mg/kg or greater, determination of the serum level was not available within 8 hours, and NAC treatment was started empirically before identification of the serum level. The patients had been treated with a 72hour oral or a 20hour intravenous (IV) NAC treatment protocol. RESULTS: Patients were classified into an Oral NAC (n=24) group and an IV NAC (n=25) group based on the treatment protocol. There were no significant intergroup differences in patient characteristics, time variables, distribution of risk categories, and hepatotoxicity. All the patients in both toxic groups were fully recovered, and the difference in the number of adverse reactions during NAC treatment were not significant between the two groups (Oral NAC vs IV NAC, 4 (16%) vs. 2 (8%), respectively; p=0.417). The numbers of patients who discontinued the NAC treatment were 14 (58%) in the Oral NAC group and 8 (32%) in the IV NAC group (p=0.088). The six patients in the nontoxic category of IV NAC group were already completed before determination of the serum level. CONCLUSION: Therapeutic decisions for AAP overdose which are based entirely on ingestion history have some limitations. IV NAC is as effective as oral treatment for patients with acute AAP overdose. If the serum level is not available within 8 hours, the clinician should preventively administer the first dose of oral NAC to patients without severe vomiting. Subsequently, when the serum level is determined, the need for additional therapy should be determined to reduce unnecessary use of NAC. However, if the patients present with severe vomiting or contraindications to oral treatment, intravenous administration is required.

Torsion of an Accessory Spleen Presenting as an Acute Abdomen: A Case Report

An accessory spleen is often incidentally discovered in up to 20% of autopsies. However, it is exceedingly rare for this condition to result in an acute abdomen. In addition, torsion of an accessory spleen is extremely rare. In spite of this, the entity should be considered in the emergency department in the differential diagnosis of an acute abdomen associated with an intraperitoneal inflammatory mass. This report describes a case of acute torsion of an accessory spleen. A 26-year-old, previously health female was admitted to our hospital with severe abdominal pain and a palpable mass. Ultrasonography showed a well-defined ovoid, hypoechogenic, avascular mass. Computed tomography demonstrated a round, homogeneous hypodense mass with a whorling appearance and an engorged vascular structure in the left side of the mass. The presumptive diagnosis of a large exoenteric mass (small bowel or mesenteric origin) associated with mesenteric volvulus was made preoperatively. However, at laparotomy, the patient was found to have torsion and an infarction of an accessory spleen that had twisted on its long vascular pedicle.

Development of the Korean Stroop Test and Study of the Validity and the Reliability

BACKGROUND: The Stroop color word test is useful to examines the frontal lobe function of selective attention and inhibition. The Korean Color Word Stroop Test(K-CWST) was widely used in Korea. But, it was difficult in elderly individual with low educational level and visual problem and in patients with more progressed dementia. So we developed the Korean Stroop Test(KST). METHODS: The KST consist of word reading(WR), color naming(CN), interference word reading(IWR) and interference color naming (ICN). The interference tasks are naming the ink color of color words which were mismatched with word meaning. We measured reaction time and number of error. This study used the K-CWST to assess and compare the KST in eighteen probable alcohol related dementia patients and nineteen normal control. All subjects received the Korean version of Mini-Mental State Examination (K-MMSE) and the K-CWST and the KST. We tested reliability and validity of the KST. Also we enrolled normal adult from 41 to 80 year old for evaluating the change of the KST test with age. RESULTS: The KST tasks were correlated with K-MMSE -0.33(p<0.05) to -0.63(p<0.001) and K-CWST correlated with K-MMSE 0.37 (p<0.05) to 0.55(p<0.01). The interference color naming of KST was correlated the most to K-MMSE -0.78(p<0.001). The interference color naming of KST and interference color naming of K-CWST was correlated by 0.81(p<0.001). The internal consistency were 0.78 (Cronbach's alpha). The KST score was statistically different between alcohol related dementia patients and normal subjects in CN, ICN and ICN error. The KST was not differ in old age group except some tasks. CONCLUSION: The KST has a excellent reliability and validity. It takes less time and easy than the K-CWST. So the KST is a good test for evaluating frontal lobe function in elderly with low educational level of older people.

A Familial Nemaline Myopathy

Nemaline myopathy is a rare congenital m opathy, characterized by nonprogressive or slowely progressive muscle weakness associated with rod-like structures in muscle fibers and characteristic dysmorphic features. We report the first farnilial nemaline myopathy in two generations of the same family, confirmed by muscle biospy in an 11-year-old boy and his mother. The patients had hypotonia and slowly progressive muscle weakness of the four limbs associated with characteristic facial dysmorphism and skeletal deformities. Light and electron microscopic study of a muscle biopsy showed numerous nemaline rods in both patients.

Short-term Prognosis of Dysphagia in Acute Ischemic Brain Stroke

We evaluated and investigated the short-term (one-week) prognosis of dysphagia and its clinical predictors in 46 ischemic brain stroke(IBS) pteients with dysphagia. Patients were divided into improving or non-improving group. Between the two groups. We compared and analyzed such clinical characteristics in IBS patients with dysphagia as age, sex, site and location of IBS, cranial nervous system deficits other than dysphagia. Dysphagia severity and Canadian Neurological Scale score. The results are as follow: 1. At one week after admission, 27 patients(58.7%) showed improving course and 23 patierits (50%) returned to nomral. 2. All the clinical characteristics e-aluated did not reveal any significance in predicting the prognosis of dysphagia in IBS patients.