Recurrent Bacterial Meningitis due to Osteomyelitis of the Odontoid Process

Recurrent meningitis is defined as more than one episode of meningitis that is separated by an entire recovery period. Causes of recurrent meningitis include anatomical defects, immune deficiency, and parameningeal infections. A thorough investigation of the underlying causes of recurrent meningitis is required for proper treatment. Herein we report a case of recurrent bacterial meningitis caused by osteomyelitis of the odontoid process.

Suicidality and Its Risk Factor in Migraine Patients

Background@#Migraine patients have a higher frequency of suicidality than people without migraine. The aim of this study was to identify suicidality and its risk factors in migraine patients. @*Methods@#We enrolled 358 migraine patients from 11 hospitals. We collected data regarding their clinical characteristics and the patients completes the questionnaires. We also interviewed patients with the Mini International Neuropsychiatric Interview (MINI)plus version 5.0.0 to identify their suicidality. The International Classification of Headache Disorders, third edition, beta version was used in headache diagnosis. @*Results@#The frequency of suicidality in migraine patients was 118 (33.0%). Migraine patients with suicidality were more likely to have a major depressive disorder or generalized anxiety disorder than those without suicidality. Among variables, risk factors for suicidality in migraine patients were female (odds ratio [OR], 4.110; 95% confidence interval [CI], 1.55310.878; p=0.004), attack duration (OR, 2.559; 95% CI, 1.2105.413; p=0.011), Patient Health Questionnaire9 (OR, 1.111; 95% CI, 1.0381.189; p=0.002), and Generalized Anxiety Disorder7 (OR, 1.194; 95% CI, 1.1011.294; p<0.001). @*Conclusions@#Suicidality in migraine patients is common. Therefore, clinicians who take care of migraine patients should be concerned about suicidality and its risk factors such as female gender, attack duration, depression or anxiety.

Trends in Prescribing of Antiseizure Medications in South Korea: Real-World Evidence for Treated Patients With Epilepsy

Background@#and Purpose We investigated the trends in the prescribing of antiseizure medication (ASM) over a 9-year period, and provide real-world data regarding ASM prescriptions of patients with epilepsy in South Korea. @*Methods@#This study used data in the Korean National Health Information Database for the period from 2009 to 2017. We included 18 oral ASMs, which were classified into older and newer ASMs based on them first becoming available on the market before or after 1991, respectively. The annual trends in ASM prescriptions were plotted over the 9-year study period, and changes in these trends were evaluated as average annual percentage changes (AAPCs) using Poisson regression. Age- and sex-stratified analyses were also conducted. @*Results@#Overall, the proportion of prescriptions involving polytherapy with three or more ASMs increased from 10.08% in 2009 to 10.99% in 2017 (AAPC=0.9%, p<0.001) over the 9-year study period. Among monotherapies, although valproate (VPA) was the most frequently prescribed ASM, the prescription rate of levetiracetam (LEV) steadily increased regardless of age and sex over the study period. The monotherapy prescription trends differed depending on age and sex. In the five most frequently used ASM combination regimens, the prescription rates of VPA/LEV, LEV/oxcarbazepine, and LEV/lamotrigine regimens showed increasing tendencies. In contrast, prescription rates for all combined regimens of older ASMs declined over time in all age groups. @*Conclusions@#This is the first epidemiological study of the changes in prescription trends for ASM in South Korea based on nationwide data from 2009 to 2017. We found progressive increases in the use of newer ASMs for both monotherapy and duotherapy, and for polytherapy with three or more ASMs over the 9-year study period.

Prevalence and Public Awareness of Sleep Apnea Syndrome in South Korea

Objectives@#In South Korea, a significant number of patients with obstructive sleep apnea have benefited from the insured continuous positive pressure for sleep apnea as of 2018. However, there is limited information on public awareness of sleep apnea syndrome in the country. A nationwide survey was conducted to evaluate the current status of public awareness on the diagnosis and treatment of sleep apnea. @*Methods@#We conducted an online survey using structured questionnaires on symptoms and knowledge of diagnosis and treatment modalities for sleep apnea. A total of 4,000 participants aged 21 to 69 were proportionally allocated according to the residential area, gender, and age group. @*Results@#The STOP questionnaire, a screening tool for sleep apnea, revealed that 1,044 (21.6%) scored ≥2 points, 327 (8.1%) scored ≥3 points, and 64 (1.6%) scored 4 points. However, only 19 of the 1,044 patients were being treated for sleep apnea, and 13 had been using continuous positive airway pressure. For the diagnosis of sleep apnea, 1,318 participants (33.0%) responded that polysomnography was necessary. For sleep apnea treatment, 1,954 (48.9%) participants responded that lifestyle modification was the treatment of choice, while 1,036 (25.9%) chose continuous positive pressure. @*Conclusions@#Although one-fifth were at high risk for sleep apnea, this disorder is still underestimated. Therefore, publicity and support are needed to improve public awareness of sleep apnea.

Consideration for Coronavirus Disease 2019 Drug Treatment in Patients with Epilepsy on Antiepileptic Drugs

Several medications are approved to treat coronavirus disease 2019 (COVID-19) in Korea including nirmatrelvir/ritonavir, remdesivir, and regdanvimab. There is potential drug-drug interaction between antiepileptic drugs (AEDs) and the medications used to treat COVID-19. Several AEDs such as phenytoin, carbamazepine, phenobarbital, and primidone are strong cytochrome P450 inducers and can inhibit the drugs used for COVID-19. Particularly, these drugs are contraindicated with nirmatrelvir/ritonavir (Paxlovid®). There is a weaker drug-drug interaction between the AEDs and remdesivir. No significant interaction has been reported between the AEDs and molnupiravir. Pharmacokinetic interactions of the AEDs are important in effective management of COVID-19 in patients with epilepsy.

Increasing Trends in the Incidence and Prevalence of Epilepsy in Korea

Background@#and Purpose There have been few reports on recent trends in the occurrence of epilepsy. The aim of this study was to estimate the incidence and prevalence of epilepsy and analyze their annual trends in Korea over the period 2009–2017. @*Methods@#This nationwide population-based study was carried out using the National Health Insurance Service of Korea database. A prevalent case was defined as one of a patient receiving a prescription of anticonvulsants under the diagnostic codes for epilepsy or seizure. An incident case was ascertained by confirming the absence of any epilepsy-related diagnostic codes and anticonvulsant prescription for 2 years or more before the operational definition for a prevalent case was met. Alternative operational definitions for epilepsy were tested. The temporal trends of the incidence and prevalence of epilepsy were analyzed using a Poisson regression model, and are expressed as average annual percentage changes (AAPCs). @*Results@#The incidence of epilepsy increased from 28.7/100,000 persons in 2009 to 35.4/100,000 persons in 2017. The prevalence increased gradually from 3.4/1,000 persons in 2009 to 4.8/1,000 persons in 2017. These increasing trends were more evident among elderly subjects aged ≥75 years and in those who had codes for epilepsy or seizure as an additional diagnosis. Age standardization revealed a less prominent but still increasing trend in both incidence (AAPC=0.48%) and prevalence (AAPC=3.11%). @*Conclusions@#There have been increasing trends in both the prevalence and incidence of epilepsy in Korea between 2009 and 2017. This finding appears to be related to societal aging and the high incidence of symptomatic epilepsy in the elderly population.

Increasing Trends in the Incidence and Prevalence of Epilepsy in Korea

Background@#and Purpose There have been few reports on recent trends in the occurrence of epilepsy. The aim of this study was to estimate the incidence and prevalence of epilepsy and analyze their annual trends in Korea over the period 2009–2017. @*Methods@#This nationwide population-based study was carried out using the National Health Insurance Service of Korea database. A prevalent case was defined as one of a patient receiving a prescription of anticonvulsants under the diagnostic codes for epilepsy or seizure. An incident case was ascertained by confirming the absence of any epilepsy-related diagnostic codes and anticonvulsant prescription for 2 years or more before the operational definition for a prevalent case was met. Alternative operational definitions for epilepsy were tested. The temporal trends of the incidence and prevalence of epilepsy were analyzed using a Poisson regression model, and are expressed as average annual percentage changes (AAPCs). @*Results@#The incidence of epilepsy increased from 28.7/100,000 persons in 2009 to 35.4/100,000 persons in 2017. The prevalence increased gradually from 3.4/1,000 persons in 2009 to 4.8/1,000 persons in 2017. These increasing trends were more evident among elderly subjects aged ≥75 years and in those who had codes for epilepsy or seizure as an additional diagnosis. Age standardization revealed a less prominent but still increasing trend in both incidence (AAPC=0.48%) and prevalence (AAPC=3.11%). @*Conclusions@#There have been increasing trends in both the prevalence and incidence of epilepsy in Korea between 2009 and 2017. This finding appears to be related to societal aging and the high incidence of symptomatic epilepsy in the elderly population.

Epilepsy and Mortality

Epilepsy is associated with an increased risk of premature death. Epilepsy-related premature mortality imposes a significant burden on public health. This review aims to update the previous assessments of mortality among people with epilepsy and to identify associated factors, causes of death, and preventable causes of death in epilepsy patients. We also reviewed the mortality of epilepsy patients who had undergone epilepsy surgery. Finally, we suggest a further direction of studies about the mortality of people with epilepsy.

Cefepime-Induced Encephalopathy in a Tertiary Medical Center in Korea

Background@#and Purpose: Cefepime is a widely used fourth-generation cephalosporin. It is commonly used as a first-line antibiotic to treat various infectious diseases such as hospital-acquired pneumonia, urinary tract infections, and bacterial meningitis. The primary outcome of this study was the development of cefepime-induced encephalopathy (CIE) at a tertiary medical center in Korea. We also aimed to describe the clinical features of CIE. @*Methods@#We enrolled 1,793 consecutive patients treated with cefepime. The CIE group included 44 patients who experienced altered consciousness after receiving cefepime without any other obvious cause and showed full recovery after stopping cefepime. This study collected demographic data, laboratory findings, and clinical data including the cause of infection, duration for onset of altered consciousness, duration of cefepime treatment, dosage of cefepime, duration of recovering consciousness after stopping cefepime, sequelae after encephalopathy, and electroencephalography data. @*Results@#Forty-four (2.5%) patients were included in the CIE group. The age was significantly higher in the CIE group than in the control group (71.2±10.8 years vs. 64.7±16.1 years, mean± standard deviation; p=0.007), and females constituted a significantly large proportion in the CIE group (27 of 44, 61.4%). The CIE group had higher blood urea nitrogen (34.7±22.6 mg/dL vs. 23.0±17.5 mg/dL, p<0.001) and creatinine (2.2±2.5 mg/dL vs. 1.1±1.3 mg/dL, p<0.001), and lower estimated glomerular filtration rate (eGFR) (56.3±46.0 mL/min/1.73 mm 2 vs. 98.8±66.3 mL/min/1.73 mm 2 , p<0.001). Multivariate analysis showed that only eGFR was significantly related to CIE. @*Conclusions@#The incidence of CIE was 2.5% in this study. It is essential to consider the possibility of CIE occurring, especially in patients with lower values of eGFR and dialysis.

Reversible Splenial Lesion in the Corpus Callosum Associated with Glufosinate Ammonium Intoxication

No abstract available.

Hypoglycemic Convulsive Seizure Due to Late Dumping Syndrome

Dumping syndrome is a common complication of esophageal or gastric surgery. Patients with late dumping syndrome usually suffer from hypoglycemic symptoms such as palpitation, tremor, and general weakness. Hypoglycemia induced convulsive seizure due to late dumping syndrome is rarely reported. We report a 46-year-old man with postprandial hypoglycemic convulsive seizure as the first symptom of late dumping syndrome.

Transient Global Amnesia after Gastroscopy

No abstract available.

Steroid Non-responsive Hashimoto's Encephalopathy Improved by Rituximab

Hashimoto's encephalopathy is a rare autoimmune disease, with symptoms of encephalopathy and high titers of serum anti-thyroid antibodies. Current diagnostic criteria include corticosteroid responsiveness, but in some cases, they are refractory to corticosteroids. In steroid non-responders, other immunomodulatory therapies could be applied. Recently, Rituximab is reported as a safe and effective treatment for Hashimoto's encephalopathy. We report a 50-year-old woman with Hashimoto's encephalopathy presented with confusion and catatonia who was refractory to corticosteroid and immunoglobulin but effectively treated with rituximab.

Clinical Characteristics of REM-Dependent Obstructive Sleep Apnea in Korean Adults

BACKGROUND: Rapid-eye-movement-sleep-dependent obstructive sleep apnea (REM-OSA) is a sleep breathing abnormality in which apneas/hypopneas occur mainly during REM sleep periods. However, the clinical significance of REM-OSA compared to sleep-stage-non-dependent OSA (SND-OSA) has been controversial. This study evaluated differences in the clinical features, polysomnography (PSG) characteristics, and subjective symptoms between REM-OSA and SND-OSA. METHODS: In total, 136 consecutive patients with mild-to-moderate OSA were enrolled. REM-OSA was defined as a rapid eye movement (REM):non-REM apnea-hypopnea index (AHI) ratio of >2 and a total duration of REM sleep exceeding 30 minutes. We compared the demographic, clinical, and PSG characteristics, and subject symptoms between REM-OSA and SND-OSA. RESULTS: The REM-OSA group comprised 45 (33%) of the 136 subjects. The mean age and total AHI did not differ between the groups, but there was a significant female predominance (35.6% vs. 16.5%) in the REM-OSA group. In terms of PSG parameters, subjects with REM-OSA showed a lower percentage of light sleep and a lower AHI in a supine position despite spending more sleep time in that position. Subjective sleep complaints, depression, anxiety, and health-related quality of life did not differ between the two study groups. CONCLUSIONS: The female predominance and sleep architecture differed between REM-OSA and SND-OSA in this study. The AHI in subjects with SND-OSA was dependent on sleep position rather than sleep stage. Further study is needed to elucidate the pathomechanism and clinical significance of REM-OSA.

Suicidality and Its Risk Factors in Korean People with Epilepsy: A MEPSY Study

BACKGROUND AND PURPOSE: People with epilepsy (PWE) are more likely to experience suicidality, with suicidal ideation and attempts, than people without epilepsy (PWoE). The aims of the present study were to determine 1) the characteristics of suicidality in Korean PWE, 2) whether PWE with suicidality receive psychiatric intervention, and 3) the risk factors for suicidality. METHODS: Patients who consecutively visited epilepsy clinics at secondary- and tertiary-care hospitals were recruited (n=684), along with age- and sex-matched PWoE (n=229). The presence of current major depressive disorder (MDD), generalized anxiety disorder (GAD), and/or suicidality was established using the Mini International Neuropsychiatric Interview-Plus Version 5.0.0. The Korean version of the Liverpool Adverse Events Profile (K-LAEP) was applied to detect adverse effects of antiepileptic drugs (AEDs). RESULTS: Suicidality was present in 208 (30.4%) of the 684 PWE. The rate of suicidality was 4.6 times higher among PWE than PWoE, and 108 (15.7%) PWE had suicidal ideation and had attempted suicide. Among those who had attempted suicide, 40.7% had made at least two attempts. The most common method of suicide attempt was drug overdose (34.9%). Unfortunately, of the 208 PWE with suicidality, 136 (65.4%) did not receive psychiatric intervention. The risk factors for suicidality were MDD [odds ratio (OR)=6.448, 95% confidence interval (CI)=3.739-11.120, p<0.001], GAD (OR=3.561, 95% CI=1.966-6.452, p<0.001), item scores of 3 or 4 on the K-LAEP (OR=2.688, 95% CI=1.647-4.387, p<0.001), and a history of febrile convulsion (OR= 2.188, 95% CI=1.318-3.632, p=0.002). CONCLUSIONS: Suicidality is more prevalent in PWE than in PWoE. Clinicians should monitor psychiatric disorders and the adverse effects of AEDs in PWE in an attempt to reduce the incidence of suicidal ideation or suicide attempts in this patient population.

Clinical Characteristics of Primary Insomniacs with Sleep-State Misperception

BACKGROUND AND PURPOSE: The aims of this study were to determine the prevalence of sleep-state misperception and to identify any differences in the clinical characteristics of primary insomniacs with and without misperception. METHODS: In total, 250 adult primary insomniacs were enrolled whose objective total sleep time (TST) was more than 120 min, as assessed by full-night polysomnography. Sleep state misperception was defined objectively as a TST of at least 6.5 h and an objective sleep efficiency (SE) of at least 85%. RESULTS: The prevalence of sleep-state misperception in primary insomniacs was 26.4%. The (low) quality of sleep and psychiatric parameters were similar in the two groups, although the objective sleep architecture was relatively normal for the misperception group. Multivariate analysis revealed that both SE and sleep quality were significant factors associated with subjective TST in the misperception group, while only SE was significant in those without misperception. Subjective TST was a significant effect factor with respect to sleep quality in the misperception group, while the Beck Depression Inventory-2 score and age were significant factors in those without misperception. CONCLUSIONS: The clinical characteristics of patients with sleep-state misperception differed from those without this condition. This suggests that these two groups should be separated and the treatment goals tailored specifically to each.

Japanese-B Viral Encephalitis with a Biphasic Illness Pattern and Recovery after Intravenous Immunoglobulin Therapy / 대한임상신경생리학회지

Japanese-B viral encephalitis (JE) usually has a monophasic illness pattern. A 45-year-old woman in an altered mentality had improved over 1 month. About 1 week after the initial improvement, the patient became comatose with aggravated EEG and MRI findings. Assays of cerebrospinal fluid and serum were positive for the IgM antibody to Japanese-B virus. After intravenous immunoglobulin (IVIG) infusion, the patient recovered. We report a patient with JE who showed a biphasic illness pattern and recovered after IVIG therapy.

Myasthenia in Acquired Neuromyotonia

BACKGROUND: Acquired neuromyotonia (NMT) forms part of the spectrum of acquired peripheral nerve hyperexcitability syndrome, and is thought to be caused by antibodies to voltage-gated potassium channels (VGKC). Exertional weakness is unusual unless autoimmune myasthenia gravis (MG) is superimposed. CASE REPORT: A case of acquired NMT accompanied by exertional weakness without coexistence of seropositive MG is reported herein. CONCLUSIONS: Clinical and electrophysiological observations suggest that the cholinergic overactivity in NMT can compromise the safety factor sufficiently to cause a defect in neuromuscular junction transmission.

A Reply to the Questions Regarding to the Article 'Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain'

No abstract available.

T2 Relaxometry Using 3.0-Tesla Magnetic Resonance Imaging of the Brain in Early- and Late-Onset Restless Legs Syndrome

BACKGROUND AND PURPOSE: Previous T2 relaxometry studies have provided evidence for regional brain iron deficiency in patients with restless legs syndrome (RLS). Measurement of the iron content in several brain regions, and in particular the substantia nigra (SN), in early- and late-onset RLS patients using T2 relaxometry have yielded inconsistent results. In this study the regional iron content was assessed in patients with early- and late-onset RLS using magnetic resonance imaging (MRI), and compared the results with those in controls. METHODS: Thirty-seven patients with idiopathic RLS (20 with early onset and 17 with late onset) and 40 control subjects were studied using a 3.0-tesla MRI with a gradient-echo sampling of free induction decay and echo pulse sequence. The regions of interest in the brain were measured independently by two trained analysts using software known as medical image processing, analysis, and visualization. The results were compared and a correlation analysis was conducted to investigate which brain areas were related to RLS clinical variables. RESULTS: The iron index in the SN was significantly lower in patients with late-onset RLS than in controls (p=0.034), while in patients with early-onset RLS there was no significant difference. There was no significant correlation between the SN iron index of the late-onset RLS group and clinical variables such as disease severity. CONCLUSIONS: Late-onset RLS is associated with decreased iron content in the SN. This finding supports the hypothesis that regional brain iron deficiency plays a role in the pathophysiology of late-onset RLS.