Early Neurodevelopmental Assessments of Neonates Discharged From the Neonatal Intensive Care Unit: A Physiatrist’s Perspective

The survival rate of children admitted in the neonatal intensive care unit (NICU) after birth is on the increase; hence, proper evaluation and care of their neurodevelopment has become an important issue. Neurodevelopmental assessments of individual domains regarding motor, language, cognition, and sensory perception are crucial in planning prompt interventions for neonates requiring immediate support and rehabilitation treatment. These assessments are essential for identifying areas of weakness and designing targeted interventions to improve future functional outcomes and the quality of lives for both the infants and their families. However, initial stratification of risk to select those who are in danger of neurodevelopmental disorders is also important in terms of cost-effectiveness. Efficient and robust functional evaluations to recognize early signs of developmental disorders will help NICU graduates receive interventions and enhance functional capabilities if needed. Several age-dependent, domain-specific neurodevelopmental assessment tools are available; therefore, this review summarizes the characteristics of these tools and aims to develop multidimensional, standardized, and regular follow-up plans for NICU graduates in Korea.

Alterations in the Swallowing Function According to the Severity of Obstructive Sleep Apnea Syndrome / 대한연하장애학회지

Objective@#Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder that can have a significant impact on the quality of life. According to recent studies, some OSAS patients exhibit swallowing abnormalities, such as the premature entry of food into the hypopharynx, and laryngeal penetration. We aimed to evaluate the swallowing function of OSAS patients and compare swallowing-related parameters between OSAS severity groups through a video fluoroscopic swallowing study (VFSS). @*Methods@#Ninety-two participants with a symptom of snoring were enrolled in this retrospective study. Eighty-four participants were diagnosed with OSAS by polysomnography. The subjects were evaluated using the apnea-hypopnea index (AHI) and divided into four groups, namely non-OSAS, mild, moderate, and severe OSAS. Since all patients reported choking symptoms, they underwent VFSS and were evaluated for penetration or aspiration. The temporal parameters evaluated were oral transit time, pharyngeal transit time, and pharyngeal delay time. The movement parameters assessed were the distance, duration, and velocity of laryngeal elevation (LE). @*Results@#Penetration was detected in six OSAS patients, but aspiration was not observed in any patient. Seventy-four patients showed vallecular and pyriform sinus residue, although the amount was not significantly large. There was no significant difference in any of the temporal parameters between the groups except pharyngeal transit time with 10 ml of yogurt. In the Pearson’s correlation and multivariate linear regression analysis, LE distance and LE velocity, both correlated with AHI scores with 5 ml of liquid, 10 ml of liquid, and 10 ml of yogurt, respectively. @*Conclusion@#Severe OSAS patients showed longer and faster hyolaryngeal movement while swallowing, which may be a compensatory movement to prevent penetration or aspiration.

The Antibiotic-Vaseline Soaked Cotton Pledget as an Adjuvant Material for Endoscopic Endonasal Fungal Ball Removal

Background and Objectives@#Treatment choice for fungal ball is endoscopic endonasal removal. However, it is not easy to remove fungal elements from the maxilla using only an endonasal approach. To overcome this difficulty, we introduced a cotton pledget technique and evaluated its efficacy through a cadaveric study and clinical research.Materials and Method: A cadaveric study was performed using 10 half heads of seven cadavers. The ease and safety of the cotton pledget technique were compared to those of a previously reported technique. In clinical research, we enrolled 52 patients who underwent surgery with the cotton pledget technique and 36 patients who underwent surgery using the conventional endoscopic approach. Demographic factors, preoperative Lund-Mackay (LM) score, sinonasal outcome test (SNOT) score, surgical morbidity, and incomplete removal rate were analyzed. @*Results@#The cadaveric study showed that the cotton pledget technique was easier (p=0.011) than the conventional technique. In addition, clinical evaluation showed that the cotton pledget group had significantly lower incomplete removal rate than that of the control group (p=0.010). @*Conclusion@#The cotton pledget technique is an easy and safe method that enables fungal ball removal more effectively than the conventional technique without need for inferior meatal antrostomy (IMA) or the Caldwell-Luc (CL) approach.

Changes in Aerobic Capacity Over Time in Elderly Patients With Acute Myocardial Infarction During Cardiac Rehabilitation

Objective@#To test the hypothesis that a longer duration of phase II cardiac rehabilitation is required to recover the exercise capacity of elderly patients compared to younger patients. @*Methods@#We retrospectively reviewed and analyzed the medical records of patients who were referred to our cardiac rehabilitation (CR) center and underwent percutaneous coronary intervention for acute myocardial infarction (AMI). A total of 70 patients were enrolled who underwent an exercise tolerance test (ETT) 3 weeks after the occurrence of an AMI (T0), 6 weeks after the first ETT (T1), and 12 weeks after the first ETT (T2). Patients older than 65 years were assigned to the elderly group (n=24) and those aged 65 years and younger to the younger group (n=46). Both groups performed center-based or home-based CR for 12 weeks (3 times per week and 1 session per day). Exercise intensity for each individual was based on the target heart rate calculated by the Karvonen formula. The change in maximal metabolic equivalents (METmax) of the two groups was measured at each assessment point (T0, T1, and T2) to investigate the recovery of exercise capacity. @*Results@#The younger group showed improvement in METmax between T0 and T1. However, METmax of the elderly group showed no significant improvement between T0 and T1. The exercise capacity, measured with METmax, of all groups showed improvement between T0 and T2. @*Conclusion@#Elderly patients with AMI need a longer duration of CR (>6 weeks) than younger patients with AMI.

Comparison of Obesity Related Index and Exercise Capacity Between Center-Based and Home-Based Cardiac Rehabilitation Programs

OBJECTIVE: To compare a center-based cardiac rehabilitation (CR) program with a home-based CR program in terms of improving obesity related index and cardiopulmonary exercise capacity after the completing a phase II CR program. METHODS: In this study, there were seventy-four patients with acute myocardial infarction after percutaneous coronary intervention who were analyzed. Patients with mild to moderate risk (ejection fraction >40%) were included in the group. The patients underwent an exercise tolerance test by measurement of the modified Bruce protocol at three assessment points. Those in the center-based CR group participated in a 4-week training program with electrocardiography monitoring of the patient’s progress and results, while those patients who were in the home-based CR group underwent self-exercise training. We measured the obesity related indices such as body mass index, fat free mass index (FFMI), and cardiopulmonary exercise capacity including peak oxygen consumption (VO(2max)), metabolic equivalents (METs), heart rate, resting systolic blood pressure and the diastolic blood pressure of the participants and noted the results. RESULTS: Of the 74 patients, 25 and 49 participated in the center-based and home-based CR programs, respectively. Both groups showed significant improvement in VO(2max) and METs at 1-month and 6-month follow-up. However, FFMI was significantly improved only in the center-based CR group after 1 month of the phase II CR. CONCLUSION: Both groups identified in the study showed significant improvement of VO(2max) and METs at 1-month and 6-month follow-up. However, there was no significant difference in the intergroup analysis. A significant improvement of FFMI was seen only in the center-based CR group after phase II CR.

Factors and Their Correlation with Injury Severity of Elderly Pedestrian Traffic Accidents

PURPOSE@#No previous study has assessed elderly pedestrian traffic accidents based on a nationwide database. This study aimed to help primary physicians who examine patients in emergency departments to determine and make prompt and accurate treatment decisions.@*METHODS@#This study used data from the Emergency Department-based Injury Indepth Surveillance from 2013 to 2017, managed by the Korea Centers for Disease Control and Prevention. Pedestrians aged ≥65 years were included, and using multivariate logistic regression multiple factors were analyzed to determine their relationship with injury severity.@*RESULTS@#Of 227,695 subjects, 6,498 were included, of whom 2,065 (31.8%) were severely injured. There were more female than male patients in all severity groups. Most accidents occurred in the afternoon and on general roads. In the multivariate analysis, the odds ratio (OR) of injury severity for male pedestrians was 1.165 (95% confidence interval: 1.034–1.313, p=0.012). Older age of patients and the use of ambulances were associated with greater injury severity. The accident time affected the degree of injury severity; i.e., compared to dawn, injury severity increased in the morning (OR: 1.246, p=0.047) and decreased at night (OR: 0.678, p<0.001). A significant difference was noted in the correlation between the type of vehicle causing the accident and the accident severity; i.e., motorcycle accidents had lower severity than bicycle accidents (OR: 0.582, p=0.047).@*CONCLUSIONS@#Injury severity was correlated with sex, age, transportation to the ED, TA onset time, and type of vehicle. The study results suggest that injury severity may be positively reflected in initial assessments and overall integrated treatments by physicians and in the related policies.

Relationship Between Post-exercise Heart Rate Recovery and Changing Ratio of Cardiopulmonary Exercise Capacity

OBJECTIVE: To determine whether heart rate recovery (HRR) following an exercise tolerance test (ETT) is correlated with a changing ratio of peak oxygen consumption (VO₂) and maximal metabolic equivalents (MET(max)). METHODS: A total of 60 acute myocardial infarction (AMI) patients who underwent ETT at both assessment points - 3 weeks (T0) after the AMI attack and 3 months after T0 (T1) were included. After achieving a peak workload, the treadmill was stopped with a 5-minute cooldown period, and the patients recovered in a comfortable and relaxed seated position. HRR was defined as the difference between the maximal heart rate (HR(max)) and the HR measured at specific time intervals - immediately after the cool down period (HRR-0) and 3 minutes after the completion of the ETT (HRR-3). RESULTS: HRR-0 and HRR-3 increased over time, whereas VO(2max) and METmax did not show significant changes. There was a positive correlation between HRR at T0 and the exercise capacity at T0. HRR at T0 also showed a positive correlation with the exercise capacity at T1. There was no significant correlation between HRR measured at T0 and the change in the ratio of VO(2max) and MET(max), as calculated by subtracting VO(2max) and MET(max) obtained at T0 from those obtained at T1, divided by VO(2max) at T0 and multiplied by 100. CONCLUSION: Post-exercise HRR measured at 3 weeks after the AMI onset can reflect the exercise capacity 3 months after the first ETT. However, it may be difficult to correlate post-exercise HRR at T0 with the degree of increase in cardiopulmonary exercise capacity in patients with AMI.

Spontaneous Cervical Epidural Hematoma Presenting as Brown-Sequard Syndrome Following Repetitive Korean Traditional Deep Bows

Spontaneous cervical epidural hematoma (SCEH) is an uncommon cause of acute nontraumatic myelopathy. SCEH presenting as Brown-Sequard syndrome is extremely rare. A 65-year-old man had motor weakness in the left extremities right after his mother's funeral. He received thrombolytic therapy under the impression of acute cerebral infarction at a local hospital. However, motor weakness of the left extremities became aggravated without mental change. After being transferred to our hospital, he showed motor weakness in the left extremities with diminished pain sensation in the right extremities. Diagnosis of SCEH was made by cervical magnetic resonance imaging. He underwent left C3 to C5 hemilaminectomy with hematoma removal. It is important for physicians to be aware that SCEH can be considered as one of the differential diagnoses of hemiplegia, since early diagnosis and management can influence the neurological outcome. We think that increased venous pressure owing to repetitive Korean traditional deep bows may be the cause of SCEH in this case.

The Effect of Combined Therapy of Exercise and Nootropic Agent on Cognitive Function in Focal Cerebral Infarction Rat Model

OBJECTIVE: To investigate the effect of combined therapy of exercise and nootropic agent on cognitive function in a focal cerebral infarction rat model. METHOD: Forty 10-week old male Sprague-Dawley rats were subjected to photothrombotic cerebral infarction of the left parietal lobe. All rats were randomly divided into 4 groups: group A was photothrombotic cerebral infarction rats without any treatment (n=10); group B was photothrombotic cerebral infarction rats with swimming exercise (n=10); group C was photothrombotic cerebral infarction rats with oral administration of acetyl-L-carnitine (n=10); group D was photothrombotic cerebral infarction rats with swimming exercise and oral administration of acetyl-L-carnitine (n=10). Cognitive function was evaluated using the Morris water maze test on the 1st day, and the 1st, 2nd, and 4th week after the induction of cerebral infarction. The activity of superoxide dismutase (SOD) and the level of malondialdehyde (MDA) in the hippocampus were measured. The neuronal cells of the hippocampus were histopathologically evaluated. RESULTS: The escape latency was shorter in groups B, C, and D than in group A. However, the differences were not statistically significant at the 1st, 2nd and 4th week. The activity of SOD was the highest in group D. The level of MDA was the lowest in group D. We observed more normal neuronal cells in groups B, C, and D. CONCLUSION: The combined therapy of exercise and nootropic agent was helpful in ameliorating oxidative stress in the focal cerebral infarction rat model. However, the effect did not translate into improvement of cognitive function.

A Case of Duodenal Mucosa-associated Lymphoid Tissue Lymphoma Presenting as a Refractory Ulcer / 대한소화기내시경학회지

Mucosa-associated-lymphoid-tissue (MALT) lymphomas are the most common primary gastrointestinal lymphomas. The stomach is the most common site of involvement in the GI tract. However, MALT lymphoma of the duodenum is rare. The differential diagnosis in a refractory peptic ulcer are current smoking, NSAID use, hypersecretory conditions (gastrinoma and Zollinger-Ellison syndrome), neoplasms, infection (cytomegalovirus, syphilis, and tuberculosis), and Crohn's disease. Endoscopic findings of duodenal MALT lymphoma are classified as ulcerative, polypoid, and diffuse types. The ulcerative type is the most common type of duodenal MALT lymphoma. Here, we report a case of a 64-year-old male with a history of a refractory duodenal ulcer who was diagnosed with a duodenal MALT lymphoma by immunohistochemical staining.

A Case of Hepatic Portal Venous Gas as a Complication of Endoscopic Balloon Dilatation

The development of hepatic portal venous gas (HPVG) is rare but it might be associated with serious disease and poor clinical outcome. Recently, several iatrogenic causes of HPVG have been reported. HPVG as a complication of endoscopic balloon dilatation is a previously unreported event. We experienced a case of HPVG after endoscopic balloon dilatation in a 31 yr-old man with pyloric stricture due to corrosive acids ingestion. The patient was treated conservatively with fluid resuscitation, antibiotics and Levin tube with natural drainage. Five days later, the follow-up CT scan showed spontaneous resolution of HPVG. This case reminded us the clinical importance and management strategy of HPVG. We report here a case of iatrogenic HPVG with a review of relevant literature.

Dural Arteriovenous Fistula on the Brain Stem and Upper Cervical Spinal Cord: A Case Report

A 53-year-old man abruptly developed headache and unconsciousness. Brain computed tomography (CT) and CT angiography showed subarachnoid hemorrhage, intraventricular hemorrhage, and multiple tortuous vascular structures on the brain stem and upper cervical spinal cord. Four-vessel angiography displayed intradural ventral arteriovenous fistula, supplied by the left vertebral and occipital arteries. Drainage was via both sigmoid sinus and cervical venous plexus. He had been treated with transarterial coil embolization of the left vertebral artery. Subsequently, he suffered from left hemiplegia and cognitive problem. Brain magnetic resonance (MR) and MR angiography performed 4 weeks later revealed multiple infarctions on the left cerebellum, left upper cervical spinal cord, and both medial thalamus, as well as occlusion of the left vertebral artery with reduction in varix size. After rehabilitative management, his muscle strength and cognitive function improved. We report a very rare case of dural arteriovenous fistula on the brain stem and upper cervical spinal cord.

Effect of Regular Exercise Program on Cognitive Function in Chronic Cerebral Hypoperfused Rat

OBJECTIVE: To investigate the effect of regular exercise program on cognitive function in chronic cerebral hypoperfused rat. METHOD: Forty-eight male Sprague-Dawley rats were used. Chronic cerebral hypoperfusion was induced by bilateral common carotid arteries occlusion (BCCAO). All rats were randomly divided into 4 groups: normal rats (group A); normal rats with regular exercise program (group B); BCCAO rats (group C); BCCAO rats with regular exercise program (group D). Regular exercise program was composed of daily 30-minute treadmill exercise for 4 weeks. Cognitive function was evaluated by Morris water maze (MWM) test. The activities of superoxide dismutase (SOD) and the level of malondialdehyde (MDA) were checked. The neurons were microscopically analyzed on Hematoxylin-Eosin and Cresyl violet stains. RESULTS: After regular exercise program, there was significant difference in the escape latency among 4 groups in hidden platform trial of MWM test (p<0.05). There was significant difference in the number of crossings among 4 groups in probe trial of MWM test (p<0.05). The activities of SOD of group A and group D were significantly higher than those of group C, respectively (p<0.05). Histopathological study displayed the formation of apoptotic cell bodies and pyknotic cells in group C and group D. There were more normal neurons in group D than group C. CONCLUSION: Regular treadmill exercise was helpful in improving cognitive function in chronic cerebral hypoperfused rat. Therefore, regular exercise program would be one of the useful strategies for treating chronic neurodegenerative diseases.

A Case of Intramural Duodenal Hematoma Accompanied by Acute Pancreatitis Following Endoscopic Hemostasis for Duodenal Ulcer Bleeding / 대한소화기학회지

Intramural duodenal hematoma is an uncommon condition, which usually develops after blunt abdominal trauma. It is also reported as a complication of anticoagulant therapy, blood dyscrasia, pancreatic disease, and diagnostic and therapeutic endoscopy. The typical clinical pictures of intramural duodenal hematoma consist of upper abdominal pain, vomiting, fever, and hematochezia, and it is rarely accompanied by intestinal obstruction, peritonitis, and pancreatitis as its complication. We report a case of intramural duodenal hematoma extended to peritoneal cavity, and accompanied by acute pancreatitis following therapeutic endoscopy for duodenal ulcer bleeding in a 32-year-old man who was on maintenance of anti-coagulation therapy after valvular heart surgery.

Bilateral Anterior Ischemic Optic Neuropathy with Sudden Sensorineural Hearing Loss in a Long term Hemodialysis Patient / 대한신장학회지

Anterior ischemic optic neuropathy (AION) is rarely reported in end stage renal disease. In particular, AION combined with sudden sensorineural hearing loss (SNHL) has not been reported in domestic and international journals. Here we report the first case of this combined condition. A 58-year-old male patient in end-stage renal disease presented on painless bilateral visual and hearing deterioration. Clinical findings and imaging studies were compatible with a diagnosis of AION and SNHL. Despite of high-dose steroid therapy, vision and hearing were not significantly recovered. Uremic patients often have coexisting pathology such as hypotension during dialysis, atherosclerosis and anemia, predisposing to AION and SNHL. We describe a patient of dialysis for 10 years who presented with bilateral visual and hearing loss due to complications of long-term dialysis. Our case suggests that nephrologists have to know and treat more carefully this rare but emergent complications of dialysis.

A Case of the Minimal Change Nephropathy Associated with Small Cell Lung Cancer / 결핵및호흡기질환

Nephrotic syndrome is a relatively rare complication of malignancy. A few cases of nephrotic syndrome accompanying Hodgkin's disease, non-Hodgkin lymphoma, leukemia and other malignancies have been reported since the first case of the nephrotic syndrome associated with extrarenal malignancy was reported in 1922. Hodgkin's disease and solid tumors are known to be the most common malignancies accompanying nephrotic syndrome. The pathologic findings of kidney in patients with Hodgkin's disease commonly show minimal change nephropathy. Membranous glomerulonephropathy is the most common pathologic feature in patients with solid tumors. Although membranous glomerulonephropathy related to small cell lung cancer has rarely been reported in Korea, minimal change nephropathy accompanying small cell lung cancer has never been reported. We present here a case of a 70 year-old male with minimal change nephropathy that was related to small cell lung cancer. We detected small cell lung cancer during the diagnosis work-up of nephrotic syndrome. We suggest that nephrotic syndrome can be a manifestation of underlying malignancy.