Clinical Validation of a Deep Learning-Based Hybrid (Greulich-Pyle and Modified Tanner-Whitehouse) Method for Bone Age Assessment

Objective@#To evaluate the accuracy and clinical efficacy of a hybrid Greulich-Pyle (GP) and modified Tanner-Whitehouse (TW) artificial intelligence (AI) model for bone age assessment. @*Materials and Methods@#A deep learning-based model was trained on an open dataset of multiple ethnicities. A total of 102 hand radiographs (51 male and 51 female; mean age ± standard deviation = 10.95 ± 2.37 years) from a single institution were selected for external validation. Three human experts performed bone age assessments based on the GP atlas to develop a reference standard. Two study radiologists performed bone age assessments with and without AI model assistance in two separate sessions, for which the reading time was recorded. The performance of the AI software was assessed by comparing the mean absolute difference between the AI-calculated bone age and the reference standard. The reading time was compared between reading with and without AI using a paired t test. Furthermore, the reliability between the two study radiologists’ bone age assessments was assessed using intraclass correlation coefficients (ICCs), and the results were compared between reading with and without AI. @*Results@#The bone ages assessed by the experts and the AI model were not significantly different (11.39 ± 2.74 years and 11.35 ± 2.76 years, respectively, p = 0.31). The mean absolute difference was 0.39 years (95% confidence interval, 0.33– 0.45 years) between the automated AI assessment and the reference standard. The mean reading time of the two study radiologists was reduced from 54.29 to 35.37 seconds with AI model assistance (p < 0.001). The ICC of the two study radiologists slightly increased with AI model assistance (from 0.945 to 0.990). @*Conclusion@#The proposed AI model was accurate for assessing bone age. Furthermore, this model appeared to enhance the clinical efficacy by reducing the reading time and improving the inter-observer reliability.

Primary Peripheral Gamma Delta T-Cell Lymphoma of the Central Nervous System: Report of a Case Involving the Intramedullary Spinal Cord and Presenting with Myelopathy

Primary central nervous system lymphoma of T-cell origin (T-PCNSL) is rare, and its clinicopathological features remain unclear. Peripheral T-cell lymphoma of γδ T-cell origin is an aggressive lymphoma mainly involving extranodal sites. Here, we report a case of γδ T-PCNSL involving the intramedullary spinal cord and presenting with paraplegia. A 75-year-old Korean woman visited the hospital complaining of back pain and lower extremity weakness. Magnetic resonance imaging revealed multifocal enhancing intramedullary nodular lesions in the thoracic and lumbar spinal cord. An enhancing nodular lesion was observed in the periventricular white matter of the lateral ventricle in the brain. There were no other abnormalities in systemic organs or skin. Laminectomy and tumor removal were performed. The tumor consisted of monomorphic, medium-to-large atypical lymphocytes with pale-to-eosinophilic cytoplasm. Immunohistochemically, the tumor cells were CD3(+), TCRβF1(-), TCRγ(+), CD30(-), CD4(-), CD8(-), CD56(+), TIA1(+), granzyme B(+), and CD103(+). Epstein-Barr virus in situ was negative. This case represents a unique T-PCNSL of γδ T-cell origin involving the spinal cord.

A Stepwise Diagnostic Approach to Cystic Lung Diseases for Radiologists

Lung cysts are commonly seen on computed tomography (CT), and cystic lung diseases show a wide disease spectrum. Thus, correct diagnosis of cystic lung diseases is a challenge for radiologists. As the first diagnostic step, cysts should be distinguished from cavities, bullae, pneumatocele, emphysema, honeycombing, and cystic bronchiectasis. Second, cysts can be categorized as single/localized versus multiple/diffuse. Solitary/localized cysts include incidental cysts and congenital cystic diseases. Multiple/diffuse cysts can be further categorized according to the presence or absence of associated radiologic findings. Multiple/diffuse cysts without associated findings include lymphangioleiomyomatosis and Birt-Hogg-Dubé syndrome. Multiple/diffuse cysts may be associated with ground-glass opacity or small nodules. Multiple/diffuse cysts with nodules include Langerhans cell histiocytosis, cystic metastasis, and amyloidosis. Multiple/diffuse cysts with ground-glass opacity include pneumocystis pneumonia, desquamative interstitial pneumonia, and lymphocytic interstitial pneumonia. This stepwise radiologic diagnostic approach can be helpful in reaching a correct diagnosis for various cystic lung diseases.

CT Findings of Quadricuspid Pulmonary Valve with Pulmonary Artery Aneurysm

Quadricuspid pulmonary valve (QPV) with pulmonary artery aneurysm is an uncommon condition. QPV is typically clinically silent, so it is often diagnosed after death. However, recent advancements in imaging modalities, such as computed tomography (CT), have allowed more frequent incidental diagnosis of QPV in living adults. We report a case of QPV with pulmonary artery aneurysm in an asymptomatic adult; the condition was detected by CT aortography but was not discernible in echocardiography. Following the case presentation, we review the prior related literature.

Hearing Loss amongst the Elderly in a Southeast Asian Population - A Community-based Study

<p><b>INTRODUCTION</b>The aim of this study was to determine the prevalence of hearing loss amongst the elderly population attending community services in Singapore. The usefulness of the Hearing Handicap Inventory for the Elderly Screening version (HHIE-S) in detecting hearing loss was also investigated.</p><p><b>MATERIALS AND METHODS</b>Pure-tone audiometry was carried out on a randomly recruited cohort of people (n = 338) over 60 years old and who were attending rehabilitation and social day care services for senior citizens at St Luke's Elder Care centres located throughout the city. Prior to the hearing test, subjects were administered the HHIE-S questionnaire, which was translated into the language they were most conversant in.</p><p><b>RESULTS</b>The study cohort showed mean pure-tone average at speech frequencies (0.5, 1, 2 and 4 kHz; 4-frequency average hearing level [4FA HL]) of the subjects' better hearing ear that has worsened with age. The percentage of the elderly with disabling hearing impairment (4FA >40 dB HL) was 9.1% (60 to 69 years old), 22.0% (70 to 79 years old), 35.7% (80 years old and above). Across all age groups, males had significantly poorer thresholds at 4 kHz than females. When adjusted for the demographic profile of the country, the prevalence of hearing loss (4FA >25 dB HL) and disabling hearing impairment (4FA >40 dB HL) amongst the elderly in Singapore was 63.7% and 16.2%, respectively. We estimate that there are currently 422,000 elderly with hearing loss greater than 25dB HL and over 100,000 elderly with disabling hearing loss of over 40 dB HL. Of subjects with a disabling hearing impairment, only 7.5% used hearing aids. The use of self-reporting HHIE-S showed poor sensitivity in detecting hearing loss of various severities amongst the elderly.</p><p><b>CONCLUSION</b>These data provide estimates of the prevalence and severity of hearing loss in older persons in Singapore and suggest that more can be done to help the elderly recognise, acknowledge and address hearing loss in the country.</p>

Spinal Myoclonus Responding to Continuous Intrathecal Morphine Pump

Spinal myoclonus is a sudden, brief, and involuntary movement of segmental or propriospinal muscle groups. Spinal myoclonus has occasionally been reported in patients undergoing opioid therapy, but the pathophysiology of opioid-induced myoclonus has not been elucidated yet. Here, we present two patients with spinal segmental myoclonus secondary to ischemic and radiation myelopathy. Conventional medications did not help treat persistent myoclonus in both legs. Continuous intrathecal morphine infusion was implanted for pain control in one patient, which relieved spinal myoclonus entirely. This experience led to the application of this method with a second patient, leading to the same gratifying result. Spinal myoclonus reemerged as soon as the morphine pumps were off, which confirmed the therapeutic role of opioids. In contrast to the opioid-induced myoclonus, these cases show a benefit of opioids on spinal myoclonus, which could be explained by synaptic reorganization after pathologic insults in the spinal cord.

Treating hepatitis C in HIV/HCV co-infected patients in Malaysia- the outcomes and challenges

Background: Co-infection by human immunodeficiency and hepatitis C viruses (HIV/HCV) is common and results in significant morbidity and mortality despite effective antiretroviral therapies (ART). Method: A retrospective and prospective evaluation of the efficacy and safety of pegylated interferon alfa 2a/2b plus ribavirin (PEG-IFN/RBV) in consecutive HIV/HCV co-infected patients treated in real life clinical practice in Malaysia. Results: Forty-five HIV/HCV co-infected patients with a median age (interquartile range, IQR) of 41 years (37; 47) were assessed for treatment with PEG-IFN/RBV. All except one are of male gender and the most common risk behaviour was injecting drug use. At baseline 75.5% was on ART and the median (IQR) CD4 count was 492 cells/µl (376; 621). The HCV genotypes (GT) were 73 % GT3 and 27% GT1. Liver biopsies in forty patients showed 10% had liver cirrhosis and another 50% had significant liver fibrosis. The treatment completion rate was 79.5% with 15.9% dropped out of treatment due to adverse effects (AE) or default and 4.6% due to lack of early virological response. The AE causing premature discontinuations were neuropsychiatric and haematological. The overall sustained virological response (SVR) was 63.6% with a trend towards higher SVR in GT3 compared with GT1 (71.9% vs. 41.7%; p=0.064). In patients with bridging fibrosis plus occasional nodules or cirrhosis on liver biopsy, the SVR was significantly lower at 20% (p=0.030) compared to those with milder fibrosis. Conclusion: HIV/HCV co-infected patients can be successfully and safely treated with PEG-IFN/RBV achieving high rates of SVR except in cirrhotic patients.

The music listening preferences and habits of youths in Singapore and its relation to leisure noise-induced hearing loss

<p><b>INTRODUCTION</b>Noise-induced hearing loss (NIHL) is a preventable condition, and much has been done to protect workers from it. However, thus far, little attention has been given to leisure NIHL. The purpose of this study is to determine the possible music listening preferences and habits among young people in Singapore that may put them at risk of developing leisure NIHL.</p><p><b>METHODS</b>In our study, the proportion of participants exposed to > 85 dBA for eight hours a day (time-weighted average) was calculated by taking into account the daily number of hours spent listening to music and by determining the average sound pressure level at which music was listened to.</p><p><b>RESULTS</b>A total of 1,928 students were recruited from Temasek Polytechnic, Singapore. Of which, 16.4% of participants listened to portable music players with a time-weighted average of > 85 dBA for 8 hours. On average, we found that male students were more likely to listen to music at louder volumes than female students (p < 0.001). We also found that the Malay students in our study listened to louder music than the Chinese students (p < 0.001).</p><p><b>CONCLUSION</b>We found that up to one in six young persons in Singapore is at risk of developing leisure NIHL from music delivered via earphones. As additional risks due to exposure to leisure noise from other sources was not taken into account, the extent of the problem of leisure NIHL may be even greater. There is a compelling need for an effective leisure noise prevention program among young people in Singapore.</p>

The Effects of Acute Resistance Exercise on Ischemia-Reperfusion Injury-Induced Macro and Microvascular Dysfunction in Healthy Young Adults / 대한스포츠의학회지

Ischemia reperfusion injury (IRI) leads to a temporary decrease in macrovascular function, but whether IRI causes microvascular dysfunction is not known. Resistance exercise involves muscular contractions that can make downstream tissues ischemic and may ischemic preconditioning the vasculature against endothelial IRI. We tested the hypothesis that an acute resistance exercise prior to IRI would prevent or attenuate IRI induced macro- and microvascular dysfunction in healthy young adults. Nineteen healthy young subjects (age 22+/-2 years) were randomly assigned to either a resistance exercise group (n=10) as a model to produce ischemic preconditioning or a control group (n=9). The resistance exercise was performed eight types of systemic resistance exercise. Ischemia was induced by inflating a cuff placed around the upper arm to 200 mm Hg for 20 minutes. carotid-femoral pulse wave velocity (cfPWV) as index of macrovascular function and reactive hyperemia index (RHI) using by fingertip arterial tonometry as index of microvascular function were measured at baselines and 15 and 30 minutes after ischemia reperfusion injury. cfPWV was increased in control group but decreased in resistance exercise group following IRI. There was a significant interaction effect between resistance exercise group and control group for cfPWV (p=0.022). The RHI was unaffected following IRI and also unchanged by a resistance exercise. These findings show that ischemia reperfusion caused macrovascular dysfunction but not microvascular dysfunction. However, this macrovascular dysfunction following IRI was not shown in the resistance exercise group. Thus, an acute bout of resistance exercise prior to ischemia may prevent against ischemia reperfusion injury induced macrovascular dysfunction.

Cerebellar Degeneration Associated with Sjogren's Syndrome

BACKGROUND: Neurologic manifestations of primary Sjogren's syndrome (PSS) have been reported to vary from sensory polyneuropathy to encephalopathy or psychiatric problems. However, marked cerebellar degeneration associated with PSS has rarely been reported. CASE REPORT: We describe a patient with Sjogren's syndrome who exhibited rapidly progressive cerebellar ataxia, nystagmus, cognitive decline, and psychiatric problems. Brain magnetic resonance imaging revealed marked atrophy of the cerebellum, and 18F-fluorodeoxyglucose positron-emission tomography demonstrated glucose hypometabolism of the cerebellum. CONCLUSIONS: Our PSS patient exhibited a progressive course of cerebellar syndrome, as evidenced by cerebellar atrophy on serial brain images.

Evaluation of Balance Control in Patients with Idiopathic Parkinson's Disease Using Tetra-ataxiometric Posturography

OBJECTIVE: To investigate the postural stability of patients with mild to moderate stage of idiopathic parkinson's disease (IPD) using Tetra-ataxiometric posturography (Tetrax) and to evaluate the correlation between balance and activity of daily living (ADL). METHOD: Twenty patients with IPD at mild to moderate stage, twenty young controls and twenty elderly controls were enrolled in this study. In order to evaluate postural stability, we checked stability index, fourier index, weight distribution index, synchronization index, and fall index at eight positions using Tetrax. We also assessed Berg Balance Scale, Postural Instability and Gait Difficulty (PIGD) score of Unified Parkinson Disease Rating Scale (UPDRS). In order to evaluate the correlation between balance and functional performance, the ADL score of UPDRS was checked in the patients with IPD. RESULTS: The patients with IPD showed a significantly higher fall index, weight distribution indices in five positions than the elderly controls. The stability indices of the patients with IPD were higher in all positions, but significantly higher in only one position than the elderly controls. The fallers in the IPD patients had a higher fall index and lower synchronization indices than the non-fallers. The balance and functional performance showed significant correlations in the IPD patients. CONCLUSION: We could identify a high falling risk and uneven weight distribution in the IPD patients and a close correlation between balance and functional performance. Therefore the evaluation of postural stability should be considered from mild stage because postural instability might impair activity of daily living and increase fall risk.

Determining Factors for the Reduction of Dopaminergic Drugs after Bilateral Subthalamic Nucleus Deep Brain Stimulation

BACKGROUND: We aimed to investigate the possible factors determining reduction of dopaminergic drugs in patients who received bilateral subthalamic nucleus (STN) deep brain stimulation (DBS). METHODS: We studied 33 consecutive Parkinson's disease (PD) patients who underwent bilateral STN DBS between March 2002 and April 2006. Patients were assessed at baseline and 6 months and 1 year after surgery. RESULTS: The dose of dopaminergic drugs was significantly decreased by 16.5% (p<0.05) and 14.9% (p<0.05), at post op 6 months and 12 months respectively. The reduction rate of dopaminergic drugs after bilateral STN DBS was positively correlated with the dopaminergic drug dosage at baseline (p<0.05) and was negatively correlated with the scores of "off"-period UPDRS II (p<0.05), III (p<0.001), and total UPDRS (p<0.001) at baseline. The difference of UPDRS scores between "on" and "off" periods on the levodopa challenge test was negatively correlated with the reduction rate of dopaminergic drug dosage after bilateral STN DBS (p<0.001). CONCLUSIONS: It is likely that the main determining factors for the reduction of dopaminergic drug dosages after bilateral STN DBS in advanced PD are the UPDRS III score during "off" periods, difference of the UPDRS III score between "on" and "off" periods on the levodopa challenge test and dose of dopaminergic drugs at baseline.

Trinucleotide Repeats Number in SCA2, SCA3, and SCA17 in Early-Onset Parkinson's Disease

BACKGROUND: Abnormal expansion of trinucleotide repeats in genes causing spinocerebellar ataxias such as SCA2, SCA3, SCA8, or SCA17 was reported in sporadic or familial Parkinson's disease. Genetic factors play an important role especially in early-onset Parkinson's disease (EOPD). To investigate mutations of ATXN2, ATXN3, and TBP as a possible cause in Korean EOPD, we analyzed mutations in these genes. We also investgated the possibility that trinucleotide repeats numbers in these genes contribute to the development of EOPD. METHODS: Mutation analysis of ATXN2, ATXN3, and TBP was done in 153 EOPD defined as age-at-onset before 51. Distribution of CAG repeats numbers were compared between EOPD and age- and sex-matched controls. RESULTS: No patients with EOPD had CAG repeats numbers in ATXN2, ATXN3, and TBP in mutation range. There was no difference in the distribution of CAG repeats between EOPD and controls, although we found a trend that CAG repeats numbers in ATXN3 appear larger in EOPD than in controls. CONCLUSIONS: Mutations of genes causing SCA2, SCA3, or SCA17 may not be a common genetic cause in Korean EOPD.

Delusion and Hallucination in Parkinson's Disease: A Pilot Study of Clinical Features and Pathogenesis

BACKGROUND: Although the clinical and epidemiological characteristics of delusions and visual hallucinations in Parkinson's disease (PD) have been described, the underlying etiology and pathogenesis of those neuropsychiatric manifestations in PD remains a matter of debate. The purpose of this study was to investigate whether or not delusion is in the same spectrum of dopamine related neuropsychiatric manifestations as visual hallucination is in patients with PD. METHODS: We studied the clinical features of 13 PD patients with delusions and 32 with hallucinations. Patients with a history of psychotic symptoms before the onset of PD were excluded. RESULTS: Age at onset of PD was younger in patients with delusions (56.3+/-8.7 years) than in those with hallucinations (63.9+/-9.2 years) (p=0.019). The level of education was higher in patients with delusions than those with hallucinations (p=0.006). Daily levodopa equivalent dosages were higher in patients with delusions (982+/-653.7 mg/day) than those with hallucinations (559+/-311.2 mg/day) (p=0.002). Dopamine agonists were more frequently used in patients with delusions than in those with hallucinations (p=0.020). CONCLUSIONS: Compared with PD patients with hallucinations, those with delusions were associated with longer disease durations, higher levodopa-equivalent daily doses, and use of dopamine agonists. To evaluate the role of dopaminergic dysfunction for the development of delusions and hallucinations in PD patients, further well- designed prospective studies are needed.

One-Year Open-Label Study of Entacapone in Patients with Advanced Parkinson Disease

BACKGROUND AND PURPOSE: A carboxy-O-methyl transferase inhibitor entacapone has been introduced as an adjuvant drug for Parkinson disease (PD) patients. Although clinical trials reported beneficial role of entacapone, a long-term trial over 3 years failed to show significant effect. The goals of this study were to evaluate the clinical benefit and the efficacy of entacapone in an open clinical practice. METHODS: After the completion of a double-blind placebo-controlled entacapone study, 149 patients from 4 centers were included. Antiparkinsonian medications were optimized by the judgment of the neurologists in charge. The clinical global impression (CGI) scale was obtained at 6 months and 1 year after the initiation of entacapone treatment. RESULTS: Of the 149 patients, 117 patients chose to try entacapone in an open-label fashion. Sixty-nine (59%) patients completed the 1-year trial. Twenty-nine patients discontinued entacpaone before 6 months, and 19 between 6 months and 1 year during trial. Twelve patients out of 48 patients discontinued entacapone because of its poor efficacy. The CGI scale was 3.9 (+/-1.5) at the beginning of the trial, 4.3 (+/-1.1) at 6 month, and 3.8 (+/-1.3) at 1 year, respectively. The CGI scale of those who discontinued between 6 month and 1 year was 3.4 (+/-1.7), which was worse, but insignificantly, than that of the continuer. CONCLUSIONS: The dropout at 1 year of our study was very high at 41%. Even though entacapone is indicated for advanced PD patients with motor fluctuation, the fluctuators commonly have dyskinesia and mental symptoms, which can become more troublesome with entacapone. In the patients with advanced PD, the clinical efficacy and side effects should be carefully considered in a long-term use of entacapone.

A Case of Intracranial Hypertension with Hypoglycorrhachia Caused by Bilateral Transverse Sinus Stenoses

Intracranial hypertension is a clinical syndrome of raised intracranial pressure with various etiologies. The possible pathogenic mechanisms of intracranial hypertension are excess CSF production, reduced CSF absorption and increased cerebral venous pressure. CSF glucose in intracranial hypertension is at usually normal levels and hypoglycorrhachia in intracranial hypertension has yet to be reported. We report a 23-year-old woman, who had intracranial hypertension with hypoglycorrhachia caused by a bilateral transverse sinus stenoses.

The Predictable Clinical Factors for the Levodopa Responsiveness of Resting Tremor in Patients with Parkinson's Disease

BACKGROUND: The pathophysiology of resting tremor in Parkinsons disease (PD) remains unclear. Dopaminergic treatment provides variable effects on resting tremor in PD. We aimed to evaluate the predictable clinical factors for the levodopa responsiveness of resting tremor in patients with PD. METHODS: Eighty-five PD patients with prominent resting tremor who visited Asan Medical Center between June 2004 and June 2005 were included. The prominent resting tremor was defined as tremor scoring more than 3 in at least one limb in the Unified Parkinsons Disease Rating Scale (UPDRS). Subjects were divided into the responsive group (RG) or non-responsive group (NRG) according to the responsiveness of resting tremor to dopaminergic treatment. Responsiveness was defined as a minimum 2 points reduction of UPDRS score for the resting tremor after dopaminergic treatment for more than 3 months. RESULTS: Among the 85 patients, there were 35 men and 50 women ages 34-87 years (mean age, 67 years). Thirty-six patients (42.4%) were grouped into RG and 49 (57.6%) into NRG. Mean age of RG was significantly younger than that of NRG. RG showed significantly higher initial UPDRS part III subtotal score (p=0.015) and more severe Hoehn & Yahr stage (p=0.010) than those of NRG. UPDRS subscores for rigidity (p=0.012), bradykinesia (p=0.021) and postural impairment (p=0.018) were correlated with the responsiveness of dopaminergic treatment. CONCLUSIONS: Resting tremor in PD patients more favorably responded to dopaminergic treatment when it presented in combination with bradykinesia and rigidity suggesting dopaminergic role in the genesis of resting tremor in those PD patients.

Efficacy of VP2 protein expressed in E. coli for protection against highly virulent infectious bursal disease virus

The ability of a heat-inactivated whole virus from a highly virulent infectious bursal disease virus (hvIBDV) and VP2 protein from hvIBDV expressed in E. coli provided protection against a hvIBDV challenge in specificpathogen- free (SPF) chickens. Six out of seven chickens that were injected three times with crude VP2 protein developed significant antibody titer against IBDV. However, only four out of the seven chickens survived the hvIBDV challenge. Despite showing low antibody titer profiles, all chickens immunized with the heat-inactivated whole virus also survived the challenged with hvIBDV. However, all of these chickens had bursal atrophy and mild to moderate depletion of lymphocytes. Thus, antibodies raised against IBDV VP2 protein expressed in E. coli and denatured IBDV proteins induced some degree of protection against mortality but not against bursal damage following challenge with hvIBDV.

Cerebral Air Embolism Following Pneumopyelography

No abstract available.

The clinical characteristics of lower back pain in Parkinson's Disease

BACKGROUND: Lower back pain (LBP) in Parkinson's disease (PD) is common but frequently overlooked, due to the tendencies of focusing on the management of the motor symptoms and signs by most neurologists. Uncontrolled LBP may impact on the activities of daily living of the PD patients. However, study on the LBP in PD has been rarely reported. METHODS: Sixty three PD patients with LBP were included, between October 2004 and April 2005. We investigated the clinical characteristics of LBP and response to the management prospectively. RESULTS: Eleven male and 52 female patients were included and the mean age was 64.4 years. On lumbar MRI and/or X-ray, degenerative spondylosis was detected in 22 patients, bulging discs in 30, and fractures in 9. Fourteen patients reported improvement of LBP after levodopa therapy. Young age at onset and abnormally flexed posture correlated with the responsiveness of LBP to levodopa therapy (p<0.05, respectively). These responders were more frequently experiencing motor fluctuation and dyskinesia than the non-responders (p<0.05, respectively). CONCLUSIONS: LBP in PD has diverse etiologies and clinical features. Some PD patients with LBP show response to levodopa therapy. We suggest that the prudent evaluation and proper management of LBP are important to achieve the better activities of daily living in PD patients.