Hipoventilação relacionada ao sono de origem central secundária à deficiência de biotinidase: relato de caso / Sleep-related hypoventilation due to partial biotinidase deficiency: a case repor

RESUMO: A hipoventilação relacionada ao sono de origem central resulta em hipercapnia relacionada ao sono na vigência de condições normais do sistema respiratório e excluindo-se outros fatores. Os pacientes portadores dessa patologia podem se apresentar assintomáticos ou com queixas de cefaleia matinal, déficit cognitivo e fadiga, além de eventos como a observação de respiração superficial. No presente relato, descreve-se o caso de uma paciente de três anos, com exame físico geral e neurológico normais, desenvolvimento neuropsicomotor adequado, apresentando irregu-laridades respiratórias e bradicardia durante o sono. Encaminhada para investigação de distúrbios respiratórios do sono, sendo diagnosticada com hipoventilação relacionada ao sono. Através do estudo genético, evidenciou-se a deficiência de biotinidase como a possível causa da sintomatologia, comprovada por dosagens enzimáticas e teste genético molecular. O tratamento medicamentoso foi iniciado precocemente, determinando resolução dos sintomas descritos. A importância do presente relato se encontra na apresentação da deficiência da biotinidase com quadro cardiorrespiratório isolado em criança neurologicamente normal, ademais trata-se de um caso em que a etiologia de Breath-Holding Spells foi a deficiência dessa enzima. Correspondência sugerida pela resolução da hipoventila-ção central após a introdução da biotina. Além disso, nesse caso, os sintomas Apparent Life-Threatening Events, que aterrorizam o observador e até o profissional, foram solucionados com tratamento simples, a ingesta oral de biotina. Esse relato de caso corrobora com a expansão das possibilidades de manifestações fenotípicas das formas tardias de deficiência de biotinidase, como o fenótipo da Síndrome da Hipoventilação Central. (AU)

ABSTRACT: Idiopathic sleep-related hypoventilation occurs in individuals with hypercapnia during sleep in normal conditions of the respiratory system in the absence of other disorders. Patients with this condition may be asymptomatic or have complaints of morning headache, cognitive deficit and fatigue, and observation of shallow breathing. This report describes the case of a 3-year-old patient with normal physical and neurological exam, appropriate neuropsychomotor development, presenting breathing irregularities, and bradycardia during sleep. The patient was referred to an investigation for sleep respiratory disturbs and was diagnosed with hypoventilation related to sleep. The genetic study, done by enzymatic dosages and molecular genetic tests, showed the deficiency of biotinidase as a possible cause of symptomatology. The drug treatment was initiated early with the resolution of the symptoms. The present clinical report highlights the biotinidase deficiency with an isolated cardiorespiratory condition in a neurologically normal child, which also led to Breath-Holding Spells. This relation was suggested after central hypoventilation resolution following biotin introduction. Besides, Apparent Life-Threatening Events symptoms, which terrify the observer and even professionals, disappeared after the oral intake of biotin. Finally, this case report corroborates the expansion of possibilities for the phenotypic manifestations of late cases from biotinidase deficiency, as the SHC phenotyp. ((AU)

Optimization of the Flip Angle and Scan Timing in Hepatobiliary Phase Imaging Using T1-Weighted, CAIPIRINHA GRE Imaging

PURPOSE: This study was designed to optimize the flip angle (FA) and scan timing of the hepatobiliary phase (HBP) using the 3D T1-weighted, gradient-echo (GRE) imaging with controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA) technique on gadoxetic acid-enhanced 3T liver MR imaging. MATERIALS AND METHODS: Sixty-two patients who underwent gadoxetic acid-enhanced 3T liver MR imaging were included in this study. Four 3D T1-weighted GRE imaging studies using the CAIPIRINHA technique and FAs of 9° and 13° were acquired during HBP at 15 and 20 min after intravenous injection of gadoxetic acid. Two abdominal radiologists, who were blinded to the FA and the timing of image acquisition, assessed the sharpness of liver edge, hepatic vessel clarity, lesion conspicuity, artifact severity, and overall image quality using a five-point scale. Quantitative analysis was performed by another radiologist to estimate the relative liver enhancement (RLE) and the signal-to-noise ratio (SNR). Statistical analyses were performed using the Wilcoxon signed rank test and one-way analysis of variance. RESULTS: The scores of the HBP with an FA of 13° during the same delayed time were significantly higher than those of the HBP with an FA of 9° in all the assessment items (P < 0.01). In terms of the delay time, images at the same FA obtained with a 20-min-HBP showed better quality than those obtained with a 15-min-HBP. There was no significant difference in qualitative scores between the 20-min-HBP and the 15-min-HBP images in the non-liver cirrhosis (LC) group except for the hepatic vessel clarity score with 9° FA. In the quantitative analysis, a statistically significant difference was found in the degree of RLE in the four HBP images (P = 0.012). However, in the subgroup analysis, no significant difference in RLE was found in the four HBP images in either the LC or the non-LC groups. The SNR did not differ significantly in the four HBP images. In the subgroup analysis, 20-min-HBP imaging with a 13° FA showed the highest SNR value in the LC-group, whereas 15-min-HBP imaging with a 13° FA showed the best value of SNR in the non-LC group. CONCLUSION: The use of a moderately high FA improves the image quality and lesion conspicuity on 3D, T1-weighted GRE imaging using the CAIPIRINHA technique on gadoxetic acid, 3T liver MR imaging. In patients with normal liver function, the 15-min-HBP with a 13° FA represents a feasible option without a significant decrease in image quality.

Changes in P-wave, T-wave, and ST segment amplitude in 12 lead electrocardiogram in children with breath holding spell / 中南大学学报(医学版)

OBJECTIVE@#To explore the change of the amplitude of P wave, T wave and ST segment of 12 lead electrocardiogram (ECG) in children with breath holding spell.
@*METHODS@#A total of 29 children (24 males and 5 females) with breath holding spell in Second Xiangya Hospital, Central South University were enrolled for this study from October, 2009 to September, 2015. Their ages ranged from 3 months to 6 years, with an average of 1.82±1.27 years old. The control group consisted of 30 age-matched and gender-matched healthy children. All subjects were underwent electrocardiography by the SR-1000A comprehensive automatic electrocardiograph analyzer, and the changes of the ECG parameters were compared between the two groups.
@*RESULTS@#Compared with the control group, the amplitude of P-wave of V5 lead was decreased [(44.10±23.98) vs (58.30±21.19) μV, P<0.05], the amplitude of T-wave of V6 lead was increased [(423.80±122.6) vs (350.00±105.73) μV, P<0.05], the amplitude of ST segment of II lead was increased [(84.80±39.97) vs (57.30±38.77) μV, P<0.05], the amplitude of ST segment of aVR lead was increased [(-77.60±37.41) vs (-51.00±33.46) μV, P<0.05], the amplitude of ST segment of aVL lead was increased [(35.20±28.24) vs (17.70±33.90) μV, P<0.05], the amplitude of ST segment of V5 lead was increased [(111.00±59.36) vs (69.00±36.33) μV, P<0.05], the amplitude of ST segment of V6 lead was increased [(79.30±45.51) vs (51.30±33.19) μV, P<0.05]. 
@*CONCLUSION@#The children with breath holding spell have autonomic nerve dysfunction. The amplitude of ST segment changes is sensitive.

Cerebral vasomotor reactivity assessment using Transcranial Doppler and MRI with apnea test

Differently from previous studies that used Transcranial Doppler (TCD) and functional MRI (fMRI) for cerebral vasomotor reactivity (CVR) assessment in patients with carotid stenosis (CS), we assessed CVR using an identical stimulus, the Breath-Holding Test (BHT). We included 15 patients with CS and 7 age-matched controls to verify whether fMRI responded differently to BHT between groups and to calculate the agreement rate between tests. For TCD, impaired CVR was defined when the mean percentage increase on middle cerebral artery velocities was ≤31% on 3 consecutive 30-s apnea intercalated by 4-min normal breathing intervals. For fMRI, the percent variation on blood oxygen level-dependent (BOLD) signal intensity in the lentiform nucleus (LN) ipsilateral to the CS (or both LNs for controls) from baseline breathing to apnea was measured. The Euclidian differences between the series of each subject and the series of controls and patients classified it into normal or impaired CVR. We found different percent variations on BOLD-signal intensities between groups (P=0.032). The agreement was good in Controls (85.7%; κ=0.69) and overall (77.3%; κ=0.54). We conclude that BHT was feasible for CVR assessment on fMRI and elicited different BOLD responses in patients and controls, with a good overall agreement between the tests.

Anatomy, Variants, and Pathologies of the Superior Glenohumeral Ligament: Magnetic Resonance Imaging with Three-Dimensional Volumetric Interpolated Breath-Hold Examination Sequence and Conventional Magnetic Resonance Arthrography

The purpose of this review was to demonstrate magnetic resonance (MR) arthrography findings of anatomy, variants, and pathologic conditions of the superior glenohumeral ligament (SGHL). This review also demonstrates the applicability of a new MR arthrography sequence in the anterosuperior portion of the glenohumeral joint. The SGHL is a very important anatomical structure in the rotator interval that is responsible for stabilizing the long head of the biceps tendon. Therefore, a torn SGHL can result in pain and instability. Observation of the SGHL is difficult when using conventional MR imaging, because the ligament may be poorly visualized. Shoulder MR arthrography is the most accurately established imaging technique for identifying pathologies of the SGHL and associated structures. The use of three dimensional (3D) volumetric interpolated breath-hold examination (VIBE) sequences produces thinner image slices and enables a higher in-plane resolution than conventional MR arthrography sequences. Therefore, shoulder MR arthrography using 3D VIBE sequences may contribute to evaluating of the smaller intraarticular structures such as the SGHL.

Influence of registration based on different reference markers on the displacement of the geometry consisted of all clips in the cavity for external-beam partial breast irradiation at moderate deep inspiration breath holding / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To investigate the influence of registration based on different reference markers on the displacement of the geometry consisted of all clips in the cavity for external-beam partial breast irradiation at moderate deep inspiration breath holding assisted by active breathing control device.</p><p><b>METHODS</b>Twenty-seven early stage breast cancer patients feasible for external beam partial breast irradiation (EB-PBI) were selected. The patients undertaken three-dimensional computed tomography (3DCT) simulation scan at moderate deep inspiration breath holding (mDIBH) assisted by active breathing control device, and two sets of mDIBH CT images were got and transferred to the Pinnacle 3 planning system. All of the silver clips were delineated and a geometry consisted of all clips were generated. On the account of automatic registration of mDIBH CT images, manual registration was carried out based separately on the topside clip in the cavity, the labeled skin at anterior surface of the cavity at central level and the metal mark on the body surface near the cavity, then the displacements of center of the geometry in left-right (LR), anterior-posterior (AP) and superior-inferior (SI) directions based separately on the three registrations were measured.</p><p><b>RESULTS</b>The displacements of center of the geometry in LR, AP and SI directions based on registration of the clips, the labeled skin and the metal mark were (0.61 ± 0.62)mm vs. (1.11 ± 1.21)mm vs. (1.31 ± 1.55)mm, (0.63 ± 0.59)mm vs. (0.92 ± 0.93)mm vs. (1.19 ± 1.24)mm and (0.91 ± 0.96)mm vs. (2.13 ± 2.12)mm vs. (1.93 ± 1.55)mm, respectively. Compared the displacements of center of the geometry in the same direction between the three registrations, significant differences were found only in SI direction between clip registration and skin registration, clip registration and mark registration (t = 5.045, 7.210 and P = 0.025, 0.007) . Compared the displacements of center of the geometry between three dimensional directions for each reference registration, there was no significant difference (all P > 0.05).</p><p><b>CONCLUSIONS</b>When EB-PBI is carried out in state of mDIBH, measurement of the intrafraction displacement based on registration of the clip in the cavity is a reasonable selection. Otherwise, excessive margin enlargement of PTV in SI direction will be generated if the regional skin or metal mark is selected as registration reference.</p>

Diagnosis of Obstructive Sleep Apnea Syndrome / 한양의대학술지

Obstructive sleep apnea is a prevalent disease and contributes to consequences like hypertension, diabetes, stroke, cardiac disease, daytime sleepiness, decreased productivity, mood change, and quality of life. The mortality and morbidity due to consequences are related to severity of obstructive sleep apnea. The severity of obstructive sleep apnea is measured by apnea-hypopnea index or respiratory disturbance index. The diagnosis of obstructive sleep apnea is made by polysomnographic findings and/or one of its symptoms (daytime symptoms like unintentional sleep episode during wakefulness, daytime sleepiness, unrefreshing sleep, insomnia, or fatigue, nighttime symptoms like breath holding, gasping, or choking, or bed partner's report about loud snoring, breath stopping). Due to high cost, inconvenience, and availability of in-lab polysomnogrpahy, simple diagnostic tools are suggested. Portable polysomnography has advantages including low cost, home monitoring, and convenience. But portable polysomnography has limitations like safety issues, lead malfunction, sensitivity, and specificity. Moreover, in some patients, portable polysomnography cannot be applied. The standard suggested diagnostic methods and available alternative tools are reviewed.

Volatile Induction and Maintenance of Anesthesia without Intravenous Access in Mild to Moderate Burn Injured Pediatric Patients

PURPOSE: Peripheral intravenous (I.V.) access is a common but stressful procedure in children, their parents and medical staffs. We evaluated the efficacy of volatile induction and maintenance of anesthesia (VIMA) without intravenous access for brief procedures in mild to moderate burn-injured pediatric patients. METHODS: VIMA without I.V. was conducted to healthy pediatric patients. Adverse events such as cough, breath holding, airway obstruction, arrhythmia, bradycardia and tachycardia, etc. were evaluated. RESULTS: From July 2008 to December 2009, 1,495 cases of VIMA with sevoflurane were performed in 859 children. Burn-injured patients were 94.9% and patients with hypertrophic scar were 5.1%. Scalding burn and contact burn were 90.1% of the burn-injured patients. Mean anesthesia duration was 29.3+/-6.2 min. In 1,495 VIMA cases, 47 cases had cardiovascular adverse events, including tachycardia (36), bradycardia (7), arrhythmia (3), and hypertension (1). All of these cardiovascular events returned normal after anesthesia. The respiratory adverse events occurred in 72 cases, including cough (49), breath holding (10), partial airway obstruction (8), hypoxia (4), and laryngospasm (1). None of the patients had bronchospasm. Most of the respiratory adverse events could be controlled by manual ventilation with mask, and oropharyngeal airway or laryngeal mask insertion. In four cases with hypoxia, the duration was less than 1 minute and these cases were no eventful after anesthesia. CONCLUSION: VIMA without I.V. access can be effective in brief procedures with mild to moderate burn-injured pediatric patients, even though a longer period of study may be required to assess the efficacy and safety.

A Case of Persistent Hiccup in a Patient with Non-small Cell Lung Cancer / 결핵및호흡기질환

A hiccup is caused by involuntary, intermittent, and spasmodic contractions of the diaphragm and intercostal muscles. It starts with a sudden inspiration and ends with an abrupt closure of the glottis. Even though a hiccup is thought to develop through the hiccup reflex arc, its exact pathophysiology is still unclear. The etiologies include gastrointestinal disorders, respiratory abnormalities, psychogenic factors, toxic-metabolic disorders, central nervous system dysfunctions and irritation of the vagus and phrenic nerves. Most benign hiccups can be controlled by traditional empirical therapy such as breath holding and swallowing water. However, though rare, a persistent hiccup longer than 48 hours can lead to significant adverse effects including malnutrition, dehydration, insomnia, electrolyte imbalance, and cardiac arrhythmia. An intractable hiccup can sometimes even cause death. We herein describe a patient with non-small cell lung cancer who was severely distressed by a persistent hiccup.

A comparison of the suppression of cough reflex by intravenous lidocaine and remifentanil prior to extubation of the endotracheal tube / 대한마취과학회지

BACKGROUND: Cough reflex in response to extubation of the endotracheal tube is common; however, the effect of remifentanil on cough reflex is uncertain. Therefore, we evaluated the effect of lidocaine and remifentanil on cough reflex following extubation. METHODS: Forty adult patients scheduled to undergo elective surgery in two hours were enrolled in this study. All patients received a standard anesthetic protocol. Following surgery, the patients were randomly divided into two groups, Group L (n = 20), which received 1.5 mg/kg of 2% lidocaine intravenously, and Group R (n = 20), which received 0.5 microgram/kg remifentanil intravenously. Treatment was administered immediately after the patients opened their eyes, after which extubation was performed. We then evaluated breath holding and recorded the number of coughs at 5 minutes, 15 minutes and 30 minutes after extubation. In addition, we checked for sore throat 30 minutes after extubation. RESULTS: The number of coughs was significantly lower in Group R than in Group L at 5 minutes after extubation. However, there was no significant difference in the number of coughs in Group R and Group L at any other times evaluated. CONCLUSIONS: There are no significant differences in suppression of the cough reflex in response to treatment with lidocaine and remifentanil.

Treatment of Persistent Hiccups with Risperidone Quicklet / 대한정신약물학회지

Hiccups are due to involuntary contraction of the diaphragm and intercostals muscles. Most hiccups are self-limiting, but sometimes intractable hiccups can lead to multiple problems including exhaustion. Persistent or intractable hiccups may be related to the presence of serious underlying system disease. A 52-year-old male who had suffered from gastric cancer was consulted from surgical department due to persistent hiccups. Initially, he was unsuccessfully managed using conservative method, i.e., breath holding, induced gag reflex, and the oral administration of chlorpromazine. We administered risperidone quicklet, and then the hiccups disappeared. We conclude that risperidone quicklet is one of the useful treatment methods for persistent hiccups.

The role of hypoxic response and breath holding at sea level in prediction of acute mountain sickness / 中国应用生理学杂志

<p><b>AIM</b>To explore whether hypoxic response and breath holding at sea level could predict acute mountain sickness (AMS).</p><p><b>METHODS</b>113 men aged (19 +/- 1) years took part in this study. Blood oxygen saturation (SaO2), heart rate and blood pressure were measured during the course of breathing 10% O2 for 10 minutes and breath holding. Two days later after reaching Lasa (3 658 m altitude) by air, the symptomatic scores of AMS were evaluated. Then the relations between them were analyzed.</p><p><b>RESULTS</b>The SaO2 reduced progressively and the heart rate speeded up, while the blood pressure represented increase at first and then decrease within 10 min during the short-term hypoxia. The heart rate was lower during short-term hypoxia in subjects who developed AMS than in subjects doing well. But significant reverse correlation existed only between AMS scores and heart rate at 7th min after hypoxic breathing (r = -0.176).</p><p><b>CONCLUSION</b>Limited information can be gained on AMS score by assessing physiological responses to short-term hypoxia and breath holding at sea level.</p>

Effects of Normocapneic Preoxygenation and Air Breathing during Vital Capacity Inhalation Induction with Sevoflurane on the Ventilation / 대한마취과학회지

BACKGROUND: Sevoflurane has been used to provide an inhaled induction by using a vital capacity breath, which is fast and has few side effects. We compared the clinical effects of a vital capacity inhalation induction (VCII) with sevoflurane in patients of preoxygenation or air-breathing before anesthetic induction. METHODS: After IRB approval, patients were randomly assigned to receive preoxygenation (O2 group, 70 patients) or air breathing (Air group, 70 patients) via SIBI (Single Breath Induction) connectorTM before VCII with 8% sevoflurane in 75% N2O/O2 from primed circuit. The clinical characteristics were compared between two groups in respect to prolongation of breath holding after loss of consciousness (response to verbal command) and side effects (airway, hemodynamic, motor) during VCII. RESULTS: O2 group showed lower incidence (60.0% vs. 87.1%, P < 0.05) and shorter duration (27.1 s vs. 36.4 s, P < 0.05) in prolongation of breath holding than Air group. Otherwise, there were no significant differences in clinical effects between two groups. CONCLUSIONS: We found that preoxygenation reduces the incidence and duration of prolongation of breath holding during VCII with sevoflurane compared with air-ventilation before VCII. We suggest that the prolongation of breath holding might be related to Hering-Breuer response to maximal lung inflation during VCII.

Cerebral CO2 Vasoreactivity by Transcranial Doppler with Rebreathing Method: Comparison between Ischemic Stroke and Normal Control

BACKGROUND: Cerebral vasoreactivity is an index of the autoregulation of cerebral perfusion, and can be measured by functional imaging such as Xe CT, SPECT, PET in reponse to a hypercapneic stimulus. Recently, a transcranial Doppler (TCD) study helped in the evaluation of cerebral CO2 vasoreactivity by a breath holding method and CO2 inhalation. However, the breath holding method had some constrictions in reliability and the CO2 inhalation method is not as feasible to apply to routine study. In order to measure cerebral CO2 vasoreactivity in a routine TCD study conveniently and reliably, we devised a method of rebreathing into a closed volume of a reservoir bag as a hypercapneic stimulus, and applied it to normal volunteers and patients with ischemic stroke. METHODS: We performed a cerebral CO2 vasoreactivity study by the rebreathing method in 22 normal volunteers and 61 ischemic stroke patients. As a hypercapneic stimulus, we applied a fitted mask connected with a closed reservoir bag for about 90 seconds, and the mean flow velocity (MFV) and pulsatility index (PI) were evaluated at the proximal middle cerebral arteries of 50-55 mm depth, before and after the hypercapneic stimulus. Cerebral vasoreactivities as percent increments of MFV in MCA were compared between the two groups. RESULTS: MFV of both the normal control and patient groups increased continuously during the hypercapneic stimulus, but the rate of the increments of MFV markedly diminished after about 60 seconds of rebreathing. The mean cerebral vasoreactivity of 61 MCA's in the ischemic stroke patient group (47.0 +/- 22.0%) was significantly lower than that of 22 MCA's in the normal control group (60.2 +/- 16.0%). But, the percent decrement of PI showed no significant difference between both groups. CONCLUSIONS: We suppose that the rebreathing method is a relatively reliable and convenient technique as a hypercapneic stimulus in determining cerebral CO2 vasoreactivity by TCD. Cerebral vasoreactivity measured by the rebreathing method is significantly lower in the ischemic stroke patient group than in the normal control group, which may reflect that the atherosclerosis itself could cause reduced distensibility of the small arteriole as well as the structural narrowing of the cerebral arteries.

Predictors of Smoking Cessation in Outpatients / 예방의학회지

OBJECTIVE: This study was conducted in order to investigate predictors of smoking cessation in outpatients. METHOD: Subjects were 401 adult smoking patients who saw their doctors in the outpatient setting at a university hospital, regardless of their willingness of otherwise in smoking cessation. Physicians delivered a brief, stop smoking prompt to all patients who smoked one or more cigarettes a day. Then they referred to on-site counselors who provided a brief, nurse assisted intervention with a survey to a randomly assigned intervention group (200 smoking patients), whom the counselors telephoned later to prevent relapse or promote the motivation to quit, or gave only a survey to a control group (201 smoking patients). After at least 5 months, self-reported current smoking cessation was confirmed later using cut-off values of 7 ppm or less in expired alveolar air after breath holding portable CO analyzer. RESULTS: After 5 months, subjects in the intervention group were 1.56 times (95% C.I. 0.89-2.73) more likely to quit smoking than those in the non-intervention group (14.0% vs. 9.0%). Willingness to quit smoking in a month, scheduled admission in a month, self efficacy score and FTND (Fagerstrom Test for Nicotine Dependence) score were all significantly related with smoking cessation. In stepwise multiple logistic regression, previous attempts to quit smoking were significant instead of self efficacy score. In the intervention group who had willingness to quit smoking in a month (132 smoking patients), FTND score, whether quit date was today, and whether quit promise paper was submitting were all significantly related with smoking cessation. In stepwise multiple logistic regression, scheduled admission in a month and whether quit date was today were significant predictor variables. Smoking cessation treatment should be tailored to individual smoking patients considering these predictors.

The effect of patient education on correct use of metered dose inhalers in patients with asthma / 천식및알레르기

BACKGROUND: Medications for asthma can be administered either by inhaled or systemic routes. The major advantages of delivering drugs directly into the lungs via inhalation are that higher concentrations can be delivered more effectively to the airways and that systemic side effects are avoided or minimized. Inhaled medications, or aerosols, are available in a variety of devices that differ in required technique and quantity of drugs delivered to the lung. OBJECTIVE: The purpose of this study was to determine the effects of patient education on correct use of metered dose inhaler in patients with asthma. METHODS: Twenty patients with asthma were instructed three times on proper inhaler usage by a physician at two-week intervals. Practical performance and theoretical knowledge were assessed (ten-item assessment). Scoring was done by one physician using a score of 1-3 for each item. RESULTS: The practical performance and theoretical knowledge scores were higher in patients after being instructed three times compared with those who were instructed once (26.2+/-2.2 vs 18.1+/-3.6, p< 0.01). The scores were higher in patients with higher education level com- pared with those with lower education level after three lessons (27.3+/-1.94 vs 24.3+/-1.80, p< 0.05). The most common errors included inadequate actuation time and breath holding, and insufficient activations. CONCLUSION: These findings suggest that patients with asthma be instructed in inhaler use and that their technique be checked regularly and repeatedly depending on education level.

Clinical Study of Differential Diagnosis between Childhood Convulsive Disorders and Nonepileptic Paroxysmal Disorders / 대한소아신경학회지

PURPOSE: Many neurologic and psychiatric behaviors can mimic epileptic seizures. Making a diagnosis of these nonepileptic paroxysmal disorders is very important to prevent inappropriate use of antiepileptic drugs. We studied the clinical characteristics of nonepileptic paroxysmal events in order to help differentiate them from true epileptic seizures. METHODS: We retrospectively reviewed 77 patients aged 2 months-15 years who visited the Pediatric Neurology clinic from January, 1990 to January, 1999 for evaluation of seizure disorders who were diagnosed as having nonepileptic paroxysmal disorders. RESULTS: Nonepileptic paroxysmal disorders were classified into 6 major groups as follows : movement disorders 19 cases (23.5%), respiratory disorders 16 (19.8%), loss of consciousness or tone 15 (18.5%), drug-induced dystonia 14 (17.3%), behavioral disorders 12 (14.8%), and perceptual disturbances 5 (6.1%). The final diagnoses of the 6 major groups were as follows : breath holding spell 16 cases (19.8%), syncope 14 (17.3%), drug-induced dystonia 14 (17.3%), pseudoseizure 6 (7.4%), sleep disorders 5 (6.1%), tics 4 (4.9%), headache 4 (4.9%), temper tantrum 4 (4.9%), sleep myoclonus 3 (3.7%), paroxysmal choreoathetosis 2 (2.5%), and masturbation 2 (2.5%). Five of the 77 patients also had idiopathic epilepsy. Breath holding spell is common in 2 months-6 years of age, syncope in 2-15 years, and pseudoseizure in 6-15 years. Monitoring in patients with pseudoseizure and abnormal eye movement with video EEG is helpful for diagnosis. CONCLUSION: Nonepileptic neurologic disorders are common and show a different incidence according to age group. The exact diagnosis of nonepileptic paroxysmal disorders using video EEG, is very important for preventing misdiagnosis and inappropriate use of antiepileptic drugs.

Dynamic Study of the Larynx with Spiral CT in the Tumors of the Pyriform Sinus and Supraglottis

PURPOSE: To evaluate the CT findings of tumor in the pyriform sinus, and to assess by functional study of thelarynx the extent the extent to which its characteristic findings differ from those of supraglottic tumor. MATERIALS AND METHODS: CT scans of 14 patients with tumor in the pyriform sinus were reviewed and compared withthose of 17 patients with supraglottic tumor. In all cases, spiral CT scanning linvolved both quiet breathing andmodified breath holding; we evaluated the images and analysed the primary site of tumors and the displacement ofair in the pyriform sinus. Extra and intralaryngeal extension of the tumors was also assessed. RESULTS: In tumorsin the pyriform sinus, CT findings were thickening of more than two walls in 14, the displacement of air in 9,extralaryngeal extension in 13, extension to the post-cricoid space in 11, invasion of the pre-epiglottic space in13, and widening of the cricothyroid space in 8 patients. In supraglottic tumors, CT findings were thickening ofthe medial wall in 17, extralaryngeal extension in 1, extension to the post-cricoid space in 1, invasion of theipsilateral paralaryngeal space in 17, and of the contralateral paralaryngeal space in 6, invasion of thepre-epiglottic space in 11, and widening of the cricothyroid space in 9 patienhts. In this type of tumor thedisplacement of air was not seen. CONCLUSION: The characteristic CT findings of tumor in the pyriform sinus werethickening of more than two walls of the pyriform sinus and the anterior or medial displacement of air. To assessthe site at which a tumor originates, spiral CT scanning is needed, together with functional study.

The Reference Values and Influencing Factors of TCD Measurements in 200 Normal Korean Adults

The clinical utility of transcranial doppler ultrasonography (TCD) in cerebrovascular disease has been extended recently. Although number of studies have been performed to define normal reference values of TCD measurements, they have some limitations to be used as reference values which include relatively small number of subjects, lack of data about some cerebral vessels and/or parameters. This study was aimed to obtain clinically useful reference values of TCD measurements with consideration of the influence of age and sex in Korean adults, particularly who are in stroke-prone age group. We measured flow velocities, pulsatility indecies, side-to-side differences and vasomotor reactivities of all intra-and extracranial cerebral arteries using TCD in 209 normal Korean adults (age, 23-78 years; 94 men and 115 women), and analyzed the influence of age and sex on those measurements. With advancing age, subjects showed significant reduction in velocity measurements and increase in pulsatility indecies of most examined arteries. Females showed hight velocities of middle cerebral, internal carotid, vertebral and basilar artery and lower pulsatility indecies of middle cerebral arteries compared with males. Asymmetry measurements including side-to-side differences and asymmetry index, and ,breath holding index testing vasomotor reactivity were also measured and the normal range of those parameters were calculated. Since present study included large number of subjects, and checked paramenters of TCD in both extra- as well as intracranial cerebral arteries, we are convinced that these results can be used as a reference data of TCD measurements in Korean adults.

A Clinical Observation on Ultrasonography of Renal Diseases / 대한비뇨기과학회지

Recent improvements in gray scale ultrasonic imaging and the development of real time ultrasound made it useful in directing the diagnostic examination and in determining which patients should undergo further, more invasive diagnostic procedures. Ultrasound scanning is cheaper and quicker than computed tomography and angiography, is not invasive and causes little discomfort to the patient. No intravenous contrast medium is used so that reactions to iodine and the difficulty in obtaining venous puncture, frequently a problem in children, are circumvented. There is no ionizing radiation or problem with breath holding. So we made a brief review of the clinical experience and value of ultrasound of renal diseases.