Kinematic analysis of movement patterns during a reach-and-grasp task in stroke patients.

Background: This study aimed to evaluate the kinematic movement patterns during a reach-and-grasp task in post-stroke patients according to the upper extremity impairment severity. Methods: Subacute stroke patients (n = 46) and healthy controls (n = 20) were enrolled in this study. Spatiotemporal and kinematic data were obtained through 3D motion analysis during the reach-and-grasp task. Stroke patients were grouped using the Fugl-Meyer Assessment (FMA) scale, and a comparison of the groups was performed. Results: The severe group showed a significantly longer movement time, lower peak velocity, and higher number of movement units than the mild group during the reach-and-grasp task (p < 0.05). Characteristic compensatory movement patterns, such as shoulder abduction, thoracic posterior tilting, and upward and external rotation were significantly greater during the forward transporting phase in the severe group than in the mild group (p < 0.05). The FMA score was significantly associated with the movement time during the forward transporting phase, number of movement units during the reaching phase, range of shoulder abduction-adduction and wrist flexion-extension movements during the reaching phase, and range of thoracic internal-external rotation during the backward transporting phase (p < 0.05). Conclusion: Post-stroke patients have unique spatiotemporal and kinematic movement patterns during a reach-and grasp-task according to the impairment severity.

Decoding auditory-evoked response in affective states using wearable around-ear EEG system.

Objective.In this paper, an around-ear EEG system is investigated as an alternative methodology to conventional scalp-EEG-based systems in classifying human affective states in the arousal-valence domain evoked in response to auditory stimuli.Approach.EEG recorded from around the ears is compared to EEG collected according to the international 10-20 system in terms of efficacy in an affective state classification task. A wearable device with eight dry EEG channels is designed for ear-EEG acquisition in this study. Twenty-one subjects participated in an experiment consisting of six sessions over three days using both ear and scalp-EEG acquisition methods. Experimental tasks consisted of listening to an auditory stimulus and self-reporting the elicited emotion in response to the said stimulus. Various features were used in tandem with asymmetry methods to evaluate binary classification performances of arousal and valence states using ear-EEG signals in comparison to scalp-EEG.Main results.We achieve an average accuracy of 67.09% ± 6.14 for arousal and 66.61% ± 6.14 for valence after training a multi-layer extreme learning machine with ear-EEG signals in a subject-dependent context in comparison to scalp-EEG approach which achieves an average accuracy of 68.59% ± 6.26 for arousal and 67.10% ± 4.99 for valence. In a subject-independent context, the ear-EEG approach achieves 63.74% ± 3.84 for arousal and 64.32% ± 6.38 for valence while the scalp-EEG approach achieves 64.67% ± 6.91 for arousal and 64.86% ± 5.95 for valence. The best results show no significant differences between ear-EEG and scalp-EEG signals for classifications of affective states.Significance.To the best of our knowledge, this paper is the first work to explore the use of around-ear EEG signals in emotion monitoring. Our results demonstrate the potential use of around-ear EEG systems for the development of emotional monitoring setups that are more suitable for use in daily affective life log systems compared to conventional scalp-EEG setups.

Clinical Practice Guideline for Stroke Rehabilitation in Korea-Part 1: Rehabilitation for Motor Function (2022).

This clinical practice guideline (CPG) is the fourth edition of the Korean guideline for stroke rehabilitation, which was last updated in 2016. The development approach has been changed from a consensus-based approach to an evidence-based approach using the Grading of Recommendations Assessment Development and Evaluation (GRADE) method. This change ensures that the guidelines are based on the latest and strongest evidence available. The aim is to provide the most accurate and effective guidance to stroke rehabilitation teams, and to improve the outcomes for stroke patients in Korea. Fifty-five specialists in stroke rehabilitation and one CPG development methodology expert participated in this development. The scope of the previous clinical guidelines was very extensive, making it difficult to revise at once. Therefore, it was decided that the scope of this revised CPG would be limited to Part 1: Rehabilitation for Motor Function. The key questions were selected by considering the preferences of the target population and referring to foreign guidelines for stroke rehabilitation, and the recommendations were completed through systematic literature review and the GRADE method. The draft recommendations, which were agreed upon through an official consensus process, were refined after evaluation by a public hearing and external expert evaluation.

Polyarteritis nodosa initially presenting as concomitant peripheral neuropathy and myositis in unilateral limb: A case report.

RATIONALE: We report the case of a patient who initially presented with peripheral neuropathy and myositis without typical organ involvement, such as the kidneys, skin, or gastrointestinal system, but was ultimately diagnosed with polyarteritis nodosa (PAN). PATIENT CONCERNS: A 62-year-old man presented with radicular pain in his right lower extremity. One week later, he complained of right ankle motor weakness and pain in the right posterior thigh, which led to admission. After 6 weeks of hospitalization, he newly experienced pain in his right testicle and anterior thigh. DIAGNOSIS: The patient was initially diagnosed with polymyositis combined with sciatic neuropathy using magnetic resonance imaging, electrodiagnostic tests, and muscle biopsy. However, with the emergence of other systemic symptoms such as testicular pain, vasculitis was suspected, and the patient was reclassified as PAN using the 2007 European Medicines Agency algorithm and the American College of Rheumatology criteria. INTERVENTIONS: The patient was treated with glucocorticoids for more than 6 months, and antiviral medication was prescribed to prevent hepatitis B virus reactivation. OUTCOMES: The patient's radicular pain and pain in the right anterior and posterior thighs and testicle improved, and there were no signs of recurrence. LESSONS: In patients presenting with radicular and focal muscle pain, it is crucial to consider the potential for PAN, as observed in this case report.

The power of positive deviance behaviours: From panic-gogy to effective pedagogy in online teaching.

This study examines university faculty members' successful behaviours and the factors influencing these behaviours, when dealing with the issues posed by emergency remote teaching during the COVID-19 pandemic. Data was gathered through interviews with 12 carefully chosen instructors who competently prepared and implemented their first online classes despite various challenges encountered during the crisis. Interview transcripts were analysed by applying the theoretical concepts of the positive deviance approach to identify exemplary behaviours in the face of crisis. The results revealed that the participants performed three unique but effective behaviours, called 'positive deviance behaviours', in their online teaching: philosophy-driven decision making informed planning and ongoing performance monitoring. These behaviours were affected by individual factors (e.g., community engagement and emotion management during different phases of emergency remote teaching) and organisational factors (e.g., networks/hardware and training/support). By examining the positive deviance behaviours of instructors who delivered effective classes, this study offers online teaching and faculty development strategies in both crisis and non-crisis situations.

Diffusion tensor tractography of the corticobulbar tract in a dysphagic patient with progressive supranuclear palsy: A case report.

RATIONALE: This paper reports the changes over time in the corticobulbar tract (CBT) analyzed using diffusion tensor tractography (DTT) in a dysphagic patient with progressive supranuclear palsy (PSP). PATIENT CONCERNS: A 53-year-old man initially presented with dysarthria, gait disturbance, and bradykinesia, and approximately 1-year later, downward gaze paralysis appeared. Initially, there was no dysphagia; however, approximately 2 years after visiting the hospital, symptoms of dysphagia, including difficulty swallowing pills, aspiration, and oral movement impairments appeared. The symptoms gradually progressed, and finally, mouth opening was severely damaged to the extent that it was difficult to orally feed. INTERVENTIONS: We performed diffusion tensor imaging 3 times; at 3-month, 20-month, and 41-month from onset. OUTCOMES: On 3-month DTT, the left CBT was well reconstructed, whereas the right CBT showed partial tearing. In the 20-month DTT, both CBTs became thinner compared to the 3-month DTT. On 41-month DTT, both CBTs became much thinner than after 3-month and 20-month DTT. LESSONS: We observed the degree of CBT injury over time in a dysphagic patient with PSP. These results suggest that the analysis of CBT using DTT is helpful in predicting the degree of dysphagia and prognosis in patients with PSP.

Instructional media selection principles for online medical education and emerging models for the new normal.

The COVID-19 pandemic, and the resulting need to avoid in-person classes, compelled many faculty members to convert to a completely online instructional format. The literature on selecting media for medical educators, however, provided little assistance for them to make choices that facilitated learning through using alternative online instruction practices. In this study, we addressed the lack of guidance for the use of media to facilitate the effective online medical education. To optimise the transition from face-to-face educational modalities to online learning, we incorporated insights from theories of media synchronicity and learning. We considered the value of existing learning theories in influencing how we could guide entrenched face-to-face educators to online learning practice. Therefore, we employed existing theories and practice to assist in developing an algorithmic approach to guiding these educators. We reassessed the way taxonomies of learning objectives, practice-oriented learning experiences, the social and collaborative features of learning activities, and media synchronicity theory could have augmented face-to-face teaching, and influenced how these could be reconfigured to assist in the transition to online learning. Consequently, we have developed key principles to inform the continuity of design and selection of instructional media in the transition to medical online learning. We have constructed specific criteria for media selection that correspond to the 12 goals of medical learning. We found that the majority of the goals can be more enhanced by synchronous media than asynchronous versions. We discuss the role of instructional media in emergency online medical education as well as emerging models of media selection for the new normal in medical education and future directions for medical education media research.

Mediating effect of reflection types: feedback on reflection-for-action and student perception of patient-centredness.

We aimed to examine the mediating effects of reflection on the relationship between feedback for reflection-for-action (RfA-feedback) and students' perception of the importance of patient-centred communication (PCC) education. A survey was conducted with 358 medical students and the mediation effects were analysed by performing multiple regression analysis and Sobel test. Three types of reflection (i.e., reflection-in-action, reflection-on-action, and reflection-for-action) partially mediate the relationship between feedback for reflection-for-action, and the perceived importance of PCC education. Based on these findings, the study suggests the importance of providing feedback on reflection-for-action. Such feedback can encourage student reflection, and is crucial for their future, as medical professionals.

Beginning of outcome-based medical education: development of medical schools' mission statements based on stakeholders' priority.

BACKGROUND: Many studies report the positive effects of outcome-based education in improving medical education quality. An important aspect of outcome-based education is the statement of learning outcomes, which is closely associated with medical schools' mission, vision, and educational goals. Medical schools' mission statement not only sets the standards to determine educational goals and outcomes but also provides an indicator to monitor and evaluate medical education quality. PURPOSE: This study identified a methodology to provide optimal mission statements at medical schools through the framework of suggested decision-making method. METHODS: This study analyzed the focus of the mission development suggested by World Federation for Medical Education and Liaison Committee on Medical Education medical education standards and searched for appropriate decision-making methods based on these standards. In addition to validate the suggested framework of mission statement, case analysis of medical schools was conducted. RESULTS: Consequently, a mission development method that applies the mission statement based on stakeholders' priority (MSSP) was derived. The MSSP involves (1) content analysis, (2) candidate extraction, (3) priority evaluation, and (4) priority validation. The keywords of the mission system derived during this process were categorized and listed in ranks to be suggested as the mission, vision, and core values. The proposed MSSP was applied in two South Korean medical schools and, thereby, the mission, vision, and core values were determined for each medical school. CONCLUSION: The two schools' case analysis verified MSSP's effectiveness as a decision-making methodology to gather and converge diverse opinions from stakeholders for the mission statement at the medical schools.

Vibration Perception Threshold and Related Factors for Balance Assessment in Patients with Type 2 Diabetes Mellitus.

Diabetic peripheral neuropathy (DPN) is a common complication of type 2 diabetes mellitus (DM). DPN causes a decrease in proprioception, which could reduce balance ability. We investigated the association of impaired vibration sense, based on vibration perception threshold (VPT), with assessments of balance and other factors affecting balance impairment and fear of falling in patients with type 2 DM. Sixty-three patients with DM aged >50 years were categorized as having normal vibration sense (NVS; n = 34) or impaired vibration sense (IVS; n = 29) according to a VPT value of 8.9 µm. The following parameters were evaluated for all patients: postural steadiness through the fall index using posturography, functional balance through the Berg Balance Scale (BBS), the Timed Up and Go test (TUG), and fear of falling through the Falls Efficacy Scale-International (FES-I). The IVS group showed a significantly greater balance impairment in fall index, BBS, and TUG, as well as greater fear of falling on the FES-I than the NVS group. The linear regression analysis showed that the fall index was associated only with the VPT, whereas BBS, TUG, and FES-I were associated with the VPT, age, and/or lower extremity muscle strength. VPT, age, and/or muscle strength were identified as predictors of balance and fear of falling in patients with type 2 DM. Therefore, along with age and lower extremity strength, the VPT can be useful for balance assessment in patients with type 2 DM.

Effects of position-triggered electrical stimulation on poststroke hemiparetic shoulder subluxation.

BACKGROUND: Shoulder subluxation is a frequent complication after stroke causing joint instability, shoulder pain, decreased activities of daily living, and impedance to rehabilitation progress. Electrical stimulation (ES) is considered an effective modality to reduce shoulder subluxation in acute stroke. However, few studies have investigated the effect of position-triggered ES, which induces active muscle contraction though accurate motion detection. AIM: The aim of this study was to investigate whether position-triggered ES was more effective in reducing acute hemiplegic shoulder subluxation after stroke than passive ES. DESIGN: Single-blind, randomized controlled trial. SETTING: The study setting was the university hospital rehabilitation center. POPULATION: Fifty poststroke subacute hemiparetic patients with shoulder subluxation. METHODS: Patients were randomly assigned into two groups. The position-triggered ES group received 30-minute ES sessions, 5 days per week for 3 weeks with specially modified Novastim® CU-FS1 (CU Medical Systems, Inc., Gangwon-do, South Korea) for motion triggering. The passive ES group received the same protocol without motion triggering. The vertical distance (VD) and the joint distance (JD), relative VD and JD (rVD, rJD), upper extremity component of Fugl-Meyer Motor Assessment (FMAupper), Motricity Index (MI), Manual Function Test (MFT), and peak torque of affected shoulder abductor (PT) were assessed at baseline (T0), end of electrical stimulation session (T1), and 3 weeks (T2) after treatment. RESULTS: Repeated-measures analysis of variance revealed significant interaction between time and intervention on JD and rJD, indicating that shoulder subluxation was significantly more reduced in position-triggered ES than in passive ES (P<0.05). However, FMAupper, MI, MFT, and PT did not show this significance. The change of (∆)JD, ∆rVD, and ∆rJD in the motion-triggered ES group improved significantly more at T1 than in the passive ES group (P<0.05). This significant improvement was not seen at T2. CONCLUSIONS: Position-triggered ES may be more effective than passive ES in improving poststroke shoulder subluxation; however, this effect was not maintained after the withdrawal of stimulation. CLINICAL REHABILITATION IMPACT: Position-triggered ES may be useful to reducing poststroke shoulder subluxation.

Risk factors for aspiration pneumonia in patients with dysphagia undergoing videofluoroscopic swallowing studies: A retrospective cohort study.

Prediction of aspiration pneumonia development in at-risk patients is vital for implementation of appropriate interventions to reduce morbidity and mortality. Unfortunately, studies utilizing a comprehensive approach to risk assessment are still lacking. The objective of this study was to analyze the clinical features and videofluoroscopic swallowing study (VFSS) findings that predict aspiration pneumonia in patients with suspected dysphagia.Medical records of 916 patients who underwent VFSS between September 2014 and June 2018 were retrospectively analyzed. Patients were divided into either a pneumonia group or a non-pneumonia group based on diagnosis of aspiration pneumonia. Clinical information and VFSS findings were evaluated.One hundred seven patients (11.7%) were classified as having pneumonia. Multivariate analysis indicated that aspiration during the 2- cubic centimeter thick-liquid trial of VFSS (odds ratio [OR] = 3.23, 95% confidence interval [CI]: 1.93-5.41), smoking history (OR = 2.63, 95% CI: 1.53-4.53), underweight status (OR = 2.27, 95% CI: 1.31-3.94), abnormal pharyngeal delay time (OR = 1.60, 95% CI: 1.01-2.53), and a Penetration-Aspiration Scale level of 8 (OR = 3.73, 95% CI: 2.11-6.59) were significantly associated with aspiration pneumonia development. Integrated together, these factors were used to develop a predictive model for development of aspiration pneumonia (DAP), with a sensitivity of 82%, specificity of 56%, and an area under the receiver operating characteristic curve of 0.73.The best predictors for DAP included videofluoroscopic findings of aspiration during a 2-cubic centimeter thick-liquid trial, prolonged pharyngeal delay time, a Penetration-Aspiration Scale level of 8, history of smoking, and underweight status. These 5 proposed determinants and the associated DAP score are relatively simple to assess and may constitute a clinical screening tool that can readily identify and improve the management of patients at risk for aspiration pneumonia.

Effect of Underlying Comorbidities on the Infection and Severity of COVID-19 in Korea: a Nationwide Case-Control Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is an emerging threat worldwide. It remains unclear how comorbidities affect the risk of infection and severity of COVID-19. METHODS: This is a nationwide retrospective case-control study of 219,961 individuals, aged 18 years or older, whose medical costs for COVID-19 testing were claimed until May 15, 2020. COVID-19 diagnosis and infection severity were identified from reimbursement data using diagnosis codes and on the basis of respiratory support use, respectively. Odds ratios (ORs) were estimated using multiple logistic regression, after adjusting for age, sex, region, healthcare utilization, and insurance status. RESULTS: The COVID-19 group (7,341 of 219,961) was young and had a high proportion of female. Overall, 13.0% (954 of 7,341) of the cases were severe. The severe COVID-19 group had older patients and a proportion of male ratio than did the non-severe group. Diabetes (odds ratio range [ORR], 1.206-1.254), osteoporosis (ORR, 1.128-1.157), rheumatoid arthritis (ORR, 1.207-1.244), substance use (ORR, 1.321-1.381), and schizophrenia (ORR, 1.614-1.721) showed significant association with COVID-19. In terms of severity, diabetes (OR, 1.247; 95% confidential interval, 1.009-1.543), hypertension (ORR, 1.245-1.317), chronic lower respiratory disease (ORR, 1.216-1.233), chronic renal failure, and end-stage renal disease (ORR, 2.052-2.178) were associated with severe COVID-19. CONCLUSION: We identified several comorbidities associated with COVID-19. Health care workers should be more careful while diagnosing and treating COVID-19 when patients have the abovementioned comorbidities.

Development of a flickering action video based steady state visual evoked potential triggered brain computer interface-functional electrical stimulation for a rehabilitative action observation game.

BACKGROUND: This study focused on developing an upper limb rehabilitation program. In this regard, a steady state visual evoked potential (SSVEP) triggered brain computer interface (BCI)-functional electrical stimulation (FES) based action observation game featuring a flickering action video was designed. OBJECTIVE: In particular, the synergetic effect of the game was investigated by combining the action observation paradigm with BCI based FES. METHODS: The BCI-FES system was contrasted under two conditions: with flickering action video and flickering noise video. In this regard, 11 right-handed subjects aged between 22-27 years were recruited. The differences in brain activation in response to the two conditions were examined. RESULTS: The results indicate that T3 and P3 channels exhibited greater Mu suppression in 8-13 Hz for the action video than the noise video. Furthermore, T4, C4, and P4 channels indicated augmented high beta (21-30 Hz) for the action in contrast to the noise video. Finally, T4 indicated suppressed low beta (14-20 Hz) for the action video in contrast to the noise video. CONCLUSION: The flickering action video based BCI-FES system induced a more synergetic effect on cortical activation than the flickering noise based system.

Most surface learning in the third year: Dental student learning approaches and implications for curriculum and assessment.

CONTEXT: Dental schools seek to educate students to become inclined toward self-directed, lifelong learning, an important mindset for healthcare professionals that may be linked to deep versus surface learning approaches. Students using a deep learning approach are more intrinsically motivated and actively engage in higher-order thinking, while those using a surface learning approach are more extrinsically motivated and aim for passive learning. OBJECTIVES: Because student learning approaches can be influenced by a wide variety of learning experiences, we sought to understand how student approaches to learning differ by year in dental school and are related to academic achievement. METHODS: A total of 244 students in a 4-year dental school program in South Korea voluntarily participated in this study. We collected data on school year and academic achievement, and approaches to learning of participants using the validated Study Processes Questionnaire to assess learning approach, which included the constructs of deep motive, deep strategy, surface motive, and surface strategy. RESULTS: We conducted 3 sets of statistical analyses and found that most students adopted a deep approach to learning (DAL) in their first and second years (Y1 and Y2), with third-year students (Y3) showing heavy dependence on a surface approach to learning (SAL) and sharp drops in intrinsic motives. Student approaches to learning were not significantly related to academic achievement. In the first 2 years of dental school, students tended to adopt a DAL, and viewed their learning as personal growth and their profession as necessitating deep intellectual inquiry. CONCLUSIONS: In the third year, the change from a DAL to a SAL coincided with entry to clinical training. The lack of integration of biomedical science (Y1 and Y2) and clinical science (Y3 and Y4), and increased stress in the initial clinical context may account for this difference. The poor correlation between a DAL and high achievement may indicate a need for change in assessment methods. This study hopes to stimulate reflection regarding student learning approaches and educational efforts that prepare future dentists for lifelong learning.

Flipped-learning course design and evaluation through student self-assessment in a predental science class.

PURPOSE: This study explores how to design a flipped classroom for a predental science course and evaluate its course through student self-assessment in order to provide practical implications for flipped learning in an undergraduate level. METHODS: Second- and third-year predental students in the Seoul National University School of Dentistry enrolled in Biodiversity and Global Environment, a 15-week, three-credit course based on a flipped learning model. At the end of the course, the students were asked to rate their self-directed learning, attitude toward social media, discussion skills, learning readiness, and class satisfaction. Out of the 82 predental students, 61 (74.3%) answered the survey. Pearson correlation and multivariate regression analyses were employed to examine the relationship between the self-rated measurements and the performance scores. RESULTS: The majority of the students felt somewhat more prepared than the medium level before the class (mean score of 3.17 out of 5.00), whereas they expressed relatively low preference concerning social media use and attitude (mean score of 2.49). Thus, it was found that learning readiness was significantly associated with both discussion skills and class satisfaction. In particular, multivariate regression analysis confirmed that learning readiness had a significant influence on learning outcomes. CONCLUSION: This study offered insights into how to design a flipped learning course in terms of predental students' preference and their learning readiness. Although learning success in a flipped classroom depends on the students' self-perceived level of preparedness, much still remains to be achieved in order to apply social media benefits in a flipped learning context.

Molecular changes of epidermal growth factor receptor (EGFR) and KRAS and their impact on the clinical outcomes in surgically resected adenocarcinoma of the lung.

Recent studies have reported that clinical response to epidermal growth factor receptor (EGFR) inhibitors is associated with somatic changes of EGFR in the advanced stage of lung cancer. However, there is no clear data demonstrating whether such molecular changes of EGFR per se can affect the clinical outcome of early stage cancer after surgical resection. DNA mutations of EGFR and KRAS were investigated in 71 adenocarcinoma patients who received surgical resection. Fluorescence in situ hybridization (FISH) of EGFR gene amplification was performed in 48 samples. We detected EGFR mutations in 25 patients (35.2%). EGFR mutation was more frequently found in cases with BAC features (13/22 (59.1%):13/49 (26.5%); p=0.008) and in non-smokers (19/41 (46.3%):7/30 (23.3%); p=0.047). However, the EGFR mutation was not associated with age, gender, or clinical stage. The amplification of EGFR copy was frequently observed in the female gender (12/29 (41.4%):3/19 (15.8%); p=0.061) and in the advanced stage (> or =Stage IIIA, 9/19 (47.4%):6/29 (20.7%); p=0.051). KRAS mutations were present in five patients (7.0%) and none of them showed EGFR mutation. KRAS mutations (p=0.000), male gender (p=0.001), absence of BAC feature (p=0.003), advanced stage (p=0.039), and smoking history (p=0.030) were poor prognostic factors for overall survival, whereas EGFR mutation (p=0.184) and amplification (p=0.756) were not. The presence of EGFR mutation was not a prognostic factor of the clinical outcome of early lung cancer after surgical resection. This result provides an important message for the protocol design of future trials of EGFR inhibitors in early lung cancer. As the KRAS mutation was a poor prognostic factor and it presents reciprocally with EGFR mutation, KRAS mutation should be investigated in such trials. DNA mutations of EGFR and KRAS were investigated in 71 adenocarcinoma patients who received surgical resection. Whereas KRAS mutation was a poor prognostic factor, EGFR mutation was not, and its presence per se did not affect the clinical outcome of early lung cancer after surgical resection.