Psychometric Hepatic Encephalopathy Score for the Diagnosis of Minimal Hepatic Encephalopathy in Thai Cirrhotic Patients.

The psychometric hepatic encephalopathy score (PHES) is the gold standard for diagnosing minimal hepatic encephalopathy (MHE). Screening for MHE is frequently overlooked in clinical practice due to time constraints. Furthermore, the simplified animal naming test (S-ANT1) is a new simple tool for evaluating MHE in cirrhotic patients. The purpose of this study was to standardize the PHES in a healthy Thai population, assess the prevalence of MHE, and validate the S-ANT1 in detecting MHE in patients with cirrhosis. The study included 194 healthy controls and 203 cirrhotic patients without overt HE. Psychometric tests and the S-ANT1 were administered to all participants. Multiple linear regression was used to analyze factors related to PHES results, and formulas were developed to predict the results for each PHES subtest. In healthy controls, age and education were predictors of all five subtests. The PHES of the control group was −0.26 ± 2.28 points, and the threshold for detecting MHE was set at ≤ −5 points. The cirrhotic group had PHES values of −2.6 ± 3.1 points. Moreover, MHE was found to be present in 26.6% of cirrhotic patients. S-ANT1 had a moderate positive correlation with PHES (r = 0.44, p < 0.001). S-ANT1 < 22 named animals detected MHE with a sensitivity of 71.2%, specificity of 65%, and area under the receiver operating curve of 0.68 (p < 0.001). In conclusion, Thai PHES normative data have been developed to detect MHE in cirrhotic patients who do not have overt HE. The optimal cutoff for detecting MHE in Thai cirrhotic patients was PHES ≤ −5 points and S-ANT1 < 22 named.

Alice in Wonderland Syndrome-Like Seizure and Refractory Supraventricular Tachycardia.

Alice in Wonderland syndrome (AIWS) is a rarely curious visual perceptual disorder which has been associated with diverse neurologic and psychiatric problems. It may be a manifestation in migraine, epileptic seizures, encephalitis, other brain lesions, medication-related side effects, schizophrenia, and depressive disorders. Principal character of AIWS is the disproportion between the external world and the self-image in which micropsia (objects appear smaller), macropsia (objects appear larger), and teleopsia (objects appear further away) are frequently reported. The cases of temporal lobe epilepsy may present with complex visual auras of visual distortions (e.g., micropsia and macropsia) like AIWS. We report an unusual case of an elderly man who presented with AIWS, focal impaired awareness seizures, ictal tachyarrhythmia, multiple episodes of transient visual disturbances of macropsia and transient loss of consciousness. During those symptoms, telemetry showed self-limited supraventricular tachycardia several times which could not be regulated with heart rate-controlled medication. The electroencephalography was later tested and showed rhythmic theta activity over the right cerebral hemisphere. He was treated with levetiracetam, and all his symptoms and tachyarrhythmias were gradually resolved thereafter. Refractory response to treatment would remind the physicians to reassess for the correct diagnosis.

Coordinate based meta-analysis of motor functional imaging in Parkinson's: disease-specific patterns and modulation by dopamine replacement and deep brain stimulation.

OBJECTIVE: To investigate factors affecting the pattern of motor brain activation reported in people with Parkinson's (PwP), aiming to differentiate disease-specific features from treatment effects. METHODS: A co-ordinate-based-meta-analysis (CBMA) of functional motor neuroimaging studies involving patients with Parkinson's (PwP), and healthy controls (HC) identified 126 suitable articles. The experiments were grouped based on subject feature, medication status (onMed/offMed), deep brain stimulation (DBS) status (DBSon/DBSoff) and type of motor initiation. RESULTS: HC and PwP shared similar neural networks during upper extremity motor tasks but with differences of reported frequency in mainly bilateral putamen, insula and ipsilateral inferior parietal and precentral gyri. The activation height was significantly reduced in the bilateral putamen, left SMA, left subthalamus nucleus, right thalamus and right midial global pallidum in PwPoffMed (vs. HC), and pre-SMA hypoactivation correlated with disease severity. These changes were not found in patients on dopamine replacement therapy (PwPonMed vs. HC) in line with a restorative function. By contrast, left SMA and primary motor cortex showed hyperactivation in the medicated state (vs. HC) suggesting dopaminergic overcompensation. Deep-brain stimulation (PwP during the high frequency subthalamus nucleus (STN) DBS vs. no stimulation) induced a decrease in left SMA activity and the expected increase in the left subthalamic/thalamic region regardless of hand movement. We further demonstrated a disease related effect of motor intention with only PwPoffMed showing increased activation in the medial frontal lobe in self-initiated studies. CONCLUSION: We describe a consistent disease-specific pattern of putaminal hypoactivation during motor tasks that appears reversed by dopamine replacement. Inconsistent reports of altered SMA/pre-SMA activation can be explained by task- and medication-specific variation in intention. Moreover, SMA activity was reduced during STN-DBS, while dopamine-induced hyperactivation of SMA which might underpin hyperdynamic L-dopa related overcompensation.

Central nervous system melioidosis: A systematic review of individual participant data of case reports and case series.

BACKGROUND: Central nervous system (CNS) melioidosis is rare. However, delayed diagnosis and treatment could lead to fatality. To identify knowledge of CNS melioidosis, we systematically review case reports and case series. METHODOLOGY/PRINCIPAL FINDINGS: We searched through PubMed, Web of Science and Thai-Journal Citation Index databases as well as Google Scholar with the last date on July 10, 2018. The diagnosis of CNS melioidosis had to be confirmed with culture, serology or polymerase chain reaction. We excluded the animal cases and the studies that the clinical data were not available. We identified 1170 relevant studies, while 70 studies with a total of 120 patients were analyzed. Ninety-three percent of patients were reported from the endemic area of melioidosis. Median age was 40 years (IQR 18-53), and 70% were men. A total of 60% had one or more risk factors for melioidosis. The median duration from clinical onset to diagnosis was ten days (IQR 5-25). Fever (82%), headache (54%), unilateral weakness (57%) and cranial nerve deficits (52%) are among the prominent presentation. Most patient (67%) had at least one extraneurological organ involvement. The CSF profile mostly showed mononuclear pleocytosis (64%), high protein (93%) and normal glucose (66%). The rim-enhancing pattern (78%) is the most frequent neuroimaging finding in encephalomyelitis and brain abscess patients. Both brainstem (34%) and frontal lobe (34%) are the most affected locations. Mortality rate was 20%. CONCLUSIONS/SIGNIFICANCE: This study is the most extensive systematic review of case reports and case series of CNS melioidosis in all age groups. However, the results should be cautiously interpreted due to the missing data issue. The propensity of brainstem involvement which correlates with prominent cranial nerve deficits is the characteristic of CNS melioidosis especially encephalomyelitis type. The presenting features of fever and neurological deficits (especially cranial nerve palsies) along with the mononuclear CSF pleocytosis in a patient who lives in the endemic area and also has the risk factor for melioidosis should raise the CNS melioidosis as the differential diagnosis.

Level of Confidence in the 12 Roles of Medical Teacher. A Descriptive Study at Faculty of Medicine, Srinakharinwirot University, Thailand.

BACKGROUND: An appropriate faculty development program is imperative for every medical school and should be tailored to suit the needs of individuals and the institution. OBJECTIVE: To measure the average level of confidence in each of the 12 roles of medical teachers and analyse if any of these factors: age, gender duration of teaching, and teaching in pre-clinical or clinical years has effect on the level of confidence in the teacher roles. MATERIAL AND METHOD: The online questionnaire invitations were sent via email to all 211 faculty members at Faculty of Medicine, Srinakharinwirot University, and 118 (55.9%) responded. The questionnaire asked about demographic data, teaching experience and their specialty or disciplines. The respondents were also asked to rate their level of confidence in each of the 12 teacher roles on a 5 point Likert scale ranging from 1 (none) to 5 (great). RESULTS: The three most highly rated roles on the level of confidence were the clinical teacher (4.11), the on the job role model (4.11) and the lecturer (3.97). The three roles with the lowest rating were the curriculum planner (3.08), the curriculum assessor (3.23) and the mentor (3.31). Age and teaching experience were positively correlated with the level of confidence in nearly all of the 12 teacher roles. The pre-clinical year teachers had a higher mean level of confidence than clinical teachers in 6 out of the 12 roles. CONCLUSION: The future faculty development programs should aim towards supporting self-evaluation of teaching, mentoring as well as promoting facilitative roles of the teacher Retention of faculty members at the institution is also important as the teaching experience significantly correlate with confidence in the teacher roles.

Relationship between poststroke depression and ischemic lesion location.

BACKGROUND: Depression is more frequently detected in stroke patient compared to other medical illness with equal disability. The relationship between poststroke depression and ischemic stroke lesion location is controversial. OBJECTIVE: To determine the relationship between early onset poststroke depression and ischemic stroke lesion location. MATERIAL AND METHOD: A cross-sectional analysis was conducted. In-patients diagnosed with first acute ischemic stroke were enrolled. CT scan and MRI of the brain were performed to confirm the diagnosis of ischemic stroke as well as ischemic stroke subtypes and to determine the ischemic stroke lesion locations. Hamilton Depression Rating Scale was used to assess early onset poststroke depression within two weeks after the onset of stroke. Statistical analysis was conducted to determine the relationship between early onset poststroke depression and ischemic stroke lesion location as well as early poststroke depression and other potential factors. RESULTS: Thirty-nine patients were enrolled. The mean age (+/- SD) is 59.7 (+/- 12.3) years. Male: female ratio was 2:1. Early onset post stroke depression was found in 11 patients (28.2%). Mild depressive, less than major depressive, and major depressive level were found in five patients (12.8%), five patients (12.8%), and one patient (2.6%) respectively. Factors that statistically significantly related to early onset poststroke depression are left sided stroke lesion, female gender and absence of hypertension. CONCLUSION: Left sided stroke lesion, female gender, and absence of hypertension are factors contributing to early onset poststroke depression.