Geun-Young Park

Assessment of the Medial Dorsal Cutaneous, Dorsal Sural, and Medial Plantar Nerves in Impaired Glucose Tolerance and Diabetic Patients With Normal Sural and Superficial Peroneal Nerve Responses

OBJECTIVE This study evaluated the nerve conduction study (NCS) parameters of the most distal sensory nerves of the lower extremities—namely, the medial dorsal cutaneous (MDC), dorsal sural (DS), and medial plantar (MP) nerves—in diabetic (DM) and impaired glucose tolerance (IGT) patients who displayed normal findings on their routine NCSs. RESEARCH DESIGN AND METHODS Standard NCSs were performed on healthy control (HC), DM, and IGT groups (N = 147). The bilateral NCS parameters of the MDC, DS, and MP nerves were investigated. The Toronto Clinical Scoring System (TCSS) was assessed for the DM and IGT groups. RESULTS The mean TCSS scores of the IGT and DM groups were 2.5 ± 2.3 and 2.8 ± 2.2, respectively. No significant differences between the two groups were observed. After adjustment of age and BMI, the DM group showed significant NCS differences in DS and MDC nerves compared with the HC group (P < 0.05). These differences were also exhibited in the left DS of the IGT group (P = 0.0003). More advanced NCS findings were observed in the DM group. Bilateral abnormal NCS responses in these distal sensory nerves were found in 40 and 16% of DM and IGT patients, respectively. CONCLUSIONS These results showed that the simultaneous assessment of the most distal sensory nerves allowed the detection of early NCS changes in the IGT and DM groups, even when the routine NCS showed normal findings.

The association between the severity of poststroke depression and clinical outcomes after first-onset stroke in Korean patients

OBJECTIVE The purpose of the present study is to evaluate the association between poststroke depression (PSD) and clinical outcomes in first-onset stroke patients who are undergoing a rehabilitation program. METHODS The present study included 180 inpatients that were recruited consecutively and followed up over a 6-month observational period. Poststroke depression was diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Symptoms of depression and clinical outcomes were assessed using the Beck Depression Inventory, the modified Barthel Index (MBI) and the Mini Mental State Examination (MMSE). All patients were assessed at baseline and at the end of the 6-month observational period. RESULTS Of the 180 patients, 127 (70.6%) were diagnosed with minimal-to-mild depression (MMD), and 53 (29.4%) were diagnosed with moderate-to-severe depression (MSD). The mean change in MBI scores from baseline to 6 months was significantly higher (P=.029) in the MMD group (23.8) than in the MSD group (8.6). The odds ratio for an unfavorable outcome (MBI score <60) in patients with MSD was approximately 3.5 in relation to patients with MMD. The mean change in MMSE score (4.4 versus 7.4) was not significantly different between the MMD and MSD groups. CONCLUSION The present findings suggest that the severity of PSD may be associated with clinical outcomes in Korean patients 6 months after a first-onset stroke. Our data agree with previous findings, which indicate that clinicians should carefully evaluate symptoms of depression in stroke patients during routine clinical practice. The methodological shortcomings of the present study may require further studies with adequate power and improved design to clarify the association between PSD and clinical outcomes following stroke.

Can botulinum toxin improve mood in depressed patients

Evaluation of: Wollmer MA, de Boer C, Kalak N et al. Facing depression with botulinum toxin: a randomized controlled trial. J. Psychiatr. Res. 46(5), 574–581 (2012). Depression has a number of significant symptoms such as depressed mood, lack of volition/energy, suicidal ideation, low concentration, sleep disturbance, anger, anxiety, psychomotor retardation, fear and sadness. In addition, various facial expressions such as frowning and sadness can also be easily recognized in depressed patients. In fact, major muscles involved in the development of such negative emotion have been reported in depressed patients, for instance, corrugators and procerus muscles in the glabellar regions of the face. Electromyography studies have also reported that depressed patients had overactivity of such grief muscles during different affective imagery paradigms. Furthermore, subjective emotion has also been found to be affected by differential facial expression via an image feedback system. Interestingly, anecdotal open-label studies have shown that botulinum toxin may have a role in treatment of depression and a recent randomized-placebo controlled study has also confirmed the effect of botulinum toxin in reduction of depressive symptoms for the first time. This article will discuss the putative role of botulinum toxin in a treatment of depression in the context of the clinical significance, limitations and future research directions.

Decreased Diaphragm Excursion in Stroke Patients With Dysphagia as Assessed by M-Mode Sonography

OBJECTIVE To record diaphragm excursion via M-mode ultrasonography in stroke patients with dysphagia and determine whether they present reduced diaphragm excursion during voluntary cough compared with stroke patients without dysphagia and healthy subjects. DESIGN Prospective cross-sectional study. SETTING University rehabilitation hospital. PARTICIPANTS Acute stroke patients with dysphagia (n=23), acute stroke patients without dysphagia (n=24), and healthy control participants (n=27) (N=74). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Diaphragm motions during quiet breathing, deep breathing, and voluntary coughing were recorded via ultrasonography using M-mode tracing (mm). Maximum inspiratory and expiratory pressures (cmH2O) and peak cough flow (L/min) during voluntary coughing were measured. RESULTS The mean diaphragm movement (mm) of the hemiplegic side for all groups during quiet breathing, deep breathing, and voluntary coughing was 14.8±4.3, 17.6±4.8, and 20.9±3.7 (P<.001); 23.8±7.1, 32.7±10.6, and 44.7±10.3 (P<.001); and 16.8±4.8, 28.5±4.9, and 36.0±8.2 (P<.001), respectively. The differences were statistically significant. Differences were observed in the maximum inspiratory (P<.001) and expiratory (P<.001) pressures and peak cough flow (P=.027) among the 3 groups. Forward selection stepwise regression analysis, which was performed to determine variables that help predict diaphragm excursion during voluntary coughing, showed that the presence of dysphagia explained up to 60% (P<.001) of the hemiplegic diaphragm movement during voluntary coughing in patients with stroke. CONCLUSIONS M-mode ultrasonography showed that stroke patients with dysphagia have decreased diaphragm excursion and compromised respiratory function during voluntary coughing.

The Effects of Visual and Haptic Vertical Stimulation on Standing Balance in Stroke Patients

Objective To explore the effect of visual and haptic vertical stimulation on standing balance in post-stroke patients. Methods Twenty-five post-stroke patients were recruited. We measured left/right standing pressure differences and the center of pressure (COP) parameters for each patient under three different conditions: no stimulation, visual, and haptic stimulated conditions. First, patients stood on a posturography platform with their eyes blindfolded. After a rest period, the patients stood on the same platform with their eyes fixed to a 1.5-m luminous rod, which was placed at a vertical position in front of the patients. After another rest period, the patients again stood touching a vertically placed long rod in their non-hemiplegic hand with their eyes blindfolded. We collected the signals from the feet in each condition and obtained the balance indices. Results Compared with the no stimulation condition, significant improvements were observed for most of the COP parameters including COP area, length, and velocity for both the visual and haptic vertical stimulation conditions (p<0.01). Additionally, when we compared visual and haptic vertical stimulation, visual vertical stimulation was superior to haptic stimulation for all COP parameters (p<0.01). Left/right standing pressure differences, increased, although patients bore more weight on their paretic side when vertical stimulation was applied (p>0.01). Conclusion Both visual and haptic vertical stimulation improved standing steadiness of post-stroke patients. Notably, visual vertical stimulation was more effective than haptic stimulation.

Effect of superficial peroneal nerve fascial penetration site on nerve conduction studies.

Using nerve conduction studies (NCS) and ultrasonography, we sought to determine the stimulation site that corresponds to the site at which the superficial peroneal nerve (SPN) penetrates the fascia and yields the most accurate NCS results. NCS parameters of the SPN sensory nerve action potential (SNAP) were recorded from 37 legs at 14, 12, 9, 7, and 5 cm (S1, S2, S3, S4, and S5, respectively) proximal to the recording electrode, and analyzed by one‐way analysis of variance. SPN penetration sites were visualized by ultrasonography. The mean SNAP amplitude/area (17.2 ± 6.7 μV/9.6 ± 4.6 μV/ms) at S3–S5 differed significantly from that at S1–S2 (11.6 ± 4.7 μV/9.2 ± 4.4 μV/ms) (F = 10.2, P < 0.001; F = 5.09, P = 0.0007). Ultrasonography showed that the SPN became subcutaneous between S3 and S4. Clinical application of these results should help in obtaining more accurate data during electrodiagnostic studies of conditions that involve the SPN. Muscle Nerve, 2010

New method to perform medial plantar proper digital nerve conduction studies

OBJECTIVE We describe a technique that records the sensory nerve action potential (SNAP) of the medial plantar proper digital nerve (MPPDN), which is the final sensory branch of the medial plantar nerve. METHODS We obtained antidromic MPPDN responses from 118 healthy volunteers, with surface recording electrodes placed on the medial side of the first metatarsal head of the great toe, with electrical stimulation applied at the 40% distance of the heel to great toe reference line. Antidromic SNAP parameters were recorded and normative reference values were obtained. RESULTS The stimulation site that corresponded to 40% of the reference line was located at a mean distance of 8.7+/-1.2 cm from the recording electrodes. MPPDN responses were easily obtained in all but 9 limbs. The mean SNAP amplitudes obtained by our technique were 16.1+/-6.7 microV, and the lower and upper range values were 6.4 microV and 34.4 microV, respectively. CONCLUSION Antidromic stimulation of the MPPDN at a distance of 8-10 cm from the medial side of the first metatarsal head of the great toe yields in reliable SNAP responses. SIGNIFICANCE This technique should be useful in the evaluation of the MPPDN involvement in Joplins neuroma.

The Association between Post-Stroke Depression and the Activities of Daily Living/Gait Balance in Patients with First-Onset Stroke Patients

This study evaluated the association between post-stroke depression (PSD) and clinical outcomes, including activities of daily living (ADL) and gait balance, in patients with first-onset stroke. One hundred and eighty inpatients were recruited and followed-up for a 6-month. The depressive, cognitive, and stroke symptoms were assessed using the Beck Depression Inventory (BDI), the Global Deterioration Scale (GDS), the modified Rankin Scale (MRS), and the Berg Balance Scale (BBS). All patients were assessed at baseline and at the end of the observation (6-month). Among 180 patients, 127 (70.6%) were diagnosed with minimal-to-mild depression (MMD) while 53 (29.4%) were diagnosed with moderate-to-severe depression (MSD). The odd ratio (OR) for poor outcome in the MSD group was approximately 3.7 relative to the MMD group. The proportion of patients with better balance classified by the BBS score at 6-month was significantly higher in the MMD group than in the MSD group (OR=1.375). Our findings demonstrate the potential relationship between PSD and rehabilitation outcomes measured by different rating scales in Korean stroke patients. Our study suggests that clinicians should carefully evaluate depressive symptoms in patients with stroke during routine clinical practice. Adequately-powered and well-controlled further studies are necessary to confirm and fully characterize this relationship.

Churg-Strauss Syndrome as an Unusual Cause of Dysphagia: Case Report

Systemic vasculitis is a rare disease, and the diagnosis is very difficult when patient shows atypical symptoms. We experienced an unusual case of dysphagia caused by Churg-Strauss syndrome with lower cranial nerve involvement. A 74-year-old man, with a past history of sinusitis, asthma, and hearing deficiency, was admitted to our department for evaluation of dysphagia. He also complained of recurrent bleeding of nasal cavities and esophagus. Brain magnetic resonance imaging did not show definite abnormality, and electrophysiologic findings were suggestive of mononeuritis multiplex. Dysphagia had not improved after conventional therapy. Biopsy of the nasal cavity showed extravascular eosinophilic infiltration. All these findings suggested a rare form of Churg-Strauss syndrome involving multiple lower cranial nerves. Dysphagia improved after steroid therapy.

Diagnostic Value of Elevated D-Dimer Level in Venous Thromboembolism in Patients With Acute or Subacute Brain Lesions

Objective To define the risk factors that influence the occurrence of venous thromboembolism (VTE) in patients with acute or subacute brain lesions and to determine the usefulness of D-dimer levels for VTE screening of these patients. Methods Medical data from January 2012 to December 2013 were retrospectively reviewed. Mean D-dimer levels in those with VTE versus those without VTE were compared. Factors associated with VTE were analyzed and the odds ratios (ORs) were calculated. The D-dimer cutoff value for patients with hemiplegia was defined using a receiver operating characteristic (ROC) curve. Results Of 117 patients with acute or subacute brain lesions, 65 patients with elevated D-dimer levels (mean, 5.1±5.8 mg/L; positive result >0.55 mg/L) were identified. Logistic regression analysis showed that the risk of VTE was 3.9 times higher in those with urinary tract infections (UTIs) (p=0.0255). The risk of VTE was 4.5 times higher in those who had recently undergone surgery (p=0.0151). Analysis of the ROC showed 3.95 mg/L to be the appropriate D-dimer cutoff value for screening for VTE (area under the curve [AUC], 0.63; 95% confidence interval [CI], 0.5-0.8) in patients with acute or subacute brain lesions. This differs greatly from the conventional D-dimer cutoff value of 0.55 mg/L. D-dimer levels less than 3.95 mg/L in the absence of surgery showed a negative predictive value of 95.8% (95% CI, 78.8-99.8). Conclusion Elevated D-dimer levels alone have some value in VTE diagnosis. However, the concomitant presence of UTI or a history of recent surgery significantly increased the risk of VTE in patients with acute or subacute brain lesions. Therefore, a different D-dimer cutoff value should be applied in these cases.