Brain lesion and echocardiogenic predictors of newly detected atrial fibrillation in acute ischemic stroke.

OBJECTIVES: Atrial fibrillation (AF) is one of the notorious risk factors in acute ischemic stroke (AIS), and the use of anticoagulants has been shown to be effective in preventing ischemic stroke in AF patients. Therefore, identifying AF in AIS patients has become increasingly important. However, the impact of brain imaging and cardiac indices on the development of new AF after stroke remains unclear. METHODS: A consecutive series of AIS patients who were admitted to the Ulsan University Hospital between January 2013 and December 2019 were identified. Patients with relevant ischemic brain lesions on MRI were included, and those without echocardiography data were excluded. We included and classified the AF patients who had the disease prior to or during hospitalization or met the criteria for cryptogenic stroke (CS). Differences in baseline characteristics, stroke risk factors, stroke severity, insular lesion, and echocardiographic data were investigated among each group. RESULTS: A total of 850 patients were enrolled in the study, comprising 231 patients with AF detected after stroke (AFDAS), 287 patients with known AF (KAF), and 350 patients with CS. Compared with KAF, patients with AFDAS had a lower prevalence of underlying coronary heart disease and stroke history. They had greater right insular cortex lesions and lesser left atrial enlargement in unadjusted analysis. Following adjusted analysis, the involvement of the right insular cortex was found to be associated with the AFDAS patient group (odds ratio, 1.57). When compared to the CS group, AFDAS patients were older, experienced more severe initial strokes, and had similar rates of pre-stroke anticoagulation prescription. Additionally, they demonstrated a higher prevalence of both insular lesions, increased left atrium volume index, reduced ejection fraction, and elevated e/e' ratio. After adjustment, age, initial stroke severity, insular involvement, left atrium volume index, ejection fraction, and e/e' ratio were found to be significant. CONCLUSIONS: These results suggest that the right insular cortex lesion on acute stroke may be a cause of AFDAS.

Temporal Changes in 18 F-FDG PET/CT in Familial Neuronal Intranuclear Inclusion Disease, Based on the Clinical Course.

ABSTRACT: We report temporal changes in 18 F-FDG PET/CT in neuronal intranuclear inclusion disease (NIID). In a patient with encephalitis-like episodes, PET showed hypermetabolism correlating with EEG alterations. Affected sites later became hypometabolic and showed diffusion changes on MRI. In another patient, hypermetabolic regions correlated well with the EEG, whereas MRI showed changes after only 1 month. One chronic patient had diffuse hypometabolism, which correlated with atrophy on MRI and cerebral dysfunction on EEG. This is the first report of temporal changes in PET in NIID and suggests that it reflects the disease activity of NIID while correlating well with EEG.

Generation of Conventional 18F-FDG PET Images from 18F-Florbetaben PET Images Using Generative Adversarial Network: A Preliminary Study Using ADNI Dataset.

Background and Objectives: 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) (PETFDG) image can visualize neuronal injury of the brain in Alzheimer's disease. Early-phase amyloid PET image is reported to be similar to PETFDG image. This study aimed to generate PETFDG images from 18F-florbetaben PET (PETFBB) images using a generative adversarial network (GAN) and compare the generated PETFDG (PETGE-FDG) with real PETFDG (PETRE-FDG) images using the structural similarity index measure (SSIM) and the peak signal-to-noise ratio (PSNR). Materials and Methods: Using the Alzheimer's Disease Neuroimaging Initiative (ADNI) database, 110 participants with both PETFDG and PETFBB images at baseline were included. The paired PETFDG and PETFBB images included six and four subset images, respectively. Each subset image had a 5 min acquisition time. These subsets were randomly sampled and divided into 249 paired PETFDG and PETFBB subset images for the training datasets and 95 paired subset images for the validation datasets during the deep-learning process. The deep learning model used in this study is composed of a GAN with a U-Net. The differences in the SSIM and PSNR values between the PETGE-FDG and PETRE-FDG images in the cycleGAN and pix2pix models were evaluated using the independent Student's t-test. Statistical significance was set at p ≤ 0.05. Results: The participant demographics (age, sex, or diagnosis) showed no statistically significant differences between the training (82 participants) and validation (28 participants) groups. The mean SSIM between the PETGE-FDG and PETRE-FDG images was 0.768 ± 0.135 for the cycleGAN model and 0.745 ± 0.143 for the pix2pix model. The mean PSNR was 32.4 ± 9.5 and 30.7 ± 8.0. The PETGE-FDG images of the cycleGAN model showed statistically higher mean SSIM than those of the pix2pix model (p < 0.001). The mean PSNR was also higher in the PETGE-FDG images of the cycleGAN model than those of pix2pix model (p < 0.001). Conclusions: We generated PETFDG images from PETFBB images using deep learning. The cycleGAN model generated PETGE-FDG images with a higher SSIM and PSNR values than the pix2pix model. Image-to-image translation using deep learning may be useful for generating PETFDG images. These may provide additional information for the management of Alzheimer's disease without extra image acquisition and the consequent increase in radiation exposure, inconvenience, or expenses.

The Use of F-18 FDG PET-Based Cognitive Reserve to Evaluate Cognitive Decline in Alzheimer's Disease, Independent of Educational Influence.

Background and Objectives: The optimal assessment of cognitive function, including the impact of education, is crucial in managing Alzheimer's disease (AD). This study aimed to evaluate the role of cognitive reserve (CR), represented by the metabolic status of regions of the cerebral cortex, to evaluate cognitive decline considering the educational attainment of patients with AD. Materials and Methods: We used data from the Alzheimer's Disease Neuroimaging Initiative database, and selected 124 patients who underwent both baseline F-18 fluorodeoxyglucose (FDG) and F-18 florbetaben (FBB) positron emission tomography (PET) scans. Demographics, cognitive function variables (Clinical Dementia Rating-Sum of Boxes [CDR]; AD Assessment Scale 11/13 [ADAS11/13] Mini-Mental State Examination [MMSE]), and the average standardized uptake value ratio (SUVR) of cerebral cortex regions to those of the cerebellum were obtained from the data. The participants' education level was divided into low and high education subgroups using four cut-offs of 12, 14, 16, and 18 years of educational attainment (G12, G14, G16, and G18, respectively). Demographic and cognitive function variables were compared between the two subgroups in each of the four groups, and their correlations with the SUVRs were evaluated. Results: There was no significant difference between the high and low education subgroups in each of the four groups, except for ADAS11/13 and MMSE in G14 and age in G16. The SUVRs of FDG PET (FDGSUVR) were significantly correlated with CDR, ADAS11/13, and MMSE scores. FDGSUVR showed different trajectories of neurodegeneration between the low and high education groups. Conclusions: FDGSUVR correlated moderately but significantly with neuropsychological test results, without being influenced by education level. Therefore, FDG PET may reflect CR independent of education level, and therefore could be a reliable tool to evaluate cognitive decline in AD.

Mortality of Deep Brain Stimulation and Risk Factors in Patients With Parkinson's Disease: A National Cohort Study in Korea.

BACKGROUND: This study aimed to investigate 1) long-term outcomes of deep brain stimulation (DBS), such as mortality after DBS as well as the causes of death, 2) demographic and socioeconomic factors influencing mortality, and 3) comorbidities affecting mortality after DBS in patients with Parkinson's disease (PD). METHODS: This study analyzed the National Health Insurance Service-National Health Information Database. Data on patients with PD diagnosis codes from 2002 to 2019 were extracted and analyzed. Data on the causes of death were obtained by linking the causes of death to data from Statistics Korea. The Kaplan-Meier method with the log-rank test was used for survival analysis. Multivariate Cox regression analyses were used to estimate hazard ratios (HRs) and their 95% confidence intervals. Regarding comorbidities such as PD dementia and fracture, which did not satisfy the assumption for the proportional HR, time-dependent Cox analysis with the Mantel-Byar method was used. RESULTS: From 2005 to 2017, among 156,875 patients diagnosed with PD in Korea, 1,079 patients underwent DBS surgery, and 251 (23.3%) had died by 2019. The most common cause of death (47.1%) was PD. In the multivariate Cox regression analysis, the higher the age at diagnosis and surgery, the higher the mortality rate. The men and medical aid groups had significantly higher mortality rates. PD dementia and fracture were identified as risk factors for mortality. CONCLUSION: Older age at diagnosis and surgery, being male, the use of medical aid, and the comorbidity of dementia and fractures were associated with a higher risk of mortality after DBS in patients with PD. Neurologists should consider these risk factors in assessing the prognosis of PD patients undergoing DBS.

The mortality of patients with Parkinson's disease with deep brain stimulation.

Background: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective in improving motor function in patients with Parkinson's disease (PD). This study aimed to investigate mortality associated with bilateral STN DBS in patients with PD and to assess the factors associated with mortality and causes of death after DBS. Methods: We reviewed the medical records of 257 patients with PD who underwent bilateral STN DBS at the Movement Disorder Center at Seoul National University Hospital between March 2005 and November 2018. Patients were evaluated preoperatively, at 3, 6, and 12 months after surgery and annually thereafter. The cause and date of death were obtained from interviews with caregivers or from medical certificates at the last follow-up. Results: Of the 257 patients with PD, 48 patients (18.7%) died, with a median time of death of 11.2 years after surgery. Pneumonia was the most common cause of death. Older age of disease onset, preoperative falling score while on medication, and higher preoperative total levodopa equivalent daily dose were associated with a higher risk of mortality in time-dependent Cox regression analysis. Conclusion: These results confirm the mortality outcome of STN DBS in patients with advanced PD.

Bilateral subthalamic nucleus deep brain stimulation is an effective treatment for diphasic dyskinesia.

BACKGROUND AND PURPOSE: The purpose was to assess the effect of bilateral subthalamic nucleus deep brain stimulation (STN DBS) on diphasic dyskinesia in patients with Parkinson disease (PD) and to assess the factors associated with the remission of diphasic dyskinesia. METHODS: Medical records for PD patients who underwent bilateral STN DBS at the Movement Disorder Center of Seoul National University Hospital from March 2005 to November 2016 were reviewed. Patients were evaluated preoperatively and at 3, 6 and 12 months after surgery, and annually thereafter. The presence of peak-dose dyskinesia and diphasic dyskinesia is based on the interview and examination of patients at baseline and at each follow-up. RESULTS: Amongst 202 patients who underwent STN DBS, 66 patients who had diphasic dyskinesia preoperatively were included in the analysis. Diphasic dyskinesia disappeared in 49 (74%) after surgery. In 27 (55.1%) patients whose diphasic dyskinesia disappeared after DBS, peak-dose and diphasic dyskinesia disappeared persistently from as early as 3 months postoperatively. Age at onset was younger and disease duration at surgery was longer in patients whose diphasic dyskinesia persisted compared with patients whose diphasic dyskinesia disappeared. Multivariate Cox regression analysis demonstrated that patients with greater postoperative decrease of dopaminergic medications were more likely to have remission of diphasic dyskinesia. CONCLUSION: This study showed that bilateral STN DBS is effective in controlling diphasic dyskinesia and should be considered in PD patients with diphasic dyskinesia.

Reliability and Validity of a Short Form of the Korean Dementia Screening Questionnaire-Cognition.

BACKGROUND AND PURPOSE: We aimed to determine the reliability and validity of a short form of the Korean Dementia Screening Questionnaire-Cognition (KDSQ-C) as a screening tool for cognitive dysfunction. METHODS: This study recruited 420 patients older than 65 years and their informants from 11 hospitals, and categorized the patients into normal cognition, mild cognitive impairment, and dementia subgroups. The KDSQ-C was completed separately by the patients and their informants. We abstracted three components of the KDSQ-C and combined these components into the following four subscales: KDSQ-C-I (items 1-5, memory domain), KDSQ-C-II (items 1-5 & 11-15, memory domain+activities of daily living), KDSQ-C-III (items 1-5 & 6-10, memory domain+other cognitive domains), and KDSQ-C-IV (items 6-10 & 11-15, other cognitive domains+activities of daily living). The reliability and validity were compared between these four subscales. RESULTS: A receiver operating characteristic (ROC) analysis of questionnaire scores provided by the patients showed that the areas under the ROC curves (AUCs) for the KDSQ-C, KDSQC-I, and KDSQ-C-II for diagnosing dementia were 0.75, 0.72, and 0.76, respectively; the corresponding AUCs for informant-completed questionnaires were 0.92, 0.89, and 0.92, indicating good discriminability for dementia. CONCLUSIONS: A short form of the patient- and informant-rated versions of the KDSQ-C (KDSQ-C-II) is as capable as the 15-item KDSQ-C in screening for dementia.

Self- and informant-reported cognitive functioning and awareness in subjective cognitive decline, mild cognitive impairment, and very mild Alzheimer disease.

OBJECTIVES: The present study examined self-reports and informant reports of cognitive function and discrepancies between the two reporting methods in healthy controls (HC), subjective cognitive decline (SCD), mild cognitive impairment (MCI), and very mild Alzheimer disease (AD) using three questionnaires. METHODS: The study included a total of 300 individuals (mean age: 74.4 ± 5.7 y), including 130 HC, 70 SCD, 51 MCI, and 49 very mild AD patients. Self-ratings and informant ratings of cognitive function were assessed using the Korean Dementia Screening Questionnaire-Cognition (KDSQ-C), AD8, and Subjective Memory Complaints Questionnaire (SMCQ). Awareness of cognitive functioning was measured on the basis of the discrepancy scores between self-reports and informant reports. RESULTS: Group comparisons on questionnaire scores adjusting for age, education, and depressive symptoms showed that self-reports were lowest in HC than other groups, with no differences between SCD and MCI groups. Informant reports were lower in SCD than in MCI, while discrepancy scores were higher in SCD than in MCI (P < .001 for KDSQ-C and SMCQ; P = .076 for AD8). There were no differences in self-reports, informant reports, and discrepancy scores between MCI and AD groups. CONCLUSIONS: These results support the usefulness of informant-reported cognitive functioning to classify MCI among elderly with subjective cognitive complaints. In addition, discrepancies between self-reports and informant reports demonstrate that overestimation and underestimation of cognitive function may serve as a clinical indicator of SCD and MCI across the cognitive continuum, respectively.

Musculoskeletal problems in PD patients have no association with socioeconomic status.

Musculoskeletal problems are common in the general population and also in Parkinson's disease (PD) patients. We aimed to assess whether socioeconomic status (SES) is associated with the prevalence of musculoskeletal problems in PD patients. This cross-sectional study used data a total of 309 patients with PD who were interviewed, and their medical records were reviewed from the Movement Disorder Clinic of Seoul National University Hospital from March to December 2016. The PD patients were divided into four age groups. Education level was divided into three groups: primary school, middle and high school, and college or higher. Monthly household income was divided into four groups. Occupation was divided into three groups: manual workers, non-manual workers, and others (unemployed and housewives). Patients with musculoskeletal problems were more likely to be women and older, had a more impaired Activities of Daily Living and depressive symptoms and less education, and were less likely to be engaged in non-manual work. For both genders, SES had no association with musculoskeletal problems. For men, similar to the patients overall, age had a positive association with musculoskeletal problems. The Unified Parkinson's Disease Rating Scale I & II scores also had positive associations with musculoskeletal problems. For women, Beck depression inventory and diabetes mellitus also had positive and negative associations with musculoskeletal problems, respectively. SES had no association with musculoskeletal problems in PD patients. Women had a higher risk of musculoskeletal problems. A gender difference was shown in the risk factors of musculoskeletal problems.

A Comparative Evaluation of the KDSQ-C, AD8, and SMCQ as a Cognitive Screening Test to Be Used in National Medical Check-ups in Korea.

BACKGROUND: Korea has a periodic general health check-up program that uses the Korean Dementia Screening Questionnaire-Cognition (KDSQ-C) as a cognitive dysfunction screening tool. The Alzheimer Disease 8 (AD8) and Subjective Memory Complaints Questionnaire (SMCQ) are also used in clinical practice. We compared the diagnostic ability of these screening questionnaires for cognitive impairment when completed by participants and their caregivers. Hence, we aimed to evaluate whether the SMCQ or AD8 is superior to the KDSQ-C and can be used as its replacement. METHODS: A total of 420 participants over 65 years and their informants were recruited from 11 hospitals for this study. The patients were grouped into normal cognition, mild cognitive impairment, and dementia subgroups. The KDSQ-C, AD8, and SMCQ were completed separately by participants and their informants. RESULTS: A receiver operating characteristic analysis of questionnaire scores completed by participants showed that the areas under the curve (AUCs) for the KDSQ-C, AD8, and SMCQ for diagnosing dementia were 0.75, 0.8, and 0.73, respectively. Regarding informant-completed questionnaires, the AD8 (AUC of 0.93), KDSQ-C (AUC of 0.92), and SMCQ (AUC of 0.92) showed good discriminability for dementia, with no differences in discriminability between the questionnaires. CONCLUSION: When an informant-report is possible, we recommend that the KDSQ-C continues to be used in national medical check-ups as its discriminability for dementia is not different from that of the AD8 or SMCQ. Moreover, consistent data collection using the same questionnaire is important. When an informant is not available, either the KDSQ-C or AD8 may be used. However, in the cases of patient-reports, discriminability is lower than that for informant-completed questionnaires.

Peripheral blood inflammatory markers in early Parkinson's disease.

The aim of this study was to characterize peripheral inflammatory markers in patients with early Parkinson's disease (PD) and to explore whether these markers contribute to motor and non-motor symptoms. We collected serum from patients with early PD (n = 58) and from healthy control subjects (n = 20). The following inflammatory markers were measured: interleukin (IL)-1ß, IL-2, IL-6, IL-10, tumor necrosis factor-α, and high-sensitivity C-reactive protein. The Movement Disorders Society Unified Parkinson's Disease Rating Scale part 3 and Hoehn and Yahr stage were used to assess motor symptoms, and the Non-motor Symptoms Scale, the Cross-Cultural Smell Identification Test, the Montreal Cognitive Assessment, and the Composite Autonomic Symptom Score 31 (COMPASS-31) were used to assess non-motor symptoms. The levels of IL-1ß, IL-2, and IL-6 were higher in the PD group than in the control group. However, only IL-1ß among those markers remained significant after Bonferroni correction (P = 0.024). In the PD group, the anti-inflammatory cytokine IL-10 levels correlated positively with the COMPASS-31 score (r = 0.277, P = 0.035), whereas no correlation was found between the other inflammatory marker levels and motor or non-motor symptoms. Among the domains of the COMPASS-31, the IL-10 levels correlated only with the gastrointestinal domain (r = 0.358, P = 0.006). Our results suggest increased peripheral inflammation in the early stage of PD, but the role of inflammation in motor and non-motor symptoms is unclear. Although we found a correlation between IL-10 levels and gastrointestinal symptoms, this finding may simply reflect a protective response against inflammatory processes associated with the disease.

A 7-year observation of the effect of subthalamic deep brain stimulation on impulse control disorder in patients with Parkinson's disease.

INTRODUCTION: Previous studies have reported improvement of impulse control disorders (ICDs) after subthalamic nucleus (STN) deep brain stimulation (DBS) as well as some de novo ICDs. However, it is not clear how STN DBS changes ICDs in the long-term. METHODS MATERIALS: Eighty-nine patients with Parkinson's disease (PD) who had received a bilateral STN DBS from 2005 to 2009 and were included in our previous study were followed for 7 years with the modified Minnesota Impulsive Disorders Interview (mMIDI). Their mMIDI scores, medication, and frontal function tests measured preoperatively and at 1 and 7 years postoperatively were compared. RESULTS: A total of 61 patients were analyzed after excluding 10 and 18 patients due to death and lost to follow-up, respectively. The numbers of the patients with an ICD at each point were 8, 10, and 7, respectively. All preoperative ICDs disappeared after DBS. De novo ICDs within 1 year after DBS disappeared except for 1 patient. Six of the seven patients, who reported ICDs 7 years after the DBS developed that ICD between 1 and 7 years. Their total levodopa equivalent daily dose (LEDD) and dopamine agonist dose were not higher compared to the other 54 patients without ICDs. There was no correlation with the frontal lobe dysfunction and the electrode position in the subthalamus. CONCLUSION: STN DBS improves baseline ICDs and results in the development of "transient" de novo ICDs in the short-term. In addition, there is a unique group of the patients who develop ICDs a long time after DBS.

Amantadine and the Risk of Dyskinesia in Patients with Early Parkinson's Disease: An Open-Label, Pragmatic Trial.

OBJECTIVE: We examined whether amantadine can prevent the development of dyskinesia. METHODS: Patients with drug-naïve Parkinson's disease (PD), younger than 70 years of age and in the early stage of PD (Hoehn and Yahr scale < 3), were recruited from April 2011 to December 2014. The exclusion criteria included the previous use of antiparkinsonian medication, the presence of dyskinesia, significant psychological disorders, and previous history of a hypersensitivity reaction. Patients were consecutively assigned to one of 3 treatment groups in an open label fashion: Group A-1, amantadine first and then levodopa when needed; Group A-2, amantadine first, dopamine agonist when needed, and then levodopa; and Group B, dopamine agonist first and then levodopa when needed. The primary endpoint was the development of dyskinesia, which was analyzed by the Kaplan-Meier survival rate. RESULTS: A total of 80 patients were enrolled: Group A-1 (n = 27), Group A-2 (n = 27), and Group B (n = 26). Twenty-four patients were excluded from the analysis due to the following: withdrawal of amantadine or dopamine agonist (n = 9), alternative diagnosis (n = 2), withdrawal of consent (n = 1), and breach in the protocol (n = 12). After exclusion, 5 of the 56 (8.93%) patients developed dyskinesia. Patients in Group A-1 and A-2 tended to develop dyskinesia less often than those in Group B (cumulative survival rates of 0.933, 0.929, and 0.700 for A-1, A-2, and B, respectively; p = 0.453). CONCLUSION: Amantadine as an initial treatment may decrease the incidence of dyskinesia in patients with drug-naïve PD.

Emergence of non-motor fluctuations with reference to motor fluctuations in Parkinson's disease.

INTRODUCTION: Non-motor fluctuations (NMF) and motor fluctuations (MF) are frequent in patients with Parkinson's disease (PD) with long-term medical treatment. We aimed to examine the timing of the emergence of NMF with reference to MF in a prospective cohort of patients with PD without symptom fluctuations. METHODS: A total of 334 patients with PD who had neither MF nor NMF were recruited. The exclusion criteria included a Mini-Mental State Examination score of less than 26 points at baseline and an alternative diagnosis or significant comorbidity during follow-up. The "SNUH-Fluctuation Questionnaire" consisting of 29 items (9 on MF and 20 on NMF) was administered on a semi-annually basis for 3 years. RESULTS: Three hundred seven out of 334 patients were analyzed for symptom fluctuations with the Kaplan-Meier survival analysis. MF were observed in more patients and developed earlier than NMF (cumulative survival of 0.572 for MF and 0.619 for NMF at 36 months of follow-up). In 212 patients who finished the follow-up for 36 months, MF and NMF developed simultaneously in 58 (27.4%), MF developed first in 45 (21.2%), and NMF developed first in only 3 (1.4%). The remaining 106 patients (50.0%) did not develop either MF or NMF. CONCLUSION: NMF developed simultaneously with or later than MF. From these data, we hypothesize that NMF develop in the disease state where the pathology in the brain has been severe enough to develop MF. Hence, pharmacologic management should consider targeting both dopaminergic and non-dopaminergic systems to treat NMF.

Depression may negatively affect the change in freezing of gait following subthalamic nucleus stimulation in Parkinson's disease.

OBJECTIVE: To assess the influence of preoperative depression on the change in freezing of gait (FOG) following subthalamic nucleus stimulation (STN-DBS) in patients with Parkinson's disease (PD). METHODS: One hundred and twelve PD patients were included who received bilateral STN-DBS. Of these, 33 had no preoperative depression (PD-ND) and the other 79 had preoperative depression (PD-D). Each PD-ND patient was matched with one PD-D patient by the propensity score for which sex, age at PD onset, disease duration, UPDRS-III score during off-medication state, levodopa-equivalent daily dose, and mini mental state examination were the independent variables. We compared both a FOG-questionnaire (FOG-Q) and the axial score from UPDRS-III between the two groups over 12-month follow-up. RESULTS: During the off-medication state, FOG-Q at 12-month was decreased with STN-DBS in both PD-ND (-52.9%, p < 0.001) and PD-D (-24.2%, p < 0.001) with a significant difference in the change of FOG in favor of PD-ND (p = 0.001). Similarly, there was an improvement in the axial score for both PD-ND (-66.1%, p < 0.001) and PD-D (-45.3%, p < 0.001) at 12-month with a significant difference between the groups. (p = 0.005). During the on-medication state, both the FOG-Q and axial score at 12-month were not improved with STN-DBS in the PD-ND and PD-D with no difference between the groups. CONCLUSIONS: Our findings suggest that preoperative depression negatively affects the outcome of FOG following STN-DBS in the off-medication state but not in the on-medication state.

A case report of thoracolumbar paraspinal myopathy as the cause of camptocormia in a patient with atypical parkinsonism.

BACKGROUND: Camptocormia is severe flexion of the thoracolumbar spine, exaggerated during standing and walking but minimized in supine position. Even though camptocormia is a relatively common condition during the course of Parkinson's disease, there is ongoing controversy concerning its mechanisms. The most widely accepted and yet still disputed one is dystonia. However, based on myopathic changes observed in the paraspinal muscle biopsies of some PD patients with camptocormia, the attempt to attribute camptocormia to myopathy has continued. This case presents evidence for paraspinal myopathy as the cause of camptocormia in a patient with atypical parkinsonism. CASE PRESENTATION: A patient presented with a relatively acute onset of camptocormia and new-onset back pain. Upon examination, she had asymmetric parkinsonism. Magnetic resonance imaging of the lumbar spine revealed alterations in muscle signal intensity in the right paraspinal muscles at the L1-2 level. In the presence of persistent back pain, repeat imaging done two months later showed diffuse enlargement and patchy enhancement of the paraspinal muscles on T1-weighted imaging from T4 through sacrum bilaterally. About fifteen months after the onset of camptocormia, she underwent ultrasound-guided gun biopsy of the paraspinal muscles for evaluation of focal atrophy of the back muscles on the right. The biopsy revealed unmistakable myopathic changes, marked endomysial and perimysial fibrosis of the muscles, and merely mild infiltration of inflammatory cells but no clues regarding the cause of myopathy. On account of persistent back pain and MRI results indicative of ongoing inflammation, she was prescribed glucocorticoid, which she refused to take. Now merely two and a half years after the onset of camptocormia, she is in Hoehn and Yahr stage 4. CONCLUSIONS: The coincidence of back pain with the appearance of camptocormia and the imaging and pathology findings supportive of myopathy give strong evidence for paraspinal myopathy as the cause of the deformity in this patient. When a patient presents with a relatively acute onset of camptocormia accompanied by back pain, the clinician should not overlook the possibility of myopathy of paraspinal muscles, which may be one of the few treatable causes of camptocormia.

Altered executive function in the welders: A functional magnetic resonance imaging study.

Chronic exposure to manganese (Mn) can lead to impairments in motor and cognitive functions. Several recent studies reported Mn-induced executive dysfunction. The present study compared the neural correlates of ongoing executive function of welders and healthy controls. Fifty-three welders and 44 healthy controls were enrolled. Participants were given functional magnetic resonance imaging (fMRI) scans and performed two modified versions of the Wisconsin Card Sorting Task (WCST) that differed in cognitive demand, and a task that established a high-level baseline (HLB) condition. Card Sorting Test and Word-Color Test were also used to assess executive performance. Neural activation of the bilateral superior-frontal cortex, right-inferior parietal cortex, and bilateral insula cortex were greater in healthy controls than in welders when contrasting the difficult version of the WCST with the HLB. There were also correlations between executive functions by the Card Sorting Test and Word-Color Test, and brain activation in the insula cortex using the WCST. Our results indicated that welders had altered neural processing related to executive function in the prefrontal cortex under conditions of high cognitive demand. Welders also had less activation of the insula cortex, a part of a larger network comprising the lateral prefrontal cortex and parietal cortex.