A revised approach for electrodiagnosis-based severity classification in carpal tunnel syndrome.

BACKGROUND: An electrodiagnostic evaluation is conducted to diagnose carpal tunnel syndrome (CTS) and evaluate its severity. OBJECTIVE: This study proposes a revised approach for classifying the severity of electrophysiological findings for patients with CTS. METHODS: This retrospective cross-sectional study included patients with CTS confirmed through electrodiagnostic evaluations. Based on the Stevens' classification, the patients were divided into three groups (mild/moderate/severe). A new intermediate group was defined to identify patients with normal motor nerve conduction studies and abnormal electromyographic results. CTS pain was evaluated using a numeric rate scale. Physical examinations and sonographic evaluation were performed to detect anatomical abnormalities. RESULTS: Overall, 1,069 CTS hands of 850 CTS patients were included. The mean age was 57.9 ± 10.8 years, and 336 (39.5%) were men. There were 522 (48.8%) mild cases; 281 (26.3%) moderate cases; and 266 (24.9%) severe cases. In the severe group, 49 cases were reclassified into the intermediate group. The median cross-sectional area in the intermediate group significantly differed from that in the severe group. However, the pain score significantly differed from that of the moderate group. CONCLUSION: The intermediate CTS group showed clinical features that were intermediate to those of the moderate and severe CTS groups.

PECI-Net: Bolus segmentation from video fluoroscopic swallowing study images using preprocessing ensemble and cascaded inference.

Bolus segmentation is crucial for the automated detection of swallowing disorders in videofluoroscopic swallowing studies (VFSS). However, it is difficult for the model to accurately segment a bolus region in a VFSS image because VFSS images are translucent, have low contrast and unclear region boundaries, and lack color information. To overcome these challenges, we propose PECI-Net, a network architecture for VFSS image analysis that combines two novel techniques: the preprocessing ensemble network (PEN) and the cascaded inference network (CIN). PEN enhances the sharpness and contrast of the VFSS image by combining multiple preprocessing algorithms in a learnable way. CIN reduces ambiguity in bolus segmentation by using context from other regions through cascaded inference. Moreover, CIN prevents undesirable side effects from unreliably segmented regions by referring to the context in an asymmetric way. In experiments, PECI-Net exhibited higher performance than four recently developed baseline models, outperforming TernausNet, the best among the baseline models, by 4.54% and the widely used UNet by 10.83%. The results of the ablation studies confirm that CIN and PEN are effective in improving bolus segmentation performance.

Normal Values of Central, Peripheral, and Root Motor Conduction Times in a Healthy Korean Population.

PURPOSE: Central, peripheral, and root motor conduction times (CMCTs, PMCTs, and RMCTs, respectively) are valuable diagnostic tools for spinal cord and motor nerve root lesions. We investigated the normal values and the effects of age and height on each motor conduction time. METHODS: This study included 190 healthy Korean subjects who underwent magnetic stimulation of the cortex and spinous processes at the C7 and L1 levels. Recording muscles were abductor pollicis brevis and abductor digiti minimi in the unilateral upper limb and extensor digitorum brevis and abductor hallucis in the contralateral lower limb. F-wave and compound motor nerve action potentials were also recorded. Central motor conduction time was evaluated as the difference between cortical motor evoked potential onset latency and PMCT using calculation and spinal stimulation methods. Root motor conduction time was computed as the difference between spinal stimulated and calculated CMCTs. RESULTS: The average age and height of the participants were 41.21 ± 14.39 years and 164.64 ± 8.27 cm, respectively; 39.5% (75/190) patients were men. In the linear regression analyses, upper limb CMCTs showed a significant and weak positive relationship with height. Lower limb CMCTs demonstrated a significant and weak positive relationship with age and height. Peripheral motor conduction times were significantly and positively correlated with age and height. Root motor conduction times showed no significant relationship with age and height, except for abductor pollicis brevis-RMCT, which had a weak negative correlation with height. CONCLUSIONS: This study provides normal values of CMCTs, PMCTs, and RCMTs, which have potential clinical applications. When interpreting CMCTs, age and height should be considered.

Characteristics of diabetic and non-diabetic carpal tunnel syndrome in terms of clinical, electrophysiological, and Sonographic features: a cross-sectional study.

BACKGROUND: Although diabetes is considered a major risk factor for carpal tunnel syndrome (CTS), the characteristics of diabetic CTS have not been fully understood. OBJECTIVE: This study is aimed at evaluation of the clinical, electrophysiological, and ultrasonographic findings of non-diabetic and diabetic CTS. METHODS: This retrospective, cross-sectional study included patients diagnosed with CTS. Patient age, sex, involved side, body mass index, clinical and electrophysiological findings, and median nerve cross-sectional area (CSA) were identified. Diabetes was identified through patient or guardian interviews, medical records, and medication history. Linear and binary logistic regression models were established to confirm the associations between the electrophysiological findings, median nerve CSA, and clinical outcomes. Covariates, such as age, sex, body mass index, diabetes, symptom duration, and thenar muscle weakness were adjusted. RESULTS: Out of the 920 hands, 126 and 794 belonged to the diabetic and non-diabetic CTS groups, respectively. The patients were significantly older in the diabetic CTS group (P < 0.001). The rate of thenar weakness in the diabetic CTS group was also significantly higher than that in the non-diabetic CTS group (P = 0.009). The diabetic CTS group had a more severe electrodiagnostic grade (P = 0.001). The prolonged onset latency of the compound motor nerve action potential (CMAP) and median nerve CSA were well associated with the degree of clinical symptoms. Increased median nerve CSA was significantly associated with prolonged CMAP onset latency (ß = 0.64; P = 0.012), prolonged transcarpal latency (ß = 0.95; P = 0.044), and decreased CMAP amplitude (ß = -0.17; P = 0.002) in the non-diabetic CTS group. CONCLUSION: Diabetic CTS had more profound electrophysiological abnormalities. Distal motor latency and median nerve CSA were not only associated with each other, but also with clinical symptoms. Further studies are needed to investigate the pathophysiological mechanisms underlying diabetic CTS.

Machine learning predictive model for aspiration screening in hospitalized patients with acute stroke.

Dysphagia is a fatal condition after acute stroke. We established machine learning (ML) models for screening aspiration in patients with acute stroke. This retrospective study enrolled patients with acute stroke admitted to a cerebrovascular specialty hospital between January 2016 and June 2022. A videofluoroscopic swallowing study (VFSS) confirmed aspiration. We evaluated the Gugging Swallowing Screen (GUSS), an early assessment tool for dysphagia, in all patients and compared its predictive value with ML models. Following ML algorithms were applied: regularized logistic regressions (ridge, lasso, and elastic net), random forest, extreme gradient boosting, support vector machines, k-nearest neighbors, and naïve Bayes. We finally analyzed data from 3408 patients, and 448 of them had aspiration on VFSS. The GUSS showed an area under the receiver operating characteristics curve (AUROC) of 0.79 (0.77-0.81). The ridge regression model was the best model among all ML models, with an AUROC of 0.81 (0.76-0.86), an F1 measure of 0.45. Regularized logistic regression models exhibited higher sensitivity (0.66-0.72) than the GUSS (0.64). Feature importance analyses revealed that the modified Rankin scale was the most important feature of ML performance. The proposed ML prediction models are valid and practical for screening aspiration in patients with acute stroke.

Three cases of jejunal tumors detected by standard upper gastrointestinal endoscopy: A case series.

BACKGROUND: In patients with obscure gastrointestinal bleeding, re-examination with standard upper endoscopes by experienced physicians will identify culprit lesions in a substantial proportion of patients. A common practice is to insert an adult-sized forward-viewing endoscope into the second part of the duodenum. When the endoscope tip enters after the papilla, which is a marker for the descending part of the duodenum, it is difficult to endoscopically judge how far the duodenum has been traversed beyond the second part. CASE SUMMARY: We experienced three cases of proximal jejunal masses that were diagnosed by standard upper gastrointestinal endoscopy and confirmed with surgery. The patients visited the hospital with a history of melena; during the initial upper gastrointestinal endoscopy and colonoscopy, the bleeding site was not confirmed. Upper gastrointestinal bleeding was suspected; thus, according to guidelines, upper endoscopy was performed again. A hemorrhagic mass was discovered in the small intestine. The lesion of the first patient was thought to be located in the duodenum when considering the general insertion depth of a typical upper gastrointestinal endoscope; however, during surgery, it was confirmed that it was in the jejunum. After the first case, lesions in the second and third patients were detected at the jejunum by inserting the standard upper endoscope as deep as possible. CONCLUSION: The deep insertion of standard endoscopes is useful for the diagnosis of obscure gastrointestinal bleeding.

Infrared thermographic changes after decompression surgery in patients with carpal tunnel syndrome.

BACKGROUND: Digital infrared thermal imaging (DITI), which detects infrared rays emitted from body surface to create a body heat map, has been utilized at various musculocutaneous conditions. Notably, DITI can demonstrate autonomic vasomotor activity in the nerve-innervated area, and thus may be of use in carpal tunnel syndrome (CTS). In this study, we compared DITI findings before and after carpal tunnel release (CTR) surgery in patients with unilateral CTS to investigate the corresponding neurophysiological changes. METHODS: In this retrospective cohort study, DITI parameters such as the temperature differences between the median and ulnar nerve territories and median nerve-innervated digital anisometry were measured. Subjective symptom duration, pain scale, and ultrasonographic findings were also compared before and after CTR. Patients were evaluated before and 6 weeks after CTR, respectively. RESULTS: A total of 27 patients aged 59.0 ± 11.2 years were finally included. After CTR, median nerve-innervated thermal anisometry was improved (2.55 ± 0.96 °C to 1.64 ± 1.34 °C; p = 0.003). The temperature differences between the median and ulnar nerve territories were not significantly changed. Subjective pain, the Simovic Weinberg Clinical Scale, and palmar bowing of the flexor retinaculum were also significantly improved (p <  0.001 for all comparisons). CONCLUSIONS: Our results demonstrated that DITI findings could reflect an improvement in autonomic function after CTR. Therefore, DITI can be an objective method to assess pre- and post-operative neurophysiologic changes in CTS.

Detection of C8/T1 radiculopathy by measuring the root motor conduction time.

BACKGROUND: Root motor conduction time (RMCT) can noninvasively evaluate the status of the proximal root segment. However, its clinical application remains limited, and wider studies regarding its use are scarce. We aimed to investigate the association between C8/T1 level radiculopathy and RMCT. METHODS: This was a retrospective cross-sectional study. Subjects were extracted from a general hospital's spine clinic database. A total of 48 C8/T1 root lesions from 37 patients were included, and 48 C8/T1 root levels from control subjects were matched for age, sex, and height. RMCT was measured in the abductor pollicis brevis muscle and the assessment of any delays owing to C8/T1 radiculopathy. RESULTS: The RMCT of the C8/T1 radiculopathy group was 1.7 ± 0.6 ms, which was significantly longer than that in the control group (1.2 ± 0.8 ms; p = 0.001). The delayed RMCT was independently associated with radiculopathy (adjusted odds ratio, 1.15; 95% confidence interval, 1.06-1.27; p = 0.011) after adjusting for the peripheral motor conduction time, amplitude of median compound motor nerve action potential, and shortest F-wave latency. The area under the Receiver Operating Characteristic curve for diagnosing C8/T1 radiculopathy using RMCT was 0.72 (0.61-0.82). The RMCT was significantly correlated with symptom duration (coefficient = 0.58; p < 0.001) but was not associated with the degree of arm pain. CONCLUSION: Our findings illustrate the clinical applicability of the RMCT by demonstrating its utility in diagnosing radiculopathy at certain spinal levels.

Clinical Usefulness of the Korean Version of the Dysphagia Handicap Index: Reliability, Validity, and Role as a Screening Test.

This study aimed to measure the validity and reliability of the Korean version of the Dysphagia Handicap Index (K-DHI) and evaluate its diagnostic efficacy for predicting aspiration. We enrolled 104 patients with dysphagia symptoms (D group) and 88 controls (ND group). Among controls, there were 43 patients without dysphagia symptoms (ND patient group). All subjects completed the K-DHI survey. The D and ND group patients underwent the Gugging Swallowing Screen (GUSS) and videofluoroscopic swallowing study (VFSS). Two weeks later, the D group completed the second session of the K-DHI survey. The internal consistency of the K-DHI was good to excellent (Cronbach's α: 0.79-0.95). The test-retest reliability of the K-DHI survey was also high (interclass correlation coefficient = 0.88). There were moderate correlations between the K-DHI and GUSS (r = - 0.65, p < 0.001) as well as findings of VFSS-videofluoroscopic dysphagia scale (r = 0.55, p < 0.001) and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale (r = - 0.55, p < 0.001). For predicting aspiration, the K-DHI cutoff value was 11 (sensitivity, 0.82; specificity, 0.72; positive predictive value, 0.34; and negative predictive value, 0.96). K-DHI ≥ 11 [odds ratio (OR), 6.43; 95% Confidence Interval (CI) (1.87-22.16); p = 0.003] and GUSS ≤ 15 [OR 4.73; 95% CI (1.59-14.07); p = 0.005] were independent risk factors for aspiration on VFSS. The K-DHI is a reliable and valid self-reporting instrument for evaluating patient's quality of life associated with dysphagia among the Korean language population. It is also useful for the screening of aspiration.

Application of digital infrared thermography for carpal tunnel syndrome evaluation.

We investigated the thermographic findings of carpal tunnel syndrome (CTS). We enrolled 304 hands with electrodiagnostically identified CTS and 88 control hands. CTS hands were assigned to duration groups (D1, < 3 months; D2, 3‒6 months; D3, 6‒12 months; D4, ≥ 12 months) and severity groups (S1, very mild; S2, mild; S3, moderate; S4, severe). The temperature difference between the median and ulnar nerve territories (ΔM-U territories) decreased as CTS duration and severity increased. Significant differences in ΔM-U territories between the D1 and D3, D1 and D4, D2 and D4, and S1 and S4 groups (P = 0.003, 0.001, 0.001, and < 0.001, respectively) were observed. Thermal anisometry increased as CTS duration and severity increased. Significant differences in thermal anisometry between the D1 and D4 as well as the D2 and D4 groups (P = 0.005 and 0.04, respectively) were noted. Thermal anisometry was higher in the S4 group than in the S1, S2, and S3 groups (P = 0.009, < 0.001, and 0.003, respectively). As CTS progresses, skin temperature tends to decrease and thermal variation tends to increase in the median nerve-innervated area. Thermographic findings reflect the physiological changes of the entrapped median nerve.

Can Evoked Potential Changes during the Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery Predict Postoperative Improvement of Cerebral Perfusion and Functional Status?

BACKGROUND: We investigated evoked potential (EP) changes during superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery and their correlations with imaging and clinical findings postoperatively. METHODS: This retrospective study included patients who underwent STA-MCA bypass surgery due to ischemic stroke with large artery occlusion (MB group). Patients who underwent unruptured MCA aneurysm clipping were enrolled in the control group (MC group). Median and tibial somatosensory evoked potentials (SSEP), and motor evoked potentials recorded from the abductor pollicis brevis (APB-MEP) and abductor hallucis (AH-MEP) were measured intraoperatively. Modified Rankin scale (mRS) and perfusion-weighted imaging (PWI) related variables, i.e., mean transit time (MTT) and time to peak (TTP), were assessed. RESULTS: Δmedian SSEP, ΔAPB-MEP, and ΔAH-MEP were significantly higher in the MB group than in the MC group (p = 0.027, p = 0.006, and p = 0.015, respectively). APB-MEP and AH-MEP amplitudes were significantly increased at the final measurement (p = 0.010 and p < 0.001, respectively). The ΔTTP asymmetry index was moderately correlated with ΔAPB-MEP (r = 0.573, p = 0.005) and ΔAH-MEP (r = 0.617, p = 0.002). ΔAPB-MEP was moderately correlated with ΔMTT (r = 0.429, p = 0.047) and ΔmRS at 1 month (r = 0.514, p = 0.015). CONCLUSIONS: MEP improvement during STA-MCA bypass surgery was partially correlated with PWI and mRS and could reflect the recovery in cerebral perfusion.

Machine learning-based approach for disease severity classification of carpal tunnel syndrome.

Identifying the severity of carpal tunnel syndrome (CTS) is essential to providing appropriate therapeutic interventions. We developed and validated machine-learning (ML) models for classifying CTS severity. Here, 1037 CTS hands with 11 variables each were retrospectively analyzed. CTS was confirmed using electrodiagnosis, and its severity was classified into three grades: mild, moderate, and severe. The dataset was randomly split into a training (70%) and test (30%) set. A total of 507 mild, 276 moderate, and 254 severe CTS hands were included. Extreme gradient boosting (XGB) showed the highest external validation accuracy in the multi-class classification at 76.6% (95% confidence interval [CI] 71.2-81.5). XGB also had an optimal model training accuracy of 76.1%. Random forest (RF) and k-nearest neighbors had the second-highest external validation accuracy of 75.6% (95% CI 70.0-80.5). For the RF and XGB models, the numeric rating scale of pain was the most important variable, and body mass index was the second most important. The one-versus-rest classification yielded improved external validation accuracies for each severity grade compared with the multi-class classification (mild, 83.6%; moderate, 78.8%; severe, 90.9%). The CTS severity classification based on the ML model was validated and is readily applicable to aiding clinical evaluations.

Electrodiagnostic, Sonographic, and Clinical Features of Carpal Tunnel Syndrome with Bifid Median Nerve.

PURPOSE: A bifid median nerve (BMN) is not a rare variant. This study aimed to investigate the features of carpal tunnel syndrome (CTS) accompanied by BMN. PATIENTS AND METHODS: In this retrospective study, we defined a BMN group as CTS with BMN and a non-bifid median nerve (NMN) group as CTS without BMN. All hands were assigned to four severity grades according to the findings of electrodiagnosis (EDx): very mild, mild, moderate, and severe. The cross-sectional area (CSA) of the median nerve, palmar bowing of the flexor retinaculum, and persistent median artery (PMA) were assessed by ultrasonography. Numerical pain rating scale (NRS) and symptom duration were assessed as clinical variables. RESULTS: Sixty-four hands (57 patients) and 442 hands (341 patients) were enrolled in the BMN and the NMN groups, respectively. BMN was prevalent in 12.6% of all CTS hands. The distribution of EDx severity grade was milder in the BMN group than in the NMN group (P<0.001). The CSA of the BMN group was 16.2±4.1 mm2, slightly larger than 15.1±4.2 mm2 in the NMN group (P=0.056). The BMN group showed higher NRS than the NMN group (5.5±1.5 and 4.4±1.7, respectively; P<0.001). In the subgroup analysis, NRS was significantly higher in the BMN group than in the NMN group at all EDx severity grades. In the BMN group, the PMA group showed greater EDx severity (P=0.037) and higher NRS (6.0 and 5.0, respectively; P=0.012) than the non-PMA group. The radial side branch's CSA was larger than that of the ulnar side branch (10.0 mm2 and 6.0 mm2, respectively; P<0.001). CONCLUSION: CTS with BMN presented more severe symptoms and relatively milder EDx severity. When assessing the severity of CTS with BMN, the clinical symptoms should primarily be considered, as well as we should complementarily evaluate the EDx and ultrasonography.

Usefulness of Intraoperative Neurophysiological Monitoring During the Clipping of Unruptured Intracranial Aneurysm: Diagnostic Efficacy and Detailed Protocol.

Background: Intraoperative neurophysiological monitoring (IONM) has been widely applied in brain vascular surgeries to reduce postoperative neurologic deficit (PND). This study aimed to investigate the effect of IONM during clipping of unruptured intracranial aneurysms (UIAs). Methods: Between January 2013 and August 2020, we enrolled 193 patients with 202 UIAs in the N group (clipping without IONM) and 319 patients with 343 UIAs in the M group (clipping with IONM). Patients in the M group were intraoperatively monitored for motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs). Irreversible evoked potential (EP) change was defined as EP deterioration that did not recover until surgery completion. Sustained PND was defined as neurological symptoms lasting for more than one postoperative month. Results: Ten (3.1%) and 13 (6.7%) in the M and N groups, respectively, presented with PND. Compared with the N group, the M group had significantly lower occurrence rates of sustained PND [odds ratio (OR) = 0.36, 95% confidence interval (CI) = 0.13-0.98, p = 0.04], ischemic complications (OR = 0.39, 95% CI = 0.15-0.98, p = 0.04), and radiologic complications (OR = 0.40, 95% CI = 0.19-0.82, p = 0.01). Temporary clipping was an independent risk factor for ischemic complications (ICs) in the total patient group (OR = 6.18, 95% CI = 1.75-21.83, p = 0.005), but not in the M group (OR = 5.53, 95% CI = 0.76-41.92, p = 0.09). Regarding PND prediction, considering any EP changes (MEP and/or SSEP) showed the best diagnostic efficiency with a sensitivity of 0.900, specificity of 0.940, positive predictive value of 0.321, negative predictive value (NPV) of 0.997, and a negative likelihood ratio (LR) of 0.11. Conclusion: IONM application during UIA clipping can reduce PND and radiological complications. The diagnostic effectiveness of IONM, specifically the NPV and LR negative values, was optimal upon consideration of changes in any EP modality.

Posterior interosseous nerve syndrome caused by a ganglion cyst and its surgical release with intraoperative neurophysiological monitoring: A case report.

RATIONALE: Intraoperative neurophysiological monitoring (IONM) has been utilized not only for the rapid detection of neural insults during surgeries, but also to verify the neurophysiological integrity of nerve lesions in the surgical field. PATIENT CONCERNS: A 32-year-old woman presented with a wrist and finger drop that had lasted about 3 months. DIAGNOSES: The result of the initial electrodiagnostic test was consistent with posterior interosseous nerve (PIN) syndrome. Ultrasonography and magnetic resonance imaging of the proximal forearm showed a cystic mass at the anterolateral aspect of the radial head, which was diagnosed as a ganglion cyst. INTERVENTIONS: Surgical release of the ganglion cyst with IONM was performed. During the surgery, we induced nerve action potentials and compound motor action potentials across the ganglion cyst, which demonstrated neural continuity. OUTCOMES: Three months after the surgery, the patient showed partial recovery of wrist and finger extensor muscle power. An electrodiagnostic test conducted 3 months after the surgery showed reinnervation potentials in PIN-innervated muscles. LESSONS: IONM during peripheral nerve surgeries can support surgical decisions and confirm the location and degree of nerve damage.

Diagnostic Role of Flexion-extension Central Motor Conduction Time in Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective study. OBJECTIVE: The purpose of this study was to assess the diagnostic usefulness of flexion-extension central motor conduction time(CMCT) for patients with cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Previous reports have suggested that cervical cord compression can be aggravated by neck motions. Thus, the importance of dynamic magnetic resonance imaging (MRI) has been emphasized. However, authors of this study found no reports conducted at the time of this research on whether flexion-extension CMCT was useful for detecting myelopathy. METHODS: We enrolled 227 patients with CSM for this study. We acquired CMCT recorded from the abductor pollicis brevis muscle. All patients underwent a dynamic CMCT study during neck flexion and extension as well as a static study during neutral neck. Static and dynamic MRIs were also scanned. We read all MR images using Muhle classification (MC). RESULTS: CMCT was significantly delayed with flexion (P < 0.01) and extension (P < 0.01) compared to neutral neck position. Patients with MC grade 1 and 2 showed significant lag in CMCT during flexion and extension. No significant lag by neck motion was observed for those in the MC grade 3. We also evaluated the amount of CMCT variation according to MC grade change (G0, G1, G2) by neck motion. Delta-CMCT of both G1 and G2 were significantly larger than those of G0 in both flexion and extension. In neutral neck, the CMCT showed significant difference between MC grades 1 and 3. They also displayed significant delay with delay with high signal intensity on T2 MRI. More than one-third of the patients whose CMCT was within normal range in neutral neck presented abnormal CMCT in neck flexion (35.3%) and extension (37.8%). CONCLUSION: CMCT is significantly slower in both neck flexion and neck extension than in the neutral neck position. These findings reflect the dynamic cervical cord impingement.Level of Evidence: 4.

Development of an Ultrasonic Doppler Sensor-Based Swallowing Monitoring and Assessment System.

Existing swallowing evaluation methods using X-ray or endoscopy are qualitative. The present study develops a swallowing monitoring and assessment system (SMAS) that is nonintrusive and quantitative. The SMAS comprises an ultrasonic Doppler sensor array, a microphone, and an inertial measurement unit to measure ultrasound signals originating only from swallowing activities. Ultrasound measurements were collected for combinations of two viscosity conditions (water and yogurt) and two volume conditions (3 mL and 9 mL) from 24 healthy participants (14 males and 10 females; age = 30.5 ± 7.6 years) with no history of swallowing disorders and were quantified for 1st peak amplitude, 2nd peak amplitude, peak-to-peak (PP) time interval, duration, energy, and proportion of two or more peaks. The peak amplitudes and energy significantly decreased by viscosity and the PP time interval and duration increased by volume. The correlation between the time measures were higher (r = 0.78) than that of the amplitude measures (r = 0.30), and the energy highly correlated with the 1st peak amplitude (r = 0.86). The proportion of two or more peaks varied from 76.8% to 87.9% by viscosity and volume. Further research is needed to examine the concurrent validity and generalizability of the ultrasonic Doppler sensor-based SMAS.

A large-cohort comparison between single incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy from a single center; 2080 cases.

BACKGROUNDS/AIMS: This study was conducted to verify and compare the safety and feasibility of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC). METHODS: A total of 2,080 patients underwent laparoscopic cholecystectomy in a single center, Konyang University Hospital, between 2010 and 2016. We retrospectively compared the demographics, perioperative outcome, and postoperative complication results between the CLC and SILC groups. RESULTS: Among the 2,080 patients who underwent laparoscopic cholecystectomy, 1,080 had CLC and 1,000 had SILC. When retrospectively reviewed, the SILC group had significantly higher percentages of patients who were aged under 80 years, who were women, and had the American Society of Anesthesiologist score of lower than 3 points compared to those of the CLC group. Furthermore, the CLC group had a higher percentage of patients with acute cholecystitis or empyema, whereas the SILC group had a higher percentage of patients with chronic cholecystitis. Preoperative percutaneous transhepatic gallbladder drainage insertion or H-vac insertion was more frequently conducted, bleeding loss was more common, and hospital stay was longer in the CLC group. Postoperative complications such as wound infection, biloma, bile duct injury, and duodenal perforation were not significantly different between the two groups. CONCLUSIONS: In conclusion, if performed after preoperative patient selection such as in younger and female patients with no abdominal operation history at the time of benign gallbladder surgery, SILC can be considered feasible and safe without additional complications when compared with CLC.

Clinical effects of intrathecal fentanyl on shoulder tip pain in laparoscopic total extraperitoneal inguinal hernia repair under spinal anaesthesia: a double-blind, prospective, randomized controlled trial.

OBJECTIVE: The study evaluated the clinical intraoperative effects of intrathecal administration of fentanyl on shoulder tip pain in patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP) under spinal anaesthesia. METHODS: Patients undergoing TEP were allocated in a double-blinded, prospective, randomized manner to two groups. Spinal anaesthesia was induced by intrathecal administration of 2.8 ml of 0.5% hyperbaric bupivacaine (14 mg) in the control group and with 2.6 ml of 0.5% hyperbaric bupivacaine (13 mg) and 10 µg fentanyl (0.2 ml) in the experimental group. RESULTS: The quality of muscle relaxation, adequacy of operative space and incidence of pneumoperitoneum were similar in the two groups (n = 36 per group). Compared with the control group, the experimental group had significantly fewer cases of hypotension (12 [33.3%]) versus 23 [63.9%]) and shoulder tip pain (nine [25%] versus 18 [50%]). Intraoperative shoulder tip pain was more severe in the control group than in the experimental group. CONCLUSIONS: Addition of intrathecal fentanyl to local anaesthetic can relieve shoulder tip pain with no change in complications, especially hypotension, during TEP under spinal anaesthesia.

Microanalysis of stomach cancer glycosaminoglycans.

Glycosaminoglycans (GAGS) are anionic, linear, polysaccharides involved in cell signaling. The GAG content, composition and structure of human tissue have been suggested to play a role in cancer and might provide useful diagnostic or prognostic markers. The current study examines 17 stomach tissue biopsy samples taken from normal individuals and from patients with gastric cancers. An ultrasensitive liquid chromatography (LC) - mass spectrometry assay was applied to individual biopsy samples as small 250 µg providing GAG content and disaccharide composition. The results of these analyses show a significant increase in non-sulfated chondroitin/dermatan sulfate concentration in all cancer samples when compared to normal tissues. In addition in advanced gastric cancer, a significant decrease is observed in hyaluronan.