Categorized hospital charges of acute ischemic stroke according to trial of org 10172 in acute stroke treatment classification.

BACKGROUND: Previous studies have shown that the cost of hospitalization due to stroke is significantly associated with the length of stay, stroke severity and other clinical characteristics, as well as various socio-demographic factors. However, these studies have been rather inconsistent with regard to the influence of stroke subtypes on costs. AIMS: This study was examined and compared hospital charges of in-patients with acute ischemic stroke according to the Trial of Org 10172 in Acute Stroke Treatment classification. MATERIALS AND METHODS: The costs of case of 749 patients with first ever ischemic stroke who were admitted to an academic medical center between January 2006 and December 2008 were analyzed. The hospital charges were compared among the stroke subtypes using Analysis of Variance. Multiple regression analyses were further performed to test the significance of the impact of the stroke subtype after controlling for other variables. RESULTS: The stroke subtype turned out to be a statistically significant factor influencing both the total charge and several categorized charges even after controlling for other contributing factors such as hospital length of stay and stroke severity. CONCLUSIONS: This study concludes that the stroke subtype should be included when considering in-patient medical expenses of acute ischemic stroke.

Osmotic demyelination syndrome caused by rapid correction of hyperammonemia and continuous hyperbilirubinemia: a case report and review of the literature.

Osmotic demyelination syndrome (ODS) is an acute demyelinating disorder characterized by the loss of myelin in the center of the basis pons, defined as central pontine myelinolysis (CPM), and demyelination in locations outside the pons, defined as extrapontine myelinolysis (EPM). ODS including CPM and EPM is mainly caused by rapid correction of hyponatremia. However, there are several reports of ODS in medical conditions such as malnutrition; alcoholism; liver transplantation; malignancy; sepsis; and electrolyte imbalance including hypernatremia, hypokalemia, hypophosphatemia, and chronic illness. ODS caused by rapid correction of hyperammonemia or continuous hyperbilirubinemia without sodium fluctuations has rarely been reported. Because ODS may be irreversible, prevention is crucial. Herein, we report a case of ODS secondary to rapid correction of hyperammonemia and continuous hyperbilirubinemia.

Contralateral glossoplegia in a lower pontine infarction.

A 65-year old man developed sudden dysarthria, dysphagia, right-sided weakness, and sensory loss. The neurologic examination revealed left-sided tongue deviation caused by right glossoplegia. A magnetic resonance imaging scan revealed an elongated acute infarction from the left ventromedial portion of the lower pons extending to the dorsal pontine tegmentum area. The ipsilateral tongue deviation of the patient may result from interruption of the contralateral crossed corticohtpoglossal projection. This finding suggests that the possibility of the corticohypoglossal decussation may exist just above the pontomedullary junction, with individual variability.

Myelin Oligodendrocyte Glycoprotein-Immunoglobulin G in the CSF: Clinical Implication of Testing and Association With Disability.

BACKGROUND AND OBJECTIVE: To investigate the clinical relevance of CSF myelin oligodendrocyte glycoprotein-immunoglobulin G (MOG-IgG) testing in a large multicenter cohort. METHODS: In this multicenter cohort study, paired serum-CSF samples from 474 patients with suspected inflammatory demyelinating disease (IDD) from 11 referral hospitals were included. After serum screening, patients were grouped into seropositive myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD, 31), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4-IgG + NMOSD, 60), other IDDs (217), multiple sclerosis (MS, 45), and non-IDDs (121). We then screened CSF for MOG-IgG and compared the clinical and serologic characteristics of patients uniquely positive for MOG-IgG in the CSF to seropositive patients with MOGAD. RESULTS: Nineteen patients with seropositive MOGAD (61.3%), 9 with other IDDs (CSF MOG + IDD, 4.1%), 4 with MS (8.9%), but none with AQP4-IgG + NMOSD nor with non-IDDs tested positive in the CSF for MOG-IgG. The clinical, pathologic, and prognostic features of patients uniquely positive for CSF MOG-IgG, with a non-MS phenotype, were comparable with those of seropositive MOGAD. Intrathecal MOG-IgG synthesis, observed from the onset of disease, was shown in 12 patients: 4 of 28 who were seropositive and 8 who were uniquely CSF positive, all of whom had involvement of either brain or spinal cord. Both CSF MOG-IgG titer and corrected CSF/serum MOG-IgG index, but not serum MOG-IgG titer, were associated with disability, CSF pleocytosis, and level of CSF proteins. DISCUSSION: CSF MOG-IgG is found in IDD other than MS and also in MS. In IDD other than MS, the CSF MOG-IgG positivity can support the diagnosis of MOGAD. The synthesis of MOG-IgG in the CNS of patients with MOGAD can be detected from the onset of the disease and is associated with the severity of the disease. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that the presence of CSF MOG-IgG can improve the diagnosis of MOGAD in the absence of an MS phenotype, and intrathecal synthesis of MOG-IgG was associated with increased disability.

Association Between Plasma Amyloid-ß and Neuropsychological Performance in Patients With Cognitive Decline.

Objective: To investigate the association between plasma amyloid-ß (Aß) levels and neuropsychological performance in patients with cognitive decline using a highly sensitive nano-biosensing platform. Methods: We prospectively recruited 44 patients with cognitive decline who underwent plasma Aß analysis, amyloid positron emission tomography (PET) scanning, and detailed neuropsychological tests. Patients were classified into a normal control (NC, n = 25) or Alzheimer's disease (AD, n = 19) group based on amyloid PET positivity. Multiple linear regression was performed to determine whether plasma Aß (Aß40, Aß42, and Aß42/40) levels were associated with neuropsychological test results. Results: The plasma levels of Aß42/40 were significantly different between the NC and AD groups and were the best predictor of amyloid PET positivity by receiver operating characteristic curve analysis [area under the curve of 0.952 (95% confidence interval, 0.892-1.000)]. Although there were significant differences in the neuropsychological performance of cognitive domains (language, visuospatial, verbal/visual memory, and frontal/executive functions) between the NC and AD groups, higher levels of plasma Aß42/40 were negatively correlated only with verbal and visual memory performance. Conclusion: Our results demonstrated that plasma Aß analysis using a nano-biosensing platform could be a useful tool for diagnosing AD and assessing memory performance in patients with cognitive decline.

Association of hospital arrival time with modified rankin scale at discharge in patients with acute cerebral infarction.

This study evaluated the time interval from the development or recognition of a symptom to hospital arrival and investigated its association with the modified Rankin Scale (mRS) at discharge in patients with acute cerebral infarction. A registry was established with ischemic stroke patients admitted to an academic medical center in Korea from January 2005 to March 2009. The time interval between symptom onset and hospital arrival was recorded for each patient and analyzed along with the patient's clinical characteristics and mRS at discharge. Regardless of initial severity at admission, mRS was significantly different between two groups of hospital arrival: within 3 h and beyond 3 h. Multiple regression analysis also showed more positive mRS scores for patients within the 3-hour arrival, controlling for other significant factors. The findings provided patients' initiatives for early hospital arrival.

Serum level of IL-1ß in patients with inflammatory demyelinating disease: Marked upregulation in the early acute phase of MOG antibody associated disease (MOGAD).

BACKGROUND: To evaluate the serum cytokine profiles in patients with myelin oligodendrocyte glycoproteins antibody associated disease (MOGAD), compared to those in neuromyelitis optica spectrum disorder with aquaporin-4 immunoglobulin G (APQ4-IgG+ NMOSD), multiple sclerosis (MS), and other inflammatory demyelinating diseases (IDDs). METHODS: The level of interleukin (IL)-1ß, IL-5, IL-6, IL-10, IL-12p70, IL-17A, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ in sera from 21 patients with MOGAD, 32 APQ4-IgG+ NMOSD, 24 MS, and 16 other IDDs were assessed. RESULTS: In MOGAD patients, the levels of IL-1ß and IL-12p70 were elevated compared to APQ4-IgG+ NMOSD. The level of IL-10 and the ratio of T helper (Th)-1/Th2-related cytokines were elevated in MOGAD patients compared to MS or other IDDs. In an intragroup analysis, the IL-1ß was increased in acute stage of MOGAD, APQ4-IgG+ NMOSD, and also MS compared to their chronic stage counterpart. It was inversely correlated with time from acute attack to sampling in MOGAD (p < 0.001) and AQP4-IgG+ NMOSD (p = 0.001), but not in MS. Moreover, the IL-1ß was most markedly upregulated in MOGAD sera sampled within 1 week from acute attack compared to those sampled after (p = 0.002). CONCLUSIONS: The serum IL-1ß can be elevated in the acute stage of patients with diverse IDDs including, MOGAD, APQ4-IgG+ NMOSD, and MS. This upregulation of serum IL-1ß can be most markedly observed in the early acute stage of MOGAD patients. Further studies seem to be needed to determine the proper mechanism for the upregulation of serum IL-1ß and also the role of IL-1ß inhibition especially at the early acute stage of MOGAD.

Interactive Effects of Apolipoprotein E ε4 and Triiodothyronine on Memory Performance in Patients With Subjective Cognitive Decline.

Background: The aim of the present study was to investigate the associations between thyroid hormones, cognitive performance, and apolipoprotein E (APOE) genotype in euthyroid patients with subjective cognitive decline (SCD). Methods: We recruited 197 euthyroid patients that fulfilled the criteria for SCD. All participants were classified into APOE ε4 carriers and non-carriers based on the presence of the APOE ε4 allele. Patients with SCD who had the APOE ε2/ε4 genotype were excluded from the study. We then performed correlation and regression analyses to evaluate the associations between cognitive performance and thyroid hormones in APOE ε4 carriers and non-carriers. Results: We found no significant differences in cognitive function between APOE ε4 carriers and non-carriers. However, higher levels of triiodothyronine (T3) were associated with better verbal memory performance (immediate and delayed recall tasks) in APOE ε4 carriers, whereas a negative association was found in APOE ε4 non-carriers. Furthermore, there was a significant interactive effect of APOE ε4 status and T3 levels on verbal memory performance (immediate and delayed recall tasks). Conclusions: These findings suggest that in patients with SCD, T3 might have a protective effect on memory in those who are APOE ε4 carriers. The differential susceptibility hypothesis would thus support a gene-by-hormone crossover interaction between APOE ε4 allele and T3 in this study. Early identification and intervention of high-risk individuals for cognitive decline is important to establish new strategies for preventing dementia.

Bone health in neuromyelitis optica: Bone mineral density and fractures.

BACKGROUND: The bone health in neuromyelitis optica spectrum disorder with aquaporin-4 immunoglobulin G antibodies (NMOSD-AQP4) have not been fully evaluated. To evaluate the prevalence of fractures and bone loss in patients with NMOSD-AQP4 compared to healthy controls and patients with multiple sclerosis (MS) and to identify the risk factors associated with fractures and low bone mineral density (BMD) in patients with NMOSD-AQP4. METHODS: Seventy-one patients with NMOSD-AQP4 were included. The two control groups consisted of 213 age-, sex-, menopause-, and body mass index (BMI)-matched healthy participants from the Korean National Health and Nutrition Examination Survey (healthy controls) and 41 patients with multiple sclerosis (disease controls). We collected demographic and clinical data related to bone health including BMD and FRAX score. RESULTS: Patients with NMOSD-AQP4 had a higher prevalence of fractures than the healthy control group (OR = 5.40, CI = 2.004-14.524, p = 0.001), with falling, but not steroid use, being associated with an increased risk of fractures after diagnosis with NMOSD-AQP4 (OR = 24.902, CI = 3.086-200.947, p = 0.003). They also had significantly lower BMD than controls (femur neck, p = 0.044; total hip, p < 0.001), which was more prominent in young participants. The BMD in the NMOSD-AQP4 group was associated with cumulative dose of oral steroids, age, sex, BMI, and partly with the prophylactic calcium supplements. Though the patients with NMOSD-AQP4 did not differ significantly from patients with MS in terms of fracture rate and BMD, they had higher risk of fractures as measured by the Fracture Risk Assessment Tool (for major osteoporotic fractures, (p = 0.001; for hip fractures, p = 0.018). CONCLUSION: Patients with NMOSD-AQP4 had a significantly higher risk of fractures that could mostly be attributed to falling. Additionally, low BMD was observed in these patients; it was more prominent among young patients, associated with steroid use, and may partially prevented by the use of prophylactic calcium supplements.

Splenium or parahippocampus involvement and its relationship to cognitive decline in posterior cerebral artery infarction.

Although cognitive impairment after a posterior cerebral artery (PCA) infarct is frequently observed, the important functional areas associated with cognitive decline, other than the thalamus, have not been determined. We investigated the locus or loci that might induce cognitive decline after a PCA infarct. Forty-one patients with unilateral PCA infarctions involving only the occipital lobe or the occipital lobe plus other PCA areas were included. All subjects received a mini-mental status examination (MMSE) within 2 months of onset; 43.9% had cognitive impairment. The severity of cognitive impairment was not associated with left hemisphere lesion location, sex, age, education level, or the time between stroke and the MMSE assessment. Only the lesion volume was negatively correlated with MMSE score. Lesion location analysis revealed that an occipital plus splenial or parahippocampal lesion contributed to a decline in MMSE, which suggests that parahippocampal or splenial involvement with an occipital lesion is associated with the cognitive decline seen after PCA infarction.

Dissociative disturbance in Hangul-Hanja reading after a left posterior occipital lesion.

Since the Korean language has two distinct writing systems, phonogram (Hangul) and ideogram (Hanja: Chinese characters), alexia can present with dissociative disturbances in reading between the two systems. A 74-year-old right-handed man presented with a prominent reading impairment in Hangul with agraphia of both Hangul and Hanja after a left posterior occipital- parietal lesion. He could not recognize single syllable words and nonwords in Hangul, and visual errors were predominant in both Hanja reading and the Korean Boston Naming Test. In addition, he had difficulties in visuoperceptual tests including Judgment of Line Orientation, Hierarchical Navon figures, and complex picture scanning. These findings are consistent with the hypothesis that Hangul reading impairment results from a general visual perceptual deficit. However, this assumption cannot explain why performance on visually complex Hanja was better than performance on visually simple Hanja in our patient. In addition, the patient did not demonstrate higher accuracy on Hanja characters with fewer strokes than on words with more strokes. Thus, we speculate that the left posterior occipital area may be specialized for Hangul letter identification in this patient. This case demonstrates that Hangul-Hanja reading dissociation impairment can occur after occipital-parietal lesions.

Sarcopenic Obesity in Elderly Korean Women: A Nationwide Cross-sectional Study.

BACKGROUND: Sarcopenia causes loss of muscle mass in the elderly and is associated with development of metabolic syndrome in those with obesity. This study evaluated the prevalence of sarcopenic obesity (SO) in healthy Korean elderly women. METHODS: This study was based on data from the Korea National Health and Nutrition Examination Survey IV and V, 2008-2011. Whole body dual energy X-ray absorptiometry and body mass index measurement were performed for all patients. Women aged 65 years or older were included in this study. Total appendicular extremity muscle mass was used to determine the skeletal muscle mass index. RESULTS: Of 2,396 women aged 65 years or older, a total of 1,491 (62.2%) were underweight, normal weight, or overweight, while 905 (37.8%) were obese. The prevalence of sarcopenia using a cut-off value of 5.4 kg/m2 was 64.9% (63/97) in underweight women, 38.2% (320/838) in normal weight women, 17.1% (95/556) in overweight women, and 6.1% (55/905) in obese women. CONCLUSIONS: The prevalence of sarcopenia was different among groups. The prevalence rate in obese women was lower than that in non-obese women. SO is a new category of obesity in older adults with high adiposity coupled with low muscle mass. The prevalence of SO was lower than that in previous studies because of differences in the definition. A consensus definition of SO needs to be established.

Sarcopenia: Neurological Point of View.

Sarcopenia is an age-related geriatric syndrome which is characterized by the gradual loss of muscle mass, muscle strength, and muscle quality. There are a lot of neurologic insults on sarcopenia at various levels from the brain to the neuromuscular junctions (NMJs) to generate a volitional task. Dopaminergic downregulation, inadequate motor programming and motor coordination impairment lead to decline of supraspinal drive. Motor unit reorganization and inflammatory changes in motor neuron decrease conduction velocity and amplitude of compound muscle action potential. Furthermore, NMJ remodeling and age related neurophysiological alterations may contribute to neuromuscular impairment. Sarcopenia is an age-associated, lifelong process which links to multiple etiological factors. Although not all the causes are completely understood, we suggest that compromised nervous system function may be one of the important contributors to the sarcopenia.

Diagonal Earlobe Crease is a Visible Sign for Cerebral Small Vessel Disease and Amyloid-ß.

We investigated the frequency and clinical significance of diagonal earlobe crease (DELC) in cognitively impaired patients using imaging biomarkers, such as white matter hyperintensities (WMH) on MRI and amyloid-ß (Aß) PET. A total of 471 cognitively impaired patients and 243 cognitively normal (CN) individuals were included in this study. Compared with CN individuals, cognitively impaired patients had a greater frequency of DELC (OR 1.6, 95% CI 1.1-2.2, P = 0.007). This relationship was more prominent in patients with dementia (OR 1.8, 95% CI 1.2-2.7, P = 0.002) and subcortical vascular cognitive impairment (OR 2.4, 95% CI 1.6-3.6, P < 0.001). Compared with Aß-negative cognitively impaired patients with minimal WMH, Aß-positive patients with moderate to severe WMH were significantly more likely to exhibit DELC (OR 7.3, 95% CI 3.4-16.0, P < 0.001). We suggest that DELC can serve as a useful supportive sign, not only for the presence of cognitive impairment, but also for cerebral small vessel disease (CSVD) and Aß-positivity. The relationship between DELC and Aß-positivity might be explained by the causative role of CSVD in Aß accumulation.