Evaluation of the Psychometric Properties of a Newly Developed Chinese Screening Tool for Speech Disorders in Patients With Parkinson's Disease.

The study aimed to analyze the psychometric properties of a newly developed Chinese screening tool, the Chinese Version of the Speech Disorders in Parkinson's Disease Questionnaire (SDPD-C). The SDPD-C contains a 24-item questionnaire with four assessment domains. Overall, 93 patients with idiopathic Parkinson's disease (PD) (age 70.1 ± 8.9 years) and 76 healthy older adults (age 67.2 ± 8.1 years) participated in the psychometric analysis study. The internal consistency of the SDPD-C was .91 (four dimensions: .69-.85), and test-retest reliability was .91 (four dimensions: .85-.88). The SDPD-C was highly correlated with the Voice Handicap Index-10 and Movement Disorder Society-Unified Parkinson's Disease Rating Scale II 2.1 (r = .83 and .78, respectively). The SDPD-C scores also differed significantly between stages 1 and 4 of the Hoehn and Yahr Scale (p < .05). The area under the receiver operating characteristic curve was .955 (95% confidence interval, .927-.983; asymptotic significance p < .001), and the optimal cut-off score of this study was 36, with a sensitivity of .849 and specificity of .947. The results indicate that SDPD-C showed good reliability, validity, accuracy, and discrimination. It can be used as a screening tool for speech disorders in patients with PD.

Insomnia in older adult females is highly associated with metabolic syndrome.

PURPOSE: The aim of this study is to investigate the relationships between insomnia and metabolic syndrome among Taiwanese older adults. METHODS: This cross-sectional study enrolled participants aged over 60 years from outpatient clinics between July and September 2018. Demographic characteristics of all participants and questionnaire data for sleep duration, use of hypnotic agents, baseline activities of daily living, 5 items of the geriatric depression scale, comorbidities, medications, and risk of obstructive sleep apnea were obtained. Insomnia was defined by scores of questionnaires of the Chinese version of the Athens Insomnia Scale higher or equal to 6 points. Metabolic syndrome was diagnosed according to criteria of the National Cholesterol Education Program Adult Treatment Panel III. Multivariable forward stepwise logistic regression analysis was applied to investigate independent associations between insomnia and metabolic syndrome before and after stratifying by gender. RESULTS: Among the 336 participants (mean age 74.9 ± 8.5 years, female 49.1%), 63.1% participants had metabolic syndrome, with significantly higher prevalence among females than males (males 56.7%; females 69.7%). Participants with metabolic syndrome had higher rates of insomnia (34.0% vs. 21.8%, P = 0.018). The significant associations between insomnia and metabolic syndrome disappeared after adjusting for all covariates. However, insomnia was independently associated with metabolic syndrome in older females (adjusted OR 2.614, 95% CI 1.011-6.763, P = 0.048) after adjusting for all covariates. CONCLUSIONS: Insomnia is significantly associated with metabolic syndrome among older female adults. These findings suggest that gender may play a role in the pathogenesis of insomnia and metabolic syndrome in older adults.

Factors associated with insomnia in older adult outpatients vary by gender: a cross-sectional study.

BACKGROUND: Insomnia is a common sleep disturbance in older adults and is associated with many poor health outcomes. This study aimed to explore factors associated with insomnia in older adult outpatient clinics, and to further analyze the influence of gender on factors associated with insomnia. METHODS: This cross-sectional study was conducted in the outpatient clinics of a tertiary hospital in Southern Taiwan from July to September 2018. A total of 400 consecutive subjects aged 60 years or older were recruited. Insomnia was defined as a score of ≥6 points on the Athens Insomnia Scale (AIS). Socio-demographics, health behaviors and clinical data were collected by face-to-face interview. Multivariable logistic regression was adopted for statistical analysis of the entire sample and stratified by gender. RESULTS: Participants' mean age was 74.74 ± 8.54 years, and the majority (93%) had more than one chronic disease. The prevalence of insomnia accounted for 30% (120/400) of all subjects, with males 22.9% (46/201) and females 37.2% (74/199). Gender, appetite, exercise, depressive symptoms, and sleep-related conditions such as short sleep duration, sleeping pills usage, medium-high risk of obstructive sleep apnea (OSA) and restless leg syndrome (RLS) were factors associated with insomnia in older adults. Exercise, sleeping pills usage, and RLS were independently associated with insomnia only in men, while appetite and medium-high risk of OSA were associated with insomnia in women only. In addition, after further adjusting for covariates, prevalence of the insomnia-related symptoms such as sleep induction, total sleep duration, sleep quality and sleepiness during the day was significantly higher in females than in males. CONCLUSIONS: Insomnia symptoms are highly prevalent among older adults, predominantly females. Significant differences are found between genders in factors associated with insomnia and insomnia-related symptoms. Understanding gender differences may help clinicians to modify associated factors when managing older adults with insomnia.

Incidence of dementia after dengue fever: Results of a longitudinal population-based study.

OBJECTIVE: To investigate the epidemiological relationship between dengue fever and the subsequent development of dementia. METHODS: Using nationwide Taiwan registries from the National Health Insurance Research (NHIRD), we identified adults aged over 40 years who received a dengue fever diagnosis from 1 January 2000 to 31 December 2012 and who did not have a history of dementia. We used a propensity score match (PSM) to balance the baseline characteristics between groups. All eligible adults were sorted into either the dengue group or non-dengue group at a ratio of 1:4, matching by age, sex, index years, income level, and relevant comorbidities. Using Cox regression with proportional hazards models, we estimated the risk of dementia. The study period started from 1 January 2000 to 31 December 2013. We conducted sensitivity analyses to cross-validate study results. RESULTS: With a median of 8.01 years of follow-up, patients in the dengue group were more at risk of developing dementia than the non-dengue group. The estimated cumulative incidence of dementia was 7.21% in the dengue group and 4.03% in the non-dengue group (adjusted hazard ratio (aHR), 1.71; 95% CI, 1.03 to 2.83). Sensitivity analyses yielded consistent findings. We excluded any stroke cases before the end of the study, and subgroup analysis by follow-up time showed that the dengue group has a significantly higher risk of new-onset dementia >6 years after the index date (aHR 3.24; 95% CI, 1.42 to 7.37). The P value for interaction was significant (<.0001). CONCLUSIONS: This study demonstrated a significantly higher risk of dementia in patients with dengue fever in Taiwan than in those without dengue fever.

Hash Transformation and Machine Learning-Based Decision-Making Classifier Improved the Accuracy Rate of Automated Parkinson's Disease Screening.

Digitalized hand-drawn pattern is a noninvasive and reproducible assistive manner to obtain hand actions and motions for evaluating functional tremors and upper-limb movement disorders. In this study, spirals and straight lines in polar coordinates are used to extract polar expression features such as the key parameters deviation (cm) and accumulation angle (rad). These parameters are quantitative manner to scale the variations of functional tremors in normal control subjects and patients with Parkinson's disease (PD) and essential tremor (ET). However, difficulty arises in using nonlinear polar expression features in the two-dimensional feature space to separate normal control subjects from those with PD and ET. To solve the nonlinear separable classification problem, hash transformation is used to map polar expression features to a high-dimensional space using hash weighing function and modulo operation. Then, a machine learning method, such as the generalized regression neural network (GRNN), is implemented to train a decision-making classifier using the particle swarm optimization (PSO) algorithm for possible class assessment. With the enrolled data from 50 subjects, the fivefold cross validation, mean true positive, mean true negative, and mean hit rates of 98.93%, 98.96%, and 98.93%, respectively, are obtained to quantify the performance of the proposed decision-making classifier to identify normal controls and subjects with PD or ET. The experimental results indicate that the proposed screening model can improve the accuracy rate compared with the conventional machine learning classifier.

Cerebellar PACNS in an Elderly Patient Present as a Tumor-Like Mass Lesion: A case Report.

PURPOSE: PACNS has a broad spectrum of clinical manifestations without typical features, and its clinical diagnosis is challenging. We report an elderly patient of cerebellar PACNS (Primary angiitis of central nervous system) presented as a brain tumor by MRI, and primary angiitis was proven by pathology. CASE REPORT: We report an 81-year-old female who complained about vertigo for 3 weeks with right arm dysmetria. There were no other neurologic symptoms/signs, and the patient was free from headache. Brain CT showed a space-occupying lesion over the right cerebellum, and a high-grade glioma was suspected by brain MRI and MRS. The pathologic result of brain biopsy showed granulomatous variant of PACNS. The patient received immunosuppressant therapy as long-term therapy, and had favorable response during a 2-year follow up. CONCLUSION: Due to variations in clinical presentation and nonspecific findings on imaging studies, PACNS is not easily diagnosed, especially in the aged population. PACNS should be considered as one of the differential diagnoses of any CNS dysfunction. PACNS is also an exclusionary diagnosis, so although brain biopsy is limited for its low sensitivity, its application is still important to exclude the possibility of other diseases. Although there have been reports of fulminant cases, PACNS can be treated successfully with immunosuppressant as maintaining therapy.

The relationship of leukoaraiosis and the clinical severity of vascular Parkinsonism.

Vascular Parkinsonism (VP) is referred to as secondary Parkinsonian syndrome. It occurs with lacunar state or sub-cortical white matter micro-angiopathy and is highly associated with vascular risk factors and leukoaraiosis, also known as cerebral white matter lesions (WML). This study aimed to assess the prevalence of different vascular risk factors and WML in patients with VP, and their impact on clinical features. Sixty-two consecutive VP patients (70.2 ± 9.2 years) were evaluated for clinical severity using the Unified Parkinson's Disease Rating Scale (UPDRS). WML was assessed and scored on fluid-attenuated inversion recovery T2-weighted (FLAIR) magnetic resonance imaging (MRI). Cerebro-vascular risk factors, WML severity, and the UPDRS for clinical disability were analyzed statistically. There were no associations between WML score and age, sex, hypertension, diabetes, previous stroke, cardiac disease, cigarette smoking, or serum levels of cholesterol and triglyceride. The WML score positively correlated with UPDRS part I (p = 0.035) and part III (p = 0.041) scores. After adjustments for age, gender, stroke history, and use of levodopa, the WML score was associated with the UPDRS total (p = 0.020), part I (p = 0.012), part II (p = 0.039), and part III (p = 0.019) scores. The severity of WML is not associated with conventional vascular risk factors in VP patients but is significantly correlated with the UPDRS total and all sub-scores, which suggests that disruption of the cortico-sub-cortical circuits may lead to impaired mentation, behavior and mood, activities of daily living, and motor performance in these patients.

Functional outcomes in patients with REM-related obstructive sleep apnea treated with positive airway pressure therapy.

STUDY OBJECTIVES: To evaluate functional outcomes in adults with REM-related obstructive sleep apnea (OSA) treated with positive airway pressure (PAP) therapy. DESIGN: Retrospective observational study. SETTING: Outpatient sleep clinic. PATIENTS: 330 adults (171 males) with OSA receiving PAP therapy, including 130 with REM OSA and 200 with OSA not restricted to REM. MEASUREMENTS AND RESULTS: REM OSA was defined as a REM apnea-hypopnea index (AHI) / NREM AHI > 2 and NREM AHI < 15. Patients had baseline and post-PAP functional outcomes, including Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Patient Health Questionnaire-9 (PHQ-9), and Functional Outcomes Sleep Questionnaire (FOSQ) scores. We compared functional outcomes, demographic, clinical and polysomnographic features, and PAP adherence in patients with REM OSA and OSA not restricted to REM. Female gender was significantly more common in REM OSA. Age, BMI, neck girth, and baseline ESS, FSS, PHQ-9, and FOSQ were similar between groups. Smoking history and comorbid disorders were also similar except for a higher prevalence of depression and cardiovascular disease in OSA not restricted to REM. All functional outcomes improved significantly after PAP therapy in both groups. Change from baseline to post treatment was similar for all functional outcomes between groups. CONCLUSIONS: The study is the first addressing clinical outcomes in REM OSA using validated measures. Functional outcomes in patients with REM OSA improve after treatment with PAP therapy comparable to that observed in patients with OSA not restricted to REM. COMMENTARY: A commentary on this article appears in this issue on page 249.

Postictal transient hyperammonemia as an indicator of seizure disorder.

BACKGROUND AND PURPOSE: Transient hyperammonemia can occur after episodes of seizure. To verify that transient hyperammonemia is a unique finding in seizure patients, we compared the change in blood ammonia concentration during the postictal period with that of other patients who suffered consciousness disturbances due to other disorders. METHODS: We compared the results of a biochemical examination, including serum ammonia levels, between adult patients sent to the emergency department (ED) with seizure and those with other causes of consciousness disturbance. RESULTS: Nineteen out of 31 patients with generalized epileptic seizures showed hyperammonemia at initial data measurement. Seventeen of these patients showed transient hyperammonemia. Only 10 patients with hepatic encephalopathy showed hyperammonemia, while none of the patients suffering from other causes of consciousness disturbance showed transient hyperammonemia within hours of arrival at the ED. CONCLUSION: Transient hyperammonemia was observed in the majority of generalized tonic-clonic seizure patients examined in this study but not in those with other causes of consciousness disturbance. Because ammonia is checked in patients presenting with transient consciousness disturbance to the ED, with or without witness, transient hyperammonemia could be an indicator of recent epileptic seizure.

Cerebrotendinous xanthomatosis patients with and without parkinsonism: clinical characteristics and neuroimaging findings.

Parkinsonism in cerebrotendinous xanthomatosis (CTX) is rare. There are no published studies with imaging findings of dopamine transporter using (99m)Tc-[2-[[2-[[[3-(4-chlorophenyl)-8-methyl-8-azabicyclo [3,2,1] oct-2-yl] methyl] (2-mercaptoethyl) amino] ethyl] amino]-ethanethiolato(3-)-N2,N2,S2,S2]oxo-[1R-(exo-exo)] ((99m)Tc-TRODAT-1) SPECT in CTX patients. This report is on the clinical details of five genetically-proven CTX patients (two with and three without parkinsonism). Imaging findings using cranial magnetic resonance (MR) imaging and (99m)Tc-TRODAT-1 SPECT are also shown. Clinical correlation of neuroimaging findings and clinical presentations was made. A literature review of the clinical and neuroimaging features of eight CTX patients with parkinsonism reported in the English literature is also presented. The parkinsonian features of our two cases and the other eight reported cases occurred before the age of 50 years. The MR imaging study showed variable findings, in which, besides the common diffuse cerebral and cerebellar white matter lesions shown in CTX, several focal brain lesions were also noted. Of the focal lesions, substantia nigra abnormalities were seen only in the two cases with parkinsonism. The (99m)Tc-TRODAT-1 SPECT study showed different degrees of unilateral or bilateral abnormalities in the striatal binding in both visual and semiquantitative assessments. parkinsonism can be one of the neurologic presentations of CTX. Even though abnormal findings of the substantia nigra were detected in both of our CTX patients with parkinsonism, basal ganglion lesions have not been uniformly described in MR imaging findings of reported CTX patients with parkinsonism. (99m)Tc-TRODAT-1 SPECT study can be of value in the detection of striatal involvement, and the study results also suggest pre-synaptic dopamine neuron involvement in CTX patients with parkinsonism.

Association of plasma homocysteine concentration with cerebral white matter hyperintensity on magnetic resonance images in stroke patients.

BACKGROUND: Homocysteine (Hcy) has been recognized as a risk factor for atherosclerosis. White matter hyperintensity (WMH) on MRI has been regarded as a hallmark for cerebral small vascular disease. The study is to investigate the relationship between plasma Hcy level and WMH on a hospital-based cohort of Taiwanese stroke patients. METHODS AND RESULTS: A total of 352 consecutive stroke patients (64.7+/-11.2 years) were included. Severity of WMH was semi-quantitatively evaluated with a scoring system. The top WMH score tertile was defined as severe white matter change (sv-WMH). Associations between Hcy tertile levels and sv-WMH were examined, adjusting for demographics and atherosclerosis risk factors. Subjects in the top Hcy tertile (>10.25 micromol/L) had higher WMH scores and prevalence of sv-WMH than those in the middle and in the bottom tertile. The adjusted odds ratio of having sv-WMH was 2.04 (95% confidence interval 1.20-3.47, p=0.008) for the top Hcy level tertile than for the lower two tertiles combined. CONCLUSION: Hcy is a risk factor for cerebral white matter lesion in stroke patients. Even mild hyperhomocysteinemia can significantly increase severity of cerebral microangiopathy.

Clinical features, neuroimaging and treatment of spontaneous intracranial hypotension and magnetic resonance imaging evidence of blind epidural blood patch.

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension (SIH) is an uncommon, but not rare, cause of headache. We analyzed a series of patients with SIH and attempted to establish a clinical procedure. METHODS: We retrospectively reviewed 11 patients with SIH who were admitted between January 2004 and May 2007. Data recorded from patients included basic data, clinical symptoms, neurological imaging studies and treatment. RESULTS: Orthostatic headache was the most common symptom, but there were still 2 patients without orthostatic headache. Diffuse pachymeningeal enhancement was the most common finding in brain MRI study and engorgement of the spinal epidural venous plexus was the most common finding in spinal MRI study. Eight of our patients received epidural blood patches in the lumbar area and 6 of these were symptom-free within 2 weeks. Two patients received spinal MRI immediately after administering the epidural blood patch, and this revealed that most of the blood had spread to the upper cervical area from the lumbar injection. CONCLUSION: A blind epidural blood patch from the lumbar area is an acceptable procedure even if the area of leakage is unknown. A reasonable clinical procedure for the patients of SIH may minimize the rate of repeat puncture.

Postictal transient hyperammonemia.

We report cases of several patients who were sent to our hospital because of seizure attacks. Transient hyperammonemia was noted. Many biochemistry abnormalities, such as prolactin and creatine kinase, may be found after an episode of seizures, but hyperammonemia seems to not have been reported before.