Revisiting Loré's retrograde thyroidectomy from the perspective of preserving the external branch of the superior laryngeal nerve.

Background: Injury to the external branches of the superior laryngeal nerve (EBSLN) is the main reported cause of inexplicable post-thyroidectomy dysphonia (PTD) without recurrent laryngeal nerve (RLN) injury. Loré proposed a retrograde thyroidectomy (RT) technique in which the superior pole is dissected as a final step after the Berry ligament division, making this approach advantageous for protecting the EBSLN. However, evidence of this protective effect remains insufficient. We aimed to evaluate EBSLN function following RT and conventional thyroidectomy (CT) using postoperative electromyography (EMG). Methods: This is a retrospective cohort study conducted at a single tertiary center. Consecutive patients who had undergone CT or RT were included. Bilateral EMG of the cricothyroid muscle was performed 2-3 months postoperatively in all patients. Patient characteristics, postoperative findings of bleeding events, drain amount, hypocalcemia, calcium replacement, RLN function, and EBSLN function were thoroughly reviewed and compared between the two surgical approaches. Abnormalities in the EMG findings were reported based on the wave configuration, and the results were graded into four categories. Results: Seven hundred and thirty-one consecutive patients who underwent CT (n=341), or RT (n=390) were included, and a total of 1,179 RLNs and EBSLNs were at risk in CT (n=601) and RT (n=578). The CT and RT groups had similar clinical characteristics and surgical data. Two groups presented similar postoperative results for bleeding incidence, drain amount, and hypocalcemia. All RLNs were identified in both groups and their permanent function was preserved. EBSLN was significantly less frequently identified in the surgical field during RT than it was during CT (0.3% vs. 4.2%, respectively; P<0.001). Abnormal rates of postoperative EMG on the EBSLN were significantly lower in the RT group than in the CT group (1.7% vs. 7.8%, respectively; P<0.001), while the CT group presented with a higher grade of abnormal EMG (P<0.001). Conclusions: The RT technique may be beneficial for preserving EBSLN function. Meticulous capsular dissection and appropriate traction of the upper pole facilitated by RT are crucial for decreasing the risk of EBSLN injury, which can be achieved without directly identifying the nerve.

Domain-specific Physical Activity and the Risk of All-cause Mortality Among Middle-aged and Older Adults in Taiwan: A Prospective Cohort Study.

BACKGROUND: The impact of meeting leisure-time physical activity (LTPA) recommendations and household physical activity (HPA) on all-cause mortality in the Taiwanese population is unclear. We aimed to investigate the relationship between sufficient LTPA and all-cause mortality in middle-aged and older Taiwanese adults and the role of HPA in those with insufficient LTPA. METHODS: This nationwide prospective cohort study included 4,960 participants aged ≥50 years from the Taiwan Longitudinal Study in Aging (TLSA) survey. Physical activity patterns were assessed in 2003 and then followed up until 2015 for mortality through the National Death Registration Record. Cox proportional hazards regression was conducted to evaluate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. RESULTS: Of the 4,960 participants, 1,712 died of all-cause mortality. Compared to those who had insufficient LTPA, participants who engaged in sufficient LTPA showed a significantly lower risk of all-cause mortality (HR = 0.84, 95% CI, 0.73-0.97). For those with insufficient LTPA, HPA also had a significantly reduced risk of all-cause mortality (HR = 0.85, 95% CI, 0.75-0.96) among general population. Similar associations were observed in subsequent sensitivity analyses. The subgroup analysis showed that the relationship between HPA and reduced mortality risk was only found in the women with insufficient LTPA group. CONCLUSION: This study confirmed that sufficient LTPA is associated with a lower risk of all-cause mortality. If sufficient LTPA cannot be performed, additional HPA is related to lower mortality.

Substituting sedentary time with physical activity in youngest-old to oldest-old community-dwelling older adults: Associations with body composition.

Introduction: Several studies have suggested that physical activity and sedentary behavior are strongly and independently associated with body composition and obesity. However, few studies have investigated whether substituting sedentary time with moderate-to-vigorous physical activity is associated with body composition in older adults, especially among those older than 75 years. Methods: This study examined the associations between replacing sedentary time with physical activity and obesity indices in a sample of 199 community-dwelling older Taiwanese adults (52.3% women; 80.6 ± 7.0 years). Physical activity and sedentary behavior were measured using the triaxial accelerometer (GT3X+, ActiGraph). Body composition indices were computed through a bioelectrical impedance analysis of body fat percentage and appendicular skeletal muscle mass index. Waist circumference and body mass index were measured by trained personnel. Isotemporal substitution analyses estimated these associations after adjusting for sociodemographic characteristics and nutritional status. Results: The study showed that substituting 30 min of sedentary behavior per day with moderate-to-vigorous physical activity was associated with lower body fat percentage (B = -1.408, 95% CI = -2.55, -0.264), body mass index (B = -0.681, 95% CI = -1.300, -0.061), and waist circumference (B = -2.301, 95% CI = -4.062, -0.539) after adjusting for covariates. Substituting 30 min of light physical activity per day with moderate-to-vigorous physical activity was associated with lower waist circumference (B = -2.230, 95% CI = -4.173, -0.287) after adjusting for covariates. Stratified analyses indicated that associations were stronger in youngest-old older adults, and in older adults with a normal nutritional status (vs. underweight status). Discussion: These findings confirm the importance of reducing sedentary behavior and increasing moderate-to-vigorous physical activity among older adults to improve their physical health, as well as highlighting the importance of taking into account nutritional status and age group.

Dark Solar Wind.

We study the solar emission of light dark sector particles that self-interact strongly enough to self-thermalize. The resulting outflow behaves like a fluid which accelerates under its own thermal pressure to highly relativistic bulk velocities in the solar system. Compared to the ordinary noninteracting scenario, the local outflow has at least ∼10^{3} higher number density and correspondingly at least ∼10^{3} lower average energy per particle. We show how this generic phenomenon arises in a dark sector composed of millicharged particles strongly self-interacting via a dark photon. The millicharged plasma wind emerging in this model has novel yet predictive signatures that encourages new experimental directions. This phenomenon demonstrates how a small step away from the simplest models can lead to radically different outcomes and thus motivates a broader search for dark sector particles.

Effects of ICT-Based Multicomponent Program on Body Composition and Cognitive Function in Older Adults: A Randomized Controlled Clinical Study.

PURPOSE: Information and communication technology (ICT)-based training devices for older adults' care related to dementia are being developed to enhance older adults' cognitive functions. Older adults who require bicycle training devices can improve muscle strength and balance of lower limbs by continuously contracting and relaxing lower-limb muscles and improving cognitive function to prevent dementia. This study was conducted to investigate the effects of an ICT-based multicomponent program on body composition and cognitive function in older adults. PATIENTS AND METHODS: In a randomized controlled intervention test on 20 people over the age of 60 (exercise group: n = 10; control: n = 10), the multicomponent program was applied to the exercise group twice per week, once per day for 12 weeks, at 30 min per session, whereas the control group was advised to maintain their usual daily activities. RESULTS: Comparing body composition changes and cognitive function changes before and after intervention exhibited statistically significant differences in skeletal muscle mass (P=0.01) and modified Alzheimer's disease assessment scale-cognitive score (P=0.01) between the two groups. CONCLUSION: It can be difficult to be engaged in a simple repetitive exercise program. Therefore, to meet older adults' interests and expectations, a customized ICT-based multicomponent program, which can improve body composition and cognitive function in older adults and is believed to help prevent dementia, is recommended. TRIAL REGISTRATION: UMIN000042129 (https://www.umin.ac.jp/english/).

Thoracic pyogenic infectious spondylitis presented as pneumothorax: A case report.

BACKGROUND: Pyogenic infectious spondylitis (PIS) is a rare condition, with an incidence between 0.2 and 2 cases per 100000 per annum. It's most common symptom-back or neck pain-occurs in more than 90% of cases. Herein, we reported a case of thoracic PIS accompanied by pneumothorax in a 65-year-old male patient. CASE SUMMARY: A 65-year-old man presented with right chest pain and dyspnea. The initial erect posteroanterior chest radiography revealed pneumothorax, which was further evaluated by chest computed tomography, revealing pleural effusion in the right lung and a paravertebral abscess with bony destruction of vertebral body. Based on magnetic resonance imaging, the patient was diagnosed with thoracic infectious spondylitis with an anterior paravertebral abscess. He was prescribed antibiotics and underwent neurosurgery due to aggravated symptoms and neurologic deficit. Tissue examination revealed that the cause of pleural effusion and pneumothorax was Staphylococcus aureus infection contiguously spread to lung pleura. After several surgical treatments with intravenous antibiotic therapy for two months and transition to oral antibiotics (rifampin 600 mg qd and ciprofloxacin 500 mg bid), the patient received physical therapy to recover balance. One month after discharge, the patient had no chest pain or dyspnea, and exhibited no elevation in inflammatory markers or new thoracic lesions. CONCLUSION: To our knowledge, this is the very first report of a case of thoracic PIS with pneumothorax.

Effect of Squat Exercises on Lung Function in Elderly Women with Sarcopenia.

We explored whether a mechanically-assisted squat exercise improved muscle mass, muscle function, and pulmonary function in elderly women with or without sarcopenia. In total, 76 community-dwelling elderly subjects (>60 years of age) were screened. We ultimately included 30 subjects who completed more than 80% of the six-week course of mechanically-assisted squat exercises (three days per week, 30 min per day). We measured body composition, lung function, knee extensor strength, hand grip strength, and the 3-min walk distance (3MWD) before and after the exercise program. Subjects with sarcopenia had poor hand grip strength and knee extensor strength, and a slow walking speed. Their lung function parameters, including forced vital capacity (FVC), was lower than those of the controls. After six weeks of squat exercises, the hand grip strength, knee extensor strength, and 3MWD increased significantly in both groups. Appendicular skeletal muscle mass and leg lean mass were increased in subjects without sarcopenia. The FVC (L) increased significantly only in the sarcopenia group (p = 0.019). The mechanically-assisted squat exercise program increased muscle function and lung function, including FVC, in patients with sarcopenia. Muscle mass increased in subjects without sarcopenia.

Is cricothyroid muscle twitch predictive of the integrity of the EBSLN in Thyroid Surgery?

OBJECTIVE: Cricothyroid (CT) muscle twitch inspection with neurostimulation is a widely accepted method to identify the external branch of the superior laryngeal nerve (EBSLN) and its integrity in thyroid surgery. However, there has been no large-scale research to evaluate the diagnostic values of CT muscle twitch inspection based on postoperative electromyography (EMG) results, which are considered the gold standard. In this study, we aimed to demonstrate the diagnostic value of CT muscle twitch inspection based on postoperative EMG. STUDY DESIGN: Prospective cohort study. METHODS: A total of 454 patients underwent primary thyroid surgery. Among them, 55 patients were excluded because of preoperative vocal fold palsy, problems with the stimulator, or refusal to participate in the EMG study. Finally, 399 patients were prospectively enrolled in this study. Intraoperatively, CT muscle twitch was inspected with neurostimulation. Bilateral EMG examination of the CT muscle was performed 2 to 3 months postoperatively in all patients. RESULTS: A total of 712 EBSLNs at risk were analyzed in this study. Of these, 21 (2.9%) nerves were visually identified, and positive CT muscle twitch by neurostimulation was observed in 694 (97.5%). Normal results on postoperative EMG of the CT muscle were reported in 657 (92.3%). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 97.7%, 5.5%, 92.5%, and 16.7%, respectively. CONCLUSION: CT muscle twitch inspection could be a useful intraoperative tool to determine EBSLN integrity considering its high sensitivity and PPV. However, the test may not completely replace EMG for evaluating EBSLN integrity due to its low specificity and NPV. LEVEL OF EVIDENCE: 2b. Laryngoscope, 2654-2661, 2018.

Reliability and Validity of the Korean Version of the Symptom Checklist-Post-Traumatic Stress Disorder Scale.

The Symptom Checklist - Post-Traumatic Stress Disorder Scale (SCL-PTSD), also known as Crime-Related PTSD Scale has been validated in survivors of interpersonal trauma in the general population. However, the psychometric properties have not been investigated in a clinical setting for patients with PTSD from diverse traumatic events. This study investigates the reliability and validity of the Korean version of the SCL-PTSD among 104 psychiatric outpatients with PTSD, caused by interpersonal (n = 50) or non-interpersonal trauma (n = 54). Self-report data of the SCL-PTSD, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Impact of Events Scale-Revised (IES-R) were gathered. The Korean version of the SCL-PTSD showed excellent internal consistency and moderate-to-good four-week temporal stability in both the interpersonal and non-interpersonal trauma groups. In comparison with other diagnostic groups, the scores of the SCL-PTSD were significantly higher compared to those of adjustment disorder, depression, other anxiety disorders, and schizophrenia, demonstrating its criteria-related validity. Convergent validity was confirmed because the scores of the SCL-PTSD were significantly correlated with BDI, SAI and TAI scores. Concurrent validity was demonstrated by significant correlation with the IES-R score. This study demonstrated the favorable psychometric prosperities of the Korean version of the SCL-PTSD, supporting its use in clinical research and practice.

Efficacy of Systemic Postoperative Pulmonary Rehabilitation After Lung Resection Surgery.

OBJECTIVE: To investigate the efficacy of systemic pulmonary rehabilitation (PR) after lung resection in patients with lung cancer. METHODS: Forty-one patients undergoing lung resection were enrolled and classified into the experimental (n=31) and control groups (n=10). The experimental group underwent post-operative systemic PR which was conducted 30 min/day on every hospitalization day by an expert physical therapist. The control group received the same education about the PR exercises and were encouraged to self-exercise without supervision of the physical therapist. The PR group was taught a self-PR program and feedback was provided regularly until 6 months after surgery. We conducted pulmonary function testing (PFT) and used a visual analog scale (VAS) to evaluate pain, and the modified Borg Dyspnea Scale (mBS) to measure perceived respiratory exertion shortly before and 2 weeks, 1, 3, and 6 months after surgery. RESULTS: A significant improvement on the VAS was observed in patients who received systemic PR >3 months. Significant improvements in forced vital capacity (FVC) and mBS score were observed in patients who received systemic PR >6 months (p<0.05). Other PFT results were not different compared with those in the control group. CONCLUSION: Patients who received lung resection suffered a significant decline in functional reserve and increases in pain and subjective dyspnea deteriorating quality of life (QoL). Systemic PR supervised by a therapist helped improve reduced pulmonary FVC and QoL and minimized discomfort during the postoperative periods in patients who underwent lung resection.

Neuroanatomical correlation of urinary retention in lateral medullary infarction.

We prospectively recruited 10 patients who presented with urinary retention as a neurological deficit that was attributable to lateral medullary infarction. Of these, 9 patients underwent a urodynamic study, which demonstrated detrusor underactivity of the bladder in 7 patients. Urinary retention developed mainly when the lesions involved the lateral tegmentum of the middle or caudal medulla. We concluded that interruption of the descending pathway from the pontine micturition center to the sacral spinal cord in the lateral medulla was responsible for the development of urinary retention.

Care Status of the ALS Patients With Long-Term Use of Tracheostomy Tube.

OBJECTIVE: To evaluate the care status of the amyotrophic lateral sclerosis (ALS) patients with long-term use of tracheostomy tube by caregivers of ALS patients. METHODS: A survey was conducted in the form of questionnaires to ALS patients and their caregivers. All measurements were performed by two visiting nurses. For statistical analysis, SPSS ver. 22.0 and Mann-Whitney U test on non-normal distribution were used. RESULTS: In total, 19 patients (15 males and 4 females) and their caregivers participated in the survey. In the case of patients, the average duration of care was 5.9±3.7 years, and the mean periods of illness and tracheostomy were 5.3±3.2 years and 3.0±2.6 years, respectively. Replacement intervals were 14 days in 11 patients, 7 days in 4 patients, 28 days in 2 patients, and 21 days in 1 patient. One patient was unable to provide an accurate replacement interval. Eighteen (99%) caregivers had experience of adding volume to a cuff without pressure measure in the following instances: due to patients' needs in 7 cases, air leakage in 7 cases, and no reason in 4 cases. Mean pressure of tracheostomy cuff was 40±9.4 cmH2O, and air volume of tracheostomy cuff was 6.7±3.2 mL, but real mean volume was 7.0±2.9 mL. The number of suctioning for airway clearance was a mean 27.5±18.2 times a day. CONCLUSION: According to this survey, we notice that almost all the patients and caregivers had an erroneous idea about cuff volume and pressure. Moreover, education and long-term professional care of tracheostomy cannot be overemphasized in this manner.

Differences in urodynamic variables for vesicoureteral reflux depending on the neurogenic bladder type.

OBJECTIVE: To compare the urodynamic study variables at the onset of vesicoureteral reflux (VUR) between the overactive and underactive bladders in patients with spinal cord injury who presented with VUR. METHODS: A total of 28 (13 cases of detrusor overactivity and 15 detrusor underactivity) men were enrolled. We compared the urodynamic variables between the two groups; detrusor pressure and bladder compliance, the infused volume at the onset of VUR measured on a voiding cystourethrography and cystometric capacity, maximum detrusor pressure, and bladder compliance during filling cystometry were recorded. RESULTS: At the onset of VUR, the bladder volume and compliance, except for the detrusor pressure, showed a significant difference between the two groups. The detrusor pressure, bladder volume, and bladder compliance relative to the cystometric capacity showed a significant difference between the two groups. The detrusor pressure, bladder volume, and bladder compliance at the onset of VUR relative to the cystometric bladder capacity did not show any significant difference between the two groups. CONCLUSION: There were differences in some variables at the onset of VUR depending on the type of neurogenic bladder. The VUR occurred at a lower capacity in neurogenic bladder with detrusor overactivity than in neurogenic bladder with detrusor underactivity at the same pressure. VUR occurred at a lower intravesical pressure compared to that known as the critical detrusor pressure (≥40 cm H2O) required for the development of VUR. The results of our study demonstrate that the detrusor pressure should be maintained lower than the well known effective critical detrusor pressure for the prevention and treatment of VUR.

Effects of Botulinum Toxin on Reducing the Co-contraction of Antagonists in Birth Brachial Plexus Palsy.

Birth brachial plexus palsy (BBPP) is usually caused by plexus traction during difficult delivery. Although the possibility of complete recovery is relatively high, 5% to 25% of BBPP cases result in prolonged and persistent disability. In particular, muscle imbalance and co-contraction around the shoulder and elbow cause abnormal motor performance, osseous deformities, and joint contracture. Physical and occupational therapies have most commonly been used, but these conventional therapeutic strategies have often been inadequate, in managing the residual muscle imbalance and muscle co-contraction. Therefore, we attempted to improve the functional movements, by using botulinum toxin type A, to reduce the abnormal co-contraction of the antagonist muscles.

Autonomic dysreflexia-induced reversible posterior leukoencephalopathy syndrome in patients with spinal cord injury: two case reports.

BACKGROUND/OBJECTIVES: To report two cases of reversible posterior leukoencephalopathy syndrome (RPLS) in patients with traumatic cervical spinal cord injury. DESIGN: Case report. SETTING: Rehabilitation Inpatient Unit, Pusan National University Hospital, Yangsan-si, Korea. RESULTS: Two men with spastic tetraplegia developed autonomic dysreflexia. Use of antihypertensive medication and Foley catheter insertion prevented further episodes of acute arterial hypertension and development of new symptoms. CONCLUSION: RPLS can occur in the setting of autonomic dysreflexia in patients with traumatic cervical cord injury. The prompt recognition of this syndrome is of importance to prevent further morbidity and mortality in patients with spinal cord injury.

Botulinum toxin in the treatment of drooling in tetraplegic patients with brain injury.

OBJECTIVE: To investigate the effect of botulinum toxin type A (BTA) injection into the salivary gland and to evaluate the changes of drooling in varied postures in tetraplegic patients with brain injury. METHODS: Eight tetraplegic patients with brain injury were enrolled. BTA was injected into each parotid and submandibular gland of both sides under ultrasonographic guidance. Drooling was measured by a questionnaire-based scoring system for drooling severity and frequency, and the sialorrhea was measured by a modified Schirmer test for the patients before the injection, 3 weeks and 3 months after the injection. Drooling was evaluated in each posture, such as supine, sitting, and tilt table standing, and during involuntary mastication, before and after the injection. RESULTS: The severity and frequency of drooling and the modified Schirmer test improved significantly at 3 weeks and 3 months after the injection (p<0.05). Drooling was more severe and frequent in tilt table standing than in the sitting position and in sitting versus supine position (p<0.05). The severity of drooling was significantly increased in the patients with involuntary mastication (p<0.05). CONCLUSION: Salivary gland injection of BTA in patients with tetraplegia resulting from brain injury who had drooling and sialorrhea could improve the symptoms for 3 months without complications. The severity and frequency of drooling were dependent on posture and involuntary mastication. Proper posture and involuntary mastication of the patients should be taken into account in planning drooling treatment.

The Correlation between Modified Ashworth Scale and Biceps T-reflex and Inter-rater and Intra-rater Reliability of Biceps T-reflex.

OBJECTIVE: To establish a correlation between the modified Ashworth scale (MAS) and amplitude and latency of T-reflex and to demonstrate inter-rater and intra-rater reliability of the T-reflex of the biceps muscle for assessing spasticity after stroke. METHOD: A total of 21 patients with hemiplegia and spasticity after ischemic stroke were enrolled for this study. The spasticity of biceps muscle was evaluated by an occupational therapist using the MAS. The mean value of manual muscle test of biceps muscles was 2.3±0.79. Latency and amplitude of T-reflex were recorded from biceps muscles by two physicians. The onset latency and peak to peak amplitude of the mean of 5 big T-reflex were measured. The examinations were carried out by two physicians at the same time to evaluate the inter-rater reliability. Further, one of the physicians performed the examination again after one week to evaluate the intra-rater reliability. The correlations between MAS and T-reflex, and the intra- and inter-rater reliability of biceps T-reflex were established by calculating the Spearman correlation coefficients and the intra-class correlation coefficients (ICCs). RESULTS: Amplitude of the biceps T-reflex increased with increasing level of MAS (r(s)=0.464 and 0.573, respectively, p<0.01). ICCs of latency and amplitude of biceps T-reflex were 0.914 and 0.822. The Spearman correlation coefficients of latency and amplitude of biceps T-reflex were 0.937 and 0.635, respectively (p<0.01). CONCLUSION: Biceps T-reflex demonstrates a good quantitative measurement and correlation tool with MAS for spasticity, and also shows acceptable inter- and intra-rater reliability, which can be used for patients with spasticity after stroke.

Candida esophagitis with fever alone in a patient with stroke.

BACKGROUND: Candida esophagitis is a rare disease, but its incidence is higher in patients with impaired immunity due to an underlying disease. Patients with candida esophagitis usually present with lower retrosternal pain or dysphagia, but they are sometimes asymptomatic. Several risk factors, including diabetes mellitus, malignancies, chronic obstructive pulmonary disease (COPD) and steroid therapy, have been shown to be associated with candida esophagitis. Candida esophagitis may mimic other disease processes and can thus be misdiagnosed. CASE STUDY: This study describes a case of candida esophagitis with fever alone in the patient with stroke. After a stroke attack, a 53-year-old man was hospitalized for rehabilitation. He had a fever unexpectedly, but the cause could not be found for 2 weeks. Esophagogastroduodenoscopy (EGD) was performed to find the cause of the fever and it was diagnosed as candida eosphagitis. Fever decreased respectively 4 days after anti-fungal therapy begun. CONCLUSION: Dysphagia, unexplained anaemia, loss of appetite and dyspepsia may require EGD to make a confirmative diagnosis. If unexplained fever is persistent without any of these symptoms, it is advisable to consider EGD in patients with stroke.

A case of generalized auditory agnosia with unilateral subcortical brain lesion.

The mechanisms and functional anatomy underlying the early stages of speech perception are still not well understood. Auditory agnosia is a deficit of auditory object processing defined as a disability to recognize spoken languages and/or nonverbal environmental sounds and music despite adequate hearing while spontaneous speech, reading and writing are preserved. Usually, either the bilateral or unilateral temporal lobe, especially the transverse gyral lesions, are responsible for auditory agnosia. Subcortical lesions without cortical damage rarely causes auditory agnosia. We present a 73-year-old right-handed male with generalized auditory agnosia caused by a unilateral subcortical lesion. He was not able to repeat or dictate but to perform fluent and comprehensible speech. He could understand and read written words and phrases. His auditory brainstem evoked potential and audiometry were intact. This case suggested that the subcortical lesion involving unilateral acoustic radiation could cause generalized auditory agnosia.