Effect of Atypical Sleep EEG Patterns on Weaning From Prolonged Mechanical Ventilation.

BACKGROUND: Approximately one-third of acute ICU patients display atypical sleep patterns that cannot be interpreted by using standard EEG criteria for sleep. Atypical sleep patterns have been associated with poor weaning outcomes in acute ICUs. RESEARCH QUESTION: Do patients being weaned from prolonged mechanical ventilation experience atypical sleep EEG patterns, and are these patterns linked with weaning outcomes? STUDY DESIGN AND METHODS: EEG power spectral analysis during wakefulness and overnight polysomnogram were performed on alert, nondelirious patients at a long-term acute care facility. RESULTS: Forty-four patients had been ventilated for a median duration of 38 days at the time of the polysomnogram study. Eleven patients (25%) exhibited atypical sleep EEG. During wakefulness, relative EEG power spectral analysis revealed higher relative delta power in patients with atypical sleep than in patients with usual sleep (53% vs 41%; P < .001) and a higher slow-to-fast power ratio during wakefulness: 4.39 vs 2.17 (P < .001). Patients with atypical sleep displayed more subsyndromal delirium (36% vs 6%; P = .027) and less rapid eye movement sleep (4% vs 11% total sleep time; P < .02). Weaning failure was more common in the atypical sleep group than in the usual sleep group: 91% vs 45% (P = .013). INTERPRETATION: This study provides the first evidence that patients in a long-term acute care facility being weaned from prolonged ventilation exhibit atypical sleep EEG patterns that are associated with weaning failure. Patients with atypical sleep EEG patterns had higher rates of subsyndromal delirium and slowing of the wakeful EEG, suggesting that these two findings represent a biological signal for brain dysfunction.

Modified Korean MIND Diet: A Nutritional Intervention for Improved Cognitive Function in Elderly Women through Mitochondrial Respiration, Inflammation Suppression, and Amino Acid Metabolism Regulation.

SCOPE: Mild cognitive impairment is associated with a high prevalence of dementia. The study examines the benefits of a modified Korean MIND (K-MIND) diet and explores biomarkers using multi-omics analysis. METHODS AND RESULTS: The K-MIND diet, tailored to the elderly Korean population, includes perilla oil, milk, or fermented milk, and avoids alcohol consumption. As a result, the K-MIND diet significantly improves subjects "orientation to place" in the Korean version of the Mini-Mental State Examination, 2nd edition test. According to multi-omics analysis, the K-MIND diet upregulates genes associated with mitochondrial respiration, including ubiquinone oxidoreductase, cytochrome C oxidase, and ATP synthase, and immune system processes, and downregulates genes related to nuclear factor kappa B activity and inflammatory responses. In addition, K-MIND affects the metabolic pathways of glycine, serine, threonine, tryptophan, and sphingolipids, which are closely linked to cognitive function through synthesis of neurotransmitters and structures of brain cell membranes. CONCLUSION: The findings imply that the K-MIND diet improves cognitive function by upregulating key genes involved in oxidative phosphorylation and downregulating pro-inflammatory cytokines.

Impact of varying food hardness on mastication/swallowing.

The purpose of this study was to analyze mastication and swallowing in the elderly and confirm the association with dysphagia characteristics. A questionnaire was developed to evaluate the masticating and swallowing functions of the elderly. Mastication was analyzed using electromyography, and tongue/lip pressures were measured using Iowa Oral Performance Instrument. The results of the questionnaire showed that statistical difference in the number of teeth between the group without and with, decreased ability to swallow, and there was a correlation with lip pressure. Additionally, the higher number of teeth, the higher muscle activity, and there is a positive correlation between the number of chews and the lip pressure. Consequently, our findings suggested oral health parameters are closely associated with mastication/swallowing ability. Finally, based on the results obtained for different foods tested, we suggested that texture-modified foods are necessary to enhance swallowing ability.

Effect of Fermented Red Ginseng Concentrate Intake on Stool Characteristic, Biochemical Parameters, and Gut Microbiota in Elderly Korean Women.

Fermented red ginseng (FRG) has been used as a general stimulant and herbal medicine for health promotion in Asia for thousands of years. Few studies have investigated the effects of FRG containing prebiotics on the gut microbiota. Here, 29 Korean women aged ≥ 50 years were administered FRG for three weeks to determine its effect on stool characteristics, biochemical parameters, and gut microbiome. Gut microbial DNA was subjected to 16S rRNA V3-V4 region sequencing to assess microbial distribution in different stages. Additionally, the stool consistency, frequency of bowel movements, and biochemical parameters of blood were evaluated. We found that FRG intake improved stool consistency and increased the frequency of bowel movements compared to before intake. Biochemical parameters such as glucose, triglyceride, cholesterol, low-density lipoprotein cholesterol, creatinine, alkaline phosphatase, and lactate dehydrogenase decreased and high-density lipoprotein cholesterol increased with FRG intake. Gut microbiome analysis revealed 20 specific bacteria after three weeks of FRG intake. Additionally, 16 pathways correlated with the 20 specific bacteria were enhanced after red ginseng intake. In conclusion, FRG promoted health in elderly women by lowering blood glucose levels and improving bowel movement frequency. The increase in bacteria observed with FRG ingestion supports these findings.

Effects of textured food masticatory performance in older people with different dental conditions.

BACKGROUND: Physiological deterioration (aging, poor dental status, and reduced tongue pressure) makes chewing difficult. This study aimed to investigate the chewing patterns of older people with or without dentures, evaluate the textural and masticatory properties of texture-modified radish Kimchi, and investigate the correlation between dental status and tongue pressure. Additionally, differences in the subjective-objective concordance of texture-modified Kimchi were investigated using the preference test. METHODS: This study included 32 Korean women aged between 65 and 85 years. Masticatory behavior was recorded by electromyography, and tongue pressure was measured using the Iowa Oral Performance Instrument. A preference test, with hardness as the relevant textural property, determined the participants' preferences among the test samples (food with a homogeneous structure-radish Kimchi). To assess preference differences, a questionnaire suitable for older people was designed. The preference for cooked radish Kimchi with various blanching times based on overall acceptability and self-reporting of preference was investigated to develop elderly-friendly food. The subjective scores indicated whether the sample (radish Kimchi) was hard or soft based on the chewing ability of the participants. Dental status, muscle activities, and tongue pressure were considered for the food design with optimized texture. The relationship between subject score and mastication properties were examined using multiple regression analysis. RESULTS: The number of chews and chewing time increased with hardness, significantly activating the masseter and temporalis muscles. The evaluation of masseter muscle activity, particularly for level-6 radish Kimchi, showed that older people with complete dentures chewed less actively than those with natural teeth (p < 0.05). The older people with natural teeth (18.94 ± 10.27 kPa) exhibited higher tongue pressure than those with complete dentures (10.81 ± 62.93 kPa), and the difference was statistically significant (p < 0.01). Older people preferred food with familiar tastes and textures. An association was found between the subjective hardness score and the objective hardness level. The perceived hardness intensity was linked to the chewing ability of the participant. Denture wearers exhibited a lower chewing ability, and at level 6, they perceived greater hardness of food than those with natural teeth. CONCLUSIONS: Developing food with a modified texture can bridge the gap between physiological and psychological aspects of food texture; texture-modified radish Kimchi, with limited blanching time, may be favorable for older people.

Variable abnormality of the melanopsin-derived portion of the pupillary light reflex (PLR) in patients with Parkinson's disease (PD) and parkinsonism features.

OBJECTIVES: Ascertain and quantify abnormality of the melanopsin-derived portion of the pupillary light reflex (PLR) in patients with Parkinson's disease (PD) and parkinsonism features based on a statistical predictive modeling strategy for PLR classification. METHODS: Exploratory cohort analysis of pupillary kinetics in non-disease controls, PD subjects, and subjects with parkinsonism features using chromatic pupillometry. Receiver operating characteristic (ROC) curve interpretation of pupillary changes consistent with abnormality of intrinsically photosensitive retinal ganglion cells (ipRGCs) was employed using a thresholding algorithm to discriminate pupillary abnormality between study groups. RESULTS: Twenty-eight subjects were enrolled, including 17 PD subjects (age range 64-85, mean 70.65) and nine controls (age range 48-95, mean 63.89). Two subjects were described as demonstrating parkinsonism symptoms due to presumed Lewy body dementia and motor system atrophy (MSA) respectively. On aggregate analysis, PD subjects demonstrated abnormal but variable pupillary dynamics suggestive of ipRGC abnormality. Subjects with parkinsonism features did not demonstrate pupillary changes consistent with ipRGC abnormality. There was no relationship between levodopa equivalent dosage or PD severity and ipRGC abnormality. The pupillary test sensitivity in predicting PD was 0.75 and likelihood ratio was 1.2. CONCLUSIONS: ipRGC deficit is demonstrated in PD subjects; however, the degree and constancy of abnormality appear variable.

The particle size of rice flour greatly affects the structural, textural and masticatory properties of steamed rice cake (Baekseolgi).

In this study, steamed rice cakes prepared with different particle sized flour were used to investigate how the structures of rice cakes affected masticatory properties and bolus starch hydrolysis. Decreasing the particle size increased the surface areas requiring hydration, resulting in a loose structure and fluffy starch network during gelatinization. Increasing the particle size led to a tight and firm network, but was easily melted in the oral cavity. The chewing cycle and time differed among the samples. The conditions of inter-individual salivary flow rate and salivary α-amylase were diverse. The oral carbohydrate hydrolysis in the bolus before swallowing showed no significant differences in reducing sugar levels among particle sizes. However, salivary concentration was related to initial starch hydrolysis in the oral cavity, indicating the food structures affected mastication factors and physiological conditions. This study provides food structure and physiological factor information that could help design customized foods in industry.

Different Reactions in Each Enterotype Depending on the Intake of Probiotic Yogurt Powder.

Probiotics can be used as a nutritional strategy to improve gut homeostasis. We aimed to evaluate the intestinal microbiota profile of 18 subjects after ingestion of probiotic yogurt powder (PYP) based on enterotype. The subjects were classified into three enterotypes according to their microbial community: Bacteroides (n = 9, type B), Prevotella (n = 3, type P), and Ruminococcus (n = 6, type R). We performed controlled termination in a transient series that included a control period of three weeks before probiotic intake, PYP intake for three weeks, and a three-week washout period. Fecal microbiota composition was analyzed by sequencing the V3-V4 super variable region of 16S rRNA. Based on the Bristol stool shape scale, abnormal stool shape improved with PYP intake, and bowel movements were activated. The abundance of Faecalibacterium, Eggerthella, and Leuconostoc, which ferment and metabolize glucose, showed a strong correlation with type B Bacteroides, and glucose metabolism improvement was observed in all type B subjects. Alkaline phosphatase was significantly improved only in type B. In addition, the abundance of type B Bacteroides showed a negative correlation with that of Lactobacillus. The abundance of Streptococcus, Agathobacter, and Christensenella, which are involved in lipid metabolism, showed a strong correlation with that of type P Prevotella, and triglyceride metabolism improvement was observed in all type P subjects. The gut microbiota showed only short-term changes after PYP intake and showed resilience by returning to its original state when PYP intake was interrupted. In summary, the different responses to PYP intake may result from the different enterotypes and associated strains; therefore, the probiotic composition should be adjusted based on the individual enterotype.

Detection of Parkinson's Disease Through Automated Pupil Tracking of the Post-illumination Pupillary Response.

Parkinson's disease (PD) is one of the most common neurodegenerative disorders, but it is often diagnosed after the majority of dopaminergic cells are already damaged. It is critical to develop biomarkers to identify the disease as early as possible for early intervention. PD patients appear to have an altered pupillary response consistent with an abnormality in photoreceptive retinal ganglion cells. Tracking the pupil size manually is a tedious process and offline automated systems can be prone to errors that may require intervention; for this reason in this work we describe a system for pupil size estimation with a user interface to allow rapid adjustment of parameters and extraction of pupil parameters of interest for the present study. We implemented a user-friendly system designed for clinicians to automate the process of tracking the pupil diameter to measure the post-illumination pupillary response (PIPR), permit manual corrections when needed, and continue automation after correction. Tracking was automated using a Kalman filter estimating the pupil center and diameter over time. The resulting system was tested on a PD classification task in which PD subjects are known to have similar responses for two wavelengths of light. The pupillary response is measured in the contralateral eye to two different light stimuli (470 and 610 nm) for 19 PD and 10 control subjects. The measured Net PIPR indicating different responsiveness to the wavelengths was 0.13 mm for PD subjects and 0.61 mm for control subjects, demonstrating a highly significant difference (p < 0.001). Net PIPR has the potential to be a biomarker for PD, suggesting further study to determine clinical validity.

Regulation of IL-6 signaling by miR-125a and let-7e in endothelial cells controls vasculogenic mimicry formation of breast cancer cells.

The role of tumor-proximal factors in tumor plasticity during chemoresistance and metastasis following chemotherapy is well studied. However, the role of endothelial cell (EC) derived paracrine factors in tumor plasticity, their effect on chemotherapeutic outcome, and the mechanism by which these paracrine factors modulate the tumor microenvironment are not well understood. In this study, we report a novel mechanism by which endothelial miR-125a and let-7e-mediated regulation of interleukin-6 (IL-6) signaling can manipulate vasculogenic mimicry (VM) formation of MDA-MB-231 breast cancer cells. We found that endothelial IL-6 levels were significantly higher in response to cisplatin treatment, whereas levels of IL-6 upon cisplatin exposure remained unchanged in MDA-MB-231 breast cancer cells. We additionally found an inverse correlation between IL-6 and miR-125a/let-7e expression levels in cisplatin treated ECs. Interestingly, IL-6, IL-6 receptor (IL-6R), and signal transducer and activator of transcription 3 (STAT3) genes in the IL-6 pathway are closely regulated by miR-125a and let-7e, which directly target its 3' untranslated region. Functional analyses revealed that endothelial miR-125a and let-7e inhibit IL-6-induced adhesion of monocytes to ECs. Furthermore, conditioned medium from cisplatin treated ECs induced a significantly higher formation of VM in MDA-MB-231 breast cancer cells as compared to that from intact ECs; this effect of cisplatin treatment was abrogated by concurrent overexpression of miR-125a and let-7e. Overall, this study reveals a novel EC-tumor cell crosstalk mediated by the endothelial miR-125a/let-7e-IL-6 signaling axis, which might improve chemosensitivity and provide potential therapeutic targets for the treatment of cancer. [BMB Reports 2019; 52(3): 214-219].

A PPARγ-dependent miR-424/503-CD40 axis regulates inflammation mediated angiogenesis.

Activation of the endothelium by pro-inflammatory stimuli plays a key role in the pathogenesis of a multitude of vascular diseases. Angiogenesis is a crucial component of the vascular response associated with inflammatory signaling. The CD40/CD40 ligand dyad in endothelial cells (EC) has a central role in promoting vascular inflammatory response; however, the molecular mechanism underlying this component of inflammation and angiogenesis is not fully understood. Here we report a novel microRNA mediated suppression of endothelial CD40 expression. We found that CD40 is closely regulated by miR-424 and miR-503, which directly target its 3' untranslated region. Pro-inflammatory stimuli led to increased endothelial CD40 expression, at least in part due to decreased miR-424 and miR-503 expression. In addition, miR-424 and miR-503 reduced LPS induced EC sprouting, migration and tube formation. Moreover, we found that miR-424 and miR-503 expression is directly regulated by peroxisome proliferator-activated receptor gamma (PPARγ), whose endothelial expression and activity are decreased in response to inflammatory factors. Finally, we demonstrate that mice with endothelial-specific deletion of miR-322 (miR-424 ortholog) and miR-503 have augmented angiogenic response to LPS in a Matrigel plug assay. Overall, these studies identify a PPARγ-dependent miR-424/503-CD40 signaling axis that is critical for regulation of inflammation mediated angiogenesis.

Negative regulation of NOD1 mediated angiogenesis by PPARγ-regulated miR-125a.

Infection with pathogens activates the endothelial cell and its sustained activation may result in impaired endothelial function. Endothelial dysfunction contributes to the pathologic angiogenesis that is characteristic of infection-induced inflammatory pathway activation. Nucleotide-binding oligomerization domain-containing protein 1 (NOD1) is a protein receptor which recognizes bacterial molecules and stimulates an immune reaction in various cells; however, the underlying molecular mechanisms in the regulation of inflammation-triggered angiogenesis are not fully understood. Here we report that peroxisome proliferator-activated receptor gamma (PPARγ)-mediated miR-125a serves as an important regulator of NOD1 agonist-mediated angiogenesis in endothelial cells by directly targeting NOD1. Treatment of human umbilical vein endothelial cells with natural PPARγ ligand, 15-Deoxy-Delta12,14-prostaglandin J2, led to inhibition of NOD1 expression; contrarily, protein levels of NOD1 were significantly increased by PPARγ knockdown. We report that PPARγ regulation of NOD1 expression is a novel microRNA-mediated regulation in endothelial cells. MiR-125a expression was markedly decreased in human umbilical vein endothelial cells subjected to PPARγ knockdown while 15-Deoxy-Delta12,14-prostaglandin J2 treatment increased the level of miR-125a. In addition, NOD1 is closely regulated by miR-125a, which directly targets the 3' untranslated region of NOD1. Moreover, both overexpression of miR-125a and PPARγ activation led to inhibition of NOD1 agonist-induced tube formation in endothelial cells. Finally, NOD1 agonist increased the formation of cranial and subintestinal vessel plexus in zebrafish, and this effect was abrogated by concurrent PPARγ activation. Overall, these findings identify a PPARγ-miR-125a-NOD1 signaling axis in endothelial cells that is critical in the regulation of inflammation-mediated angiogenesis.

Notch regulates BMP responsiveness and lateral branching in vessel networks via SMAD6.

Functional blood vessel growth depends on generation of distinct but coordinated responses from endothelial cells. Bone morphogenetic proteins (BMP), part of the TGFß superfamily, bind receptors to induce phosphorylation and nuclear translocation of SMAD transcription factors (R-SMAD1/5/8) and regulate vessel growth. However, SMAD1/5/8 signalling results in both pro- and anti-angiogenic outputs, highlighting a poor understanding of the complexities of BMP signalling in the vasculature. Here we show that BMP6 and BMP2 ligands are pro-angiogenic in vitro and in vivo, and that lateral vessel branching requires threshold levels of R-SMAD phosphorylation. Endothelial cell responsiveness to these pro-angiogenic BMP ligands is regulated by Notch status and Notch sets responsiveness by regulating a cell-intrinsic BMP inhibitor, SMAD6, which affects BMP responses upstream of target gene expression. Thus, we reveal a paradigm for Notch-dependent regulation of angiogenesis: Notch regulates SMAD6 expression to affect BMP responsiveness of endothelial cells and new vessel branch formation.

PREDICTION OF MORPHOLOGIC DETERIORATION IN PATIENTS WITH LAMELLAR MACULAR HOLES.

PURPOSE: To analyze the morphologic evolution of idiopathic lamellar macular holes (LMHs) as determined by spectral domain optical coherence tomography, and evaluate the utility of retinal function assessments through multifocal electroretinography for predicting the likelihood of morphologic deterioration in LMHs. METHODS: Twenty-eight eyes of 28 patients with LMHs were examined by spectral domain optical coherence tomography at the initial visit and after 12 months. Lamellar macular holes were subdivided into morphologic deterioration (DET) and morphologic maintenance (MAI) groups based on the change in central retinal thickness during the follow-up period. Patients with LMHs were also examined by multifocal electroretinography at the initial visit. Multifocal electroretinography amplitudes were compared between DET and MAI groups, and discriminant function was calculated to predict morphologic deterioration in LMH eyes. RESULTS: During the follow-up period, morphologic deterioration was found in 8 (28.6%) of LMH cases. On multifocal electroretinography, amplitudes in the central ring (R1) and first paracentral ring (R2) were significantly lower in the DET than in the MAI group. Discriminant analysis performed on these two variables yielded a discriminant function with 75% of cases classified correctly. CONCLUSION: Multifocal electroretinography is a useful tool for predicting morphologic deterioration of LMHs. Lower multifocal electroretinography amplitudes in R1 and R2 predict an increased risk of subsequent deterioration.

Relationship Between Vertical and Horizontal Aniseikonia Scores and Vertical and Horizontal OCT Images in Idiopathic Epiretinal Membrane.

PURPOSE: The purpose of this study was to identify the relationship between aniseikonia scores in the vertical and horizontal meridians and the foveal microstructure on vertical and horizontal spectral-domain optical coherence tomography (SD-OCT) in patients with idiopathic epiretinal membrane (ERM). METHODS: All patients (n = 65) with unilateral ERM were examined, and the aniseikonia scores in the vertical (VAS) and horizontal (HAS) meridians were determined using the New Aniseikonia Test. Vertical and horizontal images passing through the fovea were obtained by axial SD-OCT in both eyes. The thicknesses of the ganglion cell layer + inner plexiform layer, inner nuclear layer (INL), and outer retinal layer were measured on the SD-OCT images, and color histograms were analyzed using Photoshop software. RESULTS: Of the 65 ERM patients, 81.5% (53 patients) had macropsia. The VAS and HAS were equal in 52.8% (28 patients). Multiple regression analysis revealed significant correlations between the VAS and vertical INL thickness (R = 0.388, P = 0.001) and between the HAS and horizontal INL thickness (R = 0.349, P = 0.001). The difference between VAS and HAS was proportional to the ratio of the vertical INL thickness to horizontal INL thicknesses (R = 0.370, P < 0.001). CONCLUSIONS: Eyes with ERM mostly presented macropsia. The aniseikonia scores in the vertical and horizontal meridians correlate well with INL thickness on the vertical and horizontal directions of SD-OCT images, respectively. Aniseikonia induced by ERM may be related to the INL thickening detected with SD-OCT.

Epigenetic modulation as a therapeutic approach for pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a rare but progressive and currently incurable disease, which is characterized by vascular remodeling in association with muscularization of the arterioles, medial thickening and plexiform lesion formation. Despite our advanced understanding of the pathogenesis of PAH and the recent therapeutic advances, PAH still remains a fatal disease. In addition, the susceptibility to PAH has not yet been adequately explained. Much evidence points to the involvement of epigenetic changes in the pathogenesis of a number of human diseases including cancer, peripheral hypertension and asthma. The knowledge gained from the epigenetic study of various human diseases can also be applied to PAH. Thus, the pursuit of novel therapeutic targets via understanding the epigenetic alterations involved in the pathogenesis of PAH, such as DNA methylation, histone modification and microRNA, might be an attractive therapeutic avenue for the development of a novel and more effective treatment. This review provides a general overview of the current advances in epigenetics associated with PAH, and discusses the potential for improved treatment through understanding the role of epigenetics in the development of PAH.

Melatonin improves experimental colitis with sleep deprivation.

Sleep deprivation (SD) is an epidemic phenomenon in modern countries, and its harmful effects are well known. SD acts as an aggravating factor in inflammatory bowel disease. Melatonin is a sleep-related neurohormone, also known to have antioxidant and anti-inflammatory effects in the gastrointestinal tract; however, the effects of melatonin on colitis have been poorly characterized. Thus, in this study, we assessed the measurable effects of SD on experimental colitis and the protective effects of melatonin. For this purpose, male imprinting control region (ICR) mice (n = 24) were used; the mice were divided into 4 experimental groups as follows: the control, colitis, colitis with SD and colitis with SD and melatonin groups. Colitis was induced by the administration of 5% dextran sulfate sodium (DSS) in the drinking water for 6 days. The mice were sleep-deprived for 3 days. Changes in body weight, histological analyses of colon tissues and the expression levels of pro-inflammatory cytokines and genes were evaluated. SD aggravated inflammation and these effects were reversed by melatonin in the mice with colitis. In addition, weight loss in the mice with colitis with SD was significantly reduced by the injection of melatonin. Treatment with melatonin led to high survival rates in the mice, in spite of colitis with SD. The levels of pro-inflammatory cytokines, such as interleukin (IL)-1ß, IL-6, IL-17, interferon-γ and tumor necrosis factor-α, in the serum of mice were significantly increased by SD and reduced by melatonin treatment. The melatonin-treated group showed a histological improvement of inflammation. Upon gene analysis, the expression of the inflammatory genes, protein kinase Cζ (PKCζ) and calmodulin 3 (CALM3), was increased by SD, and the levels decreased following treatment with melatonin. The expression levels of the apoptosis-related inducible nitric oxide synthase (iNOS) and wingless-type MMTV integration site family, member 5A (Wnt5a) genes was decreased by SD, but increased following treatment with melatonin. Treatment with melatonin reduced weight loss and prolonged survival in mice with colitis with SD. Melatonin exerted systemic anti-inflammatory effects. Gene analysis revealed a possible mechanism of action of melatonin in inflammation and sleep disturbance. Thus, melatonin may be clinically applicable for patients with inflammatory bowel disease, particularly those suffering from sleep disturbances.

Clinical differences in Clostridium difficile infection based on age: a multicenter study.

Advancing age is a well-known risk factor for Clostridium difficile infection (CDI). However, age-specific clinical differences in CDI are uncertain. A retrospective comparative analysis was performed based on age in 1367 patients with CDI in Korea. Most clinical features were similar in the two age groups studied, however malignancy was more common in the older group (age ≥ 65 y) (p < 0.001), while chemotherapy and transplantation were more common in the younger group (age < 65 y) (p < 0.001). Endoscopic examinations were more commonly performed in the older group (p = 0.010), which had a high positive predictive value (88.3%). More patients recovered from CDI without specific antibiotic treatment in the younger group than in the older group (p < 0.001). Although advancing age is an important risk factor for CDI, the clinical features of younger patients are similar to those of the older patient population.

A patient with amyotrophic lateral sclerosis and atypical clinical and electrodiagnostic features: a case report.

INTRODUCTION: Amyotrophic lateral sclerosis is a rapidly progressive, fatal neurodegenerative disorder for which there is no effective treatment. The diagnosis is dependent on the clinical presentation and consistent electrodiagnostic studies. Typically, there is a combination of upper and lower motor neuron signs as well as electrodiagnostic studies indicative of diffuse motor axonal injury. The presentation of amyotrophic lateral sclerosis, however, may be variable. At the same time, the diagnosis is essential for patient prognosis and management. It is therefore important to appreciate the range of possible presentations of amyotrophic lateral sclerosis. CASE PRESENTATION: We present the case of a 57-year-old Caucasian man with pathological findings on postmortem examination consistent with amyotrophic lateral sclerosis but atypical clinical and electrodiagnostic features. He died after a rapid course of progressive weakness. The patient did not respond to immunosuppressive therapy. CONCLUSION: Amyotrophic lateral sclerosis should be considered in patients with a rapidly progressive, unexplained neuropathic process. This should be true even if there are atypical clinical and electrodiagnostic findings. Absence of response to therapy and the development of upper motor neuron signs should reinforce the possibility that amyotrophic lateral sclerosis may be present. Since amyotrophic lateral sclerosis is a fatal illness, however, the possibility of this disease in patients with atypical clinical features should not diminish the need for a thorough diagnostic evaluation and treatment trials.