Reference Respiratory Muscle Strength Values and a Prediction Equation Using Physical Functions for Pulmonary Rehabilitation in Korea

Background@#In Korea, tests for evaluating respiratory muscle strength are based on other countries’ clinical experience or standards, which can lead to subjective evaluations. When evaluating respiratory function based on the standards of other countries, several variables, such as the race and cultures of different countries, make it difficult to apply these standards. The purpose of this study was to propose objective respiratory muscle strength standards and predicted values for healthy Korean adults based on age, height, weight, and muscle strength, by measuring maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and peak cough flow (PCF). @*Methods@#This cross-sectional study analyzed MIP, MEP, and PCF in 360 people, each group comprising 30 adult men and women aged 20–70, diagnosed as healthy after undergoing medical check-ups at a general hospital. Hand grip strength (HGS) and the five times sitto-stand test (FTSST) results were also recorded. Correlations among respiratory muscle strength, participant demographics, and overall muscle strength were evaluated using Pearson’s correlation analysis. The predicted values of respiratory muscle strength were calculated using multiple regression analysis. @*Results@#Respiratory muscle strength differed from the values reported in studies from other countries. In the entire samples, both MIP and MEP had the highest correlations with peak HGS (r= 0.643, r = 0.693; P < 0.05), while PCF had the highest correlation with forced expiratory volume in 1 s (r = 0.753; P < 0.05). Age, body mass index, peak HGS, and FTSST results were independent variables affecting respiratory muscle strength. A predictive equation for respiratory muscle strength was developed using the multiple regression equation developed in this study. @*Conclusion@#Respiratory muscle strength index may differ by country. For more accurate diagnoses, standard values for each country are required. This study presents reference values for Korea, and a formula for estimation is proposed when no respiratory muscle strength measurement equipment is available.Trial Registration: Clinical Research Information Service Identifier: KCT0006778

Cluster Analysis on the Mental Health States in a Community Sample of Young Women During Pre-Pregnancy, Pregnancy, or the Postpartum Period

Objective@#It is necessary to identify the mental health types of young women considering the importance of the mental health during the peripartum period. This study aimed to classify the mental health types in a community sample of young women with pre-pregnancy, pregnancy, or the postpartum period. @*Methods@#A total of 293 young women during pre-pregnancy, pregnancy, or the postpartum period were included in this study. The clinical characteristics of depression, anxiety, perceived stress, and quality of life were assessed. The clinical characteristics of the subject were classified by cluster analysis and compared by analysis of variance. @*Results@#From the cluster analysis, the subjects were classified into three groups. Cluster 1 showed significantly lower depression and anxiety and higher quality of life than those of cluster 2 and 3. Cluster 2 demonstrated significantly higher depression and anxiety and lower quality of life than those of cluster 3 and 1. Cluster 3 represented the intermediate levels between cluster 2 and 1. @*Conclusion@#This study suggested that young women during pre-pregnancy, pregnancy, or the postpartum period might be in a good mental health group, a high-risk group requiring active monitoring, or a group in need of treatment. By monitoring mental health, the groups with high risk or requiring treatment could be discovered and proper management for prevention or improvement of mental health and quality of life can be provided.

Difference in Cognitive Performance in Virtual Reality– Assisted Mental Health Promotion Program According to Groups Clustered Based on Mental Health / 우울ㆍ조울병

Background@#Several studies support the effectiveness and tolerability of virtual reality (VR) interventions in the psychiatric field. This study aimed to examine changes of cognitive performance in VR-assisted mental health promotion programs and to investigate the difference in performance according to clinical characteristics. @*Methods@#Thirty subjects aged >55 years participated in the study. The clinical characteristics of depression, anxiety, perceived stress, quality of life, and cognition were assessed. Cognitive performance in VR-assisted mental health promotion programs was compared between the clusters classified by clinical characteristics. @*Results@#Cluster analysis classified the subjects into three groups. In Cluster 1, the Module 3 training score was significantly different before and after VR performance. In Cluster 2, significant differences were observed in the Module 1 training score, the Module 2 training score, the Module 2 defense failure score, and the Module 3 training score.In Cluster 3, a significant difference was observed in the Module 3 training score. @*Conclusion@#The results of this study suggest that VR performance might differ according to clinical characteristics. A cognitive training strategy using VR has to be differentially established depending on the characteristics of the community population.

What is the Adequate Cuff Volume for Tracheostomy Tube? A Pilot Cadaver Study

Objective@#To determine the patterns of tracheostomy cuff pressure changes with various air inflation amounts in different types of tracheostomy tubes to obtain basic data for appropriately managing longterm tracheostomy. @*Methods@#We performed tracheostomy on a 46-year-old male cadaver. Three types of tracheostomy tubes (single-cuffed, double-cuffed, and adjustable flange), divided into 8 different subtypes based on internal tube diameters and cuff diameters, were inserted into the cadaver. Air was inflated into the cuff, and starting with 1 mL air, the cuff pressure was subsequently measured using a manometer. @*Results@#For the 7.5 mm/14 mm tracheostomy tube, cuff inflation with 3 mL of air yielded a cuff pressure within the recommended range of 20–30 cmH2O. The 7.5 mm/24 mm tracheostomy tube showed adequate cuff pressure at 5 mL of air inflation. Similar values were observed for the 8.0 mm/16 mm and 8.0 mm/27 mm tubes. Double-cuffed tracheostomy cuff pressures (7.5 mm/20 mm and 8.0 mm/20 mm tubes) at 3 mL air inflation had cuff pressures of 18–20 cmH2O at both the proximal and distal sites. For the adjustable flange tracheostomy tube, cuff pressure at 6 mL of cuff air inflation was within the recommended range. Maximal cuff pressure was achieved at inflation with almost 14 mL of air, unlike other tube types. @*Conclusion@#Various types of tracheostomy tubes showed different cuff pressures after inflation. These values might aid in developing guidelines For patients who undergo tracheostomy and are discharged home without cuff pressure manometers, this standard might be helpful to develop guidelines.

Duodenoduodenal Intussusception due to a Migrated Percutaneous Radiologic Gastrostomy Tube: A Case Report / 대한연하장애학회지

Patients with dysphagia often have difficulty in supplying adequate nutrition orally, and thus they often use gastrostomy for nutrition support. If the nutrition affects the deterioration of the disease, as in amyotrophic lateral sclerosis, the majority of patients will have a gastrostomy tube for proper nutrition. To prevent complications from gastrostomy tubes, it is important to educate the caregiver or patient about how to properly manage it. If these patients opt for home care because of financial or cultural reasons, it will be difficult for their healthcare team to observe them closely, leading to complications due to lax tube management. In this case, appropriate management education becomes more important. This paper reports an extremely rare case of duodenal intussusception caused by a migrated percutaneous radiologic gastrostomy (PRG) tube in a patient with amyotrophic lateral sclerosis (ALS) using simultaneous oral and enteral nutrition. The patient was treated successfully with urgent tube removal using the air reduction maneuver. This case highlights the importance of gastrostomy management.

Association between Medical Costs and the ProVent Model in Patients Requiring Prolonged Mechanical Ventilation / 결핵

BACKGROUND: The purpose of this study was to determine whether components of the ProVent model can predict the high medical costs in Korean patients requiring at least 21 days of mechanical ventilation (prolonged mechanical ventilation [PMV]). METHODS: Retrospective data from 302 patients (61.6% male; median age, 63.0 years) who had received PMV in the past 5 years were analyzed. To determine the relationship between medical cost per patient and components of the ProVent model, we collected the following data on day 21 of mechanical ventilation (MV): age, blood platelet count, requirement for hemodialysis, and requirement for vasopressors. RESULTS: The mortality rate in the intensive care unit (ICU) was 31.5%. The average medical costs per patient during ICU and total hospital (ICU and general ward) stay were 35,105 and 41,110 US dollars (USD), respectively. The following components of the ProVent model were associated with higher medical costs during ICU stay: age <50 years (average 42,731 USD vs. 33,710 USD, p=0.001), thrombocytopenia on day 21 of MV (36,237 USD vs. 34,783 USD, p=0.009), and requirement for hemodialysis on day 21 of MV (57,864 USD vs. 33,509 USD, p<0.001). As the number of these three components increased, a positive correlation was found betweeen medical costs and ICU stay based on the Pearson's correlation coefficient (γ) (γ=0.367, p<0.001). CONCLUSION: The ProVent model can be used to predict high medical costs in PMV patients during ICU stay. The highest medical costs were for patients who required hemodialysis on day 21 of MV.

Early Stage Lymphedema in Breast Cancer Patient Detected by Indocyanine Green Lymphography but not by Lymphoscintigraphy: A Case Report

Secondary upper extremity lymphedema after lymph node dissection in breast cancer patients is a major complication affecting their quality of life. As lymphatic function is compromised before symptoms develop in most cases, early diagnosis and intervention before symptomatic manifestation is known to prevent severe progression of lymphedema. In this case report, we present a patient with secondary lymphedema, whose disease could be diagnosed at an early stage using indocyanine green (ICG) lymphography. The patient had mild edema of the left upper extremity that regressed with elevation, had normal lymph vessel distribution without dermal backflow pattern in lymphoscintigraphy. Her symptom improved after early prescription of complex decongestive physiotherapy. We conclude that ICG lymphography could be an effective diagnostic tool in addition to other imaging methods, for early diagnosis and intervention of lymphedema.

Sarcopenia Associated with Chronic Obstructive Pulmonary Disease

Sarcopenia is frequently associated with chronic diseases such as chronic obstructive pulmonary disease (COPD) and cancer. COPD, which is characterized by an irreversible airflow limitation, exacerbates respiratory distress as the disease progresses. The prevalence of sarcopenia in stable COPD was reported to be 15% to 25% in previous foreign studies and 25% in a Korean study. As the amount of activity decreases, muscle mass decreases and eventually oxygen cannot be used effectively, resulting in a vicious cycle of deterioration of exercise capacity. Deconditioning due to decreased activity is a major cause of limb muscle dysfunction in patients with COPD. In these patients, the factors that decrease muscle strength and endurance include chronic inflammation, oxidative stress, inactivity, hypoxemia, hormone abnormality, deficits of nutrients such as protein and vitamin D, and the use of systemic corticosteroid. Therefore, treatment and management should either inhibit this process or should be directed toward supplementing the deficiency, such as with exercise, nutritional support, and medications and supplements. The relationship between sarcopenia and COPD is increasingly being reported, with some overlap in clinical features and treatments. We are fascinated to be able to diagnose 2 diseases through similar physical performance tests and to improve both diseases using the same treatment such as exercise. Therefore, this review summarizes the clinical relevance and integrative management of the 2 diseases.

Erratum: Correction of Figure in the Article: Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

The present erratum notice corrects one figure of the article.

Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

BACKGROUND: Accurate volume measurement is important in the management of patients with congestive heart failure or renal insufficiency. A bioimpedance analyser can estimate total body water in litres and has been widely used in clinical practice due to its non-invasiveness and ease of results interpretation. To change impedance data to volumetric data, bioimpedance analysers use equations derived from data from healthy subjects, which may not apply to patients with other conditions. Bioelectrical impedance vector analysis (BIVA) was developed to overcome the dependence on those equations by constructing vector plots using raw impedance data. BIVA requires normal reference plots for the proper interpretation of individual vectors. The aim of this study was to construct normal reference vector plots of bioelectrical impedance for Koreans. METHODS: Bioelectrical impedance measurements were collected from apparently healthy subjects screened according to a comprehensive physical examination and medical history performed by trained physicians. Reference vector contours were plotted on the RXc graph using the probability density function of the bivariate normal distribution. We further compared them with those of other ethnic groups. RESULTS: A total of 242 healthy subjects aged 22 to 83 were recruited (137 men and 105 women) between December 2015 and November 2016. The centers of the tolerance ellipses were 306.3 Ω/m and 34.9 Ω/m for men and 425.6 Ω/m and 39.7 Ω/m for women. The ellipses were wider for women than for men. The confidence ellipses for Koreans were located between those for Americans and Spaniards without overlap for both genders. CONCLUSION: This study presented gender-specific normal reference BIVA plots and corresponding tolerance and confidence ellipses on the RXc graph, which is important for the interpretation of BIA-reported volume status in patients with congestive heart failure or renal insufficiency. There were noticeable differences in reference ellipses with regard to gender and ethnic groups.

Pharyngeal Dystonia Misdiagnosed as Cricopharyngeal Dysphagia Successfully Treated by Pharmacotherapy

A 43-year-old woman suffered from drooling and dysphagia after a stroke in the left posterior inferior cerebellar artery territory. Videofluoroscopic swallowing study showed compatible findings of cricopharyngeal dysphagia. Despite the injection of botulinum neurotoxin, no symptom improvement was achieved and pharyngeal dystonia was considered as the cause. Medications for dystonia dramatically helped with saliva control and resulted in a small improvement in the progression of food from the pharyngeal to esophageal phase. After adjusting the drug dose, the patient was able to perform social activities without drooling. Moreover, she could consume food orally; however, this was limited to small amounts of liquid, and the main method of nutrition support was via an orogastric tube. Therefore, we suggest that physicians should make a differential diagnosis of combined dystonia in patients complaining of dysphagia by esophageal manometry and electromyography.

Secondary Lymphedema After Intestinal Tuberculosis: A Case Report

Lymphedema, a chronic disease that lowers patients' quality of life, is categorized as primary or secondary. Secondary lymphedema can be improved by treating the underlying cause. However, in many cases, efforts are not made to identify the primary cause of lymphedema and treatment is targeted at the edema itself, resulting in misdiagnosis. Here, we describe the case of a 61-year-old man with right leg edema of unknown cause that had persisted for 3 years. Intestinal tuberculosis was confirmed during a re-evaluation of the cause, and his symptoms improved after anti-tuberculous treatment. This improvement was assessed qualitatively by indocyanine green lymphography before and after treatment, as well as by observation of the clinical symptoms. Lower extremity lymphedema caused by intestinal tuberculosis is extremely rare, and this case reveals the importance of continuing to identify the causes of resistant pathologies.

Association between Medical Costs and the ProVent Model in Patients Requiring Prolonged Mechanical Ventilation / 결핵및호흡기질환

BACKGROUND@#The purpose of this study was to determine whether components of the ProVent model can predict the high medical costs in Korean patients requiring at least 21 days of mechanical ventilation (prolonged mechanical ventilation [PMV]).@*METHODS@#Retrospective data from 302 patients (61.6% male; median age, 63.0 years) who had received PMV in the past 5 years were analyzed. To determine the relationship between medical cost per patient and components of the ProVent model, we collected the following data on day 21 of mechanical ventilation (MV): age, blood platelet count, requirement for hemodialysis, and requirement for vasopressors.@*RESULTS@#The mortality rate in the intensive care unit (ICU) was 31.5%. The average medical costs per patient during ICU and total hospital (ICU and general ward) stay were 35,105 and 41,110 US dollars (USD), respectively. The following components of the ProVent model were associated with higher medical costs during ICU stay: age <50 years (average 42,731 USD vs. 33,710 USD, p=0.001), thrombocytopenia on day 21 of MV (36,237 USD vs. 34,783 USD, p=0.009), and requirement for hemodialysis on day 21 of MV (57,864 USD vs. 33,509 USD, p<0.001). As the number of these three components increased, a positive correlation was found betweeen medical costs and ICU stay based on the Pearson's correlation coefficient (γ) (γ=0.367, p<0.001).@*CONCLUSION@#The ProVent model can be used to predict high medical costs in PMV patients during ICU stay. The highest medical costs were for patients who required hemodialysis on day 21 of MV.

Testosterone and Sarcopenia

Aging affects metabolism, leading to physiological and functional impairments, and is also related to changes in body composition, including reduced skeletal muscle mass and increased body fat. These changes are correlated with the pathophysiology of sarcopenia, which is defined as age-related loss of skeletal muscle mass and strength. Low testosterone levels are associated with unfavorable body composition changes, and sex hormones decrease with aging. Androgen deficiency, along with lack of exercise and poor nutrition, may be among the modifiable contributors to sarcopenia. Testosterone treatment has been reported to have beneficial effects on muscle mass and function, but the results have been inconsistent. Here, we discuss the correlation between testosterone and muscle mass and function, the impact of testosterone on sarcopenia, and the probable mechanisms underlying these effects.

Amount of Weight-Bearing During Tilt Table Inclination, With Neutral and Unilateral Knee Flexion Postures

OBJECTIVE: To analyze the amount of weight-bearing during tilt table increments, with a review of neutral and unilateral knee flexion postures. METHODS: There were 17 healthy participants enrolled in this study. The subjects were tilted from 10° to 90°, and their body weight was measured at each 10° increment. In the first test, both plantar pressures, with the subjects in neutral posture, were recorded. During the second and third tests, the angle of inclination was thus recorded and increased, with the subjects in unilateral knee flexion posture; flexion was maintained at 25° by attaching a cylindrical support to the tilt table at the level of the popliteal fossa. RESULTS: The study was divided into two types of postures: neutral and unilateral knee flexion. The percentage of body weight (%BW) between each leg during neutral posture was noted as not being statistically significant. The %BW of one side during tilt table inclination was significantly different between the two postures at 10° to 80° (p < 0.05). The weight during unilateral knee flexion posture was lower as analyzed, regardless of tilt table inclination compared with that in neutral posture. We note that fifty percent of the ratio of %BW was noted at 33.12° and 38.76° in neutral and flexion postures, respectively. CONCLUSION: The unilateral knee flexion could induce the effect of decreased body weight compared with non-flexion side. The results of this study will help in setting a safe and quantitative percentage of weight-bearing on the lower extremity during tilt training.

Successful Management of Acquired Tracheomalacia of Patients With Amyotrophic Lateral Sclerosis: A Report of Three Cases

Tracheomalacia is characterized by weakness of the tracheal walls and supporting cartilage. It results in dynamic compression of the airway, where the cross-sectional area of the trachea is reduced by expiratory compression. Acquired tracheomalacia results from complications associated with the use of endotracheal or tracheostomy tubes. In this report, we present three cases of patients with amyotrophic lateral sclerosis (ALS) successfully treated for tracheomalacia, including one case where the patient underwent surgery for combined tracheoesophageal fistula. We discuss the appropriate management strategies for tracheomalacia in patients with ALS. Through these case reports, we note the results of ALS patients who will have tracheostomy, and who are therefore at risk of sustaining a long term high cuff pressure, this study provides an evaluation for tracheomalacia and therapeutic management which should be considered for improving patient care outcomes.

An Autopsy Confirmed Case of Semantic Variant Primary Progressive Aphasia with Frontotemporal Lobar Degeneration-TDP type C

A 62-year-old man presented with a one-year history of word finding difficulty, impaired single word comprehension and personality changes including aggression, apathy and eating change. Brain MRIs showed severe atrophy in the left anterior temporal lobe. The clinical syndromic diagnosis was semantic variant primary progressive aphasia. He died at age 70 of pneumonia. At autopsy, transactive response DNA-binding protein (TDP) immunoreactive long dystrophic neurites were predominantly found in the cerebral cortices, which were compatible with frontotemporal lobar degeneration-TDP type C pathology.

Maximal Inspiratory Pressure and Maximal Expiratory Pressure in Healthy Korean Children

OBJECTIVE: To evaluate respiratory muscle strength in healthy Korean children in order to establish the criteria for normal reference values for future applications. In contrast with the other parameters for testing pulmonary function, normal values for respiratory muscle strength in healthy Korean children have not been assessed to date. METHODS: We conducted a complete survey of 263 students at Sinmyung Elementary School in Yangsan, Gyeongsangnam-do, and measured their height and body weight, performed pulmonary function tests, and evaluated maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) as measures of respiratory muscle strength. We excluded the subjects with respiratory or cardiovascular diseases that could affect the results. The subjects were children aged 8–12 years, and they consisted of 124 boys and 139 girls. RESULTS: The MIP and MEP values (mean±standard deviation) for the entire subject group were 48.46±18.1 cmH₂O and 47.95±16 cmH₂O, respectively. Boys showed higher mean values for MIP and MEP in every age group. Korean children showed lower mean values for MIP and MEP compared to those in previous studies conducted in other countries (Brazil and USA). CONCLUSION: Our results showed that boys generally have greater respiratory muscle strength than girls. We found a significant difference between the results of our study and those of previous studies from other countries. We speculate that this may be attributed to differences in ethnicity, nutrition, or daily activities.

Analysis of Pulmonary Function Test in Korean Patients With Duchenne Muscular Dystrophy: Comparison of Foreign and Korean Reference Data

OBJECTIVE: To determine the abnormal pulmonary function value in Korean Duchenne muscular dystrophy (DMD) patients, we performed a comparative analysis of the patients' pulmonary function value expressed as % of the overseas reference data and Korean healthy children and adolescent reference data. METHODS: We performed pulmonary function test (PFT) in a total of 27 DMD patients. We compared the patients' FVC% and FEV1% of the overseas reference data with those of the Korean children and adolescent reference data. Also, we compared the patients' MIP% and MEP% of the prediction equation data with those of the Korean children and adolescent reference data. RESULTS: Age of the subjects ranged from 8 to 16 years (12.03±2.27 years). The mean maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP), vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and peak cough flow (PCF) were 36.93±9.5 cmH₂O, 45.79±17.46 cmH₂O, 1.4±0.43 L, 1.45±0.45 L, 1.40±0.41 L, and 206.25±61.21 L/min, respectively. The MIP%, MEP%, and FVC% of the Korean children and adolescent reference data showed statistically significant higher values than those of the prediction equation data. CONCLUSION: We observed a clear numeric difference between Korean DMD patients' pulmonary function value expressed as % of the overseas data and inland data. To perform a precise assessment of respiratory function and to determine appropriate respiratory therapy, pulmonary function values of Korean DMD patients should be interpreted taking into account the inland normal pulmonary function test data.

Correction: Physiological Responses During the Lower Body Positive Pressure Supported Treadmill Test

We found an error of funding acknowledgment in this article.