Efficacy of Oxygen Treatment Using Home Oxygen Concentrators for the Treatment of Cluster Headaches: A Randomized, Crossover, Multicenter Study

Background@#and Purpose Oxygen treatment is the first-line acute treatment for cluster headaches (CHs), but this can be impeded by insurance coverage and oxygen-tank maintenance. Oxygen concentrators filter nitrogen from ambient air to produce oxygen-rich gas, and can therefore be an alternative to conventional oxygen therapy using a tank. We investigated the effectiveness and safety of using two home oxygen concentrators and compared them with using oral zolmitriptan for the acute treatment of CHs. @*Methods@#Forty patients with episodic CHs in an active cluster period were enrolled in this randomized, crossover, multicenter study. Two attacks during the cluster period were treated using oxygen delivered by connecting two home oxygen concentrators, whereas the other two attacks were treated using oral zolmitriptan (5 mg) in a random sequence. The primary endpoint was substantial pain reduction (0 or 1 on a five-point rating scale from 0 to 4 points) at 15 min after treatment. @*Results@#In total, 125 attacks among 32 patients were randomized and treated (63 attacks using oxygen and 62 using zolmitriptan) according to the study protocol. More attacks treated using oxygen reached the primary endpoint than did those treated using zolmitriptan (31.7% [20/63] vs. 12.9% [8/62], p=0.013). After 30 min, 57.1% of the patients who received oxygen and 38.7% who received zolmitriptan reported pain relief (p=0.082). All patients treated using oxygen reported an improvement in pain, and 61.3% preferred oxygen while only 9.7% preferred zolmitriptan. No adverse events occurred during the oxygen treatment. @*Conclusions@#Oxygen treatment administered using two home oxygen concentrators resulted in better pain relief than oral zolmitriptan in patients with episodic CHs. Our results suggest that home oxygen concentrators are capable of efficiently supplying oxygen in a similar manner to using an oxygen tank.

Brain Frailty and Outcomes of Acute Minor Ischemic Stroke With Large-Vessel Occlusion

Background@#and Purpose The influence of imaging features of brain frailty on outcomes were investigated in acute ischemic stroke patients with minor symptoms and large-vessel occlusion (LVO). @*Methods@#This was a retrospective analysis of a prospective, multicenter, nationwide registry of consecutive patients with acute (within 24 h) minor (National Institutes of Health Stroke Scale score=0–5) ischemic stroke with anterior circulation LVO (acute minor LVO). Brain frailty was stratified according to the presence of an advanced white-matter hyperintensity (WMH) (Fazekas grade 2 or 3), silent/old brain infarct, or cerebral microbleeds. The primary outcome was a composite of stroke, myocardial infarction, and all-cause mortality within 1 year. @*Results@#In total, 1,067 patients (age=67.2±13.1 years [mean±SD], 61.3% males) were analyzed. The proportions of patients according to the numbers of brain frailty burdens were as follows: no burden in 49.2%, one burden in 30.0%, two burdens in 17.3%, and three burdens in 3.5%. In the Cox proportional-hazards analysis, the presence of more brain frailty burdens was associated with a higher risk of 1-year primary outcomes, but after adjusting for clinically relevant variables there were no significant associations between burdens of brain frailty and 1-year vascular outcomes. For individual components of brain frailty, an advanced WMH was independently associated with an increased risk of 1-year primary outcomes (adjusted hazard ratio [aHR]=1.33, 95% confidence interval [CI]=1.03–1.71) and stroke (aHR=1.32, 95% CI=1.00–1.75). @*Conclusions@#The baseline imaging markers of brain frailty were common in acute minor ischemic stroke patients with LVO. An advanced WMH was the only frailty marker associated with an increased risk of vascular events. Further research is needed into the association between brain frailty and prognosis in patients with acute minor LVO.

Safety and Efficacy of Intravenous Thrombolysis in the 3- to 4.5-hour Window in Acute Ischemic Stroke Patients Who Have Both Diabetes Mellitus and History of Prior Stroke

Background@#For acute ischemic stroke (AIS) patients with history of prior stroke (PS) and diabetes mellitus (DM), intravenous recombinant tissue plasminogen activator (IV-tPA) therapy in the 3- to 4.5-hour window is off-label in Korea. This study aimed to assess the safety and efficacy of IV-tPA in these patients. @*Methods@#Using data from a prospective multicenter stroke registry between January 2009 and March 2021, we identified AIS patients who received IV-tPA in the 3- to 4.5-hour window, and compared the outcomes of symptomatic intracranial hemorrhage (SICH), 3-month mortality, 3-month modified Rankin Scale (mRS) score 0-1 and 3-month mRS distribution between patients with both PS and DM (PS/DM, n=56) versus those with neither PS nor DM, or with only one (non-PS/DM, n=927). @*Results@#The PS/DM group versus the non-PS/DM group was more likely to have a prior disability, hypertension, hyperlipidemia, coronary heart disease and less likely to have atrial fibrillation. The PS/DM and the non-PS/DM groups had comparable rates of SICH (0% vs. 1.7%; p>0.999) and 3-month mortality (10.7% vs. 10.2%; p=0.9112). The rate of 3-month mRS 0-1 was non-significantly lower in the PS/DM group than in the non-PS/DM group (30.4% vs. 40.7%; adjusted odds ratio [95% confidence interval], 0.81 [0.41-1.59]). @*Conclusions@#In the 3- to 4.5-hour window, AIS patients with PS/DM, as compared to those with non-PS/DM, might benefit less from IV-tPA. However, given the similar risks of SICH and mortality, IV-tPA in the late time window could be considered in patients with both PS and DM.

A Huge Radiation-Induced Cavernous Hemangioma Following Stereotactic Radiosurgery for Meningioma: A Case Report

Radiation-induced cavernous hemangiomas (RICHs) have been increasingly reported as a late complication after conventional radiotherapy. RICH after stereotactic radiosurgery (SRS) is extremely rare and the few cases have been reported to demonstrate their properties. A 72-year-old female patient presented with progressive neurologic deficits. She underwent tumor surgery for meningioma 13 years ago and two times of SRS for treating a residual tumor. Newly-developed mass was 4.3 cm-sized heterogeneously enhancing mass with severe cerebral edema. She underwent surgical resection and the histologic examinations revealed organized hematoma. Finally, it was diagnosed as a RICH following SRS based on radiological and histological findings and a history of multiple radiosurgeries. Clinical, radiological, and histological features of a RICH following SRS were discussed in this report.

Reperfusion therapy in acute ischemic stroke

Until mid-2010, intravenous thrombolysis remains the only reperfusion therapy for acute ischemic stroke. In 2015, the five pivotal endovascular recanalization therapy (ERT) trials demonstrated that ERT improved the prognosis of acute ischemic stroke with large artery occlusion within 6 hours after onset. Currently, ERT has been established as a crucial acute ischemic stroke treatment option. The prognosis of acute ischemic stroke is known to be time-dependent. Several studies addressed that ERT expands the time window for reperfusion therapy; thereby, improving prognosis.Current Concepts: Recent randomized clinical trials revealed that ERT improved the outcome in patients even within the late time window of up to 24 hours of stroke onset. The trials enrolled participants who had target mismatch, defined as either clinical-core or perfusion-core mismatch, which prompted an update of the national guidelines in several countries. To select the patients with stroke who were eligible for ERT, advanced imaging tools could be recommended.Discussion and Conclusion: According to the updated ERT guidelines, stroke centers were recommended to establish an appropriate imaging protocol and strategy for patients with acute ischemic stroke who were within the late time window. Additionally, if ERT is further practiced nationally, more manpower and infrastructure for patients with stroke should be supported at the stroke center.

Cerebral Venous Thrombosis without Thrombocytopenia after COVID-19 Vaccination

Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular attack and its predisposing factors commonly co-exist. In the coronavirus disease 2019 (COVID-19) era, various side effects of COVID-19 vaccine have been reported, and CVT is one of the well-known types. It is usually explained as prothrombotic immune thrombocytopenia by an antibody binding to platelet factor 4 receptor. However, some cases are irrelevant to thrombocytopenia and calls for a new explanation. Here we report a case of CVT without thrombocytopenia after COVID-19 vaccination.

Comparing the cut score for the borderline group method and borderline regression method with norm-referenced standard setting in an objective structured clinical examination in medical school in Korea / 보건의료교육평가

Purpose@#Setting standards is critical in health professions. However, appropriate standard setting methods do not always apply to the set cut score in performance assessment. The aim of this study was to compare the cut score when the standard setting is changed from the norm-referenced method to the borderline group method (BGM) and borderline regression method (BRM) in an objective structured clinical examination (OSCE) in medical school. @*Methods@#This was an explorative study to model the implementation of the BGM and BRM. A total of 107 fourth-year medical students attended the OSCE at 7 stations for encountering standardized patients (SPs) and at 1 station for performing skills on a manikin on July 15th, 2021. Thirty-two physician examiners evaluated the performance by completing a checklist and global rating scales. @*Results@#The cut score of the norm-referenced method was lower than that of the BGM (P<0.01) and BRM (P<0.02). There was no significant difference in the cut score between the BGM and BRM (P=0.40). The station with the highest standard deviation and the highest proportion of the borderline group showed the largest cut score difference in standard setting methods. @*Conclusion@#Prefixed cut scores by the norm-referenced method without considering station contents or examinee performance can vary due to station difficulty and content, affecting the appropriateness of standard setting decisions. If there is an adequate consensus on the criteria for the borderline group, standard setting with the BRM could be applied as a practical and defensible method to determine the cut score for OSCE.

Comparing the cut score for the borderline group method and borderline regression method with norm-referenced standard setting in an objective structured clinical examination in medical school in Korea / 보건의료교육평가

Purpose@#Setting standards is critical in health professions. However, appropriate standard setting methods do not always apply to the set cut score in performance assessment. The aim of this study was to compare the cut score when the standard setting is changed from the norm-referenced method to the borderline group method (BGM) and borderline regression method (BRM) in an objective structured clinical examination (OSCE) in medical school. @*Methods@#This was an explorative study to model the implementation of the BGM and BRM. A total of 107 fourth-year medical students attended the OSCE at 7 stations for encountering standardized patients (SPs) and at 1 station for performing skills on a manikin on July 15th, 2021. Thirty-two physician examiners evaluated the performance by completing a checklist and global rating scales. @*Results@#The cut score of the norm-referenced method was lower than that of the BGM (P<0.01) and BRM (P<0.02). There was no significant difference in the cut score between the BGM and BRM (P=0.40). The station with the highest standard deviation and the highest proportion of the borderline group showed the largest cut score difference in standard setting methods. @*Conclusion@#Prefixed cut scores by the norm-referenced method without considering station contents or examinee performance can vary due to station difficulty and content, affecting the appropriateness of standard setting decisions. If there is an adequate consensus on the criteria for the borderline group, standard setting with the BRM could be applied as a practical and defensible method to determine the cut score for OSCE.

Exploring medical educators’ readiness and the priority of their educational needs for online teaching / 한국의학교육

Purpose@#This study investigated medical educators’ readiness for online teaching by exploring their perceived ability and importance of online teaching competencies and identified the highest priority of their educational needs. @*Methods@#In this study, 144 medical education faculty members from a university were invited to participate. The faculty online teaching readiness scale was virtually distributed at the end of the spring semester of 2020 and 38 faculty members responded for 2 weeks. The collected data were analyzed with descriptive statistics, paired t-tests, Borich Needs Assessment, and the Locus for Focus model. @*Results@#The overall average perceived ability was 2.76, while the overall average perceived importance was 3.36. The course design and the technical competency categories showed the highest and lowest educational needs, respectively. Five competencies were given the highest priority of educational needs. @*Conclusion@#The results revealed that the medical educators are not ready for online teaching; thus, urgent educational needs for online teaching competencies exist.

Clinical performance of medical students in Korea in a whole-task emergency station in the objective structured clinical examination with a standardized patient complaining of palpitations / 보건의료교육평가

This study assessed the clinical performance of 150 third-year medicalstudents in Busan, Korea in a whole-task emergency objective structured clinical examination station that simulated a patient with palpitations visiting the emergency department. The examination was conducted from November 25 to 27, 2019. Clinical performance was assessed as the number and percentage of students who performed history-taking (HT), a physical examination (PE), an electrocardiography (ECG) study, patient education (Ed), and clinical reasoning (CR), which were items on the checklist. It was found that 18.0% of students checked the patient’s pulse, 51.3% completed an ECG study, and 57.9% explained the results to the patient. A sizable proportion (38.0%) of students did not even attempt an ECG study. In a whole-task emergency station, students showed good performance on HT and CR, but unsatisfactory results for PE, ECG study, and Ed. Clinical skills educational programs for subjected student should focus more on PE, timely diagnostic tests, and sufficient Ed.

Associations between Physical Activity Level and Metabolic Risk Factors in Gynecological Cancer Survivors / 대한스포츠의학회지

Purpose@#This study aimed to investigate the associations between physical activity (PA), health-related fitness, and metabolic risk factors in Korean gynecological cancer survivors using propensity score matching. @*Methods@#A cross-sectional analysis was performed using national representative data between 2015 and 2018 from the Korea National Health and Nutrition Examination Survey (KNHANES VI3 and VI1–3). PA was self-reported through the global PA questionnaire, and health-related fitness was measured using handgrip strength and resting heart rate. Metabolic risk factors were measured by performing blood analyses, including fasting glucose, total cholesterol, and triglyceride levels, and blood pressure. @*Results@#The total number of subjects was 268 (gynecological cancer, n=134; non-cancer, n=134). The results showed that the gynecological cancer survivors (time since diagnosis, ＜5 years and ≥5 years) participated in less amounts of weekly total moderate-to-vigorous intensity PA (160.0±170.1 vs. 144.6±177.3 vs. 334.1±191.3 min/wk; p＜0.001), travel PA (94.5±119.3 vs. 109.4±143.9 vs. 215.7±170.7 min/wk; p＜0.001), and walking (190.7±174.5 vs. 258.8±280.8 vs. 444.5±434.7 min/wk; p＜0.001) than did the non-cancer population. Moreover, the gynecological cancer survivors who met the aerobic PA guidelines had significantly lower fasting glucose (p=0.035) and triacylglyceride levels (p=0.013), and systolic blood pressure (p=0.035) than the non-active participants. @*Conclusion@#The PA of the gynecological cancer survivors was lower than that of the general population. Aerobic PA was significantly associated with lower levels of metabolic disturbances in Korean gynecological cancer survivors.

lity and Acceptability of Prehabilitation before Surgery for Endometrial Cancer / 대한스포츠의학회지

Purpose@#To investigate the safety of and adherence to a prehabilitation program among patients with endometrial cancer and to provide preliminary evidence of the program’s efficacy in terms of health-related fitness (HRF) and patient-reported outcomes. @*Methods@#Nineteen patients with endometrial cancer were recruited in a 2-week trial for a one-on-one supervised exercise program. All patients participated in an individual exercise program—the Challenge, Overcome, Resolve, and Enhance (CORE) program—which consisted of 60 minutes of moderate-to-vigorous intensity resistance, core stability, and aerobic exercise, supervised five times within 2 weeks before surgery. @*Results@#Seventeen (89.5%) of the 19 participants completed the CORE program, and no adverse events occurred. All participants accomplished the daily mean step counts and sustained the prescribed target heart rate (reserve 50%–60%) during the CORE program sessions. Participants who completed the exercise program exhibited significantly improved HRF (cardiorespiratory fitness, 30-second chair stand, hand grip strength, curl-ups, sit and reach, single-leg standing with closed eyes; p＜0.001 for all) without changes in the body mass index (p=0.113). Their quality of life (general, p=0.001; function, p=0.001; symptom, p=0.003), symptom clusters (p=0.006), anxiety (p＜0.001), and depression (p＜0.001) were significantly improved. @*Conclusion@#The 2-week prehabilitation CORE program is safe and feasible for patients scheduled to undergo surgery for early-stage endometrial cancer and may improve their physical and psychological health status.

A Guillain-Barré Syndrome with Anti-GQ1b and Anti-GT1a Antibodies Positivity Manifesting with Acute Bulbar Palsy and Subsequent Delayed Ophthalmoplegia / 대한신경근육질환학회지

In Guillain-Barré syndrome (GBS) and its variant, anti-GQ1b antibody has a pathogenic role for ophthalmoplegia. In addition, anti-GT1a antibody is related with lower cranial nerve involvement. This report describes a 60-year-old male patient with GBS manifesting with initially isolated dysphagia and subsequently developed ophthalmoplegia. Both immunoglobulin G type anti-GQ1b and anti-GT1a antibodies were detected in the patient’s serum. A mechanism regarding subsequent involvement of respective cranial nerves remains to be elucidated.

Clinical performance of medical students in Korea in a whole-task emergency station in the objective structured clinical examination with a standardized patient complaining of palpitations / 보건의료교육평가

This study assessed the clinical performance of 150 third-year medicalstudents in Busan, Korea in a whole-task emergency objective structured clinical examination station that simulated a patient with palpitations visiting the emergency department. The examination was conducted from November 25 to 27, 2019. Clinical performance was assessed as the number and percentage of students who performed history-taking (HT), a physical examination (PE), an electrocardiography (ECG) study, patient education (Ed), and clinical reasoning (CR), which were items on the checklist. It was found that 18.0% of students checked the patient’s pulse, 51.3% completed an ECG study, and 57.9% explained the results to the patient. A sizable proportion (38.0%) of students did not even attempt an ECG study. In a whole-task emergency station, students showed good performance on HT and CR, but unsatisfactory results for PE, ECG study, and Ed. Clinical skills educational programs for subjected student should focus more on PE, timely diagnostic tests, and sufficient Ed.

A Guillain-Barré Syndrome with Anti-GQ1b and Anti-GT1a Antibodies Positivity Manifesting with Acute Bulbar Palsy and Subsequent Delayed Ophthalmoplegia / 대한신경근육질환학회지

In Guillain-Barré syndrome (GBS) and its variant, anti-GQ1b antibody has a pathogenic role for ophthalmoplegia. In addition, anti-GT1a antibody is related with lower cranial nerve involvement. This report describes a 60-year-old male patient with GBS manifesting with initially isolated dysphagia and subsequently developed ophthalmoplegia. Both immunoglobulin G type anti-GQ1b and anti-GT1a antibodies were detected in the patient’s serum. A mechanism regarding subsequent involvement of respective cranial nerves remains to be elucidated.

In-Hospital and Post-Discharge Recovery after Acute Ischemic Stroke: a Nationwide Multicenter Stroke Registry-base Study

BACKGROUND: Using data from a large national stroke registry, we aimed to investigate the incidence and determinants of in-hospital and post-discharge recovery after acute ischemic stroke and the independence of their occurrence. METHODS: In-hospital recovery was defined as an improvement of 4 points or > 40% in the National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge. Post-discharge recovery was defined as any improvement in the modified Rankin Scale (mRS) score from discharge to 3 months after stroke onset. Two analytic methods (multivariate and multivariable logistic regression) were applied to compare the effects of 18 known determinants of 3-month outcome and to verify whether in-hospital and post-discharge recovery occur independently. RESULTS: During 54 months, 11,088 patients with acute ischemic stroke meeting the eligibility criteria were identified. In-hospital and post-discharge recovery occurred in 36% and 33% of patients, respectively. Multivariate logistic regression with an equality test for odds ratios showed that 7 determinants (age, onset-to-admission time, NIHSS score at admission, blood glucose at admission, systolic blood pressure, smoking, recanalization therapy) had a differential effect on in-hospital and post-discharge recovery in the way of the opposite direction or of the same direction with different degree (all P values < 0.05). Both in-hospital and post-discharge recovery occurred in 12% of the study population and neither of them in 43%. The incidence of post-discharge recovery in those with in-hospital recovery was similar to that in those without (33.8% vs. 32.7%, respectively), but multivariable analysis showed that these 2 types of recovery occurred independently. CONCLUSION: Our findings suggest that, in patients with acute ischemic stroke, in-hospital and post-discharge recovery may occur independently and largely in response to different factors.

Executive Summary of Stroke Statistics in Korea 2018: A Report from the Epidemiology Research Council of the Korean Stroke Society / 대한뇌졸중학회지

Despite the great socioeconomic burden of stroke, there have been few reports of stroke statistics in Korea. In this scenario, the Epidemiologic Research Council of the Korean Stroke Society launched the “Stroke Statistics in Korea” project, aimed at writing a contemporary, comprehensive, and representative report on stroke epidemiology in Korea. This report contains general statistics of stroke, prevalence of behavioral and vascular risk factors, stroke characteristics, pre-hospital system of care, hospital management, quality of stroke care, and outcomes. In this report, we analyzed the most up-to-date and nationally representative databases, rather than performing a systematic review of existing evidence. In summary, one in 40 adults are patients with stroke and 232 subjects per 100,000 experience a stroke event every year. Among the 100 patients with stroke in 2014, 76 had ischemic stroke, 15 had intracerebral hemorrhage, and nine had subarachnoid hemorrhage. Stroke mortality is gradually declining, but it remains as high as 30 deaths per 100,000 individuals, with regional disparities. As for stroke risk factors, the prevalence of smoking is decreasing in men but not in women, and the prevalence of alcohol drinking is increasing in women but not in men. Population-attributable risk factors vary with age. Smoking plays a role in young-aged individuals, hypertension and diabetes in middle-aged individuals, and atrial fibrillation in the elderly. About four out of 10 hospitalized patients with stroke are visiting an emergency room within 3 hours of symptom onset, and only half use an ambulance. Regarding acute management, the proportion of patients with ischemic stroke receiving intravenous thrombolysis and endovascular treatment was 10.7% and 3.6%, respectively. Decompressive surgery was performed in 1.4% of patients with ischemic stroke and in 28.1% of those with intracerebral hemorrhage. The cumulative incidence of bleeding and fracture at 1 year after stroke was 8.9% and 4.7%, respectively. The direct costs of stroke were about ₩1.68 trillion (KRW), of which ₩1.11 trillion were for ischemic stroke and ₩540 billion for hemorrhagic stroke. The great burden of stroke in Korea can be reduced through more concentrated efforts to control major attributable risk factors for age and sex, reorganize emergency medical service systems to give patients with stroke more opportunities for reperfusion therapy, disseminate stroke unit care, and reduce regional disparities. We hope that this report can contribute to achieving these tasks.

Cefepime Induced Encephalopathy Mimicking Acute Stroke

Cefepime is a fourth-generation cephalosporin, developed in 1994, and is well known for its adverse effects. In 2002, the Food and Drug Administration adjusted the labeling to account for increased risk of seizures, encephalopathy and myoclonus, especially in the setting of renal impairment. Here we present a case of an 86-year-old female, undergoing Cefepime treatment, with encephalopathy mimicking acute stroke.

Complete Sequence of the Mitochondrial Genome of Spirometra ranarum: Comparison with S. erinaceieuropaei and S. decipiens

This study was undertaken to determine the complete mitochondrial DNA sequence and structure of the mitochondrial genome of Spirometra ranarum, and to compare it with those of S. erinaceieuropaei and S. decipiens. The aim of this study was to provide information of the species level taxonomy of Spirometra spp. using the mitochondrial genomes of 3 Spirometra tapeworms. The S. ranarum isolate originated from Myanmar. The mitochondrial genome sequence of S. ranarum was compared with that of S. erinaceieuropaei (GenBank no. KJ599680) and S. decipiens (Gen-Bank no. KJ599679). The complete mtDNA sequence of S. ranarum comprised 13,644 bp. The S. ranarum mt genome contained 36 genes comprising 12 protein-coding genes, 22 tRNAs and 2 rRNAs. The mt genome lacked the atp8 gene, as found for other cestodes. All genes in the S. ranarum mitochondrial genome are transcribed in the same direction and arranged in the same relative position with respect to gene loci as found for S. erinaceieuropaei and S. decipiens mt genomes. The overall nucleotide sequence divergence of 12 protein-coding genes between S. ranarum and S. decipiens differed by 1.5%, and 100% sequence similarity was found in the cox2 and nad6 genes, while the DNA sequence divergence of the cox1, nad1, and nad4 genes of S. ranarum and S. decipiens was 2.2%, 2.1%, and 2.6%, respectively.

Reversible Cerebral Vasoconstriction Syndrome with Concurrent Anterior Cerebral Artery Dissection

The pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS) is not known but coexisting vascular lesion, such as carotid artery and vertebral artery dissection, has been reported. However, RCVS concurrent with anterior cerebral artery dissection has never been reported. We describe a 28-year old patient presenting with anterior cerebral artery dissection with RCVS associated with coughing. This case could support the causality between RCVS and arterial dissection.