A multicenter study of altered level of consciousness in the emergency room

New-onset altered level of consciousness (ALC) is a challenge in real-world clinical practice. Although its presentation is nonspecific and its etiology is intricate, the term ALC is frequently used in the emergency room (ER). This study aimed to clarify and classify the etiologies and outcomes of the ALC in the ER. We retrospectively investigated ALC patients in the ER of four tertiary referral centers from February 2018 to January 2020. The etiology of ALC was comprehensively analyzed by a consortium of university professors, board-certified clinicians in neurology, emergency medicine, or internal medicine. The time point to determine the etiology of ALC was at the time of discharge from the ER. A total of 315,526 patients who visited ER due to ALC were reviewed and found 7988 eligible patients, of which 4298 (53.8%) were male and 5282 (66.1%) were older than 60. The overall mortality was 13.5%. Except undetermined, the 9 etiologies (n = 7552) were categorized into extra- (n = 4768, 63.1%) or intracranial etiology (n = 2784, 36.9%). The most common etiology of ALC in the ER was metabolic cause (n = 1972, 24.7%), followed by systemic infection (n = 1378, 17.3%). The majority of ALC in the ER was derived from extracranial etiology. ALC in the ER is a neurological manifestation of diverse etiologies; not all can be confirmed in the ER. Not only neurological but also critical systemic illnesses should be considered to assess the protean manifestations of ALC in the ER.

Alterations of Functional Connectivity in Patients With Restless Legs Syndrome

Restless legs syndrome (RLS) is a common neurological illness marked by a strong desire to move one’s legs, usually in association with uncomfortable sensations. Recent studies have investigated brain networks and connectivity in RLS. The advent of network analysis has greatly improved our understanding of the brain and various neurological disorders. A few studies have investigated alterations in functional connectivity in patients with RLS. This article reviews functional connectivity studies of patients with RLS, which have identified significant alterations relative to healthy controls in several brain networks including thalamic, salience, default-mode, and small-world networks. In addition, network changes related to RLS treatment have been found, including to repetitive transcranial magnetic stimulation, transcutaneous spinal cord direct-current stimulation, and dopaminergic drugs. These findings suggest that the underlying pathogenesis of RLS includes alterations in the functional connectivity in the brain and that RLS is a network disorder.

Diagnostic Delay and Its Predictors in Cluster Headache

Objective

Cluster headache (CH) is a rare, primary headache disorder, characterized of excruciating, strictly one-sided pain attacks and ipsilateral cranial autonomic symptoms. Given the debilitating nature of CH, delayed diagnosis can increase the disease burden. Thus, we aimed to investigate the diagnostic delay, its predictors, and clinical influence among patients with CH.

Methods

Data from a prospective multicenter CH registry over a 4-year period were analyzed. CH was diagnosed according to the International Classification of Headache Disorders (ICHD)-3 criteria, and diagnostic delay of CH was assessed as the time interval between the year of the first onset and the year of CH diagnosis. Patients were classified into three groups according to the tertiles of diagnostic delay (1st tertile, <1 year; 2nd tertile, 1–6 years; and 3rd tertile, ≥7 years).

Results

Overall, 445 patients were evaluated. The mean duration of diagnosis delay was 5.7 ± 6.7 years, (range, 0–36 years). Regarding the age of onset, majority of young patients (age <20 years) belonged to the third tertile (60%), whereas minority of old patients (>40 years) belonged to the third tertile (9.0%). For year of onset, the proportion of patients in the 3rd tertile was the highest for the groups before the publication year of the ICHD-2 (74.7%) and the lowest for the groups after the publication year of the ICHD-3 beta version (0.5%). Compared with the first CH, episodic CH [multivariable-adjusted odds ratio (aOR) = 5.91, 95% CI = 2.42–14.48], chronic CH (aOR = 8.87, 95% CI = 2.66–29.51), and probable CH (aOR = 4.12, 95% CI = 1.48–11.43) were associated with the tertiles of diagnostic delay. Age of onset (aOR = 0.97, 95% CI = 0.95–0.99) and PHQ-9 score (aOR = 0.96, 95% CI = 0.93–0.99) were inversely associated with the tertile of diagnostic delay. The prevalence of suicidal ideation was highest in the patients of the third tertile. The mean HIT-6 score increased significantly with the diagnostic delay (p = 0.041).

Conclusions

Patients with a younger onset of CH have a higher risk of diagnostic delay. Nevertheless, the rate of delayed diagnosis gradually improved over time and with the publication of the ICHD criteria, supporting the clinical significance of diagnostic clinical criteria and headache education to reduce the disease burden of CH.

Sex differences in seizure effects on social anxiety in persons with epilepsy

PURPOSE

We investigated sex differences in the effect of seizures on social anxiety in persons with epilepsy.

METHOD

In this cross-sectional multicenter study, social anxiety was measured using the short forms of the Social Phobia Scale (SPS-6) and Social Interaction Anxiety Scale (SIAS-6). SPS-6 scores ≥ 9 and SIAS-6 scores ≥ 12 were considered to indicate social phobia and social interaction anxiety, respectively. The Patient Health Questionnaire-9, Stigma Scale-Revised, and Family Adaptation-Partnership-Growth-Affection-Resolve scale were also completed. A logistic regression analysis with an interaction term was used to analyze the data.

RESULTS

Out of 285 participants, a SPS-6 score ≥ 9 and a SIAS-6 score ≥ 12 were noted in 62 (21.8%) and 36 (12.6%) of participants, respectively. There was no difference in the prevalence of social anxiety between men and women. Intractable seizures and lack of seizure freedom were associated with a SPS-6 score ≥ 9 and a SIAS-6 score ≥ 12, but statistical significance was lost in the adjusted models. However, intractable seizures and lack of seizure freedom significantly interacted with sex for a SPS-6 score ≥ 9 (p = 0.018) and a SIAS-6 score ≥ 12 (p = 0.048) in both the separate and adjusted models. Specifically, intractable seizures tended to be positively associated with SPS-6 scores ≥ 9 than non-intractable seizures in men only (odds ratio = 2.602, p = 0.068), whereas lack of seizure freedom tended to be negatively associated with SIAS-6 scores ≥ 12 than seizure freedom in women only (odds ratio = 4.804, p = 0.053).

CONCLUSION

We found significant sex differences in seizure effects on social anxiety. Intractable seizures were associated with social phobia in men, whereas lack of seizure freedom in the last year was associated with social interaction anxiety in women.

Survey on Antiepileptic Drug Therapy in Patients with Drug Resistant Epilepsy

Background and Purpose

Individualized anti-epileptic drug (AED) selection in patient with epilepsy is crucial. However, there is no unified opinion in treating patients with drug resistant epilepsy (DRE). This survey aimed to make a consolidate consensus with epileptologists’ perspectives of the treatment for Korean DRE patients by survey responses.

Methods

The survey was conducted with Korean epilepsy experts who have experience prescribing AEDs via e-mail. Survey questionnaires consisted of six items regarding prescription patterns and practical questions in treating patients with DRE in Korea. The research period was from February 2021 to March 2021.

Results

The survey response rate was 83.3% (90/108). Most (77.8%) of the responders are neurologists. The proportion of patients whose seizures were not controlled by the second AED was 26.9%. The proportion of patients who had taken five or more AEDs is 13.9%, and those who are currently taking five or more AEDs are 7.3%, of which 54.5% and 37.9% reported positive effects on additional AED, respectively. The majority (91.1%) of respondents answered that the mechanism of action was the top priority factor when adding AED. Regarding data priority, responders considered that expert opinion should have the top priority, followed by clinical experiences, reimbursement guidelines and clinical evidence. Responders gave 64.9 points (range from 0 to 100) about overall satisfaction on reimbursement system of Health Insurance Review and Assessment Service for AED.

Conclusions

This study on AED therapy for DRE patients is the first nationwide trial in Korean epilepsy experts. In five drug failure, the top priorities on AED selection are mechanism of action and expert opinion. These findings might help to achieve consensus and recognize the insight on optimal therapy of AED in DRE.

Treatment of epilepsy in adults: Expert opinion in South Korea

OBJECTIVE

The aim of this study was to gather the expert opinions of Korean epileptologists regarding the treatment of adult patients with epilepsy.

METHODS

A total of 42 neurologists who specialized in epilepsy were surveyed. They completed an online questionnaire describing multiple patient scenarios. Using these scenarios, they evaluated treatment strategies and gave their preference for specific antiepileptic drugs (AEDs) used to treat genetically mediated generalized epilepsy and focal epilepsy.

RESULTS

Initial AED monotherapy, followed by a second form of alternative monotherapy or an add-on combination therapy, was the preferred treatment strategy. The experts reached consensus for 87.2% of the items. The most commonly selected AEDs for the initial monotherapy for patients with generalized epilepsy were levetiracetam or valproate. For those with focal epilepsy, levetiracetam, oxcarbazepine, or lamotrigine were the most popular selections. Ethosuximide was the treatment of choice only for patients with generalized epilepsy with prominent absence seizures. Levetiracetam was preferred as an add-on therapy for both generalized and focal epilepsy. For special populations of patients, such as elderly adults or those with comorbid diseases, levetiracetam or lamotrigine was selected as the treatment of choice.

CONCLUSION

Most of the survey results were in accordance with the US expert opinion survey published in 2016. This survey can assist clinicians in making clinical decisions when treating individual adult patients with epilepsy.

Does the new Korean term for epilepsy reduce the stigma for Korean adults with epilepsy?

PURPOSE

The purpose of this study was to evaluate differences in stigma, disclosure management of epilepsy, and knowledge about epilepsy between patients with epilepsy who recognized and did not recognize the new Korean term for epilepsy.

METHODS

This was a cross-sectional, multicenter study. The Stigma Scale-Revised, the Disclosure Management Scale, the Patient Health Questionnaire-9, and a questionnaire assessing knowledge about epilepsy were used. The set of questionnaires had two versions, using either the old or new name for epilepsy. Multivariate logistic regression analyses were used.

RESULTS

A total of 341 patients with epilepsy and 509 family members were recruited. Approximately 62% of patients felt some degree of epilepsy-related stigma. Mild stigma, severe concealment of epilepsy diagnosis, and increased knowledge about epilepsy were independently identified as factors associated with recognition of the new term in patients. Recognition of the new term was more prevalent in patients and family members with higher education, female family members, and family members having patients with younger age at seizure onset and shorter duration of epilepsy. There were no significant differences between the two types of questionnaires. About 81% of patients and 93% of family members had a positive attitude about renaming epilepsy.

CONCLUSION

The use of the new Korean term for epilepsy (cerebroelectric disorder) increased knowledge about epilepsy but did not reduce stigma and concealment of epilepsy diagnosis in Korean adults with epilepsy. Higher education may be an important factor for knowing the new term in patients and family members.

Factors associated with social anxiety in South Korean adults with epilepsy

PURPOSE

The aim of this study was to examine social anxiety in South Korean adults with epilepsy and to identify associated factors.

METHOD

This was a cross-sectional, multicenter study in South Korea. Social anxiety was assessed using short forms of the Social Phobia Scale (SPS-6) and Social Interaction Anxiety Scale (SIAS-6). The SPS-6 scores ≥9 and SIAS-6 scores ≥12 were considered indicative of social phobia and social interaction anxiety, respectively. The Patient Health Questionnaire-9 (PHQ-9); Stigma Scale-Revised (SS-R); Disclosure Management Scale; Family Adaptation, Partnership, Growth, Affection, Resolve (F-APGAR) scale; and a questionnaire assessing knowledge about epilepsy were also used.

RESULTS

Of a total of 219 patients with epilepsy, 21% and 11% had SPS-6 scores ≥9 and SIAS-6 scores ≥12, respectively. In logistic regression analysis, SPS-6 scores ≥9 were independently associated with SS-R scores of 4-9 (odds ratio [OR]: 8.626, 95% confidence interval [CI]: 2.515-29.587, p = .001), SS-R scores 1-3 (OR: 5.496, 95% CI: 1.757-17.197, p = .003), and PHQ-9 scores ≥10 (OR: 4.092, 95% CI: 1.823-9.185, p = .001). In contrast, SIAS-6 scores ≥12 were related only to PHQ-9 scores ≥10 (OR: 8.740, 95% CI: 3.237-23.599, p < .001). Belonging to a dysfunctional family and lack of knowledge about epilepsy tended to be associated with social phobia (p = .071) and social interaction anxiety (p = .090), respectively. Epilepsy-related variables were not related to social anxiety.

CONCLUSION

Social anxiety is not rare in patients with epilepsy. In this study, social phobia was associated with perceived stigma and depressive symptoms, whereas social interaction anxiety was related only to depressive symptoms in patients with epilepsy.

Suicidality and its risk factors in tension-type headache patients: A multicenter case-control study

This study evaluated suicidality and its risk factors in patients with tension-type headache (TTH). We recruited new patients with TTH who visited general hospitals. We recorded their clinical characteristics and conducted the Headache Impact Test-6 (HIT-6) and the Insomnia Severity Index (ISI) for assessment. We also interviewed the patients to identify major depressive disorder (MDD), generalized anxiety disorder (GAD), and suicidality with the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI). The frequency of suicidality was compared between TTH patients and healthy controls. Major risk factors for suicidality were also determined. A total of 332 TTH patients with the same number of healthy controls were recruited from five general hospitals. Suicidality was observed in 82 (24.7%) TTH patients. The frequency of suicidality was significantly higher in patients with TTH than in the controls. Furthermore, the frequency of suicidality was higher in patients with chronic TTH (CTTH) than in the controls. The major risk factors for suicidality were MDD, GAD, a low education level, insomnia, chronicity of TTH, and pericranial tenderness. Suicidal ideation or attempt seems to be a common feature in TTH. Therefore, it is important to identify risk factors related to suicidality in TTH patients, which may help reduce suicidality.

Stress Is Associated with Poor Outcome of Acute Treatment for Chronic Migraine: A Multicenter Study

Background

Chronic migraine (CM) is associated with severe psychological symptoms and disabilities. Information on the relationship between stress and the outcomes of acute CM treatment is limited.

Methods

We evaluated the clinical presentation and stress levels of patients with CM who visited the neurology departments of 14 hospitals between September and December 2015. The patients were divided into stress and reference groups on the basis of the Korean version of the Brief Encounter Psychosocial Instrument (BEPSI-K). Quality of life was evaluated using EuroQol Five Dimension Questionnaire Three-Level. The Migraine Assessment of Current Therapy questionnaire was used to assess the outcomes of acute treatment.

Results

This study included 186 CM patients. On the basis of the BEPSI-K score, 79 and 107 patients were assigned to the stress and reference groups, respectively. The stress group had more patients with poor outcomes of acute treatment than the reference group (67.1% vs 40.2%, P < 0.001). In a multivariate analysis, female gender (odds ratio [OR] = 3.266, 95% confidence interval [CI] = 1.172-9.103, P = 0.024), the number of headache-free days per month (OR = 0.932, 95% CI = 0.883-0.985, P = 0.012), and BEPSI-K score (OR = 1.667, 95% CI = 1.051-2.643, P = 0.030) predicted poor outcomes of acute treatment.

Conclusions

High levels of stress were reported by 42.5% of patients with CM. The association between stress and the outcomes of acute treatment suggests that stress is an important clinical variable for improving the management of CM.

Aggression and its association with suicidality in migraine patients: a case-control study

Background

To identify aggression and its association with suicidality in migraine patients.

Methods

We enrolled 144 migraine patients who made their first visit to our headache clinic. We collected data regarding their clinical characteristics and the patients completes the Aggression Questionnaire (AQ) and other questionnaires. We also interviewed patients with the Mini International Neuropsychiatric Interview—Plus Version 5.0.0 (MINI) to identify their suicidality. The degree of aggression in migraine patients was compared to the degree of aggression in healthy controls. Major determinants for aggression and its association with suicidality were also examined.

Results

The overall AQ score and anger and hostility subscale scores were higher in migraine patients than controls. For migraine chronicity, patients with chronic migraine (CM) had a higher overall AQ score and physical aggression, anger, and hostility subscale scores than controls. On the other hand, all AQ scores in patients with episodic migraine were not different from the scores of the controls. Although several factors were associated with the overall AQ score, major determinants were anxiety (ß = 0.395, p < 0.001), headache intensity (ß = 0.180, p = 0.016), and CM (ß = − 0.165, p = 0.037). Patients who had suicidality based on the MINI showed a higher overall AQ score than patients without suicidality (p < 0.001).

Conclusions

Aggression is likely to be a common feature in CM. Comorbid aggression may help to identify suicidality in migraine patients.

Significance of fatigue in patients with migraine

Fatigue is often stated as a headache trigger or migraine-specific symptom. We investigated predictors of fatigue and its impact on quality of life (QOL) in patients with migraine. Patients with migraine were recruited from a headache clinic and completed psychosomatic instruments, including the 12-item Allodynia Symptom Checklist (ASC-12), the Migraine Disability Assessment Scale (MIDAS), the Patients Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7), the Epworth Sleepiness Scale (ESS), the Insomnia Severity Index (ISI), the Fatigue Severity Scale (FSS), and Migraine-Specific Quality of Life Questionnaire (MSQ). Two hundreds twenty-six patients with migraine were eligible for the study. Pathologic fatigue was manifested in 133 patients (58.8%). The FSS score was significantly associated with age, age of onset, the Visual Analog Scale (VAS) depicting headache intensity, photophobia, phonophobia, and the scores of the ASC-12, the MIDAS, the ESS, the ISI, the PHQ-9 and the GAD-7. The strongest predictor for the FSS was the PHQ-9 (β = 0.432, p < .001), followed by age (β = -0.169, p = .002), the ISI (β = 0.151, p = .016), and the VAS (β = 0.139, p = .018). There was an inverse correlation between the FSS score and three dimensional scores of the MSQ (p < .001). Appropriate interventions for depression, insomnia, and headache intensity are likely to lessen fatigue and improve QOL.

Validation of the Korean Migraine-Specific Quality of Life Questionnaire Version 2.1 in Episodic and Chronic Migraine

AIMS

To evaluate the validity of the Korean Migraine-Specific Quality of Life Questionnaire version 2.1 (K-MSQ v 2.1) in patients with episodic migraine (EM) or chronic migraine (CM).

METHODS

Subjects were recruited from a headache clinic and completed several self-report instruments, including the K-MSQ v 2.1, the Migraine Disability Assessment Scale (MIDAS), the Headache Impact Test-6 (HIT-6), the Migraine-Specific Quality of Life (MSQoL), the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7). Some of the subjects were assessed 4 weeks later and underwent the K-MSQ v 2.1 to examine test-retest reproducibility. Internal consistency and test-retest reproducibility were assessed to determine reliability. Construct validity was also assessed. Internal consistency (Cronbach's α) and test-retest reproducibility (intraclass correlation coefficients) were assessed to determine reliability. Pearson correlations were used to determine the validity.

RESULTS

For the 180 eligible patients, the value of Cronbach's α for the three dimensions of the K-MSQ v. 2.1 (Role Function-Restrictive, Role Function-Preventive, and Emotional Function) were 0.954, 0.909, and 0.898, respectively, indicating excellent internal consistency. The intraclass correlation coefficients between baseline and the 4-week retest showed reliable reproducibility. The scores of the three dimensions for the K-MSQ v. 2.1 were well correlated with scores for the MIDAS, the HIT-6, the MSQoL, the PHQ-9, and the GAD-7. Internal consistency and construct validity showed similar tendencies in patients with EM and those with CM.

CONCLUSION

The K-MSQ v 2.1 is a reliable and valid screening tool for evaluating QoL in patients with EM and CM.

Perceived stress in patients with migraine: a case-control study

Background

Perceived stress is the most common trigger for migraine. The objective of this study was to examine the clinical significance of perceived stress in migraine patients.

Methods

This is a case-control study. Consecutive migraine patients who visited a tertiary care hospital were enrolled for this study. They completed self-reported questionnaires including Perceived Stress Scale (PSS), 12-item Allodynia Symptom Checklist (ASC-12), Migraine Disability Assessment Scale (MIDAS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), and Migraine-Specific Quality of Life Questionnaire (MSQ). Degree of perceived stress in migraine patients was measured and compared to that in healthy controls. Predictors for perceived stress and their impact on quality of life (QOL) of migraine patients were also determined.

Results

A total of 227 migraine patients were eligible for this study, including 103 (45.4%) who had chronic migraine (CM). Mean PSS score was significantly (p < 0.05) higher in CM patients than that in controls after adjusting for education, depression, and anxiety. Although several factors were associated with PSS score, major predictors for PSS were GAD-7 score (β = 0.358, p < 0.001), PHQ-9 score (β = 0.304, p < 0.001), ISI score (β = 0.154, p = 0.005), and CM (β = −0.104, p = 0.027). There was an inverse relationship between PSS scores and three-dimensional scores of MSQ (p < 0.001).

Conclusions

Chronic migraine is a critical factor for perceived stress. Perceived stress affects QOL of migraine patients.

Validation of the Generalized Anxiety Disorder-7 (GAD-7) and GAD-2 in patients with migraine

Background

Psychiatric problems have been commonly reported in patients with migraine. This study investigated the reliability and validity of the Generalized Anxiety Disorder-7 (GAD-7) and Generalized Anxiety Disorder-2 (GAD-2) in patients with migraine.

Methods

Subjects were recruited from a headache clinic and a neuropsychologist examined their GAD using the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI). Subjects completed several instruments, including the GAD-7, the Beck Anxiety Inventory (BAI), the Migraine Disability Assessment Scale (MIDAS), the Headache Impact Test-6 (HIT-6), and the Migraine-Specific Quality of Life (MSQoL).

Results

Among 146 participants, 32 patients (21.9 %) had GAD as determined by the MINI. Cronbach’s α for the GAD-7 and GAD-2 were 0.915 and 0.820, respectively. At a cutoff score of 5, the GAD-7 had a sensitivity of 78.1 %, a specificity of 74.6 %, a positive predictive value (PPV) of 46.3 %, and a negative predictive value (NPV) of 92.4 %. At a cutoff score of 1, the GAD-2 had a sensitivity of 84.4 %, a specificity of 72.8 %, a PPV of 46.6 %, and a NPV of 94.3 %. The scores of the GAD-7 and GAD-2 well correlated with the BAI score, the MIDAS score, the HIT-6 score, and the MSQoL score.

Conclusions

The GAD-7 and GAD-2 are both reliable and valid screening instruments for GAD in patients with migraine.

Validation of the Patient Health Questionnaire-9 (PHQ-9) and PHQ-2 in patients with migraine

Background

Psychiatric problems have been commonly reported in patients with migraine. This study investigated the reliability and validity of the Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire-9 (PHQ-2) in patients with migraine.

Methods

Patients with migraine (with or without aura) were consecutively recruited from our headache clinic. They completed several instruments, including the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI), the PHQ-9, the Beck Depression Inventory-II (BDI-II), the Migraine Disability Assessment Scale (MIDAS), the Headache Impact Test-6 (HIT-6), and the Migraine-Specific Quality of Life (MSQoL).

Results

Among 132 participants, 39 patients (29.5 %) had a major depressive disorder (MDD) as determined by the MINI. Cronbach’s α coefficients for the PHQ-9 and PHQ-2 were 0.894 and 0.747, respectively. At a cutoff score of 7, the PHQ-9 had a sensitivity of 79.5 %, a specificity of 81.7 %, a positive predictive value (PPV) of 64.6 %, and a negative predictive value (NPV) of 90.5 %. At a cutoff score of 2, the PHQ-2 had a sensitivity of 66.7 %, a specificity of 90.3 %, a PPV of 74.3 %, and a NPV of 86.6 %. The scores of the PHQ-9 and PHQ-2 well correlated with the BDI-II score, the MIDAS score, the HIT-6 score, and the MSQoL score.

Conclusions

The PHQ-9 and PHQ-2 are both reliable and valid screening instruments for MDD in patients with migraine.

Factors associated with frovatriptan response in patients with migraine: A prospective, observational study

BACKGROUND

Almost one-third of patients with migraine do not adequately respond to triptans. We examined factors contributing to frovatriptan response in patients with migraine.

METHODS

We enrolled new patients with migraine who consecutively visited our headache clinic. Eligible patients were instructed to take 2.5 mg of frovatriptan as soon as possible after migraine attack. The responsiveness was determined by whether headache was relieved or absent within 4 hours after the intake of frovatriptan. We assessed frovatriptan to be efficacious when headache responded to its administration in at least one of two successive migraine attacks and inefficacious when headache was not relieved in either attack. We included demographic, clinical and psychiatric variables in the analysis of factors associated with frovatriptan response.

RESULTS

Of 128 eligible patients, 28 (21.9%) experienced frovatriptan inefficacy. In 24 patients with current major depressive disorder, 12 (50.0%) had frovatriptan inefficacy. Only current major depressive disorder was identified as a risk factor for inefficacy (odds ratio = 5.500, 95% confidence interval 2.103-14.382, ITALIC! p = 0.001).

CONCLUSIONS

Depression may be a risk factor of frovatriptan inefficacy in patients with migraine, even though half of patients with major depressive disorder respond to frovatriptan.

Osmophobia and allodynia are critical factors for suicidality in patients with migraine

Background

Sensory hypersensitivities are common phenomena in migraine. We examined the role of sensory hypersensitivities on suicidality in patients with migraine.

Methods

Patients with migraine (with or without aura) were consecutively recruited from our headache clinic. We asked them if they experienced photophobia, phonophobia, osmophobia, and allodynia during migraine attack. The Mini International Neuropsychiatric Interview was used to diagnose current major depressive disorder (MDD), current generalized anxiety disorder (GAD) and suicidality.

Results

Among 220 subjects, 25.5 % had current MDD, 17.3 % had current GAD, and 31.8 % had suicidality. Patients with suicidality were more like to have a low household income, chronic migraine (CM), medication overuse headache, high headache intensity, osmophobia, allodynia, high disability, MDD, and GAD than those without suicidality. The strongest risk factor for suicidality by multivariate analyses was osmophobia (adjusted Odds Ratio [AOR] 3.12, 95 % confidence interval [CI] 1.57-6.21, p = 0.001), followed by current MDD (AOR 2.99, 95 % CI 1.33-6.76, p = 0.008), CM (AOR 2.48, 95 % CI 1.21-5.09, p = 0.013), current GAD (AOR 3.11, 95 % CI 1.22-7.91, p = 0.017), and allodynia (AOR 2.72, 95 % CI 1.19-6.21, p = 0.018).

Conclusions

Osmophobia and allodynia are critical factors for suicidality in patients with migraine, after controlling for depression, anxiety, and CM.

Suicidality and Its Risk Factors in Korean People with Epilepsy: A MEPSY Study

Background and Purpose

People with epilepsy (PWE) are more likely to experience suicidality, with suicidal ideation and attempts, than people without epilepsy (PWoE). The aims of the present study were to determine 1) the characteristics of suicidality in Korean PWE, 2) whether PWE with suicidality receive psychiatric intervention, and 3) the risk factors for suicidality.

Methods

Patients who consecutively visited epilepsy clinics at secondary- and tertiary-care hospitals were recruited (n=684), along with age- and sex-matched PWoE (n=229). The presence of current major depressive disorder (MDD), generalized anxiety disorder (GAD), and/or suicidality was established using the Mini International Neuropsychiatric Interview-Plus Version 5.0.0. The Korean version of the Liverpool Adverse Events Profile (K-LAEP) was applied to detect adverse effects of antiepileptic drugs (AEDs).

Results

Suicidality was present in 208 (30.4%) of the 684 PWE. The rate of suicidality was 4.6 times higher among PWE than PWoE, and 108 (15.7%) PWE had suicidal ideation and had attempted suicide. Among those who had attempted suicide, 40.7% had made at least two attempts. The most common method of suicide attempt was drug overdose (34.9%). Unfortunately, of the 208 PWE with suicidality, 136 (65.4%) did not receive psychiatric intervention. The risk factors for suicidality were MDD [odds ratio (OR)=6.448, 95% confidence interval (CI)=3.739-11.120, p<0.001], GAD (OR=3.561, 95% CI=1.966-6.452, p<0.001), item scores of 3 or 4 on the K-LAEP (OR=2.688, 95% CI=1.647-4.387, p<0.001), and a history of febrile convulsion (OR= 2.188, 95% CI=1.318-3.632, p=0.002).

Conclusions

Suicidality is more prevalent in PWE than in PWoE. Clinicians should monitor psychiatric disorders and the adverse effects of AEDs in PWE in an attempt to reduce the incidence of suicidal ideation or suicide attempts in this patient population.

Hirayama disease with juvenile myoclonic epilepsy: A case report

Hirayama disease (HD) is rare, but benign anterior horn cell disease, predominantly affecting young men. One of the symptoms, besides weakness, is abnormal movement in the hand. Juvenile myoclonic epilepsy (JME) is one of the most common types of generalized epilepsies and can be recognized by a myoclonic jerk and electroencephalography (EEG) features. We report the case of a 19-year-old male who had HD, with unilateral abnormal movement in the hand, which was diagnosed as JME. We should consider performing an EEG in patients with HD, who present with atypical hand movements, in order to differentiate it from seizure.

Posterior reversible encephalopathy syndrome due to hyponatremia

Posterior reversible encephalopathy syndrome (PRES) is characterized by variable associations of seizure activity, consciousness impairment, headaches, visual abnormalities, nausea/vomiting, and focal neurological signs. The PRES may occur in diverse situations. The findings on neuroimaging in PRES are often symmetric and predominate edema in the white matter of the brain areas perfused by the posterior brain circulation, which is reversible when the underlying cause is treated. We report the case of PRES in normotensive patient with hyponatremia.

Validation of the generalized anxiety disorder-7 in people with epilepsy: a MEPSY study

The Generalized Anxiety Disorder-7 (GAD-7) is a valuable instrument to screen for anxiety in primary care patients. However, it has not been validated in people with epilepsy (PWE). Therefore, we validated the GAD-7 and examined its differential effect from adverse effects of antiepileptic drugs (AEDs) on the detection of anxiety in Korean PWE. Eligible patients who visited outpatient clinics in 4 tertiary care hospitals and 1 secondary care hospital underwent several instruments including the Mini International Neuropsychiatric Interview-Plus Version 5.0.0 (MINI-Plus 5.0.0), the Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E), the Korean version of the Liverpool Adverse Event Profile (K-LAEP), and the Quality of Life in Epilepsy-10 (QOLIE-10). Two hundred forty-three patients were enrolled in the study, and 51 (21.0%) patients had GAD by the MINI-Plus 5.0.0. Cronbach's α coefficient for the GAD-7 was 0.924. At a cutoff score of 6, the GAD-7 had a sensitivity of 92.2%, a specificity of 89.1%, a positive predictive value of 69.1%, and a negative predictive value of 97.7%. The GAD-7 score was well correlated with the K-NDDI-E score, the K-LAEP score, and the QOLIE-10 overall and subscale scores. The impact of adverse effects of AEDs on the GAD-7 was less than that on the K-NDDI-E. In conclusion, the GAD-7 is a reliable and valid screening tool for detecting GAD in PWE.

Prevalence and related factors for high-risk of obstructive sleep apnea in a large korean population: results of a questionnaire-based study

Background and Purpose

A population-based door-to-door study of cross-sectional methods for assessing the prevalence and factors related to a high risk of obstructive sleep apnea (OSA) was conducted using the Korean version of the Berlin Questionnaire (K-BQ).

Methods

Pooled data collected from Community Health Surveys by the Korea Center for Disease Control and Prevention were analyzed. Of 8,140 respondents from the population, 7,955 were finally included in this study.

Results

Of the 7,955 included subjects, 15.7% of the men and 9.8% of the women were at high risk of OSA. Significant differences were found in the following factors between the subjects with a high risk of OSA: gender, age, marital status, educational level, occupation, and presence of smoking, harmful alcohol use, and chronic diseases. Male sex, harmful alcohol use, and the presence of chronic diseases were identified as factors independently associated with a high risk of OSA.

Conclusions

This is the first study to confirm the usefulness of the K-BQ to study the prevalence of OSA in the Korean general population. The findings demonstrate that harmful alcohol use and chronic diseases are very common characteristics among those with a high risk of OSA.

Enhancement of algicidal activity by immobilization of algicidal bacteria antagonistic to Stephanodiscus hantzschii (Bacillariophyceae)

AIMS

Enhancement of algicidal activity by immobilization of algicidal bacteria antagonistic to Stephanodiscus hantzschii.

METHODS AND RESULTS

In laboratory studies, A diatom-lysing bacterium, Pseudomonas fluorescens HYK0210-SK09 showed strong algicidal activity against S. hantzschii, but a natural mesocosm study revealed that this bacterium failed to fully control natural blooms of Stephanodiscus at the low water temperatures that favour these blooms. Here, we sought to develop an effective immobilization strategy for enhancing the algicidal activity of HYK0210-SK09 in the natural setting. Bacterium HYK0210-SK09 was immobilized with various carriers including agar, alginate, polyurethane and cellulose sponge. The bacterial cells immobilized with cellulose sponge (CIS) induced more rapid and complete lysis of S. hantzschii than other carriers, and had a higher packing ability than polyurethane. Furthermore, CIS-immobilized cells showed higher lysis of S. hantzschii at the same concentrations as that of free cells (< or =1 x 10(7) cells ml(-1)), and had especially strong algicidal activity at the low temperatures (<10 degrees C). Based on these laboratory studies, we assessed the possible application of HYK0210-SK09 cells in the field by performing a mesocosm study during the winter season. The CIS-immobilized cells with species-specific activity towards the genera Stephanodiscus showed extremely high algicidal activity (up to 95%) against a bloom of Stephanodiscus hantzschii even at low water temperatures, because of high cell packing and subsequent cell protection against low temperatures and predators, whereas free cells showed negligible algicidal activities under these conditions.

CONCLUSION

Immobilizing cells of HYK0210-SK09 in CIS foam, rather than in the other matrices tested, could achieve more efficient control of Stephanodiscus blooms and showed a significant algicidal activity on in vitro and in vivo blooms, even at low water temperature.

SIGNIFICANCE AND IMPACT OF THE STUDY

Collectively, these results indicate that CIS of algicidal bacteria may form an important strategy for effective management of Stephanodiscus blooms at low water temperatures.

Comparison of cognitive effects of lamotrigine and oxcarbazepine in epilepsy patients

BACKGROUND AND PURPOSE

This study compared the cognitive effects of 1 year of treatment with lamotrigine (LTG) and oxcarbazepine (OXC) in epilepsy patients.

METHODS

This retrospective study investigated 60 epilepsy patients undergoing neuropsychological tests who were either newly diagnosed or untreated in the preceding 6 months. The cognitive function in 30 patients receiving LTG monotherapy and 30 age-matched patients receiving OXC monotherapy was compared after 1 year. The neuropsychological scores at baseline and all of the epilepsy-relevant variables except seizure type did not differ between the groups. The mean daily dosages of LTG and OXC at 1 year were 93 mg and 825 mg, respectively.

RESULTS

The posttreatment list-learning performance was better in the LTG group than in the OXC group (p<0.05). The incidence of cognitive complaints did not differ between the two groups. The list-learning performance and Trail Making Test scores were better in each group after treatment.

CONCLUSIONS

LTG and OXC monotherapies have similar, slightly beneficial effects on cognitive function, and are probably not harmful.

A revisit of MRI analysis for synovial sarcoma

We evaluated magnetic resonance imaging (MRI) findings of synovial sarcomas in 22 patients, and the most common MRI findings were oval and well-defined nodular masses with heterogeneous intermediate signal intensity (SI) on T1 weighted images (WI), high SI on T2-WI and heterogeneous contrast enhancement. A cystic component was seen in 77%, intratumoral hemorrhage in 73%, and calcification in three monophasic sarcomas. Metastases were noted in lung (mostly biphasic type), lymph node, and bone. Posttreatment changes revealed diffusely increased S1 on T2-W1 and slightly diffuse contrast enhancement with feathery appearance. Morphology and MR signal characteristics assist in synovial sarcoma management.

Reconstruction of the anterior cruciate ligament with Achilles tendon autograft

The increasingly serious complications of artificial ligaments and allografts have brought them into disrepute. Recently, autografts have drawn more attention. A new type of autograft, the Achilles tendon autograft, has been developed and applied to anterior cruciate ligament reconstructions. This report describes the advantages of the Achilles tendon autograft used and presents the results of a prospective study of 21 patients with minimum 2 year follow up. Of the 21 cases, 16 patients (75%) had a rating of excellent; 2 (10%) good, 2 (10%) fair, and 1 (5%) poor. Preoperative knee scores of 56.7 were improved to 89.5 postoperatively. The authors removed less than half of the Achilles tendon with the calcaneal bone incorporated. Through magnetic resonance imaging we confirmed that the remaining Achilles tendon of the donor site regained its volume and strength within a year without significant complication. Achilles tendon autograft offers the advantages of length, elastic strain modulus, reproducibility in technique, and consistency of the result without significant complications.