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Byline: Wen-Sou. Lin, Yaw-Don. Hsu Sir, Neurologic manifestation of Sj?gren's syndrome (SS) can affect both peripheral and central nervous systems. [sup][1],[2] Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an extremely rare [...]

Holmes tremor is also known as rubral or midbrain tremor. The tremor usually involves lesions near the red nucleus and the nerve fiber tracts originating in the cerebellum and the substantia nigra. We report a case of a 62-year-old woman who presented with Holmes tremor 5 months after a left thalamic hemorrhage, with a partial recovery 3 years later. Sequential technetium-99mTRODAT-1 single-photon emission computed tomography (SPECT) of the patient’s brain revealed partially improved tracer uptake reduction in the striatums, particularly on the left side. We propose that involvement of both the nigrostriatal and the dentate-rubro-thalamic pathways are essential in the pathogenesis of Holmes tremor after a thalamic lesion, and regeneration of the nigrostriatal system is possible in this type of tremor after the initial degeneration. The 99mTc-TRODAT-1 SPECT study is a useful and convenient tool for evaluating the nigrostriatal dopamine function in patients with Holmes tremor. [ABSTRACT FROM AUTHOR]

A variety of acquired disorders cause chorea, such as hypoxia-ischemia injury, drugs, toxins, infections, autoimmune disorders, and endocrine and electrolyte abnormalities, but rarely subdural hematoma. We report the case of a 76-year-old woman who presented with sudden onset of generalized choreiform movements 1 day prior to admission. Computed tomography revealed a bilateral lateral convexity subdural effusion, which was later confirmed by magnetic resonance imaging as a chronic subdural hematoma. After surgical evacuation of the subdural hematoma, the choreoathetoid movements ceased completely. We propose that transient ischemia in the bilateral subcortical regions was from compression and distortion of the brain by the bilateral hematomas and resulted in generalized chorea. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article presents a case study of a 56-year-old man with a history of continuous occipital pain, odontoid fracture.

Clinical Introduction: An 88-year-old woman presented with acute onset of involuntary limb movements for one day. Two days prior she had fallen a suffered a left hip contusion but no head trauma. There was no fever or difficulty breathing. Her heart rate was 72 bpm with blood pressure of 109/68 mm Hg. Physical examination revealed restricted left hip motion due to pain and a sustained twisted posture of the upper extremity without paresis. Glasgow Coma Scale was 15, and there was no evidence of Kernig's or Brudzinski's sign. She underwent a hip X-ray and non-contrast CT scan (figures 1 and 2).emermed;36/7/415/F1F1F1Figure 1Anteroposterior X-radiograph of the hip.emermed;36/7/415/F2F2F2Figure 2A non-contrast brain CT.Question: What is the most likely cause of the clinical presentation?Acute meningitisCerebral fat embolismHaemorrhagic strokeHypertensive encephalopathy For answer see page 2For question see page 1. [ABSTRACT FROM AUTHOR]

Training and examining healthcare practitioners' nursing skills by situating them in a contextualized environment to interact with trained simulated patients and making required decisions based on the collected information is a widely adopted approach in nursing training. In a nursing skills course, the flipped learning method shifts the lecture time to the before-class time, allowing more time for teachers' guidance and skills practice in the class. However, if students do not have in-depth understanding in the individual learning space, their learning achievement is often not as expected. In this study, an ASQ (Annotation, Summarizing and Questioning)-based flipped learning strategy for nursing skills training is proposed to engage nurse practitioners (NPs) in deep and effective learning. Moreover, an experiment was conducted to evaluate the effects of the proposed approach on learners' learning achievement, nursing skills, self-efficacy, cognitive load, and critical thinking tendency. The experimental results showed that the approach not only improved NPs' nursing skills, but also significantly increased their self-efficacy and critical thinking tendency. • An ASQ-based flipped learning approach was proposed. • The approach helps students effectively identify key concepts before the class. • An experiment was conducted in a clinical nursing skills training course. • The approach improved the learners' nursing skills performance. • The approach improved the learners' self-efficacy and critical thinking tendency. [ABSTRACT FROM AUTHOR]

Designing activities for learners to deal with problems and cultivate their higher order thinking is critical in professional training. Peer review is to allow a group of learners with similar abilities and knowledge background to promote their higher order thinking and reflective thinking through mutual observation and comments. However, in the conventional peer-review approach, the interaction between assessors and assessees is one-way. That is, assessors cannot receive any responses from assessees, so they have no opportunity to reflect on their comments. The online interactive peer-review approach aims to enable assessees to express their points of view and to allow assessors to understand whether their ratings and comments are accurate or helpful to assessees. During the interaction, both assessors and assessees have the opportunity for reflection, which then promotes the quality of ratings and comments and facilitates their learning effectiveness and critical thinking. The present study developed an online interactive peer-review system and applied it to the health assessment learning course for nurse practitioners (NP). An experiment was designed to explore the effects of different online peer-review approaches on NP students' learning achievement and higher order thinking. Also, the study recorded the students' peer-review content and analyzed its effects on the quality of their peer review. The experimental group adopted the online interactive peer-review approach, while the control group adopted the conventional online peer-review approach in a flipped learning context. The results indicated that integrating the online interactive peer-review learning approach could not only strengthen the NP students' knowledge and clinical skills, but could also significantly improve their critical thinking tendency and reflective thinking. Moreover, based on the analytic findings of the peer-review content, students using the online interactive peer-review approach were better able to significantly address more specific suggestions to assist their peers in improving their health assessment performance than those using the conventional online peer-review approach. • An online interactive peer-review approach was proposed. • The approach aimed to promote students' performance in decision-making tasks. • An experiment was conducted in a health assessment skills training course. • The approach improved the performance of students' health assessment skills. • The approach improved the students' reflection and peer-assessment quality. [ABSTRACT FROM AUTHOR]

Clinical Introduction: An 88-year-old woman presented with acute onset of involuntary limb movements for one day. Two days prior she had fallen a suffered a left hip contusion but no head trauma. There was no fever or difficulty breathing. Her heart rate was 72 bpm with blood pressure of 109/68 mm Hg. Physical examination revealed restricted left hip motion due to pain and a sustained twisted posture of the upper extremity without paresis. Glasgow Coma Scale was 15, and there was no evidence of Kernig's or Brudzinski's sign. She underwent a hip X-ray and non-contrast CT scan (figures 1 and 2).emermed;36/7/415/F1F1F1Figure 1Anteroposterior X-radiograph of the hip.emermed;36/7/415/F2F2F2Figure 2A non-contrast brain CT., Question: What is the most likely cause of the clinical presentation?Acute meningitisCerebral fat embolismHaemorrhagic strokeHypertensive encephalopathy For answer see page 2 For question see page 1 ., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The osmotic demyelination syndrome (ODS) has been identified as a neurological complication of the rapid correction of hyponatremia. In recent years, however, various medical conditions have been associated with the development of ODS, irrelevant to changes in serum sodium. We present a rare case of a eunatremic patient who developed ODS with manifestation of parkinsonism., Case: A 55 years old woman who has hypertension, type 2 diabetes nephropathy in end-stage renal disease under maintenance hemodialysis came to us with complaint about newly developed resting tremor of bilateral upper limbs, slowness of movements and small shuffling steps. Brain magnetic resonance imaging (MRI) showed bilateral lentiform nuclei demyelination. ODS was diagnosed concerning the comorbidities and her medical history. Her neurological deficits improved dramatically after treatment of Ropinirole., Conclusion: ODS may develop in patient with risk factors regardless of change in serum sodium concentration. Brain MRI could help in early detection of the demyelination. Secondary parkinsonism may occur as a rare manifestation of ODS. Supportive treatment, monitoring of vital signs and neurological deficits are warranted. Dopaminergic agent may be beneficial in symptomatic control.

Purpose: We had recently reported one case at American Journal of Emergency Medicine about centralvariant posterior reversible encephalopathy syndrome (PRES) in an 84-year-old woman with an initial misdiagnosis as central pontine myelinolysis (CPM). Here, we introduce another case of centralvariant PRES in a 49-year-old man mimicking as acute brainstem infarction in the cranial computed tomography (CT) findings., Case Report: A 49-year-old man was admitted to the emergency department with a 5-day history of vertigo, cognitive decline, and difficulty in walking. Neurologic examination revealed drowsiness with a Glasgow Coma Scale score of 12 (eye opening: 3, best verbal response: 4, and best motor response: 5), slow movement in pursuit and saccades, and gait instability with a Medical Research Council scale of grade 4-5. Non-contrast cranial CT showed hypodense lesions in the pons, and antiplatelet agent was initiated for presumed pons infarction. However, the brain magnetic resonance imaging (MRI) demonstrated vasogenic edema in the corresponding area, consistent with the diagnosis of central-variant PRES., Conclusion: This case report raises the awareness that when hypodense brainstem lesions on brain CT in patients with progressive neurological dysfunction, the rare condition of central-variant PRES should be considered in the differential diagnosis to avoid inadequate management. Cranial magnetic resonance imaging (MRI) may help in diagnosis and dealing with of these patients with similar radiological and clinical abnormalities.

Animal stroke models suggest that valproate has multiple neuroprotective mechanisms against ischemic brain damage. This study investigated whether valproate improves functional recovery in patients with acute middle cerebral artery (MCA) infarction. This was an open-label controlled trial. Three to 24 hours after acute MCA infarction, patients were assigned to either the valproate group (n = 17) or the non-valproate group (n = 17). The valproate group received intravenous valproate (400 mg) at enrollment, and then every 12 hours for three days, followed by oral valproate (500 mg) every 12 hours for three months. Neurological function, laboratory data, and brain magnetic resonance imaging were examined at stroke onset, and at two-week and three-month follow-up. No significant differences were observed between the groups with regard to demographics or baseline characteristics. All patients were elderly, had a high pretreatment score on the NIH stroke scale (NIHSS), and slow stroke lesion growth with a final large infarct volume at two-week follow-up. At the three-month follow-up, functional outcome between pre- and post-treatment had improved significantly in the valproate group (NIHSS, p = 0.004; modified Rankin scale (mRS), p = 0.007; Barthel index (BI), p = 0.001). No such improvement was noted in the NIHSS or mRS for the non-valproate group, though mild improvement was seen on the BI (p = 0.022). This open-label trial is the first to demonstrate that valproate treatment markedly improves functional outcome in patients with acute MCA infarction.

A 26-year-old patient developed ascending weakness and paresthesias. Megaloblastic anemia and mildly reduced serum vitamin B12 (B12) concentration were noted. Myoclonus-like muscular contractions appeared over four extremities and in the trunk. She admitted inhaling nitrous oxide (N2O) as a euphoriant repeatedly at party. Following parenteral B12 administration, her neurological deficit promptly resolved. This case demonstrated the abuse of N2OI is an important cause of subacute combined degeneration (SCD) of the spinal cord. To our knowledge, this is the first report of involuntary movements in a patient with N2O intoxication. Although the mechanism remains unknown, involuntary movements similar to myoclonus should be considered as one of the extraordinary neurological manifestations of N2O intoxication.

We have recently encountered a rare case of fibromuscular dysplasia (FMD) of the vertebral artery (VA) presenting as lateral medullary syndrome. A 39-year-old male was admitted to our hospital due to vertigo, dysarthria and numbness of the left face and the right limbs. A magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of brain revealed lateral medullary infarction in the territory of the left posterior inferior cerebellar artery (PICA). The angiography of the VA revealed tubular stenosis of the left extracranial VA and a focal vascular kinking as well as web in the right extracranial VA, confirming the diagnosis of FMD. We present this rare case to emphasize that FMD could be one of the risk factors causing lateral medullary syndrome in young people.

Muscular dystrophies are a genetically heterogeneous group of degenerative muscle disorders. It characterized by progressive muscle wasting and weakness of variable distribution and severity. There are several subgroups including Duchenne/Becker, fascioscapulohumeral, limb-girdle, oculopharngeal, and congenital muscular dystrophy. Diagnosis is dependent to the characteristic clinical features in distribution of predominant muscle weakness, disease course and age onset as well as variable serum concentration creatine kinase, muscle histology, and genetic inheritance. Nearly 30 genes and encoded proteins are known to give rise to various forms of muscular dystrophy. Development of new prospects therapy for the muscular dystrophies is a big challenge. The target of strategies is aimed at inducing of a functional protein and improving the function of muscle weakness. These strategies include gene, cell and pharmacological therapies. However, efficiency of systemic delivery vectors to targets, immune reaction to vector and gene products, and toxicity to vector that must be solved before an effective treatment is available.

Background and Purpose: Previous studies demonstrated that ADH2*2, encoding for high-maximal velocity (Vmax) beta2-alcohol dehydrogenase (ADH) activity, and mutant ALDH2*2, encoding for null aldehyde dehydrogenase (ALDH) 2 activity, independently influence susceptibility to alcoholism. A single copy of the ALDH2*2 allele may protect less strongly than a single copy of ADH2*2 in individuals carrying only one copy of either ALDH2*2 or ADH2*2. Individuals with various ADH2 and ALDH2 gene status may exhibit different alcohol metabolism and alcohol sensitivity, which affects drinking behavior. To explore the underlying pharmacogenetic mechanism, alcohol metabolism and alcohol sensitivity were tested using ethanol challenge in Taiwanese men with different ADH2 and ALDH2 genotypes., Methods: Twenty-four adults, matched by age, body mass index, nutritional state, and homozygosity at ADH3, were recruited from a population base of 304 men. Six individuals were chosen with each of the different ADH2 and ALDH2 genotypes: ADH2*1/*1, ALDH2*1/*1; ADH2*2/*2, ALDH2*1/*1; ADH2*1/*1, ALDH2*1/*2; and ADH2*2/*2, ALDH2*1/*2. After a low-to-moderate challenge with ethanol (0.3 g/kg), blood ethanol and acetaldehyde concentrations, heart rate, and facial capillary blood flow (FCBF) were measured for 130 minutes., Results: All heterozygous ALDH2*2 individuals were found to be strongly responsive to low-to-moderate ethanol, as evidenced by pronounced increases in heart rate and FCBF. Conversely, there were no significant differences in alcohol metabolism and alcohol sensitivity between the ADH2*2 and ADH2*1 homozygotes with identical ALDH2 genotype., Conclusion: Individuals heterozygous for ALDH2*2 exhibit strong alcohol hypersensitivity caused by persistent accumulation of large amounts of acetaldehyde, but homozygosity for ADH2*2 is not dependent upon this pathway against alcoholism.