Journal of Clinical Neurology最新文献

Background and purpose: The Cognitive Impairment Screening Test (CIST) was developed to detect early-stage cognitive impairment. The clinical utility of this test has not yet been validated in real-world settings. This study compared the diagnostic performance of the CIST with that of the previously used screening test (PST).

Methods: We used research data from the ANSYS database of the National Institute of Dementia, Republic of Korea. Individuals who underwent screening tests between 2017 and 2023 were analyzed. Scores were compared among participants stratified by age, sex, and education duration. The discriminative performance of both screening tests in detecting cognitive impairment was assessed. The equipercentile equating method was used to enable score conversion between the CIST and PST.

Results: In total, 7,492,613 individuals (CIST: 3,195,129; PST: 4,297,484) were analyzed. The average screening score was higher for PST than for CIST. A larger proportion of cognitively impaired individuals was identified by the CIST (12.68%) than by the PST (10.72%, p<0.001). The CIST score (area under the receiver operating characteristic curve [AUC]=0.790, 95% confidence interval [CI]=0.70-0.850) outperformed the PST score (AUC=0.776, 95% CI=0.700-0.850) in predicting cognitive impairment based on diagnostic tests. CIST scores of 20, 15, and 5 were found to correspond to PST scores of 24, 20, and 10, respectively.

Conclusions: This study supports the validity and utility of the CIST as a screening tool for cognitive impairment. The CIST outperformed the PST in predictive accuracy. However, direct score conversion between the two tests should be approached with caution.

Background and purpose: Clinical trial data indicate that early anticoagulation is generally safe after an ischemic stroke, but there is a paucity of real-world data regarding the safety of early initiation in large strokes. We sought to determine the association between the time to the initiation of anticoagulation and the 90-day risk of recurrent ischemic and major hemorrhagic events.

Methods: We analyzed consecutive patients with an acute large ischemic stroke (volume ≥60 mL) who were included in the multicenter Initiation of Anticoagulation After Cardioembolic Stroke (IAC) study. We assessed recurrent ischemic events (transient ischemic attack, ischemic stroke, and systemic embolism), major hemorrhagic events (symptomatic intracranial hemorrhage [sICH] and major extracranial hemorrhage [ECH]), and the combined outcome within 90 days.

Results: This study included 155 patients (57.4% females) with a median NIHSS (National Institutes of Health Stroke Scale) score of 14. Only 11 (7.1%) events occurred, comprising 4 (2.6%) ischemic events, 2 (1.3%) sICHs, and 5 (3.2%) major ECHs. The median time to anticoagulation initiation did not differ significantly between subjects with and without recurrent ischemic events (13.5 days versus 9 days, p=0.221), major hemorrhagic events (4 days versus 10 days, p=0.334), or combined events (13 days versus 9.5 days, p=0.980). None of the patients who were started on anticoagulation within 7 days (n=71, 45.8%) experienced an ischemic event, and only one had an sICH, which occurred 20 days later. Two of the three recurrent strokes occurred prior to anticoagulation initiation in patients in whom this was done after 7 days.

Conclusions: Early anticoagulation after large ischemic stroke (volume ≥60 mL) in the IAC study was associated with a low risk of sICH and no recurrent ischemic strokes.

Background and purpose: Hyperactive delirium in neurological wards frequently results in patient harm, falls, device removal, and caregiver injuries, alongside significant staff burnout. To address inconsistent management practices, we developed the Prevention of Unbearable Situations and Harms (PUSH) protocol, a structured multidisciplinary approach to proactively manage hyperactive delirium. This study evaluated the effectiveness of the PUSH protocol in reducing delirium-related adverse events (primary outcome), and improving clinical workflow, staff burnout, and satisfaction (secondary outcomes).

Methods: We conducted a pre-post study in three phases: pre-implementation (November 2021-May 2022), pilot testing (June-August 2022), and post-implementation (September 2022-March 2023). The PUSH protocol includes Standard Care (routine delirium prevention), Preparation (anticipatory medication planning for patients at risk, Nursing Delirium Screening Scale ≥2), and Action (rapid response for escalating delirium) phases. Outcomes included delirium rates, hyperactive delirium episodes, adverse event incidence, medication response times, and staff burnout and satisfaction surveys. We compared pre- and post-implementation data using Poisson regression.

Results: Among 2,457 patients, 174 developed delirium during 2,958 observed person-days. Unbearable situations or harms decreased from 5.6 to 4.2 events per 100 person-days, with a fully adjusted incidence rate ratio of 0.539 (95% confidence interval: 0.368-0.788, p=0.001). Response times to sedative medication administration improved markedly (16 to 0 min; p<0.001). Staff burnout significantly decreased (32 to 27; p<0.001), and satisfaction notably increased (3 to 4; p=0.009).

Conclusions: The PUSH protocol significantly reduced delirium-related harms, enhanced clinical workflow efficiency, decreased staff burnout, and increased satisfaction, supporting its broader implementation in neurological settings.

Background and purpose: Myasthenia gravis (MG) is an antibody-mediated disease characterized by fluctuating muscle weakness and fatigue due to impaired neuromuscular junction transmission. Although primarily considered a motor dysfunction disorder, there is emerging evidence that MG can also present with nonmotor symptoms, including olfactory impairment. However, the prevalence and clinical relevance of olfactory dysfunction in MG remain poorly understood. This study compared olfactory function between MG patients and healthy controls with the aim of identifying clinical factors associated with olfactory impairment in MG.

Methods: Acetylcholine receptor (AChR)-antibody-positive MG patients and healthy controls were recruited from a single-center outpatient clinic. Olfactory function was assessed using the KVSS II (Korean version of the Sniffin' Sticks II) test, comprising odor threshold, discrimination, and identification subtests. We compared olfactory function and clinical factors between MG patients and healthy controls after adjusting and matching for age and sex.

Results: This study enrolled 51 MG patients and 43 healthy controls. Logistic regression analyses revealed that the MG patients had a significantly increased risk of olfactory dysfunction (odds ratio=3.6, 95% confidence interval=1.4-9.1, p=0.008), which remained after adjusting for age and sex. Among the MG patients, those with olfactory dysfunction were older (p=0.002) and had lower AChR antibody titers (p=0.029).

Conclusions: Olfactory dysfunction was significantly more prevalent in the MG patients than in the healthy controls. These findings highlight the need for further research into the underlying mechanisms and potential clinical implications of olfactory impairment in MG.