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REVIEW ARTICLE
COVID-19 associate neurological complications
Leyla Baysal-Kirac, Hilmi Uysal
January-March 2020, 37(1):1-3
DOI:10.4103/NSN.NSN_28_20  
2019-novel Coronavirus disease (COVID-19) is a global health problem that affected >2.000.000 people in the world. Although the main component of the disease is pulmonary disturbances, recent reports suggested neurological manifestations. Neurological complications have been rarely reported with other Coronavirus associated diseases. In this short review, we would like to draw attention to COVID-19-related neurological symptoms. Heath-care providers should be aware that COVID-19 can associate neurological manifestations.
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RESEARCH PAPERS
Decision-making and impulse-control disorders in Parkinson's disease: Influence of dopaminergic treatment
Elif Yildirim, Sibel Altinayar, Raif Cakmur
January-March 2020, 37(1):11-17
DOI:10.4103/NSN.NSN_12_20  
Objective: Dopaminergic treatment is proved to ameliorate motor deficits in Parkinson's disease (PD); however, it could have negative effects on behavior and cognition, including impulse controlling and decision-making. We aimed (1) to investigate the decision-making and impulse-control disorders (ICDs) of PD patients and their correlations with sociodemographical and clinical variables, dopaminergic treatment in particular, and (2) to determine the relation of decision-making with ICDs. Methods: The sample of 39 patients with PD and 37 healthy controls underwent cognitive tests and the task which analyzed decision-making (Iowa Gambling Task [IGT]). Besides assessing motor and nonmotor symptoms of patients with PD, ICDs were also scanned using the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease. Results: Although patients with PD performed similarly to healthy controls on IGT, decision-making profile in PD related to clinical variables: dopaminergic treatment and duration of illness. In addition to this younger age of onset, higher dose of dopamine agonists, longer duration of illness, and impaired decision-making were together accounted for a substantial amount of variance in impulsive behaviors. Conclusions: Dopaminergic medication likely contributes to the impairment in decision-making, which may be the underlying mechanism of ICDs. Further studies will be necessary to understand the potential implications of this finding.
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Evaluation of the presence of neuropathy and pruritus in predialysis patients
Cansu Soylemez, Ufuk Emre, Sennur Köse, Aysel Tekesin
January-March 2020, 37(1):4-10
DOI:10.4103/NSN.NSN_13_20  
Objective: Neuropathy is seen in approximately 70% of patients in the predialysis stage; it is more common in individuals with pruritus, which may be an indicator of neuropathy. The aim of this study was to evaluate the presence of neuropathy and pruritus in the predialysis stage. Methods: The study included 60 patients in the predialysis stage and 30 volunteer controls. Neuropathic symptoms and severity and frequency of itching were recorded. The polyneuropathy (PNP) protocol and sympathetic skin responses (SSRs) were examined. Results: Electromyographic PNP was detected in 28.3% of the patients and pruritus in 36.7%. There was no significant difference in terms of neuropathy and SSR between the groups with and without pruritus (P > 0.05). Body mass index (BMI,P < 0.05) and uric acid levels (P = 0.022) were higher in the group with pruritus. The group in the predialysis stage was divided into two groups according to the stages. There was no difference between the groups in terms of neuropathy and pruritus (P > 0.05), whereas the amplitude and velocity of the median nerve, amplitude and velocity of the tibial nerve, amplitude of the sural nerve, and velocity of the peroneal nerve motor were found to be higher in the control group than in the two groups in the predialysis stage. Furthermore, a prolongation of the distal latency median motor nerve was found in two groups in the predialysis stage compared with the control group (P > 0.05). There was no significant difference between the two groups in terms of the presence of neuropathic symptoms and pruritus (P > 0.05). Conclusion: More than one-third (36.7%) of the patients had pruritus. Increased BMI and uric acid levels showed that it could be important to evaluate the patients in the predialysis stage.
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Validity and reliability of the Turkish version of the mig-scog scale in migraine patients
Burcu Polat, Aynur Özge, Nesrin Helvacı Yılmaz, Bahar Taşdelen, Özge Arıcı Düz, Seyma Kılı, Saygın Sarı
January-March 2020, 37(1):29-35
DOI:10.4103/NSN.NSN_20_20  
Objectives: This study assesses the validity and reliability of the Turkish version of the Mig-SCog scale used to determine and monitor the cognitive functions of migraine patients during attacks. Methods: After completion of the translation process, for this validity and reliability study the Mig-SCog was administered to a total of 154 migraine patients (91 without aura, 32 with aura, and 31 chronic migraine patients) presenting to the Neurology Clinic of Istanbul Medipol University University. Internal consistency of the factors and the instrument as a whole were evaluated using Cronbach's alpha coefficient and an alpha value >0.60 was considered acceptable. Results: As in the original, the result of factor analysis found a good fit for a 4-factor structure of the Turkish version (KMO = 0.82 and Chi-square P = 0.409), and the factor structure was similar to the original. The factors of the instrument were evaluated as consistent (Cronbach's alpha >0.60), and an overall Cronbach's alpha of 0.8485 was calculated. Conclusions: The Mig-SCog showed sufficient validity and reliability to be used in Turkish society.
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ORIGINAL ARTICLES
Electrodiagnostic patterns of demyelination and hughes functional grading in typical chronic inflammatory demyelinating polyneuropathy
Fatin Hatim Towman, Farqad Bader Hamdan
April-June 2020, 37(2):50-56
DOI:10.4103/NSN.NSN_8_20  
Background: Chronic inflammatory demyelinating polyneuropathy (CIDP) is characterized by progressive or relapsing motor or sensory symptoms, with variants differing in the relative distribution of these symptoms and electrophysiologic findings. We aimed to correlate the electrodiagnostic patterns of demyelination using Hughes Functional Grading Scale in patients with CIDP. Methods: A case–control study was conducted at the neurophysiology department of Al-Imamian Al-Kadhymian Medical city and Nursing Home Hospital, Medical City, Baghdad from December 2017 to June 2018. Fifteen patients with CIDP aged 30–60 years with disease duration between 6 months and 2 years and 20 age-matched healthy subjects (control group) were included in the study. The participants were submitted to medical history, clinical neurological examination, and electrophysiologic tests. Results: Patients with CIDP demonstrated prolonged distal sensory and motor latencies, decreased sensory nerve action potential amplitude, slowing of sensory and motor nerve conduction velocity, and prolonged mean F-wave latency. The majority showed absent sural sensory responses. Significant relationships were demonstrated between the Hughes Functional Grading Scale and different neurophysiologic parameters, and no correlation was found with the terminal latency index. Conclusions: Patients with high Hughes functional scoring also have severe abnormalities in motor parameters, usually in the range of demyelination. The involvement of nerve segments was multifocal affecting mostly the proximal and intermediate nerve segments; the terminal segments were involved to a lesser extent.
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LETTERS TO EDITOR
Nonconvulsive status epilepticus presented with wernicke aphasia: Case report
Hulya Ozkan, Melodi Cakar, Meliha Akpinar, Sezgin Kehaya, Baburhan Guldiken
January-March 2020, 37(1):36-37
DOI:10.4103/NSN.NSN_17_20  
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RESEARCH PAPERS
Impact of intermittent hypoxia on peripheral nervous systems in obstructive sleep apnea syndrome
Mustafa Emir Tavsanli, Gulcin Benbir Senel, Aysegul Gunduz, Derya Karadeniz, Nurten Uzun Adatepe
January-March 2020, 37(1):18-23
DOI:10.4103/NSN.NSN_18_20  
Objectives: Intermittent hypoxia resulting in endothelial dysfunction in microvascular circulation constitutes one of the mechanisms underlying complications of obstructive sleep apnea syndrome (OSAS), such as hypertension and atherosclerosis. The role of intermittent hypoxia on peripheral nerves, however, is still debated. Here, we designed a study in patients with OSAS to investigate different levels of the central and peripheral nervous systems, in order to delineate what kind of pathologic substrate was present, if any, and at which level of the neuromuscular pathway. Methods: A total of 20 patients with OSAS and 18 sex- and age-matched healthy controls were enrolled in our study. All participants underwent nerve conduction studies (NCSs) to analyze peripheral nerves, evoked potentials for somatosensory, visual evoked potential (VEP) and brainstem auditory pathways, blink reflex studies to analyze brainstem and subcortical structures, and transcranial magnetic stimulation to analyze the motor cortex and corticospinal pathway. Results: A comparison of NCSs between the two groups showed that the motor amplitudes of the ulnar nerve (P = 0.015) and sensory amplitudes of the sural nerve (P = 0.026) were significantly smaller in the OSAS group than those in the control group. The mean P100 amplitudes of VEP responses were 7.11 ± 2.73 μV in the OSAS group and 9.75 ± 3.52 μV in the control group (P = 0.022). In correlation analysis, the amplitude of P100 responses was positively correlated with the lowest oxygen saturation (P = 0.026). Conclusion: Our results confirmed the presence of generalized axonal involvement in the peripheral nervous system in OSAS, probably secondary to chronic intermittent hypoxemia.
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Investigation of insulin resistance and vitamin E deficiency in chronic inflammatory demyelinatıng polyneuropathy: A 5-year retrospective study
Hilal Tastekin Toz, Eren Gozke
January-March 2020, 37(1):24-28
DOI:10.4103/NSN.NSN_19_20  
Objective: Chronic inflammatory demyelinating polyneuropathy (CIDP) is a treatable disease; therefore, accurate diagnosis and detection of coexisting disorders are very important. Some authors have reported that CIDP was more frequently observed in patients with diabetes mellitus when compared with the population in general. Vitamin E deficiency leads to demyelinating neuropathy, and Vitamin E supplementation ensures clinical and electrophysiological recovery. In this study, identifying the association between insulin resistance, Vitamin E deficiency, and CIDP is aimed. Materials and Methods: Thirty-three patients with CIDP and forty healthy controls were evaluated. Two groups were compared in terms of insulin resistance and Vitamin E level status. Results: A statistically significant difference was not found between CIDP and control groups as for the distribution of mean ages, genders, Homeostatic Model Assessment Index values, impaired fasting glucose, and a statistically significant difference was not found between CIDP and control groups as for Vitamin E deficiency. Conclusion: Our study could not reveal any evidence about insulin resistance and Vitamin E deficiency in CIDP patients.
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REVIEW ARTICLE
Vestibular migraine: Considered from both the vestibular and the migraine point of view
Gulden Akdal, Pınar Özçelik, Aynur Özge
April-June 2020, 37(2):41-49
DOI:10.4103/NSN.NSN_72_20  
A temporal overlap between vestibular symptoms, such as vertigo and head movement intolerance, and migraine symptoms, such as headache, photophobia, and phonophobia, is a requisite diagnostic criterion for the diagnosis of vestibular migraine (VM). Diagnostic criteria for VM have been proposed by an International Vestibular Research Group (the Bárány Society) and a headache research group (International Headache Society); however, in practice, it is still acceptable to divide patients suspected of VM into “definite VM” and “probable VM” groups. Here, a neuro-otologist and a headache specialist consider VM from their own points of view using four real cases, two from a dizzy clinic and two from a headache clinic, with expert opinions and arguments according to the current literature. The management is summarized on the basis of mechanism and comorbidity and the importance of prophylactic medication.
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LETTERS TO EDITOR
Long-term intense exercise training in becker muscular dystrophy: 3-year follow-up
Gokce Yagmur Gunes Gencer, Naciye Fusun Toraman
January-March 2020, 37(1):38-39
DOI:10.4103/NSN.NSN_21_20  
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ORIGINAL ARTICLES
Reliability and validity of the Turkish version of king's Parkinson's disease pain scale
Ferhan Soyuer, Murat Gültekin, Feyzan Cankurtaran, Ferhan Elmalı
April-June 2020, 37(2):57-62
DOI:10.4103/NSN.NSN_34_20  
Objective: Pain, a nonmotor symptom in Parkinson's disease (PD), affects approximately 40%–85% of patients and adversely affects their daily activities. Therefore, our aim was to establish the validity and reliability of the Turkish version of King's PD Pain Scale (KPDPS) and to make it available for Turkish patients with PD patients. Methods: The first phase of the study involved the translation and adaptation of the KPDPS to Turkish. For the language validity of the scale, a translation back-translation method was applied, and expert's opinion was considered for content validity. In the second stage, the developed Turkish scale was administered to 152 patients with PD. In the study, test-retest was performed in 50 patients for 1 week. Results: The internal consistency value was found as 0.856 in the KPDPS. When the test-retest was performed, the internal consistency value of the scale showed excellent reliability. The test-retest-Cronbach's alpha value for the whole scale was 0.827. According to the data analysis results, it showed that 14 items on the scale were sufficient for the evaluation of pain in patients with PD. Conclusion: The results from this study show that KPDPS items have adequate internal consistency and test-retest reliability. The Turkish KPDPS can be used as a reliable and valid instrument for assessing the pain symptoms common to patients with PD.
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Bilateral nerve conduction studies must be considered in the diagnosis of sciatic nerve injury due to intramuscular injection
Halit Fidanci, İlker Öztürk, Ahmet Candan Köylüoğlu, Mehmet Yıldız, Zülfikar Arlıer
April-June 2020, 37(2):94-99
DOI:10.4103/NSN.NSN_22_20  
Objectives: Although compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) amplitudes of the nerves are reduced in sciatic nerve injury due to intramuscular injection (SNIII), they may still be higher than the reference values if there is a mild axonal degeneration. In this case, comparing the outcomes of nerve conduction studies of intact and affected lower extremities becomes important. We aimed to determine the role of this comparison in the diagnosis of SNIII. Methods: Patients with SNIII were included. Reference values for lower extremity nerve conduction studies were obtained from healthy participants. Peroneal, posterior tibial, superficial peroneal, and sural nerve conduction studies were performed in both lower extremities. In the first analysis, the CMAP or SNAP amplitude of the nerve was considered abnormal if it was less than the reference value. In the second analysis, the CMAP or SNAP amplitude of the nerve was considered abnormal if it was less than the reference value or <50% of the CMAP or SNAP amplitude obtained from the intact limb nerve. Results: Thirty patients and 31 controls were included in the study. Compared with those found in the first analysis, the number of posterior tibial nerve CMAPs with reduced amplitudes, and the sural and superficial peroneal nerve SNAPs with reduced amplitudes were higher in the second analysis (P = 0.008, P < 0.001, and P = 0.031; respectively). Conclusion: This study showed that nerve conduction studies should be performed in both the intact and affected extremities in SNIII.
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Comparison of medium supplements in terms of the effects on the differentiation of SH-SY5Y human neuroblastoma cell line
Belgin Sert Serdar, Tuğba Erkmen, Bekir Uğur Ergür, Pınar Akan, Semra Koçtürk
April-June 2020, 37(2):82-88
DOI:10.4103/NSN.NSN_15_20  
Objective: Human SH-SY5Y cell line has been frequently used for in vitro experiments in neuroscience-related research. To reflect a better neuronal characteristic the cell line needs to a differentiation. To compare the results obtained from in vitro models, the similarity of the phenotype and characteristic of the cells has great importance. However, many studies have been performed using the different medium ingredients which affect the differentiation progress of the cells. Therefore, we aimed to compare generally used differentiation mediums, contain only retinoic acid (RA) and supplemented with different ingredients, in the aspect of neuron-like phenotype characteristics and stability. Materials and Methods: The effects of medium ingredients on differentiation levels were evaluated using morphological changing, neurite length, and immunofluorescence detection of neuronal markers such as NFH, β-III Tubulin, and microtubule-associated protein 2 (MAP2). The stability of differentiated cells was followed microscopically at the 7th, 10th, and 14th days by morphological changings and neurite length using Neuron J software. Results: The results revealed that the cells pretreated with RA for 5-day treatment and followed by 5-day treatment with the mix medium and brain-derived neurotrophic factor (BDNF), provided significantly higher neurite length than the other groups (P < 0.001). In this group, the expressions of β-tubulin III, MAP2, and NF-H were also significantly higher than the control group (P < 0.05, P < 0.001, and P < 0.05, respectively) and differentiated cells were stable until the 7th day. Conclusion: The results demonstrated that enriched mediums are necessary for a better differentiation of SH-SY5Y cells. We recommend 10-day treatment period and using of RA, BDNF, dc-AMP, KCI together in SH-SY5Y cell differentiation.
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Analysis of vestibular-evoked myogenic potentials in the vestibular migraine
Belgin Tutar, Güler Berkiten, Onur Akan, Ziya Saltürk, Berk Gürpinar, Semih Karaketir, Tolgar Lütfi Kumral, Yavuz Uyar, Ömür Biltekin Tuna
April-June 2020, 37(2):63-69
DOI:10.4103/NSN.NSN_4_20  
Objectives: The objective of this study is to determine the subclinical vestibular dysfunction of patients with vestibular migraine (VM) in the interattack period who had no vestibular symptoms. We assessed ascending utricular and descending saccular pathways using cervical vestibular-evoked myogenic potentials (cVEMP) and ocular vestibular-evoked myogenic potentials (oVEMP) in patients with VM and a healthy control group and then compared the electrophysiologic findings with each other. Materials and Methods: Between January 2017 and January 2018, 116 patients (aged 18–62 years) were enrolled in the study. The study group consisted of 68 women with VM and the control group comprised 48 healthy women. Results: For cVEMP findings, the mean left ear P1 latency of the VM group was statistically significantly longer than that of the control group (P = 0.024; P < 0.05). No statistical significance was found in left ear N1 latency, P1-N1 interpeak intervals and mean amplitudes between the VM and the control groups (P > 0.05). Amplitude asymmetry ratios (AARs) were not statistically significantly different between the two groups in cVEMP (P > 0.05). In terms of oVEMP findings, no statistically significant difference was found in the right ear parameters of N1, P1, P1-N1 intervals, and amplitudes of the VM and the control groups (P > 0.05). The left ear oVEMPs of the VM group showed absent responses in 12 cases and were statistically significant compared with the control group (P = 0.037; P < 0.05). The AARs were significantly greater for the the VM group than the control group in oVEMP (P = 0.006; P < 0.05). Conclusion: These electrophysiologic findings suggest that peripheral vestibular structures such as the utricle, saccule and also other central vestibular structures might be affected in VM. Patients with VM had subclinical vestibular dysfunction despite being in the interattack period. To support the diagnosis of VM, VEMPs are easy and cost-effective tests.
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The role of leukoaraiosis on outcomes and recombinant tissue-plasminogen activator-related symptomatic intracerebral hemorrhages in acute stroke
Ezgi Sezer Eryildiz, Atilla Özcan Özdemir, Dilek Yılmaz, Demet Funda Baş
April-June 2020, 37(2):70-74
DOI:10.4103/NSN.NSN_11_20  
Background and Purpose: We aimed to assess whether severe leukoaraiosis (LA) is associated with outcomes and symptomatic intracerebral hemorrhages (sICH) in patients who were treated with recombinant tissue-plasminogen activator (rt-PA) for acute stroke. Methods: We analyzed the data of anterior circulation stroke patients who were treated with rt-PA at our stroke center during 2009–2016. LA was scored according to the van Swieten scale (VSS) on computed tomography (CT) and dichotomized into groups as absent or moderate versus severe LA. We used the safe implementation of thrombolysis in stroke definition for sICH and the modified Rankin Scale (mRS) scores at 3 months after rt-PA were recorded. Results: Of 302 patients, 47 (15.6%) showed severe LA (VSS >4) on CT. The overall sICH rate was 3.6%. Moreover, sICH was significantly more frequent in patients with severe LA (n = 5 of 47; 10.6%) than in patients with absent/moderate LA (n = 6 of 255; 2.4%; P = 0.017). In addition, patients with severe LA had higher baseline glucose level (P = 0.006) and systolic blood pressure (P = 0.005) compared to patients with absent/moderate LA. Patients with severe LA were more likely to have a poor outcome (mRS: 3–6) compared to those without severe LA (P = 0.009). Conclusion: The presence of severe LA on CT increases the risk of sICH and poor outcome in patients treated with rt-PA for acute stroke.
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Validity of international classification of functioning, disability, and health core set in patients with Parkinson's disease and the correlation with other Parkinson scales
İbrahim Acir, Hacı Ali Erdoğan, Vildan Yayla
April-June 2020, 37(2):89-93
DOI:10.4103/NSN.NSN_16_20  
Objectives: Idiopathic Parkinson's Disease (IPD) is a movement disorder that cause tremor, rigidity, bradykinesia, postural instability and deterioration quality of life. To assess the disease different scales can be used: The Unified Parkinson's Disease Rating Scale (UPDRS) for clinical severity, Parkinson's Disease Questionnaire (PDQ39) to assess quality of life, Beck Depression Scale (BD) for mood assessment and Hoehn Yahr Scale (HY) for clinical staging. The International Classification of Functioning, Disability and Health (ICF) is a classification to develop an international common language for the evaluation of the functionality and disability of patients. We aimed to compare validity and efficacy of ICF classification with other scales. Materials and Methods: Thirty-one patients with idiopathic Parkinson's disease were evaluated. PDQ39, UPDRS, Hoehn Yahr, Beck Depression Scale and 'Brief ICF core set for hand condition' which was recommended for Parkinson's disease were applied to patients. The brief ICF core set and other scales were compared and assessed if there was any correlation. For analyzes, the MedCalc Statistical Software version 12.7.7 programme was used. Results: The mean age of the IPD patients was 68.3 ± 6.9 years and 71% of them were female (22) and 29% were male (9). According to ICF codes, patients who have eight or more corrupted codes were recorded as 'major code impairment patients', and those with less than eight codes recorded as 'minor code impairment patients'. The total UPDRS score of major code impairment patients was 58.4 ± 29.8, while the mean score of minor code impairment patients was 21.2 ± 14.05. The PDQ39 score of major code impairment patients was 66.4 ± 24.1, while the mean score of minor code impairment patients was 19.3 ± 13.5. According to Hoehn Yahr stage, the ratio of stage 1 were higher in minor ICF patients. Conclusion: While assessing the functioning of the Parkinson's disease patients, we need comprehensive scales that include many parameters. The ICF coding system is an international system, which is very important to develop a common language. The significant correlation between ICF coding system and other scales in our Parkinson's patients, shows the validity of the coding system.
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Motor unit potential analysis of the palatal muscles in obstructive sleep apnea syndrome
Feray Karaali-Savrun, Nurten Uzun Adatepe, Gülçin Benbir Şenel, Rahsan Inan, Hakan Kaynak, Asim Kaytaz, Derya Karadeniz
April-June 2020, 37(2):75-81
DOI:10.4103/NSN.NSN_14_20  
Objectives: Among different theories about pathogenesis of obstructive sleep apnea syndrome (OSAS), dysfunction of upper airway muscles still awaits to be delineated. The aim of this study is to examine differences in motor unit potential (MUP) parameters of upper airway muscles between OSAS patients and healthy controls. Methods: Ten male patients diagnosed as OSAS by whole-night polysomnography were analyzed for MUP parameters of genioglossus (GG) muscle, palatoglossus muscle (PG), palatopharyngeus muscle, and uvular (U) muscle. Eight healthy volunteer men matched by age were enrolled as a control group. Results: In PG muscle parameters, the mean MUP area was significantly smaller (P = 0.040) in OSAS patients than those in controls. On the other hand, U muscle parameters showed a significantly larger mean MUP area (P = 0.022) in OUAS patients compared to those in the control group. In OSAS patients, the percentages of polyphasic MUPs of GG and PG muscles were significantly high (P < 0.001 and P = 0.05, respectively). Body mass index was positively correlated with number of phases of GG muscle (rs = 0.63, P < 0.05) and duration of U muscle (rs = 0.71, P < 0.05) in OSAS patients. Other MUP parameters of palatal muscles were similar between the two groups. Conclusion: Our results showed that, although mild in severity, structural neurogenic and myogenic changes characterized as mild and nonuniform MUP changes may co-exist in OSAS patients. These changes in palatal muscles may be attributed to compensatory adaptation of muscle fibers to other precipitating factors in OSAS.
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