Treating Vestibular Migraine When Pregnant and Postpartum: Progress, Challenges and Innovations.

Vestibular migraine is a leading cause of vertigo in pregnancy and, although not a distinct migraine subtype, is an episodic syndrome associated with migraine. Vestibular migraine is associated with diverse symptoms such as vertigo, aura, allodynia, osmophobia, nausea, vomiting and tinnitus, many of which may be exacerbated by, masked or even dismissed in pregnancy. Vestibular migraine is likely an underdiagnosed and undertreated condition in pregnancy. The aetiology of vestibular migraine remains incompletely understood, although various theories have been proposed, including genetic predisposition, neurochemical dysregulation and pro-inflammatory mechanisms, all of which are derived from the pathophysiology of classical migraine. Physiologic changes to the endocrine, haematologic and vascular systems in pregnancy may affect pathophysiological processes in vestibular migraine, and can alter the course of symptoms experienced in pregnancy. These changes also predispose to secondary headache disorders, which may have similar presentations. There has been considerable progress in therapeutic advances in vestibular migraine prophylaxis and treatment outside of pregnancy. There is currently no significant evidence base for acute treatment or prophylaxis for pregnant patients, with treatment recommendations extrapolated from studies on classical migraine, and offered on a benefit versus risk basis. Challenges commonly encountered include difficulty establishing a diagnosis, in addition to recognising and treating neuropsychiatric and gestational co-morbidities. Anxiety, depression, hypertensive disorders and cardiovascular disease are closely associated with migraine, and important contributors to morbidity and mortality during pregnancy. Identifying and treating vestibular migraine during pregnancy offers a unique opportunity to impact future patient health through screening and early treatment of associated co-morbidities. There have been innovations in classical migraine therapy that may confer benefit in vestibular migraine in pregnancy, with emphasis on lifestyle modification, effective prophylaxis, abortive therapies, cognitive behaviour therapy and management of vestibular migraine-related comorbidities.

Segmental zoster paresis as a cause for persistent fever in an immunocompromised patient.

Herpes zoster reactivation is a frequently encountered condition that can result in several uncommon complications. This case report highlights one such frequently overlooked complication, segmental zoster paresis. We discuss a case of prolonged fever and lower limb weakness in an immunocompromised patient with breast cancer on active chemotherapy after resolution of a herpetiform rash in the L2, L3 and L4 dermatomes. Early investigation with lumbar puncture, looking for cerebrospinal fluid pleocytosis, varicella zoster virus detection by PCR or molecular testing and immunoglobulins against varicella zoster virus, should be undertaken to support the diagnosis. Nerve conduction studies, electromyography and MRI of the spine can sometimes help with neurolocalisation. Intravenous acyclovir and a tapering course of steroids can help with resolution of symptoms. The variegate presentation can make diagnosis challenging. Awareness and a high index of suspicion can prevent delays in diagnosis and treatment and improve patient outcomes.

Factors affecting choice of sponsoring institution for residency among medical students in Singapore.

INTRODUCTION: Postgraduate medical education in Singapore underwent a major transition recently, from a British-style system and accreditation to a competency-based residency programme modelled after the American system. We aimed to identify the relative importance of factors influencing the choice of sponsoring institution (SI) for residency among medical students during this transition period. METHODS: A questionnaire-based cross-sectional study of Singapore undergraduate medical students across all years of study was performed in 2011. Participants rated the degree of importance of 45 factors (including research, academia and education, marketing, reputation of faculty, working conditions, posting experience and influence by peers/seniors) to their choice of SIs on a five-point Likert scale. Differences in gender and seniority were compared. RESULTS: 705 out of 1,274 students completed the survey (response rate 55.3%). The top five influencing factors were guidance by mentor (4.48 ± 0.74), reputation for good teaching (4.46 ± 0.76), personal overall experience in SI (4.41 ± 0.88), quality of mentorship and supervision (4.41 ± 0.75), and quality and quantity of teaching (4.37 ± 0.78). The five lowest-rated factors were social networking (2.91 ± 1.00), SI security (3.01 ± 1.07), open house impact (3.15 ± 0.96), advertising paraphernalia (3.17 ± 0.95) and research publications (3.21 ± 1.00). Female students attributed more importance to security and a positive working environment. Preclinical students rated research and marketing aspects more highly, while clinical students valued a positive working environment more. CONCLUSION: Quality of education, mentorship, experiences during clerkship and a positive working environment were the most important factors influencing the choice of SI.