Neck pain with radiculopathy: A systematic review of classification systems.

BACKGROUND: Disparities in eligibility criteria for cervical radiculopathy (CR) in clinical trials have been acknowledged previously. The increasing use of CR related neck pain classification systems to inform eligibility criteria in clinical trials warrants evaluation. OBJECTIVE: To evaluate existing neck pain classification systems for CR. DESIGN: Systematic review and critical appraisal, reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. METHODS: Database searches were performed from inception until 31/7/2020. Neck pain classification systems containing CR as a component were included. Methodological quality of each classification system was assessed using seven measurement property domains and scored using a framework developed by Buchbinder and colleagues. Classification criteria for CR from classification systems assessed as moderate or good quality were narratively synthesised using inductive content analysis which consisted of selecting unit of analysis, open coding, grouping and categorisation. RESULTS: Out of 19,975 references, 14,893 remained after elimination of duplicates with 17 articles reporting 11 classification systems included. Five moderate and one good quality classification systems were identified. Nine classification criteria for CR were derived, including dermatomal sensory deficit, positive Spurling's test, positive upper limb tension test. CONCLUSION: All classification systems had methodological limitations with Childs et al. (2008) classification system identified as good quality and most clinically useful. Future studies should investigate the reliability of Childs et al. (2008) classification system as it has the potential to further strengthen its methodological quality and clinical utility. The nine derived classification criteria can inform eligibility criteria in future trials.

Endobronchial tuberculosis simulating bronchial asthma.

Pulmonary tuberculosis is still a major health problem worldwide, but the principles of diagnosis and treatment are well-established. Endobronchial tuberculosis (EBTB) is known to complicate pulmonary tuberculosis and its importance lies in the potential for bronchostenosis. In the absence of parenchymal disease, EBTB is less well-recognised and can lead to difficulties in diagnosis. We report a 26-year-old woman who presented with symptoms of cough, shortness of breath and wheezing simulating bronchial asthma. Although the chest radiograph did not show any lung infiltrate, a bronchoscopy was carried out. The findings, suspicious of malignancy, were actually due to EBTB, which was confirmed on histology by special stains and on culture for Mycobacterium tuberculosis. The patient subsequently developed bronchostenosis, a well-described complication.

Critically ill elderly who require mechanical ventilation: the effects of age on survival outcomes and resource utilisation in the medical intensive care unit of a general hospital.

INTRODUCTION: Advanced age has been a criterion for denying admission to the medical intensive care unit (MICU) due to the perceived poorer outcome and increased resource utilisation. We studied the relationship between age and outcome of the critically ill mechanically-ventilated patients admitted to the MICU. MATERIALS AND METHODS: This prospective study included patients admitted to the MICU for mechanical ventilation between 1994 and 1998. These were divided into 2 cohorts, with 206 patients aged 65 and above and 159 below 65 years. Outcome measures were MICU and hospital mortality and length of stay (LOS) in the MICU and hospital. Logistic and linear regression analyses were performed to determine the association between age and MICU and hospital mortality, as well as MICU and hospital LOS. Factors adjusted for included gender, smoking history, pre-hospitalisation functional status, ambulatory status, use of inotropes and APACHE II (m) scores (APACHE II scores were modified to exclude age points). RESULTS: Multivariate analysis revealed no statistically significant relationship between age and MICU or hospital mortality and LOS. However, APACHE IIM scores were significantly related to both MICU and hospital mortality (OR, 1.1; CI, 1.07-1.14 and OR, 1.1; CI, 1.09-1.18 respectively), but did not predict MICU or hospital LOS. CONCLUSION: Severity of acute illness and chronic co-morbidities, but not age, are predictors of MICU and hospital mortality in elderly ventilated patients.

High prevalence of psychiatric morbidity in a medical intensive care unit.

This study seeks to determine the prevalence of psychiatric morbidity within a medical intensive care unit, examine its correlation with the various physiological parameters and delineate any clinical predictors for psychiatric morbidity. Seventy-seven patients who gave informed consent were administered the General Health Questionnaire (GHQ), Acute Physiological And Chronic Health Evaluation II (APACHE II) and thyroid function tests were performed. A high prevalence of psychiatric morbidity was found (36.4%). However, no statistically significant association was found between psychiatric morbidity and gender, age, APACHE II scores and thyroid function indices. Nevertheless, it is hoped that the index of suspicion for psychiatric morbidity can be raised in order to optimise the clinical management of patients within this setting.

A case of Mycobacterium scrofulaceum osteomyelitis of the right wrist.

INTRODUCTION: The objective of the case report is to highlight the possibility of osteomyelitis caused by atypical mycobacteria. Such an infection may simulate tuberculous bone infection and yet fail to respond to standard anti-tuberculous drug therapy. CLINICAL PICTURE: A 66-year-old man who suffered from diabetes mellitus presented with osteomyelitis of the right wrist, with extensive synovial swellings of the flexor tendon sheaths. The clinical features, radiological appearances and histology suggested a tuberculous infection, but subsequent culture grew an atypical mycobacterium, Mycobacterium scrofulaceum. TREATMENT AND OUTCOME: There was good clinical improvement and control of the infection with a regime of kanamycin, ethambutol and ethionamide to which the organism was sensitive. CONCLUSION: This case illustrates the need to be aware of the possibility of infection with atypical mycobacteria in cases of suspected tuberculosis of the skeletal system which fail to respond to standard treatment.

Hypertension in the young adult--come feel the pulse.

Hypertension occurring in teenagers and young adults is uncommon. Though the most common form is still essential hypertension, secondary causes are more commonly found here than in older adults. Renal, cardiovascular and endocrine diseases constitute most of these causes. Coarctation of the aorta is the most common cardiovascular cause of hypertension, and its importance lies in the fact that it is correctable, and that its persistence often leads to dangerous complications and early death. The cardinal sign of differential pulse and blood pressures between the upper and lower limbs can be detected clinically. Hence, the importance of a detailed physical examination in all young hypertensives, including palpation of all the pulses, cannot be overemphasized. We present 2 hypertensive young men who were found to have isolated coarctation of the aorta. The lesion in the first patient was located postductally just distal to the left subclavian artery. This area has been found to be the most common site of coarctation. The second patient had an unusual mid-thoracic coarctation. The clinical and radiological features as well as complications are highlighted. In young hypertensive patients, a high index of suspicion may enable the physician to make a timely diagnosis and hence avert the potentially disastrous complications that may arise in undetected cases.

Acute mercury vapour poisoning in a shipyard worker--a case report.

Acute mercury vapour poisoning is a serious, potentially fatal but fortunately rarely encountered problem. It is most commonly due to industrial accidents. The vapour is a direct respiratory tract irritant as well as a cell poison, exerting its greatest effects in the lungs, nervous system, kidneys and liver. We present a case of mercury vapour poisoning in a shipyard workers presenting as an acute chemical pneumonitis, which resolved with aggressive supportive therapy. Further investigations later revealed transient mild neuropsychiatric symptoms, and residual peripheral neuropathy. No chelation therapy was instituted. The detailed investigative work that led to the discovery of the source of mercury is also presented. This case alerts us to the potential hazard to shipyard workers who may work in ships previously carrying oil contaminated with mercury. There have been no previous reports of mercury poisoning in shipyard workers. A high index of suspicion leading to early diagnosis and institution of appropriate supportive measures in suspected cases can be life-saving.

One-week ranitidine bismuth citrate versus colloidal bismuth subcitrate-based anti-Helicobacter triple therapy: a prospective randomized controlled trial.

OBJECTIVE: The efficacy of 1 wk bismuth triple therapy is adversely influenced by the presence of metronidazole resistance. In vitro studies suggest that ranitidine bismuth citrate (RBC) plus metronidazole exhibit synergistic activity against metronidazole resistant strains of Helicobacter pylori (H. pylori). Whether this confers a superior clinical efficacy remains unproven. This study compared the efficacy of RBC-based triple therapy with bismuth triple therapy in eradication of H. pylori. METHODS: Patients with H. pylori-related ulcer disease or gastritis were randomized to receive either 400/mg of RBC twice daily plus 400/mg of metronidazole and 500/mg of tetracycline four times daily for 1 wk (RMT) or 120/mg of colloidal bismuth subcitrate, 400/mg of metronidazole, and 500/mg of tetracycline, all given four times daily for 1 wk (BMT). Metronidazole susceptibility was determined by the E-test and pretreatment resistance was defined as minimum inhibitory concentration > or = 32/mg/L. RESULTS: Of 100 consecutive patients randomized, two patients were lost to follow-up in each group. Forty-three of 85 (51%) H. pylori isolates were metronidazole resistant. Per-protocol cure rate for RMT and BMT was 40 of 41 (98%) and 37 of 44 (84%), respectively (p = 0.058). Intent-to-treat cure rate for RMT and BMT was 46 of 50 and 41 of 50, respectively (92% vs 82%, p = 0.23). A significantly higher eradication of metronidazole resistant H. pylori was observed in the RMT group (25 of 25, 100%) than in the BMT group (12 of 16, 75%), (p = 0.018). Side effects observed in the two treatment groups were comparable. CONCLUSIONS: One week of RBC triple therapy with metronidazole and tetracycline is an effective anti-Helicobacter therapy. This regimen is more appropriate in areas of high prevalence of metronidazole resistance.

Diagnosis of tuberculous peritonitis.

The diagnosis of tuberculous peritonitis may be difficult and elusive. The patient may present with non-specific symptoms of fever, general ill-health or vague abdominal pains. There may be no pulmonary symptoms and the chest X-ray may be normal. The CT scan of the abdomen is sometimes helpful in suggesting the diagnosis. We have found that laparoscopic examination of the abdominal contents and the peritoneum is an effective way to obtain a conclusive diagnosis.

Peak expiratory flow rate guided protocol did not improve outcome in emergency room asthma.

UNLABELLED: BACKGROUND AND AIMS OF STUDY: All current international practice guidelines recommend that treatment of acute asthma in the emergency room (ER) should be guided by the peak expiratory flow rate (PEFR). The aim of this study was to assess the efficacy of a PEFR guided protocol in treating ER asthma. METHODS: We compared two different management protocols in adult asthmatics who presented to the ER with acute exacerbations. The routine protocol (RP) assessed and dispensed patients according to overall subjective and clinical response without predetermined criteria. The peak protocol (PP) used serial measurements of PEFR to guide intensity of bronchodilator treatment and fitness for hospital discharge. On the PP, a threshold PEFR of > or = 60% predicted had to be achieved before the patient could be discharged from the ER. RESULTS: There were 79 patients in the RP group and 70 in the PP group. There was no significant difference between the two groups in baseline PEFR, PEFR after treatment and percentage increase in PEFR with treatment. The PP resulted in a higher hospital admission rate than RP. CONCLUSION: We conclude that in the management of acute asthma in the ER, a PEFR guided protocol neither improved overall PEFR response to treatment nor reduced admission rates when compared with current management as it is practised in Singapore.

Starting thrombolytic therapy for patients with acute myocardial infarction in Accident and Emergency Department: from implementation to evaluation.

OBJECTIVE: To evaluate the effectiveness of initiating thrombolysis for patients with acute myocardial infarction (AMI) in the Accident and Emergency Department. METHODS: From January 1993 to December 1995, all AMI patients who were admitted to the United Christian Hospital and given thrombolytic therapy were studied. The patients' demographic data, time and mode of presentation, site of myocardial infarction, treatment modality and timing, and complications related to AMI or treatment were recorded prospectively in our AMI database. The frequency of thrombolysis administered in Accident and Emergency Department and Coronary Care Unit, as well as the median door-to-needle time (time interval between hospital arrival to initiation of thrombolytic therapy) were compared. Cases of inappropriate thrombolysis and complication were also analyzed. RESULTS: Over these 3 years, 257 patients received thrombolysis in the United Christian Hospital. The percentage of patients receiving thrombolysis in Accident and Emergency Department increased from 3.2% in 1993 to 12.3% in 1994, and to 39.4% in 1995. The median time interval between arrival to hospital and thrombolysis (door-to-needle time) was 25 minutes, compared with 81 minutes in the Coronary Care Unit. The door-to-needle time also improved over these 3 years: from 95 minutes in 1993 to 75 minutes in 1995 in Coronary Care Unit group, and from 35 minutes in 1993 to 20 minutes in 1995 in the Accident and Emergency Department group. Over these 3 years, 2 cases of inappropriate thrombolysis were reported but these did not result in any mortality. Four complications from thrombolytic therapy were reported, and these were managed appropriately by the staff in Accident and Emergency Department and did not result in mortality. CONCLUSIONS: Starting thrombolytic therapy in Accident and Emergency Department is safe and effectively decreases the door-to-needle time.

Humoral immune response to membrane components of Chlamydia trachomatis and expression of human 60 kDa heat shock protein in follicular fluid of in-vitro fertilization patients.

Recent evidence suggests that Chlamydia trachomatis can persist in the female upper genital tract in an unculturable state. Since unsuspected C. trachomatis infection has been associated with adverse in-vitro fertilization (IVF) outcome we sought to detect further evidence of C. trachomatis in the genital tracts of women undergoing IVF. The prevalence and distribution of antibodies to the major structural proteins of C. trachomatis in paired follicular fluid and sera of women undergoing IVF were examined. Sera and follicular fluid samples from 149 women were assayed for immunoglobulin (Ig)G and IgA antibodies to two C. trachomatis antigens, the major outer membrane protein (MOMP) and a recombinant lipopolysaccharide (rLPS) fragment. Additionally, the expression of human 60 kDa heat shock protein (hsp 60) in follicular fluid was determined. All cervical and follicular fluid samples were negative for C. trachomatis by polymerase chain reaction, ligase chain reaction and DNA probe. Sera from 60% of the subjects were positive for antichlamydial rLPS IgG; 36% were positive for anti-MOMP IgG. Similarly, rLPS-directed and MOMP-directed IgA were detected in sera of 34 and 14% of the subjects respectively. IgG antibodies to MOMP and rLPS were detected in 42 and 41% of the follicular fluid examined respectively. Anti-MOMP IgA was identified in 8.7% of the follicular fluid while 27.5% were positive for anti-rLPS IgA. Human hsp 60 expression was documented in 11.6% of the follicular fluid tested. IgA antibodies to both MOMP (P = 0.03) and rLPS (P = 0.02) in follicular fluid were associated with a failure to become pregnant after embryo transfer. IgG antibodies in sera and follicular fluid and IgA antibodies in sera were unrelated to IVF outcome. Similarly only anti-MOMP IgA (P = 0.02) and anti-rLPS IgA (P = 0.04) in follicular fluid were correlated with human hsp 60 expression in follicular fluid. The unique association between IgA antibodies to two chlamydial antigens in follicular fluid and both hsp 60 expression and IVF failure provides further support for the possibility that a persistent upper genital tract chlamydial infection contributes to IVF failure in some women.

A profile of acute asthma patients presenting to the emergency room.

We conducted a three-month prospective study on the profile of 70 acute adult asthmatic patients presenting to the Accident and Emergency Unit of a general hospital. The overall background asthmatic activity, clinical features of current exacerbation, maintenance drug treatment, gross psycho-social problems, previous experience of near-fatal asthma, and admission and relapse rates were documented. Ninety percent of the presentations were within 24 hours of the initial attack, with an average pre-hospital therapy duration of 6.5 hours. Sixty-seven percent sought further treatment after failure to find relief from their salbutamol metered-dose inhalers. Sixteen percent did not receive any treatment before presentation. Ten percent gave a past history of mechanical ventilation for severe or near fatal asthma. The majority (94%) had asthmatic symptoms in the mild to moderate range. About half (46%) had attended the Emergency Room (ER) at least once in the previous six months. On average, patients were on two items of drugs and 23% were on maintenance inhaled steroids. One-third (33%) of the patients were found to have psycho-social problems relating to their condition. The admission rate was 37% with relapse rate following ER discharge of 13%. The study showed a high proportion of patients with psycho-social problems relating to asthma, and a subset of patients with frequent visits to the ER. It also revealed the infrequent use of prophylactic therapy.

Mortality of patients while on treatment for active tuberculosis.

In the era of effective antituberculous chemotherapy, some patients with tuberculosis still die while on treatment. The aim of this study was to review deaths occurring in patients while on treatment for active tuberculosis in Alexandra Hospital during the 4-year period from 1991 to 1994. Medical records of 30 such patients were reviewed retrospectively. Twenty-one patients were certified as dying from tuberculosis; in the remaining 9 patients, the principal cause of death was other than tuberculosis. Of the patients who died of tuberculosis, 7 (33.3%) died within a week and 19 (90.5%) died within a month of initiation of antituberculous treatment. Seventeen (81%) were males and 15 (71%) were smokers. All the 21 patients had pulmonary involvement and in 4 patients, there was disseminated disease. Chest roentgenographic findings of bilateral involvement were seen in 16 (76.2%) patients and of cavitary disease in 15 (71.4%) patients. Eighteen (86%) had a positive sputum smear result. Seven patients received corticosteroid cover. In 14 patients who had their weights recorded at initiation of antituberculous treatment, the mean weight was 36.3 kg (range 25.5k g-47k g). Notable biochemical derangements included hyponatraemia (86%) and hypoalbuminaemia (95%). Plasma cortisol and/or Synacthen stimulation test were performed in 4 patients; none was indicative of adrenal hypofunction. We conclude that death attributed to tuberculosis in patients while on treatment occurs early and is largely due to advanced disease.

Cervicofacial actinomycosis with paravertebral spread: a case report.

We report a case of cervicofacial actinomycosis with paravertebral extension in a 60-year-old man who presented with recurrent neck masses. Diagnosis was confirmed on culture and histology of pus and debris obtained from surgical drainage. He improved only after lengthy in-hospital high dose penicillin therapy. He is currently well and is on maintenance doxycycline therapy for 6 months following the high dose penicillin therapy.

Massive pleural effusion in pancreatitis: 2 case reports.

We report 2 patients with left-sided pleural effusion occurring in the setting of acute pancreatitis. Both patients had a strong history of alcohol consumption. In each case the pleural fluid amylase was markedly elevated, higher than that in the serum. The effusions resolved with closed chest tube drainage and the pancreatitis subsided with conservative therapy. In patients presenting with significant pleural effusions and acute upper abdominal symptoms, a thoracentesis with determination of the amylase titre may provide a quick means of diagnosing acute pancreatitis.

A fulminant case of neuroleptic malignant syndrome.

We report a fulminant case of Neuroleptic Malignant Syndrome in a 31-year-old male schizophrenic on haloperidol, thioridazine, benzhexol and flurazepam who presented with rigidity, fever, stupor and autonomic instability. He succumbed rapidly over 6 days to rhabdomyolysis, acute renal failure, status epilepticus and disseminated intravascular coagulopathy despite treatment with dantrolene and bromocriptine at the outset.

Massive haemothorax as a complication of primary lung cancer--a case report.

A 58-year-old man was admitted with a massive haemothorax. At thoracotomy, the cause was found to be due to a bleeding primary lung cancer, the cell type of which was adenocarcinoma. A literature search revealed that this complication of lung cancer has not previously been described. Reasons as to the infrequency of this complication are discussed.