Ultrasound findings of the urinary tract in patients with spinal cord injury: a study of 1005 cases.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To document urinary tract abnormalities (UTAs) in patients with spinal cord injury (SCI) and to assess demographic and clinical features associated with UTA detected via ultrasound (US). SETTING: Turkish Armed Forces Rehabilitation Center, Ankara, Turkey. METHODS: The medical and radiological records of all patients with SCI were screened. Variables in each patient with SCI, including age at the time of the US examination, gender, etiology, level and severity of SCI, time since injury, bladder management methods and findings of urinary tract US, were reviewed and analyzed. RESULTS: Data were obtained from 1005 patients during the 6-year study period (2008-2013). The mean age was 35.67 ± 14.79 years and the male-female ratio was 2.84:1. Trabeculated bladder (TB) was observed in 35.1% of the patients, bladder calculi in 6%, renal calculi in 6%, hydronephrosis in 5.5% and renal atrophy in 1.2%. Bladder calculi, renal calculi and renal atrophy were observed in patients with TB at higher rates than in those without TB (P = 0.001, 0.036 and 0.004, respectively). The association of TB with hydronephrosis was very close to significance level (P = 0.052). CONCLUSION: A large number of SCI patients had UTAs including TB, renal and bladder calculi, hydronephrosis and renal atrophy. The time since injury, level and severity of SCI and bladder management method may influence development of UTA. In addition, TB may be a helpful parameter for predicting UTA in SCI patients.

Demographic and clinical characteristics of patients with traumatic cervical spinal cord injury: a Turkish hospital-based study.

STUDY DESIGN: Retrospective study. OBJECTIVES: To determine the demographic and clinical characteristics of patients with cervical spinal cord injury (CSCI) admitted to a single Center. SETTING: Turkish Armed Forces Rehabilitation Center, Ankara, Turkey. METHODS: The medical records of all patients with spinal cord injury admitted from January 2009 to December 2013 were screened. Variables of each patient with cervical injury (CSCI), such as age at the time of injury, gender, etiology, degree and level of neurological impairment, associated injuries, surgical stabilization and length of rehabilitation stay (LOS), were analyzed. RESULTS: In all, there were 804 patients with traumatic spinal cord injury (SCI) during the 5-year study period, of which 562 (69.9%) were paraplegic and the remaining 242 (30.1%) had a CSCI (C1-C8) and were included in the study. Among the CSCI patients, 80.6% were male (male:female ratio is 4.15:1), mean age at the time of injury was 32.58±14.71 years (range: 4-79 years), the largest age group was 16-30 years (n=117, 48.3%), followed by 31-45 years (n=70, 28.9%). Motor vehicle accident (MVA) was the most common cause of injury (49.2%), followed by falls (21.5%) and diving accidents (18.2%). Low CSCI (C5-8; 61.2%) and incomplete injury (55%) occured more often than high CSCI (C1-4) and complete injury. In total, 202 (83.5%) patients underwent surgical stabilization. Thirty-seven (15.3%) had associated injuries. CONCLUSION: The present findings show that most of the CSCI patients were aged 16-30 years. In addition, based on the frequency of the causes of injuries we think that prevention efforts should mainly focus on MVA, falls and diving accidents.

Exacerbation of myasthenia gravis by alendronate.

Myasthenia gravis is an important indication for the long-term prescription of corticosteroids. We present a patient with myasthenia gravis who had worsening of symptoms associated with the use of alendronate. A 24-year-old patient with myasthenia gravis had been administered oral systemic corticosteroid (deflazacort 40 mg/day) for 3 years in order to control his myasthenic symptoms. One year earlier, his lumbar spine bone mineral density was decreased. He was started on oral calcium/vitamin D3 and alendronate (70-mg tablets once a week) for osteoporosis. He reported an exacerbation of muscle weakness and extreme fatigue on days when he took alendronate. He could not work on these days and has to be on leave. Alendronate was stopped, and he was started on intravenous ibandronate injections given every 3 months. He did not experience muscle weakness and fatigue with ibandronate therapy. Alendronate should be used with caution in patients with myasthenia gravis who have corticosteroid-induced osteoporosis.

Diabetic retinopathy in native and non-native Sarawakians--findings from the Diabetic Eye Registry.

This study aims to determine the risk factors associated with diabetic retinopathy (DR) among natives and non-natives Sarawakians who were seen at 3 public hospitals and one health clinic in Sarawak. It is a cross sectional study where data on patients with DM were collected by staff at these healthcare facilities and entered into the web-based Diabetic Eye Registry. Univariate and multivariate analysis was used to determine the association factors for DR. DR was significantly less associated with natives (24.4%) compared to non-native Sarawakians (34.1%) (p < 0.001). The odds of getting DR was higher in patients whose duration of DM was more than 20 years (OR = 2.6), who have renal impairment (OR = 1.7) and non-natives (OR = 1.4).

Severe diabetic papillopathy mimicking non-arteritic anterior ischemic optic neuropathy (NAION) in a young patient.

With the pathophysiology not clearly understood and fewer than 130 cases having been reported in the literature, diabetic papillopathy presents a special challenge to the ophthalmologist. We report a case of a young patient with more than 12 years of type 1 diabetes mellitus (T1DM) on insulin with poor compliance to treatment who presented with sudden bilateral loss of vision. Ocular examination, fluorescence angiography (FA) and systemic signs were conclusive of diabetic papillopathy. His fasting blood sugar level was high and serum glycosylated haemoglobin (HbA1c) indicated a long term fluctuating blood glucose control. His vision initially improved with treatment, but later deteriorated with tight glycemic control.

Computer-assisted quantitative upper airway analysis following modified uvulopalatal flap and lateral pharyngoplasty for obstructive sleep apnoea: a prospective case-controlled study.

OBJECTIVES: The study aims to perform static and dynamic quantitative assessment of the anatomical changes of the upper airway before and after modified uvulopalatal flap and lateral pharyngoplasty and comparison of the improvement in airway dimensions, collapsibility and extent of normalisation to that of control patients. DESIGN: Prospective case-controlled study. SETTING: Computer-assisted quantitative measurement is used to compare upper airway parameters before and after modified uvulopalatal flap and lateral pharyngoplasty in patients with obstructive sleep apnoea (OSA). PARTICIPANTS: Patients with obstructive sleep apnoea diagnosed on sleep study and failed positive airway pressure therapy. MAIN OUTCOME MEASURES: Sleep study results, upper airway parameters and symptom score following surgery and its comparison to normal patients to assess the degree and extent of normalisation. RESULTS: Thirty-five study and 32 control subjects were recruited and completed the study. All the retropalatal airway dimensions like area, transverse diameter, longitudinal diameter and collapsibility showed statistically significant improvement following surgery. The success rate of this surgery is 43% (15 of 35) overall, 58% (14 of 24) for patients with isolated palatal obstruction and only 9% (1 of 11) for patients with multi-level obstruction. Comparing obstructive sleep apnoea to the control subjects, there are obvious and logical differences in their biostatistics, sleep study parameters and airway dimensions. The postoperative obstructive sleep apnoea retropalatal longitudinal diameter has a higher tendency of normalising to be comparable to those of control patients. CONCLUSIONS: Modified uvulopalatal flap and lateral pharyngoplasty is an effective surgical technique for the treatment of obstructive sleep apnoea. The surgery increases the resting retropalatal dimensions and reduces the retropalatal collapsibility.

Reversible post-pregabalin peripheral edema in a spinal cord injury patient.

STUDY DESIGN: Case report. OBJECTIVES: To report a case of paraplegia with limb edema caused by pregabalin. SETTING: Turkish Armed Forces Rehabilitation Center, Ankara, Turkey. CASE REPORT: A 40-year-old male patient with T11 paraplegia had the complaint of swelling in both the lower limbs. He had been given pregabalin because of the neuropathic pain in both the lower limbs. At 10 months, the patient has experienced edema in lower limbs. There was severe edema in both legs, ankles and feet, more evident on the left. Venous Doppler ultrasound was normal on both sides. Blood tests for possible etiologies were normal. No other etiology could be found. The edema was considered to be caused by pregabalin and the medicine was ceased gradually. The edema resolved completely in 2 weeks. CONCLUSION: Pregabalin, which is one of medications used for neuropathic pain, might cause limb edema, that is, a condition needs differential diagnosis. This is particularly important for patients with spinal cord injuries (SCIs). Such adverse effect of pregabalin should be kept in mind as an etiology of limb edema in SCI management.

An unusual entry site of an intraorbital foreign body in a child.

Intraorbital foreign bodies (IOrbFB) are associated with both sight and life threatening injuries. We report a case of an IOrbFB associated with retrobulbar hemorrhage and injury of the frontal sinus in an 11 year-old boy, after history of fall from the tree. Imaging studies revealed a metallic foreign body (FB) in the orbit and fracture of the walls of the frontal sinus. The usual entry route of an IOrbFB is either through the eye or orbital walls and extremely rare through the paranasal sinuses. This is the first reported case of a FB entering the orbit through the frontal sinus.

Sudden severe chest pain: thoracic dural arteriovenous fistula aneurysm rupture with intracranial subarachnoid haemorrhage.

Spinal perimedullary arteriovenous fistula (AVF) or dural arteriovenous fistula (DAVF) presenting as intracranial subarachnoid haemorrhage (SAH) is uncommon. A total of 16 cases have been reported to date. A majority of the reports described cervical spinal DAVF, while two other case reports described intracranial SAH secondary to lumbar and thoracic DAVF, respectively. We report a 61-year-old Chinese man with intracranial SAH secondary to thoracic DAVF aneurysm, who presented with sudden, severe chest pain, initially suggestive of aortic dissection/acute myocardial infarction. However, a careful examination of the history and physical signs, followed by appropriate and timely investigations enabled effective treatment to be administered promptly with a good outcome. This serves to illustrate the importance of investigating the entire cerebrospinal system when neurological symptoms and clinical signs suggest extracranial primary pathology.

Central retinal artery occlusion and ophthalmoplegia following spinal surgery in the prone position.

A 14 year old boy underwent a 7 hour long spinal surgery for scoliosis in the prone position. In the immediate postoperative period, he developed right proptosis, periorbital swelling, chemosis and total ophthalmoplegia. The vision in his right eye was only counting fingers and the intraocular pressure was 68 mmHg. Fundus examination revealed occlusion of the right central retinal artery. A rare manifestation of both vein and artery occlusion was possible in this patient as a result of external ocular compression due to a prolonged period in the prone position. This report highlights the importance of being aware of the possible complications of external ocular compression in non-ocular surgery.

Chromosome 13q deletion with Cornelia de Lange syndrome phenotype.

A 3-year-old girl with facial dysmorphic features suggestive of Cornelia de Lange syndrome was seen in the ophthalmology unit for a right leukocoria. The leukocoria was found to be caused by a large retinoblastoma and the right eye was enucleated. Chromosomal analysis revealed partial chromosome 13q deletion involving band 14 which is associated with a high risk of retinoblastoma. This case shows that patient with chromosome 13q deletion syndrome cannot be diagnosed based on dysmorphic features only. Chromosomal analysis is warranted in all infants with facial dysmorphism suggestive of Cornelia de Lange syndrome so that those with chromosome 13q deletion can be referred early for early detection of retinoblastoma.

A 9-year review of dystonia from a movement disorders clinic in Singapore.

The clinical features of dystonia have not been evaluated in Southeast Asia. We therefore investigated the clinical spectrum and characteristics of dystonia in Singapore, a multi-ethnic Southeast Asian country comprising 77% Chinese, 14% Malays, and 8% Indians. We identified all dystonia patients from the Movement Disorders database and Botulinum Toxin clinic between 1995 and November 2004. Their medical records were reviewed to verify the diagnosis of dystonia and obtain demographic and clinical data using a standardized data collection form. A total of 119 (73%) patients had primary dystonia whilst 45 (27%) had secondary dystonia. There were 77% Chinese, 9% Malays, and 8% Indians. The most common focal dystonia were cervical dystonia (47%), writer's cramp (32%), and blepharospasm (11%). There was no significant difference in the distribution of dystonia between the different races. Males were noted to have earlier onset of dystonia overall. There was a significant male predominance in primary dystonia overall (M:F 1.6:1, P=0.008) and in the subgroup of focal dystonia (M:F 1.6:1, P=0.037). This contrasts with previous studies that found a female predominance. The role of genetic, hormonal, and environmental factors and their interactions need to be investigated to better understand the gender differences in the occurrence of dystonia.

Clinical characteristics of patients with multiple system atrophy in Singapore.

INTRODUCTION: Our study aimed to describe the clinical features of multiple system atrophy (MSA) in Singapore and verify its diagnosis using the consensus statement in the diagnosis of MSA. MATERIALS AND METHODS: All patients suspected to have MSA between 1995 and March 2005 were identified from the Movement Disorders database and the autonomic function testing results. The medical records were reviewed using a standardised data collection form. The diagnosis of MSA was verified using the consensus statement. Disease progression was evaluated using 2 pre-determined events: aid-requiring walking and wheelchair use. RESULTS: Seventy-two per cent (33/46) fulfilled the consensus statement. There were 85% Chinese, 9% Malays, and 6% Indians. The mean age at onset of the disease was 60 +/- 10 years. We found a predominance of males (M:F = 1.5:1) as well as MSA-C cases (67%). The most common initial presenting features were parkinsonism and cerebellar signs (27% each). Abnormal neuroimaging was seen in 29 patients (91%). Autonomic function testing was abnormal in 58% (7/12). The risk for aid-requiring walking and wheelchair use at 3 years from onset of the disease was 31% and 17%, respectively. By 5 years, this had increased to 45% and 30%, respectively. There was no difference in the events rate between MSA subtypes. CONCLUSIONS: The clinical characteristics of MSA in Singapore are presented. Our study revealed a predominance of MSA-C patients as well as a later age at onset of disease and longer median time to aid-requiring walking and wheelchair use compared to Japanese patients.

Clinical predictors in obstructive sleep apnoea patients with calibrated cephalometric analysis--a new approach.

AIM: Utilization of a new method to accurately quantify differences in cephalometric parameters between obstructive sleep apnoea (OSA) and normal patients, and to identify good predictors for OSA. To illustrate the ethnic differences in cephalometry. METHOD: This prospective study involves 106 South-east Asians. A calibrated catheter is inserted into the upper airway during standard cephalometry to obtain the precise magnification and allow exact measurement of anatomical parameters of cephalometry in both erect and supine positions. RESULTS: The OSA patients have longer lower-facial length, narrower skull base, shorter and receding mandible, smaller posterior airway space (PAS), narrower retropalatal space, longer and thicker soft palate, smaller hard and soft palate angles longer tongue length and more inferiorly displaced hyoid. For the palatal level, retropalatal distance of 11.2 mm cut-off/predictive value for male (receiver operating characteristics (ROC) = 0.8414 with PPV = 77.46, NPV = 90.00) and 5.5 mm for female (ROC = 0.9180 with PPV = 100.00, NPV = 84.21) at erect position were selected. For retrolingual level, erect PAS of 10.1 mm cut-off/predictive value for male (ROC = 0.7000 with PPV = 78.38, NPV = 37.78), 5.3 mm for female (ROC = 0.7227 with PPV = 75.00, NPV = 75.00) were selected. Our study showed that South-east Asians have different cephalometric values compared with White people, Black people and Hispanics. CONCLUSION: This new method of cephalometry using a calibrated catheter provides an accurate and simple method of obtaining precise cephalometric measurements. There is no cephalometric data on OSA from South-east Asia available. These results suggested that surgeons managing OSA patients and using cephalometry as a diagnostic method should have a set of normative and OSA cephalometric values that apply to their local populations.

Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea.

An association between mouth breathing during sleep and increased propensity for upper airway collapse is well documented, but the effect of treatment for nasal obstruction on mouth breathing during sleep and simultaneous obstructive sleep apnoea (OSA) severity has not been described previously. A randomised single blind placebo- and sham-controlled crossover study of treatment (topical decongestant and external dilator strip) for nasal obstruction was carried out in 10 patients (nine males; mean+/-SEM 46+/-5 yrs) with nasal obstruction and OSA. All patients had normal acoustic pharyngometry. The effect of treatment on nasal resistance, mouth breathing during sleep and OSA severity was quantified. Treatment of nasal obstruction was associated with a dramatic and sustained reduction in nasal resistance and the oral fraction of ventilation during sleep (mean (95% confidence interval) absolute reduction in oral fraction 30% (12-49)). Improvements in sleep architecture were observed during active treatment, and there was a modest reduction in OSA severity (change in apnoea-hypopnoea index 12 (3-22)). In conclusion, treating nasal obstruction reduced mouth breathing during sleep and obstructive sleep apnoea severity, but did not effectively alleviate obstructive sleep apnoea.

10th Yahya Cohen Memorial Lecture: Clinical predictors in obstructive sleep apnoea patients with computer-assisted quantitative videoendoscopic upper airway analysis.

AIM: To identify the clinical predictors and assist surgeons in their clinical management of obstructive sleep apnoea (OSA) - a prospective study with a new approach to analyse the static and dynamic upper airway morphology between patients with OSA and normal subjects. To introduce a new method of assessment for surgical outcome. MATERIALS AND METHODS: Quantitative computer-assisted videoendoscopy (validated with upper airway magnetic resonance imaging) was performed in 49 (43 males, 6 females) patients with OSA and compared with 39 (22 males, 17 females) controls (apnoea-hypopnoea index <5). Absolute cross-sectional areas, transverse and longitudinal diameters at the retro-palatal and retro-lingual levels were measured during end of quiet respiration and during Mueller's manoeuvre in the erect and supine positions, allowing us to study static and dynamic morphology (collapsibility) of the upper airway. We analysed 3744 parameters. RESULTS: In males, retro-palatal and retro-lingual areas during Mueller's manoeuvre in the supine position of 0.7981 cm2 [receiver operating characteristics (ROC) = 0.9284, positive predictive value (PPV) = 86.05%, negative predictive value (NPV) = 84.62%] and 2.0648 cm2 (ROC = 0.8183, PPV = 76%, NPV = 83.33%), respectively, were found to be good predictors/ cut-off values for OSA. Retro-palatal area measured in the supine position during Mueller's manoeuvre (AS1M) and collapsibility of retro-palatal area in the supine position calculated (CAS1) were found to have significant correlations with severity of OSA. In females, areas measured during Mueller's manoeuvre in the supine position of 0.522 cm2 at retropalatal level (ROC = 1, 100% PPV and NPV) and transverse diameter at retro-lingual level during erect Mueller's manoeuvre of 1.1843 cm (ROC = 0.9056, PPV = 100%, NPV = 83.33%) were found to be predictive. All measurements at the retro-palatal level and in the supine position had higher predictability. Area measurements obtained during Muller's manoeuvre were more predictive (ROC >0.9910) than resting measurements (ROC >0.8371). Several gender and anatomical-site specific formulas with excellent predictability (ROC close or equal to 1) were also devised. Examples of surgical outcome assessment were introduced. CONCLUSION: Upper airway Mueller's studies are predictive and useful (independent samples t-test/Mann Whitney U test, ROC) in identifying patients with OSA. With these gender and anatomical-site specific OSA predictors/formulas and this innovative clinical method, we hope to assist other surgeons with quantitative clinical diagnosis, assessment, surgical planning and outcome assessment tools for OSA patients.

Prevalence of Parkinson disease in Singapore: Chinese vs Malays vs Indians.

OBJECTIVE: To investigate the prevalence of Parkinson disease (PD) in Singapore and compare the rates between Singaporean Chinese, Malays, and Indians. METHODS: A three-phase community-based survey among a disproportionate random sample of 15,000 individuals (9,000 Chinese, 3,000 Malays, 3,000 Indians) aged 50 years and above who live in central Singapore was conducted. In phase 1, trained interviewers conducted a door-to-door survey using a validated 10-question questionnaire. In phase 2, medical specialists examined participants who screened positive to any of the questions. Participants suspected to have PD had their diagnosis confirmed in phase 3 by a movement disorders specialist. RESULTS: The participation rate was 67% among 22,279 eligible individuals. Forty-six participants with PD were identified of which 16 were newly diagnosed cases. The prevalence rate of PD for those aged 50 and above in Singapore was 0.30% (95% CI: 0.22 to 0.41), age-adjusted to US 1970 census. The prevalence rates increased significantly with age. The age-adjusted prevalence rates among Chinese (0.33%, 95% CI: 0.22 to 0.48), Malays (0.29%, 95% CI: 0.13 to 0.67), and Indians (0.28%, 95% CI: 0.12 to 0.67) were the same (p = 1.0). CONCLUSIONS: The prevalence of PD in Singapore was comparable to that of Western countries. Race-specific rates were also similar to previously reported rates and similar among the three races. Environmental factors may be more important than racially determined genetic factors in the development of PD.