Young Age, Liver Dysfunction, and Neurostimulant Use as Independent Risk Factors for Post-Traumatic Seizures: A Multiracial Single-Center Experience.

We aimed to determine the potentially modifiable risk factors that are predictive of post-traumatic brain injury seizures in relation to the severity of initial injury, neurosurgical interventions, neurostimulant use, and comorbidities. This retrospective study was conducted on traumatic brain injury (TBI) patients admitted to a single center from March 2008 to October 2017. We recruited 151 patients from a multiracial background with TBI, of which the data from 141 patients were analyzed, as 10 were excluded due to incomplete follow-up records or a past history of seizures. Of the remaining 141 patients, 33 (24.4%) patients developed seizures during long-term follow up post-TBI. Young age, presence of cerebral contusion, Indian race, low Glasgow Coma Scale (GCS) scores on admission, and use of neurostimulant medications were associated with increased risk of seizures. In conclusion, due to increased risk of seizures, younger TBI patients, as well as patients with low GCS on admission, cerebral contusions on brain imaging, and those who received neurostimulants or neurosurgical interventions should be monitored for post-TBI seizures. While it is possible that these findings may be explained by the differing mechanisms of injury in younger vs. older patients, the finding that patients on neurostimulants had an increased risk of seizures will need to be investigated in future studies.

Spinal segmental myoclonus following spinal surgery.

A 44-year-old male was admitted with L5/S1 spondylodiscitis complicated by a posterior epidural abscess that was compressing the thecal sac with severe narrowing of the canal and compression of the cauda equine. He underwent computed tomography (CT) guided drainage followed by L5/S1 decompression laminectomy and was started on a 6-week course of intravenous antibiotics with good response. He remained well and afebrile with inflammatory markers showing improvement. During this period, he developed intermittent myoclonic movements of right lower limb with severe pain over the back radiating to the gluteal region which hindered his rehabilitation potential. He was diagnosed with spinal segmental myoclonus based on clinical findings and history of recent spinal surgery. He was successfully treated with a course of clonazepam and continues to make functional improvements during his rehabilitation program.

Acute kidney injury without need for dialysis, incidence, its impact on long-term stroke survival and progression to chronic kidney disease.

INTRODUCTION: Patients who had a stroke are at increased risk of sepsis, dehydration and fluctuations in blood pressure, which may result in acute kidney injury (AKI). The impact of AKI on long-term stroke survival has not been studied well. OBJECTIVE: We aimed to identify incidence of AKI during acute stroke, follow-up period and its impact on long-term survival and development of chronic kidney disease (CKD). DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of patients who had a stroke admitted at the rehabilitation facility in Changi General Hospital, Singapore, between June 2008 and May 2017, with median follow-up of 141 (95% CI 120 to 163) months. OUTCOME MEASURES AND RESULTS OF UNIVARIATE ANALYSIS: Total 681 patients, median age (63.6) years, 173 (28%) died during follow-up. Elevated blood urea (3.02, 95% CI 2.17 to 4.22; p≤0.001) and creatinine (1.96, 95% CI 1.50 to 2.57; p≤0.001) during stroke affected survival adversely.Excluding patients with CKD, we analysed the remaining 617 patients. AKI was noted in 75 (12.15%) patients during the index admission, and it affected survival adversely (2.16, 95% CI 1.49 to 3.13; p<0.001). Of the patients with AKI, 21 of 75 (28%) progressed to CKD over a median follow-up of 40.7 months. CONCLUSIONS: We found AKI during stroke admission was associated with increased mortality as compared with those without AKI on univariate analysis. AKI without need of renal replacement therapy was also associated with progression to CKD in this cohort. This suggests that patients with AKI need to have their renal function monitored longitudinally for development of CKD.

Hip fractures in elderly patients with non-dialysis dependent chronic kidney disease: Outcomes in a Southeast Asian population.

ABSTRACT: Chronic kidney disease (CKD) causes bone and mineral disorders and alterations in vitamin D metabolism that contribute to greater skeletal fragility. Hip fracture in elderly is associated with significant morbidity and mortality. The aim of this study was to investigate the outcome of elderly patients with non-dialysis dependent CKD and hip fracture undergoing surgery.Retrospective study with IRB approval of patients above 65 years of age, with hip fractures admitted between June 2014 to June 2016 in a Southeast Asian cohort. Data collected included demographic variables and the haematological and biochemical parameters HBA1c, estimated glomerular filtration rate (eGFR), serum calcium, phosphorous, and 25(OH) Vitamin D. Co-morbidities investigated were ischemic heart disease, congestive heart failure, peripheral vascular disease, malignancy, chronic obstructive pulmonary disease, cerebro vascular accident, hypertension and hyperlipidaemia. All patients were followed up from index date to either death or June 1, 2018.Of the 883 patients, 725 underwent surgery and 334 had CKD. Death rates for CKD patients with hip fractures and those with normal renal function did not differ significantly [8.08% vs 6.54%, (HR= 1.33, 95% CI: 0.95, 1.86; P = .102)], whilst median hospital length of stay was significantly higher in CKD patients [10.5 vs 9.03 days (P = .003)]. Significant risk factors associated with higher risk of mortality in the elderly with hip fracture were male gender, age ≥80 years and serum albumin < 30 g/L (all, P < .0001).In summary, in elderly, non-dialysis dependent CKD patient with hip fracture we found that male gender, age ≥80 years, low serum albumin and eGFR < 30 mL/min/1.73 m2 were associated with higher risk of death. The hospital stay in the CKD group was also longer. Additional studies are needed to validate our findings.

Influence of chronic kidney disease and haemodialysis on stroke outcome.

INTRODUCTION: Stroke patients with underlying chronic kidney disease (CKD) and those on haemodialysis have complex rehabilitation needs, and their survival and functional outcomes are limited. This study aimed to review post-stroke survival and functional outcomes following rehabilitation in patients with CKD and those on haemodialysis. METHODS: We conducted a retrospective analysis of consecutive stroke patients with underlying CKD (Stages G3b, G4 and G5; n = 30) and those on dialysis at the time of stroke (n = 7), who underwent in-patient rehabilitation between June 2008 and May 2017. The mean duration of follow-up was 56 months. Demographic details, associated comorbidities and laboratory parameters were reviewed. Baseline and follow-up scores of the National Institute of Health Stroke Scale (NIHSS) and Functional Independence Measure (FIM), and dates of death of the patients were analysed. RESULTS: Of the 37 consecutive stroke patients (mean age 64.7 years), 34 had ischaemic stroke and three had haemorrhagic transformation. Significant improvements in NIHSS and FIM scores were observed from the time of admission to after discharge. Older age, longer duration of hospital stay, lower estimated glomerular filtration rate and low haemoglobin levels were all significantly related to mortality. CONCLUSION: Despite significant functional and neurological improvements following rehabilitation, stroke patients with underlying CKD had higher average duration of hospital stay, more recurrent hospitalisations and poorer survival outcomes than those without underlying CKD. This could be attributed to the complications associated with CKD rather than stroke. Multidisciplinary community rehabilitation may be an alternative to reduce recurrent hospitalisations and morbidity in this group of patients.

A calcified central venous fibrin sheath mimicking a fractured catheter.

A 75-year-old female with end stage kidney failure had her tunneled central venous dialysis catheter (CVC) removed. A subsequent computed tomopgraphy (CT) scan of the chest reported a filling defect in the central vein that appeared to represent a fractured remnant of the CVC. The catheter had been retained for culture and was available for direct visualization, which showed it to be entirely intact. A subsequent venogram confirmed that the CT findings represented a retained calcified central venous fibrin sheath. As retained CVC fragments may require intervention, this diagnosis should be established carefully. A calcified fibrin sheath associated with a chronic CVC is a known, although rare, complication and should be considered in the differential diagnosis of an apparent CVC fracture prior to further interventions.

Role of Parathyroid Hormone Assay and Bedside Ultrasound in the Emergency Department in Differentiating Acute Kidney Injury from Chronic Kidney Disease: A Systematic Review.

INTRODUCTION: It is not uncommon for patients without preceding history of kidney disease to present to the Emergency department with renal failure. The absence of prior medical records or renal imaging presents a diagnostic challenge. Elevated parathyroid hormone levels or echogenic contracted kidneys on ultrasound are known to point to a diagnosis of chronic kidney disease. The literature in this regard is surprisingly limited. The objective of this study is to assess the role of intact parathyroid (iPTH) blood level and bedside ultrasound in differentiating acute kidney injury from chronic kidney disease. METHODS: A systematic review which included a literature search of 3 databases, PubMed, Embase, and Cinahl (R) as also secondary sources, was done. The inclusion criteria evaluated studies which evaluated iPTH or bedside ultrasound in differentiating acute kidney injury from chronic kidney disease. We excluded studies which used other laboratory biomarkers like neutrophil gelatin associated lipocalin (NGAL) or carbamylated haemoglobin. A total of 2256 articles were identified. After screening, the relevant articles were reviewed, and an assessment of their methodological quality was made based on the CASP: Critical Appraisals Skill Programme. RESULTS: Of the 2256 articles identified, after screening, only 5 were identified as relevant. CONCLUSIONS: An elevated parathyroid hormone level and echogenic contracted kidneys on bedside ultrasound in the Emergency department can help differentiate acute kidney injury from chronic kidney disease. This differentiation helps decide need for admission as well as further management. Although iPTH level may also rise in acute kidney injury, the value (2.5 times normal) can discriminate it from chronic kidney disease.

Post-stroke seizure-Do the locations, types and managements of stroke matter?

OBJECTIVE: To determine the incidence of post-stroke seizures and the associated risk factors in a government-restructured hospital in Singapore. METHODS: This retrospective study included consecutive patients (age ≥21 years) admitted to the stroke rehabilitation facility at Changi General Hospital, Singapore, between June 2008 and May 2017, with a minimum post-discharge follow-up of 6 months. Patients with known epilepsy central nervous system infection or tumor, a history of neurosurgery and or missing data were excluded from study. To determine the incidence of seizures, the patients' hospital records, including those for all initial and subsequent admissions and outpatient follow-ups, were reviewed. All prescribed medications were checked and documented. Seizures were diagnosed on the basis of clinical examination with or without electroencephalography. RESULTS: In total, 722 patients (women, 38%) with a mean age of 64 years were included. Of these, 48 (6.64%) experienced post-stroke seizures during a follow-up period of 6-108 months. The incidence of seizures was significantly higher in patients with hemorrhagic stroke (42%, p = 0.010), those with ischemic partial anterior circulation stroke (PACS) (27%, p = 0.025), those who underwent a neurosurgical procedure after stroke (p < 0.001), those with a low activated partial thromboplastin time (APTT) at admission (mean, 25.6; p = 0.015), and those using levodopa (21%, p < 0.001). Neurosurgical intervention after stroke (odds ratio [OR] 6.2, 95% confidence interval [CI] 2.9-13.1; p < 0.001), APTT (per-unit increase; OR 0.86, 95% CI 0.76-0.98; p = 0.028), and underlying ischemic heart disease (IHD; OR 2.2, 95% CI 1.08-4.60; p = 0.029) were found to be independent predictors of seizure occurrence after stroke. SIGNIFICANCE: Post-stroke seizure incidence from our study is 6.64%, with a median follow-up of 49 months. Among patients with stroke, those with underlying IHD, those who undergo a neurosurgical procedure, and those with a low APTT at admission need careful monitoring. Levodopa should be used with caution and withdrawn as soon as possible.

Complete resolution of extensive thrombosis of atheromatous non-aneurysmal descending aorta and pulmonary embolism with warfarin therapy.

A 54-year-old man underwent decompressive craniectomy following a stroke. He further developed right lower limb ischaemia, and CT aortography revealed extensive aortic atherosclerotic disease. Urgent embolectomy prevented him from having a major amputation. He subsequently developed pulmonary embolism. This was initially treated with heparin followed by warfarin apart from antiplatelets and statin. A follow-up aortography at 3 months interval showed near complete resolution of atheromatous disease of the aorta. This report raises the possibility that apart from antiplatelets and lipid-lowering agents, anticoagulation may be responsible for resolution of such an extensive atheromatous disease and whether this can be considered as part of regular treatment.

Evaluation of unplanned dialysis as a predictor of mortality in elderly dialysis patients: a retrospective data analysis.

BACKGROUND: Increasing numbers of elderly patients are undergoing long-term dialysis. However, the role of dialysis in survival and quality of life is unclear, and poor outcomes may be associated with comorbidities rather than with age only. The initiation of unplanned dialysis in elderly patients with chronic kidney disease (CKD) has been reported to be associated with poor survival. We evaluated patient and practice factors associated with poor survival. METHODS: We performed a retrospective analysis of 90 consecutive elderly patients (≥75 years) with CKD initiated on long-term dialysis at our renal unit between October 2010 and February 2014. Six patients were excluded; data from 84 remaining patients (≥75 years) with end-stage renal disease undergoing planned or unplanned dialysis were analyzed. Patients were followed up until death or January 2015. Patient factors such as age at initiation of dialysis and comorbidities (i.e., diabetes mellitus, ischemic heart disease [IHD], peripheral vascular disease, cancer, chronic obstructive pulmonary disease, and cognitive dysfunction) were analyzed. Practice factors such as planned or unplanned initiation of dialysis were compared in relation to survival outcomes. "Unplanned dialysis" was defined as a patient with known CKD stage 4 or 5 who had not been evaluated by a nephrologist in the 3 months before dialysis initiation. RESULTS: The average age at dialysis initiation was 81.5 ± 4.5 years), serum albumin level was 24.8 ± 6 g/L, body mass index was 22.5 ± 4.8 kg/m2, and glycated hemoglobin A1c level was 6.3 ± 1.3. Overall, 51 (61%) and 33 (39%) patients underwent unplanned and planned dialysis, respectively. On univariate analysis, the presence of IHD, peripheral vascular disease, ≥3 comorbidities, and unplanned initiation of dialysis were significantly related to death. On multivariate analysis, unplanned start of dialysis, ischemic heart diseases and peripheral vascular disease remained significant. Survival rates at 3 and 12 months were 38.6% vs. 90.9% and 14.4% vs. 73.6% for unplanned vs. planned dialysis, respectively (p < 0.001). Unplanned dialysis was significantly associated with greater mortality. CONCLUSIONS: In elderly dialysis patients, unplanned start of dialysis was associated with poor survival. Patient characteristics such as associated peripheral vascular disease and IHD were associated with poor survival.

Hereditary haemochromatosis: a tale of eight siblings.

Hereditary haemochromatosis (HH) is an autosomal recessive condition in which inappropriately excess iron absorption from the intestine results in pathological deposition of iron in the parenchymal cells of organs leading to tissue damage associated with characteristic arthropathy. It is an important cause of joint pain in middle age and early diagnosis and treatment can reduce the long-term complications of the disease.

Unusual case of hypomagnesaemia induced seizures.

Alterations in electrolyte homeostasis associated with major surgery and critical illness are common but usually non-specific. We report an unusual case of hypomagnesaemia induced seizures in a 73-year-old woman who was recovering from ileal resection and limited right hemicolectomy for small bowel volvulus. Hypomagnesaemia as a de novo cause of seizures is rarely reported.