Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke.

BACKGROUND AND PURPOSE: Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke. MATERIALS AND METHODS: Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively. RESULTS: Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes. CONCLUSIONS: Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

Clinical features and outcomes of posterior reversible encephalopathy syndrome following bevacizumab treatment.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a potentially devastating complication of bevacizumab treatment. AIM: We examined the clinical features, treatment and outcomes of patients who developed PRES following bevacizumab treatment at our institution and those reported in the literature. DESIGN: Retrospective audit and systematic review. METHODS: Patients were identified from the Mayo Clinic database and the published literature using 'PubMed' and 'OVID' databases, from January 2006 to June 2010, who developed PRES features within 3 weeks of bevacizumab treatment, who had brain imaging findings of focal vasogenic edema and radiologic proof of reversibility. RESULTS: Two patients with definite PRES were identified from our institution and a further 10 cases were identified from the published literature (total, n=12). The mean age of these patients was 52 years (range 4-68 years), four of whom were men and eight women. Headaches (n=7), seizures (n=6), visual disturbances (n=5) and nausea and vomiting (n=3) were the common presenting symptoms. In a majority of patients (n=10), an increase in blood pressure from their baseline values was observed during their acute presentation. PRES resolved following withdrawal of bevacizumab and blood pressure control in all patients. CONCLUSIONS: PRES is a catastrophic neurological complication of bevacizumab treatment, which responds favorably to prompt bevacizumab withdrawal and blood pressure control.

Readiness exercise to combat avian influenza.

AIM: To examine the readiness of our hospital for the potential pandemic threat of avian influenza, we developed and implemented simulation case scenarios in our hospital. METHODS: Two volunteers, who assumed the identity of 'actual' patients, were trained to simulate acute respiratory symptoms following a visit to an avian influenza-affected area, and their identities and locations were kept confidential prior to the readiness exercise. A team of auditors was stationed at high-risk areas to assess adherence to the use of personal protective equipment (PPE) and infection control procedures. RESULTS: A total of 324 healthcare workers and 84 administrators participated in this hospital-wide exercise. Following disclosure of their symptoms, the 'patients' were masked and isolated in negative-pressure rooms. A quarantine order was enforced on 38 inpatients and 45 healthcare workers who were present in the affected wards at the time of the exercise, which mandated the use of PPE. Although all affected healthcare workers were competent in the use of PPE, we observed breaches in PPE and isolation procedures in eight medical and nursing students, and 10 healthcare attendants. The exercise concluded after H5N1 tests returned negative. CONCLUSION: We recommend the use of case simulation as an effective means of assessing potential breaches in infection control procedures.

Overcoming preconceptions and perceived barriers to medical communication using a 'dual role-play' training course.

BACKGROUND: Communication is a core component of clinical competence. We introduced a dual role-play (DRP) course, in which participants role-played both the doctor-candidate and the standardized patient. The aim of the study was to assess the usefulness of a DRP communication course for physicians and to identify factors that inhibit effective medical communication. METHODS: We conducted four medical communication skills courses from 2004 to 2006. A questionnaire was administered before and after completion of each course. We assessed respondents' confidence levels before and after the course and sought to identify perceived barriers to effective communication among medical trainees in Singapore. Finally, we asked if they found participation in the course and its DRP nature to be useful. RESULTS: Twenty-six participants, 20 men, 6 women, of mean age 30.2 years (standard deviation (SD) 2.01) completed the survey. The pre-course confidence levels (rated on a scale of 1-10) of 6.23 (SD 1.18) rose significantly to 7.58 (SD 0.95) on completion of the course (P = 0.001, Wilcoxon signed rank test). All respondents felt that they had benefited from participation in the medical communication skills course. 24 (92.3%) respondents deemed it useful to have role-played both the doctor and standardized patient in the exercise. We identified respondents with language difficulties to have benefited the most from the course (P = 0.031, odds ratio 2.906 (95%CI 0.292-5.519), linear regression analysis). CONCLUSION: DRP is an effective way to train doctors in medical communication.

Botulinum toxin: description of injection techniques and examination of controversies surrounding toxin diffusion.

The benefits derived from botulinum toxin (BTX) injections may be negated by unintentional weakness of adjacent uninjected muscles. Such weakness may be the result of inaccurate targeting, or diffusion of BTX to surrounding muscles. Several techniques, using electromyographic, endoscopic or imaging guidance are purported to increase the accuracy of targeting. Diffusion of BTX is thought to be influenced by factors such as dose, concentration, injectate volume, number of injections, site and rate of injection, needle gauge, muscle size, muscular fascia, distance of needle tip from the neuromuscular junction, and protein content of the BTX formulation. This article describes techniques that aim to increase the accuracy of BTX injections and examines the controversies surrounding diffusion of BTX following injection.

Segmental dystonia following electrocution in childhood.

Electrical injuries to the extremities may result in a range of neurologic manifestations, which include movement disorders such as parkinsonism, segmental myoclonus, choreoathetosis, tremors and dystonia. A 66-year-old man developed segmental dystonia of the right upper extremity at the age of nine, three years after he accidentally held a live 240-V electrical wire in his right hand. MRI brain and cervical cord were normal. We discuss this unusual cause of secondary dystonia and review the literature.

Attitudes of medical students to placebo therapy.

BACKGROUND: Studies have described opposing perceptions of placebo use, with laypersons for and health-care workers against it. Opinions of medical students have not previously been elicited. This study was based on online electronic survey on beliefs, knowledge and attitudes about placebo therapy, that is, use of placebo in clinical practice, rather than in randomized controlled clinical trials. METHODS: The participants were preclinical (years 1, 2) and clinical (years 3-5) medical students. Descriptive analyses and chi2 tests were used to compare the opinions of preclinical and clinical students with statistical significance set at P < 0.05. RESULTS: Four hundred and two (35.6%) out of 1153 students responded, of which 181 were preclinical and 221 were clinical students. Two hundred and eighty-five (70.9%) students felt that placebo therapy was acceptable and 134 (33.3%) believed that it was beneficial in organic disease. Fifty-two (12.9%) students felt that it was ethical to prescribe placebo for organic disease with known definitive treatment, 259 (64.4%) for organic disease with no known treatment and 328 (81.6%) for psychogenic disease. More preclinical than clinical students approved of placebo therapy (odds ratio 2.140 (95% confidence interval 1.161-3.944), P = 0.015) and opined that it was ethical to prescribe placebo therapy to organic diseases for which there was appropriate treatment (odds ratio 1.800 (95% confidence interval 0.992-3.266), P = 0.053). A greater number of clinical when compared with preclinical students said that there is evidence that placebo therapy has a beneficial effect on organic disease (odds ratio 2.299 (95% confidence interval 1.468-4.405), P < 0.001). CONCLUSION: Our medical students felt that placebo therapy is acceptable in certain situations. We identified their erroneous acceptance of placebo therapy in organic diseases, for which there is established treatment, as an area to be addressed in our undergraduate curriculum.

Symptoms associated with electrophysiologically verified carpal tunnel syndrome in Asian patients.

Sensory symptoms are crucial for the diagnosis of carpal tunnel syndrome (CTS). We have studied the spectrum of sensory symptoms in 67 cases of neurophysiologically confirmed CTS in Singapore and investigated the correlation of semi-quantitative clinical ('Historical-Objective') and neurophysiological ('Bland') scales. The range of sensory symptoms was large. The more frequent use of the terms 'woodenness' and 'aching' rather than 'pins and needles' suggests racial and cultural differences in symptom expression, or recognition of previously ignored descriptors. 'Numbness' (97%) was the most common descriptive symptom, followed by 'tingling' (81%), 'tightness' (60%), 'aching' (45%), 'woodenness' (39%) and 'pins and needles' (33%). Less common were 'deadness' (27%), prickling (24%), and cramp-like pain (18%). Uncommon sensations included 'jabbing' (10%), 'shooting pain' (10%), 'stabbing' (9%), 'tight-band like pressure' (9%), 'cold' (8%), 'crushing' (6%) and 'burning' (6%). The semi-quantitative clinical and neurophysiological scales correlated well (Pearson 0.645, P<0.001).

Headaches and the N95 face-mask amongst healthcare providers.

BACKGROUND: During the 2003 severe acute respiratory distress syndrome epidemic, healthcare workers mandatorily wore the protective N95 face-mask. METHODS: We administered a survey to healthcare workers to determine risk factors associated with development of headaches (frequency, headache subtypes and duration of face-mask wear) and the impact of headaches (sick days, headache frequency and use of abortive/preventive headache medications). RESULTS: In the survey, 212 (47 male, 165 female) healthcare workers of mean age 31 years (range, 21-58) participated. Of the 79 (37.3%) respondents who reported face-mask-associated headaches, 26 (32.9%) reported headache frequency exceeding six times per month. Six (7.6%) had taken sick leave from March 2003 to June 2004 (mean 2 days; range 1-4 days) and 47 (59.5%) required use of abortive analgesics because of headache. Four (2.1%) took preventive medications for headaches during this period. Multivariate logistic regression showed that pre-existing headaches [P = 0.041, OR = 1.97 (95% CI 1.03-3.77)] and continuous use of the N95 face-mask exceeding 4 h [P = 0.053, OR = 1.85 (95% CI 0.99-3.43)] were associated with development of headaches. CONCLUSIONS: Healthcare providers may develop headaches following the use of the N95 face-mask. Shorter duration of face-mask wear may reduce the frequency and severity of these headaches.

Botulinum toxin-A injections via electrical motor point stimulation to treat writer's cramp: pilot study.

PURPOSE: Writer's cramp describes a task-specific dystonia, in which the act of writing initiates dystonic posturing of the hands. Previous studies have described the efficacy of injections of botulinum toxin type-A (BTX-A) under electromyographic guidance, in which the injected muscle is either voluntarily, or less often, electrically (electrical motor point stimulation, EMPS) activated to ensure that the needle is in the target muscle. We performed an open label, prospective study to assess the efficacy of BTX-A injections, performed with EMPS under electromyographic guidance. METHODS: Eight patients (seven male and one female) of mean age 44 (range 25-66) were recruited. All had idiopathic writer's cramp. Outcome measures, which included timed writing, objective assessment of dystonia (modified Ashworth scale and a visual analog scale rating) and patient assessment of functional disability, were assessed before injections and at six weeks follow-up. RESULTS: The total dose of BTX-A injected for writer's cramp ranged from 50 to 130 units, which was less than that reported in previous studies using muscle activation techniques (up to 300 units). Improvements were observed in all outcome measures. Patients reported mild (non-disabling) weakness of injected, but not of uninjected muscles. CONCLUSION: Lower dosages of BTX-A, administered using EMPS, offers the advantages of decreased cost and increased accuracy of targeting, while achieving good outcomes.

Adult-onset re-emergent stuttering as a presentation of Parkinson's disease.

INTRODUCTION: The basal ganglia-thalamocortical motor circuits are postulated to play a key role in the aetiopathogenesis of stuttering. The main dysfunction is thought to be an impairment in the ability of the basal ganglia to produce timing cues for the initiation of the next motor segment of speech, explaining the association of acquired and re-emergent stuttering with diseases such as dystonia and Parkinson's disease. CLINICAL PICTURE: We describe a 61-year-old man presenting with re-emergent stuttering and mild hypomimia, only to develop unilateral rest tremors, hypo- and bradykinesia, rigidity and gait difficulties one year later. TREATMENT AND OUTCOME: His parkinsonism responded well to treatment with bromocriptine, but he continued to stutter. DISCUSSION: This case illustrates the association between acquired or re-emergent stuttering and basal ganglia disorders, and highlights the need to assess such patients for an underlying aetiology.