Effect of the use of earplugs and eye masks on the quality of sleep after major abdominal surgery: a randomised controlled trial.

Significant sleep disturbance can occur following major abdominal surgery. We aimed to evaluate the effectiveness of earplugs and eye masks in improving sleep quality and patient satisfaction, reducing nursing demands and in the incidence of delirium in patients after major abdominal surgery. We conducted a randomised controlled trial in 100 patients undergoing major abdominal surgery. We randomly allocated participants to sleep with or without earplugs and eye masks on postoperative days 1-3. The primary outcome measure was sleep quality as measured by the Richards-Campbell Sleep Questionnaire. Secondary outcomes were patient satisfaction, frequency of nursing demand and incidence of delirium measured by the Neelon and Champagne Confusion Scale. Median (IQR [range]) sleep scores were 64 (38-74 [0-100] and 60 (44-82 [18-100]) for the control and intervention groups, respectively (p = 0.310). Age and Pittsburgh Sleep Quality Index scores were found to be significant factors affecting sleep quality. There were no differences in patient satisfaction, reduction in frequency of nursing demands or incidence of delirium on postoperative days 1-3 after major abdominal surgery. The compliance rate in the intervention group was 60-65%. This study has demonstrated that the use of earplugs and eye masks did not contribute to improvements in sleep quality. Of note, sleep quality was moderate, with higher age and worse baseline sleep quality contributing to worse sleep scores. More studies are needed to investigate interventions to improve sleep quality after major abdominal surgery.

Strategies to improve survival outcomes of out-of-hospital cardiac arrest (OHCA) given a fixed budget: A simulation study.

BACKGROUND: Our study aimed to identify a strategy that maximizes survival upon hospital discharge or 30-days post out-of-hospital cardiac arrest (OHCA) in Singapore for fixed investments of S$1, S$5, or S$10 million. Four strategies were compared: (1) no additional investment; (2) reducing response time via leasing of more ambulances; (3) increasing number of people trained in cardiopulmonary resuscitation (CPR); and (4) automated external defibrillators (AED). METHODS: We estimated the effect of ambulance response time, bystander CPR and AED on survival based on Singapore's 2010-2015 OHCA registry data. We simulated the changes in ambulance response times and likelihood of (1) CPR and (2) AED usage as a function of their increased availability, which was then combined with the effect of each factor to determine the increase in survival for each strategy. RESULTS: Survival given no additional investment was 4.03% (95% CI: 3.96%, 4.10%). The investments in ambulances, CPR training and AEDs for a given budget of S$1M changed survival to 4.03% (95% CI: 3.96%, 4.10%), 4.04% (95% CI: 3.98%, 4.11%), and 4.44% (95% CI: 4.35%, 4.54%), respectively. This generated 0, 2 and 102 additional life years saved respectively. Given a budget of S$5M or S$10M, 509 or 886 additional life years could be saved, by investing in an additional 10,000 or 20,000 AEDs respectively. The strategies reached a saturation effect whereby improvement in survival was marginal when the budget was increased to ≥S$5M for investment in ambulances and CPR training. CONCLUSIONS: Investing in AEDs had the most gain in survival.

An overview of lower limb cellulitis in an acute medical ward-a few lessons we can learn.

Lower limb cellulitis is a common cause for hospital admissions. In this retrospective study, we assessed the characteristics and outcome of patients admitted in an acute medical unit. The mean duration of treatment was 10.48 days, with 95.5% receiving antibiotics for more than 5 days. Mean length of stay (LOS) was 5.19 days. 12-month readmission rate was higher in patients with diabetes, chronic kidney disease (CKD) and previous stroke. Diabetes, CKD, previous stroke, and elevated procalcitonin levels were independently associated with prolonged admission (>3 days).

Multimorbidity in bullous pemphigoid: a case-control analysis of bullous pemphigoid patients with age- and gender-matched controls.

BACKGROUND: Bullous pemphigoid (BP) is the most common autoimmune blistering disease in the elderly and is associated with increased mortality. The extent of multimorbidity in patients with BP and its impact on survival are unclear. OBJECTIVES: To describe the extent and spectrum of multimorbidity in patients with BP and to ascertain its impact on survival. METHODOLOGY: This was a case-control study conducted in the setting of an academic medical centre. Cases defined as newly diagnosed BP patients referred to the inpatient dermatology service between 2005 and 2014. For every case, three age- and gender-matched controls were randomly selected. Retrospective review of medical records was performed. Univariate and multivariate comparisons of cases and controls were performed using conditional logistic regression. RESULTS: A total of 105 cases and 315 controls were included in this study. Eighty-eight cases (84%) were multimorbid (≥2 chronic diseases) as compared to 205 controls (65%) (P < 0.001), while the mean number of comorbid conditions was 3.2 ± 1.6 in cases compared to 2.4 ± 1.6 in controls (P < 0.001). 43% of cases had ≥4 comorbidities compared to 27% in controls (P = 0.003). On multivariate analysis (adjusting for age, gender and comorbidities), neurological disease (OR 10.93; CI: 5.74, 20.79) and hypertension (OR 2.38; CI: 1.18, 4.77) were positively associated with BP. Charlson comorbidity index was 6.0 ± 2.5 in cases compared to 5.0 ± 2.1 in controls (P = 0.002), and the 1-year mortality of cases and controls was 32.4% and 17.8%, respectively. CONCLUSION: Our study has shown that a significant proportion of patients with BP are multimorbid and individually have a higher number of comorbidities compared to matched controls. Disease burden and multimorbidity may well impact the prognosis of patients with BP.

Motor and somatosensory abnormalities are significant etiological factors for adolescent idiopathic scoliosis.

OBJECTIVE: In adolescent idiopathic scoliosis (AIS), we explore the role of lateralized motor and somatosensory abnormalities as a possible etiological factor. METHODS: Intraoperative transcranial electrical stimulation was performed in 15 AIS and 14 adult degenerative scoliosis (ADS) patients. Inter-side motor output balance (MOB) by comparing the ratios of right to left motor evoked potentials (MEP) amplitudes, and inter-side motor output excitability (MOE) computed with MEP amplitude, was determined separately for both patients groups. For somatosensory evoked potentials (SSEP), peak to peak P37 amplitudes from right and left lower limb SSEP and inter-side P37 amplitude ratios were obtained. RESULTS: Inter-side MOB was significantly asymmetric in AIS patients, contributed mainly by inter-side MOB changes in the upper than the lower limbs. Inter-side MOE comparisons of ipsilateral and contralateral MEP amplitudes were significantly different between AIS and ADS patients. Mean upper limb MEP amplitudes were significantly reduced in AIS patients. Amplitude of the right upper limb MEPs were positively correlated with inter-side MEP ratio. AIS patients show larger mean MEP amplitudes on the same side as the scoliotic curve. Overall, no correlation of Cobb's angle or total levels of scoliosis involvement with inter-side MOB and MOE parameters was found. Inter-side SSEP ratios were significantly higher in AIS patients. CONCLUSIONS: Primary dysfunctional and distributed motor output contributing to abnormalities of inter-side MOB and MOE changes involving the upper limbs is evident in AIS. Simultaneous but independent somatosensory and motor observations seen these patients suggest a central mechanism as an etiological factor.

A comparison study of repetitive transcranial magnetic stimulation for tinnitus treatment in an Asian population.

BACKGROUND: Tinnitus, a subjective auditory perception of sounds or noise not triggered by external auditory stimuli, carries considerable morbidity. To date, pharmacological, physical or behavioral therapy is the mainstay of management. METHODS: We compared repetitive transcranial magnetic stimulation (rTMS) of 1000 or 2000 stimulations/day at 1 Hz and 110% of the motor threshold for 5 consecutive days over the left auditory cortex. Ratings based on the Tinnitus Handicap Inventory (THI) rating scale were completed weekly for 4 weeks. None of the patients had significant hearing impairment. RESULTS: All 28 patients (age range 21-72; 18 men) tolerated rTMS well and no adverse effects were observed. Analysis of variance (ANOVA) showed significant decrease in THI scores over the entire time period (F (1,26)=11.33, p=0.002). At every weekly time point of evaluation, ANOVA with repeated measures demonstrated significantly lower THI score compared to baseline (p<0.02 for all). RTMS treatment had resulted in tinnitus reduction in the range of 15-25% over the 4 week period. Separately, ANOVA also demonstrated significantly reducing THI for both the 1000 pulse (F (1,14)=4.8, p=0.04) and 2000 pulse (F (1,14)=6.56, p=0.02) rTMS treatment arms. Comparison of THI ratings between the 2 treatment arms did not result in significant difference (F (1,26)=1.48, p=0.24). CONCLUSIONS: The present study has revalidated the efficacy and safety of rTMS for improving tinnitus up to 4 weeks post-treatment in Asians. However, there was no significant difference with THI evaluation between the 1000 pulse and 2000 pulse treatment arms.

Predictive Value of Electrophysiology for Presence of Thymic Pathology in Myasthenia Gravis.

OBJECTIVE: Single fibre electromyography (SFEMG) and repetitive nerve stimulation (RNS) are routinely performed investigations in evaluation of patients with myasthenia gravis (MG). Significant number of MG patients have a thymic pathology. We aimed to explore the relationship between the SFEMG and RNS findings with the presence of thymic pathology. METHODS: We studied 159 consecutive patients with MG over a 10 year period. The SFEMG parameters - mean jitter (MJ) and percentage of abnormal fibres (POAF) and the RNS result were correlated with the thymic findings. RESULTS: As compared to patients with normal thymus (MJ:58.3 µsec; POAF:63.5%), patients with thymic pathology had a significantly higher MJ (80.9 µsec; p < 0.0005) and POAF (83.5%; p < 0.0005). MG patients with thymic hyperplasia had the highest MJ (87.6 µsec) and POAF (84.4%) followed by patients with thymoma (MJ:78.6 µsec; POAF:83.2%). The MJ and POAF did not correlate with the stage of thymoma. Mean jitter values above 34.9 µsec and POAF above 31% had 100% sensitivity for the presence of thymic pathology. A positive RNS increased the risk of thymic pathology (OR = 3.9, CI = 1.8-8.5) and thymoma. (OR = 3.5; CI = 1.5-8.1). CONCLUSION: Electrophysiology could be valuable complimentary tool to identify MG patients at high risk for thymic pathology. However, it does not aid us to identify the exact thymic pathology and does not correlate with the stage of thymoma. All OMG patients with higher MJ and PAOF values should also be screened for thymoma. The results reinforce the immunological role of thymic pathology in neuromuscular transmission interference.

Complementary therapies in hemifacial spasm and comparison with other movement disorders.

OBJECTIVES: We determined the prevalence, range and factors influencing the use of complementary therapy among hemifacial spasm patients and compared the patterns of use of complementary therapies across different movement disorders in a systematic pooled analysis of published literature. METHODS: A structured questionnaire was administered to 96 hemifacial spasm patients evaluating frequency of complementary therapy use, and factors influencing patients' decision to seek these therapies. We also performed a PubMed search of epidemiology studies on use of complementary therapies in movement disorders. RESULTS: Fifty-one per cent of patients had tried complementary therapies, of which 47% reported some perceived benefit and 4.1% informed their doctor. Acupuncture (71.4%) and facial massage (17.6%) were most commonly used. Complementary therapy use was associated with greater HFS severity. The mean cost of treatment was about $78 per month. We identified eight articles on use of complementary therapies in movement disorders; Parkinson's disease (5), Tourette syndrome (2) and dystonia (1). Twenty-five to 88% of patient had tried complementary therapies, of which 32-70% reported some benefit. Trials of acupuncture (2-63%) and massage (7-38%) were reported across the spectrum of movement disorders studied. Mean cost of complementary therapies varied from 43 to 102 USD per month. CONCLUSION: Complementary therapies are used by over 50% of HFS patients, and the use is correlated with severity of disease. Despite differences in race, culture and population demographics, acupuncture and massage are used by patients across the spectrum of movement disorders.

Effect of anaesthetic technique on mortality following major lower extremity amputation: a propensity score-matched observational study.

We investigated whether the type of anaesthesia affects mortality and length of stay after non-traumatic major lower extremity amputations. A total of 1365 eligible patients who were operated on between 2002 and 2010 were included in the final analysis. Propensity score matching was used to produce 475 matched pairs of patients undergoing operation with either general or regional anaesthesia. We found that 30-day mortality was significantly greater in the general anaesthesia group compared with the regional anaesthesia group, with an odds ratio (95% CI) of 1.5 (1.0-2.3) in the total matched population and 4.2 (1.3-13.4) in a high-risk subgroup. The median (IQR [range]) length of postoperative hospital stay was significantly less in the patients of the high-risk subgroup who had general anaesthesia at 15 (7-21 [1-101]) days compared with 25 days (10-37 [0-78]) for those who had regional anaesthesia (p = 0.027). The results of our study suggest that 30-day mortality is significantly higher in patients undergoing major lower extremity amputations under general anaesthesia compared with regional anaesthesia.

Headache in hemifacial spasm patients.

OBJECTIVES: To assess prevalence of headaches in patients with hemifacial spasm. To determine whether hemifacial spasm provokes headaches and identifies predictive factors. To evaluate whether botulinum toxin given for hemifacial spasm improves headaches. METHODS: Seventy patients with hemifacial spasm were evaluated for headaches. The relationship of headaches with hemifacial spasm, impact on quality of life (HIT-6), and improvement in headaches from botulinum toxin was recorded. Data on duration, severity, and impact on quality of life (HFS-7) of hemifacial spasm were collected. RESULTS: Hemifacial spasm-related headache was significantly associated with increased hemifacial spasm severity (P < 0.001) and HIT-6 (P = 0.024). Greater hemifacial spasm severity was predictive of hemifacial spasm-related headache (P = 0.006, OR 19.1, 95% CI 2.35-155.64). Botulinum toxin (BTX) for hemifacial spasm improved hemifacial spasm-related headaches (P < 0.001). CONCLUSIONS: Hemifacial spasm can complicate headaches, particularly in patients with greater hemifacial spasm severity. Individually tailored regimens of botulinum toxin may be indicated in these patients.

Erectile dysfunction in young surgically treated patients with lumbar spine disease: a prospective follow-up study.

STUDY DESIGN: This is a prospective study. OBJECTIVE: The prevalence of erectile dysfunction (ED) in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression without other risk factors for ED is evaluated. SUMMARY OF BACKGROUND DATA: There is little literature documenting ED in young patients with atraumatic lumbar spine disease. METHODS: All male patients younger than 50 years who underwent lumbar spine surgery during June 2006 to November 2007 without risk factors for ED were included. Patient demographics, neurological dysfunction, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), North American Spine Society score for neurogenic symptoms (NS), and the International Index of Erectile function (IIEF-5) scores were recorded preoperatively, at 1, 3, and 6 months. RESULTS: There were 61 patients with mean age 38.4 years (SD = 7.0; range, 20-49). Most of patients had (43 or 70.5%) prolapsed intervertebral disc with discectomy being the commonest operation. Mean VAS scores, ODI, and NS improved significantly postoperatively. However, the mean IIEF-5 scores did not. Preoperatively, there was no correlation between ED and VAS scores on back pain (P = 0.70), leg pain (P = 0.91), ODI (P = 0.93), or NS (P = 0.51). At 6 months, patients with NS > 70 had an increased risk of ED (P = 0.03). Eighty percent of patients with NS > 70 had ED compared with 30% of patients with NS ≤ 70. There was, however, no correlation between ED with ODI (P = 0.38) and VAS scores on back pain (P = 0.20) or leg pain (P = 0.08) at 6 months. CONCLUSION: The incidence of ED in patients younger than 50 years with nonfracture-related lumbar spine disease undergoing surgery without risk factors was 34.3%. Despite improvement in VAS, ODI, and NS scores postoperatively, ED did not improve. Patients with NS > 70 postoperatively were more likely to have ED reflecting possible permanent nerve damage from lumbar spine pathology.

ACE gene sequence and nucleotide variants in IgA nephropathy.

INTRODUCTION: Association studies with single nucleotide polymorphisms (SNPs) have been contradictory. Haplotypes may be more helpful. With gene sequencing, all SNPs can be found for construction of haplotypes. METHODS: The ACE gene was sequenced in four healthy Chinese subjects and 20 patients with IgA nephropathy (IgAN) to observe if differences exist among SNPs and haplotypes. 20 patients on angiotensin 1-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ATRA) therapy were then compared with another 20 patients not treated with ACEI /ATRA to determine their renal outcome in response to ACEI/ATRA therapy and whether their genetic profile of ACE gene could play a role in determining their outcome to ACEI /ATRA therapy and progression to end-stage renal failure (ESRF). RESULTS: IgAN patients had 53 variants, of which 17 were unique, whereas normal subjects had 38 variants, of which two were unique (p less than 0.005). No unique variant was a significant risk factor for IgAN. Significant genotype and allele frequency differences in five variants were observed between IgAN patients with renal impairment and those with ESRF (p less than 0.02). CONCLUSION: Our data suggests that at least in the ACE gene, haplotyping SNPs within a single gene seems to have no added advantage over genotyping the individual component SNPs. The D allele and haplotype 3 confer an adverse prognosis, while the I allele and haplotype 5 appear to be renoprotective. The data suggests that genotypes of the ACE gene are linked to certain haplotypes, which could influence IgAN patients' response to ACEI/ATRA therapy.

Ovarian hyperstimulation syndrome: an analysis of patient characteristics in the Asian population.

INTRODUCTION: We aimed to identify the variables associated with ovarian hyperstimulation in Asian patients and compare them with western standards. METHODS: This is a retrospective case record analysis of 79 patients with ovarian hyperstimulation at a tertiary restructured hospital. RESULTS: Gonadotropin doses resulting in hyperstimulation did not vary between long and antagonist cycles in women less than 35 years with polycystic ovaries (PCO). Mean oestradiol levels at hyperstimulation were not different between PCO and non-PCO patients in a long cycle. Hyperstimulation was mostly due to higher starting doses. Total follicle counts of more than 20 on Day 5-7 after stimulation may be predictive of subsequent hyperstimulation. Hyperstimulation tended to be more severe in lean PCO patients, and prophylactic albumin helped to reduce its severity. CONCLUSION: Gonadotropin doses at stimulation should start at 150 iu or less in women below 35 years of age, with a step up of 37.5 iu, as necessary. Transfer should be abandoned in the presence of high oestradiol levels (more than 5,000 pg/ml), when the total number of intermediate and large follicle count exceeds 30 on the day of oocyte retrieval, or when more than 19 eggs are retrieved. Variables in the Asian population appear to be similar to those in the western population.

Short duration repetitive transcranial magnetic stimulation for tinnitus treatment: a prospective Asian study.

BACKGROUND: Tinnitus is a subjective auditory perception of sounds or noise not triggered by external auditory stimuli. To date, treatment in severe cases is generally unsatisfactory. Characteristic functional brain imaging changes associated with tinnitus include hyperactivity encompassing both the primary auditory cortex (AC) and the secondary or associative cortex. Brief repetitive transcranial magnetic stimulation (rTMS) trains applied to the scalp overlying the hyperactive left AC is known to produce moderate tinnitus attenuation. OBJECTIVE: Although Western studies have documented the value of rTMS in tinnitus treatment, we evaluate the efficacy of a short duration rTMS protocol for the first time in the Asian setting. METHOD: Consecutive patients were recruited at our tinnitus clinic. Detailed history, examination, audiogram and baseline tinnitus scales were recorded. RTMS consisted of 1000 pulses/day at 1 Hz and 110% of the motor threshold, for five consecutive days over the left temporoparietal cortex. Tinnitus ratings were determined weekly for 4 weeks after rTMS. RESULT: Fifteen patients completed the trial; none experienced significant side effects. Repeated measures ANOVA showed significant linear decrease in Tinnitus Handicap Inventory (THI) scores over the time period (F((1,14))=4.7, p=0.04). However, none of the other parameters (severity, annoyance, effect on lifestyle and overall impression: visual analogue scale) showed beneficial outcomes. CONCLUSIONS: Our findings point to a positive effect of short duration rTMS in tinnitus treatment using the THI. However, no significant benefits were demonstrated for other subjective patient ratings. Although well tolerated and convenient, short duration rTMS may prove inadequate for modulating maladaptive plastic changes at the cortical level, and our results suggest the need for delivery of more stimuli. Future studies will utilize at least 2000 pulses/day, in line with previous experience in Western settings.

CALHM1 variant is not associated with Alzheimer's disease among Asians.

In a case control study involving 484 study subjects, we showed that the CALHM1 allele (13.5% vs 16.7%) and genotype frequency was not significantly different between Alzheimer's disease (AD) and controls. Logistic regression analysis did not reveal any interaction between ApoE4 allele and CALHM1 allele.

A prospective study to compare the diagnostic performance of breast elastography versus conventional breast ultrasound.

AIM: To compare the diagnostic performance of breast elastography versus conventional ultrasound in the assessment of breast lesions. MATERIALS AND METHODS: The study was approved by the hospital's institutional review board. A prospective study involving 99 consecutive women who gave informed consent were enrolled from September 2007 to March 2008. One hundred and ten breast lesions were evaluated separately by conventional ultrasound, elastography and combined conventional ultrasound with elastography. Ultrasound assessment was based on the BIRADS classification, whereas elastographic assessment was based on strain pattern and the elastographic size ratios. Histological diagnosis was used as the reference standard. The sensitivity, specificity, and accuracy of each technique were compared. RESULTS: The mean age of the patients was 46.7 years. Twenty-six lesions were malignant and 84 were benign. Sensitivity, specificity, and accuracy were 88.5, 42.9 and 53.6%, respectively, for conventional ultrasound, 100, 73.8, and 80%, respectively, for elastography, and 88.5, 78.6, and 80.9%, respectively, for combined imaging. The specificity and accuracy of elastography and combined imaging were significantly better than that of conventional ultrasound (p<0.0001), whereas there was no statistically significant difference in the sensitivity between all three groups. Two-thirds (66.7%) of sonographic false-positive lesions had benign elastogram findings, which might have been spared from biopsy. CONCLUSION: This initial experience with ultrasound breast elastography showed that it was more specific and more accurate than conventional ultrasound. Combining elastography with ultrasound improved specificity and accuracy of ultrasound and can potentially reduce unnecessary breast biopsies.

The changing pattern of primary glomerulonephritis in Singapore and other countries over the past 3 decades.

This review of 2,586 renal biopsies over the past 3 decades in Singapore documents the changing pattern of glomerulonephritis (GN) from that of a third world country to that of a developed nation. In the 1st decade, mesangial proliferative glomerulonephritis was the most common form of primary GN, just as it was in the surrounding Asian countries. In the 2nd decade, the prevalence of mesangial proliferative GN decreased with a rise in membranous, GN which is also seen in China and Thailand. In the 3rd decade, there was a dramatic increase in focal sclerosing glomerulosclerosis. This increase reflects aging and obesity in keeping with more developed countries like Australia, India, Thailand and the United States of America. IgA nephritis remains the most common GN. Apart from the geographical influence, other socioeconomic factors play a significant role in the evolution of the renal biopsy pattern. Mesangial proliferative GN remains prevalent in many Asian countries, but in Singapore the prevalence is decreasing just as it is in Japan, Korea and Malaysia. Worldwide, the prevalence of focal sclerosing glomerulosclerosis continues to increase in many countries.

Clinical and physiological effects of transcranial electrical stimulation position on motor evoked potentials in scoliosis surgery.

BACKGROUND: During intraoperative monitoring for scoliosis surgery, we have previously elicited ipsilateral and contralateral motor evoked potentials (MEP) with cross scalp stimulation. Ipsilateral MEPs, which may have comprised summation of early ipsilaterally conducted components and transcallosally or deep white matter stimulated components, can show larger amplitudes than those derived purely from contralateral motor cortex stimulation. We tested this hypothesis using two stimulating positions. We compared intraoperative MEPs in 14 neurologically normal subjects undergoing scoliosis surgery using total intravenous anesthetic regimens. METHODS: Trancranial electrical stimulation was applied with both cross scalp (C3C4 or C4C3) or midline (C3Cz or C4Cz) positions. The latter was assumed to be more focal and result in little transcallosal/deep white matter stimulation. A train of 5 square wave stimuli 0.5 ms in duration at up to 200 mA was delivered with 4 ms (250 Hz) interstimulus intervals. Averaged supramaximal MEPs were obtained from the tibialis anterior bilaterally. RESULTS: The cross scalp stimulating position resulted in supramaximal MEPs that were of significantly higher amplitude, shorter latency and required lower stimulating intensity to elicit overall (Wilcoxon Signed Rank test, p < 0.05 for all), as compared to the midline stimulating position. However, no significant differences were found for all 3 parameters comparing ipsilaterally and contralaterally recorded MEPs (p > 0.05 for all), seen for both stimulating positions individually. CONCLUSIONS: Our findings suggest that cross scalp stimulation resulted in MEPs obtained ipsilaterally and contralaterally which may be contributed to by summation of ipsilateral and simultaneous transcallosally or deep white matter conducted stimulation of the opposite motor cortex. Use of this stimulating position is advocated to elicit MEPs under operative circumstances where anesthetic agents may cause suppression of cortical and spinal excitability. Although less focal in nature, cross scalp stimulation would be most suitable for infratentorial or spinal surgery, in contrast to supratentorial neurosurgical procedures.

A pilot study of topiramate dosages for migraine prophylaxis in an Asian population.

Topiramate is known to be efficacious in migraine prophylaxis, but its optimal dose has not been systematically studied in the Asian population. Here, we show that a fixed low dose of topiramate 25 mg/day is efficacious in migraine prophylaxis and also attest to advantages in terms of medication cost savings and more favourable side effect profile.