Perceived changes in symptoms and quality-of-life amongst patients with dizziness: A single-centre experience in Malaysia.

INTRODUCTION: Dizziness is a common complaint by patients, yet it always presents as a diagnostic challenge to the attending clinician. An accurate diagnosis is essential to correctly administer the precise treatment regime, alleviate the symptoms, and improve the quality-of-life of patients who present with dizziness. A specialised vestibular clinic with a holistic approach of meticulous history-taking, complete physical examination, a collection of audiovestibular test battery, and facilities for vestibular rehabilitation was set up to assist in the management of these patients. This study aims to investigate the effect of vestibular clinic intervention on the symptoms and qualityof- life of patients who were managed in the vestibular clinic. MATERIALS AND METHODS: A total of 64 new patients who were managed in the vestibular clinic were selected and the validated Malay - Vestibular Rehabilitation Benefit Questionnaire (My-VRBQ) was completed during the first and follow-up visits to measure the changes in symptoms and quality-of-life before and after receiving care at the vestibular clinic. RESULTS: Our study showed that there was a positive effect of vestibular clinic intervention on the symptoms and quality-of-life of patients who were managed by the vestibular clinic. Statistically significant improvements were seen in the total My-VRBQ scores, symptoms scores, and quality-of-life scores. The subscale scores of dizziness, anxiety, and motion-provoked dizziness also showed statistically significant improvement among the patients who received care at the vestibular clinic. CONCLUSION: This indicates that the vestibular clinic was an essential part of the work-up, diagnosis, and treatment of patients with dizziness; and a specialised vestibular clinic was able to bring about positive outcomes in the symptoms and quality-of-life of patients with balance disorders.

Cortical thinning and sleep slow wave activity reductions mediate age-related improvements in cognition during mid-late adolescence.

STUDY OBJECTIVES: Gains in cognitive test performance that occur during adolescence are associated with brain maturation. Cortical thinning and reduced sleep slow wave activity (SWA) are markers of such developmental changes. Here we investigate whether they mediate age-related improvements in cognition. METHODS: 109 adolescents aged 15-19 years (49 males) underwent magnetic resonance imaging, polysomnography (PSG), and a battery of cognitive tasks within a 2-month time window. Cognitive tasks assessed nonverbal intelligence, sustained attention, speed of processing and working memory and executive function. To minimize the effect of sleep history on SWA and cognitive performance, PSG and test batteries were administered only after at least 8 nights of 9-h time-in-bed (TIB) sleep opportunity. RESULTS: Age-related improvements in speed of processing (r = 0.33, p = 0.001) and nonverbal intelligence (r = 0.24, p = 0.01) domains were observed. These cognitive changes were associated with reduced cortical thickness, particularly in bilateral temporoparietal regions (rs = -0.21 to -0.45, ps < 0.05), as well as SWA (r = -0.35, p < 0.001). Serial mediation models found that ROIs in the middle/superior temporal cortices, together with SWA mediated the age-related improvement observed on cognition. CONCLUSIONS: During adolescence, age-related improvements in cognition are mediated by reductions in cortical thickness and sleep SWA.

Splitting sleep between the night and a daytime nap reduces homeostatic sleep pressure and enhances long-term memory.

Daytime naps have been linked with enhanced memory encoding and consolidation. It remains unclear how a daily napping schedule impacts learning throughout the day, and whether these effects are the same for well-rested and sleep restricted individuals. We compared memory in 112 adolescents who underwent two simulated school weeks containing 8 or 6.5 h sleep opportunities each day. Sleep episodes were nocturnal or split between nocturnal sleep and a 90-min afternoon nap, creating four experimental groups: 8 h-continuous, 8 h-split, 6.5 h-continuous and 6.5 h-split. Declarative memory was assessed with picture encoding and an educationally realistic factual knowledge task. Splitting sleep significantly enhanced afternoon picture encoding and factual knowledge under both 6.5 h and 8 h durations. Splitting sleep also significantly reduced slow-wave energy during nocturnal sleep, suggesting lower homeostatic sleep pressure during the day. There was no negative impact of the split sleep schedule on morning performance, despite a reduction in nocturnal sleep. These findings suggest that naps could be incorporated into a daily sleep schedule that provides sufficient sleep and benefits learning.

Memory performance following napping in habitual and non-habitual nappers.

STUDY OBJECTIVES: Afternoon naps benefit memory but this may depend on whether one is a habitual napper (HN; ≥1 nap/week) or non-habitual napper (NN). Here, we investigated whether a nap would benefit HN and NN differently, as well as whether HN would be more adversely affected by nap restriction compared to NN. METHODS: Forty-six participants in the nap condition (HN-nap: n = 25, NN-nap: n = 21) took a 90-min nap (14:00-15:30 pm) on experimental days while 46 participants in the Wake condition (HN-wake: n = 24, NN-wake: n = 22) remained awake in the afternoon. Memory tasks were administered after the nap to assess short-term topographical memory and long-term memory in the form of picture encoding and factual knowledge learning respectively. RESULTS: An afternoon nap boosted picture encoding and factual knowledge learning irrespective of whether one habitually napped (main effects of condition (nap/wake): ps < 0.037). However, we found a significant interaction for the hippocampal-dependent topographical memory task (p = 0.039) wherein a nap, relative to wake, benefitted habitual nappers (HN-nap vs HN-wake: p = 0.003) compared to non-habitual nappers (NN-nap vs. NN-wake: p = 0.918). Notably for this task, habitual nappers' performance significantly declined if they were not allowed to nap (HN-wake vs NN-wake: p = 0.037). CONCLUSIONS: Contrary to concerns that napping may be disadvantageous for non-habitual nappers, we found that an afternoon nap was beneficial for long-term memory tasks even if one did not habitually nap. Naps were especially beneficial for habitual nappers performing a short-term topographical memory task, as it restored the decline that would otherwise have been incurred without a nap. CLINICAL TRIAL INFORMATION: NCT04044885.

Cognitive effects of split and continuous sleep schedules in adolescents differ according to total sleep opportunity.

STUDY OBJECTIVES: We compared the basic cognitive functions of adolescents undergoing split (nocturnal sleep + daytime nap) and continuous nocturnal sleep schedules when total sleep opportunity was either below or within the recommended range (i.e. 6.5 or 8 h). METHODS: Adolescent participants (age: 15-19 year) in the 8-h split (n = 24) and continuous (n = 29) sleep groups were compared with 6.5-h split and continuous sleep groups from a previous study (n = 58). These protocols involved two baseline nights (9-h time-in-bed [TIB]), 5 nights of sleep manipulation, 2 recovery nights (9-h TIB), followed by a second cycle of sleep manipulation (3 nights) and recovery (2 nights). Cognitive performance, subjective sleepiness, and mood were evaluated daily; sleep was assessed using polysomnography. RESULTS: Splitting 6.5 h of sleep with a mid-afternoon nap offered a boost to cognitive function compared to continuous nocturnal sleep. However, when total TIB across 24 h increased to 8 h, the split and continuous sleep groups performed comparably in tests evaluating vigilance, working memory, executive function, processing speed, subjective sleepiness, and mood. CONCLUSIONS: In adolescents, the effects of split sleep on basic cognitive functions vary by the amount of total sleep obtained. As long as the total sleep opportunity across 24 h is within the recommended range, students may fulfill sleep requirements by adopting a split sleep schedule consisting of a shorter period of nocturnal sleep combined with a mid-afternoon nap, without significant impact on basic cognitive functions. CLINICAL TRIAL REGISTRATION: NCT04044885.

Reward supports flexible orienting of attention to category information and influences subsequent memory.

Preparatory control of attention facilitates the efficient processing and encoding of an expected stimulus. However, this can occur at the expense of increasing the processing cost of unexpected stimuli. Preparatory control can be influenced by motivational factors, such as the expectation of a reward. Interestingly, expectation of a high reward can increase target processing, as well as reduce the cost associated with reorienting. Using a semantic cueing paradigm, we examined the interaction of reward expectation and cue-validity on semantic judgment performance and subsequent memory. Preparatory attention was assessed with pupillometry. Valid category cueing was associated with better semantic judgment performance and better subsequent memory compared to invalidly cued items. Higher reward also resulted in a larger pre-target pupil diameter, which could be indicative of increased preparatory task engagement or arousal. Critically, higher reward also reduced reorienting cost in both semantic judgment and subsequent memory performance. Our findings suggest that reward expectation can facilitate the effective control of preparatory attention for semantic information, and can support optimal goal-directed behavior based on changing task demands.

Intra-articular Entrapment of Medial Epicondyle Fracture Fragment in Elbow Joint Dislocation Causing Ulnar Neuropraxia: A Case Report.

Traumatic elbow dislocations in children are rare but most of them are complex dislocations, and in such dislocations, medial humerus epicondyle fractureis the most common associated injury. Fracture incarceration in the elbow joint occurs in 5-18% of medial humerus epicondyle fractures but ulnar neuropraxia is very rare. Open reduction internal fixation is indicated in medial humerus epicondyle fracture with fracture incarceration, ulnar neuropraxia, marked instability or open fracture. Operative treatment options include fragment excision and sutures, closed or open reduction and Kirschner wire fixation, open reduction and suture fixation, open reduction and smooth pin fixation, and open reduction and screw fixation. However, ulnar nerve transposition is debatable as good outcome had been reported with and without nerve transposition. We report a case of a 13-year old boy, who presented with right elbow dislocation and intra-articular entrapment of medial humerus epicondyle fracture fragment, complicated with sensory ulnar neuropraxia, following a fall onto his right outstretched hand in a motor vehicle accident. The elbow joint was reduced using close manipulative reduction but the fracture fragment remained entrapped post-reduction. The patient then underwent open reduction and screw fixation of the medial humerus epicondyle fracture without ulnar nerve transposition. He had good functional outcome six weeks after surgical intervention, with complete recovery of ulnar neuropraxia six months later. Currently, he is doing well at school and is active with his sporting activity.

Stimulus-response incompatibility eliminates inhibitory cueing effects with saccadic but not manual responses.

There are thought to be two forms of inhibition of return (IOR) depending on whether the oculomotor system is activated or suppressed. When saccades are allowed, output-based IOR is generated, whereas input-based IOR arises when saccades are prohibited. In a series of 4 experiments, we mixed or blocked compatible and incompatible trials with saccadic or manual responses to investigate whether cueing effects would follow the same pattern as those observed with more traditional peripheral onsets and central arrows. In all experiments, an uninformative cue was displayed, followed by a cue-back stimulus that was either red or green, indicating whether a compatible or incompatible response was required. The results showed that IOR was indeed observed for compatible responses in all tasks, whereas IOR was eliminated for incompatible trials-but only with saccadic responses. These findings indicate that the dissociation between input- and output-based forms of IOR depends on more than just oculomotor activation, providing further support for the existence of an inhibitory cueing effect that is distinct to the manual response modality.

Humeral Supracondylar Fractures in Children: A Novel Technique of Lateral External Fixation and Kirschner Wiring.

Introduction: Supracondylar fracture of the humerus is the most common fracture around the elbow in children. Pinning with Kirschner wires (K-wires) after open or closed reduction is generally accepted as the primary treatment modality. However, it comes with the risk of persistent instability and if the K-wire is not inserted properly, it may cause displacement and varus deformity. We present our two-year experience with a new technique of lateral external fixation and K-wiring of the humeral supracondylar fracture. Materials and Methods: A total of seven children with irreducible Gartland Type III supracondylar humeral fracture were treated with closed reduction and lateral external fixation and lateral Kirschner wiring. Patients with ipsilateral radial or ulnar fracture, open fracture and presence of neurovascular impairment pre-operatively were excluded. All the patients were followed up at one, three and six weeks and three and six months. The final outcomes were assessed based on Flynn's criteria. Results: All the patients achieved satisfactory outcomes in terms of cosmetic and functional aspects. All patients except one (85.5%) regained excellent and good cosmetic and functional status. One patient (14.3%) sustained pin site infection which resolved with oral antibiotic (Checketts- Otterburn grade 2). There was no neurological deficit involving the ulnar nerve and radial nerve. Conclusion: The introduction of lateral external fixation and lateral percutaneous pinning provide a promising alternative method for the treatment of humeral supracondylar fracture. This study demonstrates that it has satisfactory cosmetic and functional outcomes with no increased risk of complications compared to percutaneous pinning.

Humeral Supracondylar Fractures in Children: A Novel Technique of Lateral External Fixation and Kirschner Wiring

Introduction: Supracondylar fracture of the humerus is the most common fracture around the elbow in children. Pinning with Kirschner wires (K-wires) after open or closed reduction is generally accepted as the primary treatment modality. However, it comes with the risk of persistent instability and if the K-wire is not inserted properly, it may cause displacement and varus deformity. We present our two-year experience with a new technique of lateral external fixation and K-wiring of the humeral supracondylar fracture. Materials and Methods: A total of seven children with irreducible Gartland Type III supracondylar humeral fracture were treated with closed reduction and lateral external fixation and lateral Kirschner wiring. Patients with ipsilateral radial or ulnar fracture, open fracture and presence of neurovascular impairment pre-operatively were excluded. All the patients were followed up at one, three and six weeks and three and six months. The final outcomes were assessed based on Flynn's criteria. Results: All the patients achieved satisfactory outcomes in terms of cosmetic and functional aspects. All patients except one (85.5%) regained excellent and good cosmetic and functional status. One patient (14.3%) sustained pin site infection which resolved with oral antibiotic (CheckettsOtterburn grade 2). There was no neurological deficit involving the ulnar nerve and radial nerve. Conclusion: The introduction of lateral external fixation and lateral percutaneous pinning provide a promising alternative method for the treatment of humeral supracondylar fracture. This study demonstrates that it has satisfactory cosmetic and functional outcomes with no increased risk of complications compared to percutaneous pinning.

Reliability and accuracy of the tape measurement method with a nearest reading of 5 mm in the assessment of leg length discrepancy.

INTRODUCTION: The aim of this study was to determine the reliability and accuracy of the tape measurement method (TMM) with a nearest reading of 5 mm in assessing leg length discrepancy (LLD). METHODS: This was a cross-sectional study conducted on 35 patients with LLD and 13 patients without LLD. Two blinded surgeons measured the lower limbs from the anterior superior iliac spine to the medial malleolus using TMM with a nearest reading of 5 mm. Computed tomography (CT) scanograms of the lower limbs of 22 patients were conducted by two blinded radiologists. Intraclass correlation coefficient (ICC) with 95 percent confidence interval was calculated to assess the interobserver reliability of TMM. The accuracy of TMM was assessed by comparison with CT as the gold standard. RESULTS: The interobserver reliability of LLD measurement using both TMM and CT scanogram was high, with ICCs of 0.924 and 0.971, respectively. No significant mean difference on paired sample t-test was observed for both TMM and CT scanogram. Compared to CT scanogram, TMM had good accuracy, with an ICC of 0.805. When the mean TMM readings by two observers were compared to those derived from CT scanogram, the ICC was found to be 0.847, with a mean difference of 1.95 (range -3.17 to 7.07) mm. CONCLUSION: There was excellent agreement in the LLD measurements between the two surgeons using TMM, between the two radiologists using CT sonogram, and between the TMM and CT measurements. This study showed that one TMM with the nearest reading of 5 mm was reliable and accurate in measuring LLD.

Aldrin-induced stimulation of locomotor activity and brain regional glutamate.

Single administration of aldrin (2-10 mg/kg) to adult male albino rats (120-130 g) enhanced locomotor activity (LA), with the maximum effect reached 2 h after treatment. The measurement of steady state levels of glutamate, glutamine and the activities of their metabolizing enzymes in different regions of the brains of rats treated with aldrin under its nontolerant condition showed that aldrin enhanced the activity of the neuronal glutamate system in the cerebral cortex, cerebellum and hypothalamus. Moreover, treatment with the glutamatergic NMDA receptor antagonist D,L-2-amino-7-phosphonoheptanoic acid, in the absence and presence of aldrin, reduced the LA of control rats and attenuated the aldrin-induced increase in LA of treated rats. These results suggest that aldrin-induced activation of the central glutamate system may be a cause of stimulation of LA with aldrin under its nontolerant condition.

Role of brain regional GABA: aldrin-induced stimulation of locomotor activity in rat.

Aldrin, a chlorinated hydrocarbon group of pesticide, is a well known central nervous system (CNS) stimulant. The CNS stimulating effect of aldrin is manifested in the form of an increase in locomotor activity (LA) of animals. Maximum increase in LA was observed at 2 h following aldrin (2-10 mg/kg, p.o.) treatment and this aldrin-induced increase in LA attained a peak at a dose of 10 mg/kg, p.o. Administration of aldrin (2 or 5 mg/kg/day, p.o.) enhanced LA of rats and reached a maxima after 12 consecutive days of treatment following which aldrin-induced LA was gradually reduced and restored to control value after 20 consecutive days of aldrin treatment. A single administration of aldrin (2-10 mg/kg, p.o.) reduced the GABA system in cerebellum, hypothalamus and pons-medulla. The treatment with aldrin (2 mg/kg/day, p.o.) for 12 consecutive days produced more inhibition in those brain regional GABA system than that observed with a single dose of aldrin. These results, thus, suggest that aldrin-induced inhibition of central GABA may be a cause of stimulation of LA with aldrin either at a single dose or for 12 consecutive days.

Aldrin-induced locomotor activity: possible involvement of the central GABAergic-cholinergic-dopaminergic interaction.

Aldrin (5 mg/kg/day, p.o.) under nontolerant condition, administered either for a single day or for 12 consecutive days, enhanced locomotor activity (LA) of rats. The increase in LA was greater in rats treated with aldrin for 12 consecutive days than that observed with a single dose. The aim of the present study is to evaluate the involvement of possible interactions of central GABAergic, cholinergic and dopaminergic systems using their agonist(s) and antagonist(s) in the regulation of LA in aldrin nontolerant rats. Administration of either L-DOPA along with carbidopa or bicuculline potentiated aldrin-induced increase in LA under nontolerant condition as well as LA of the control rats. Treatment with muscimol, haloperidol, atropine or physostigmine all decreased the LA of both aldrin nontolerant and control rats. Further, the application of (a) haloperidol along with bicuculline, atropine or physostigmine and (b) physostigmine along with bicuculline or L-DOPA + carbidopa significantly reduced LA but L-DOPA + carbidopa along with atropine or bicuculline increased LA of the control rats. These agonist(s)/antagonist(s)-induced decrease or increase in LA of the control rats were attenuated or potentiated, respectively, when those agonist(s)/antagonist(s) under abovementioned condition were administered to aldrin nontolerant rats. The attenuating or potentiating effects of aldrin on agonist(s)/antagonist(s) (either individually or in different combinations)-induced change in LA were greater in rats treated with aldrin for 12 consecutive days than that observed with a single-dose aldrin treatment. These results suggest that aldrin, under nontolerant condition, reduces central GABAergic activity and increases LA by activating dopaminergic system via inhibition of cholinergic activity. The treatment with aldrin for 12 consecutive days produces greater effect than that caused by a single-day treatment.