Increased fracture risk and osteoporosis not associated with vitamin D levels in Malaysian patients with inflammatory bowel disease.

INTRODUCTION: Osteoporosis and osteopenia are well-recognized complications of inflammatory bowel disease. Previous studies have suggested that vitamin D deficiency is an important risk factor for the development of osteoporosis. We hypothesized that low vitamin D levels is the main reason for reduced bone mineral density in patients with inflammatory bowel disease. We aimed to study its potential role in Malaysia, which is a tropical country with 3 large ethnic groups. We also sought to examine the relationship between fracture risk and bone mineral density in this group. METHODOLOGY: Relevant history as well as 25-hydroxycholecalciferol (vitamin D) levels and bone mineral density were obtained. Normal, inadequate, and low vitamin D levels were defined as 61-160 nmol/L (24-64 ng/mL), 30-60 nmol/L (12-24 ng/mL), and less than 30 nmol/L (<12 ng/mL), respectively. RESULTS: Seventy-two patients were recruited. The prevalence of osteopenia and osteoporosis, respectively, were 58% and 17% in the spine and 51% and 14% in the hip. Mean vitamin D level in the group was low at 45.12 ± 17.4 nmol/L (18.05 ± 6.96 ng/mL), but there was no significant association between bone mineral density and vitamin D level. Twelve patients (16.7%) had a fragility fracture after the diagnosis of inflammatory bowel disease. The cumulative fracture incidence was 10% at 5 years and 35% at 10 years. There was a statistically significant association between osteoporosis of hip and a history of fracture (odds ratio 5.889; 95% confidence interval 1.41-24.53, P = .009). CONCLUSION: Osteoporosis is prevalent among Malaysian patients with inflammatory bowel disease and is associated with a 6-fold increased risk of fractures. Most inflammatory bowel disease patients had inadequate or low vitamin D levels, but there was no association between vitamin D levels and BMD.

Is utilisation of computed tomography justified in clinical practice? Part IV: applications of paediatric computed tomography.

Computed tomography (CT) has been recognised as the most widely used imaging technique in both adults and children, owing to technological developments, especially with the recent innovations in multislice CT. This has resulted in an increase in the use of CT examinations in children younger than 15 years of age in developed countries. The increasing use of paediatric CT in clinical practice has raised concerns regarding the potential risk of radiation-induced malignancy. This is because CT examinations deliver a much higher radiation dose than conventional radiographic techniques. Children are more sensitive to radiation exposure than adults and have a longer time ahead of them to manifest radiation-induced effects and injuries. Therefore, it is of paramount importance to reduce or minimise the radiation dose to children when choosing CT as the major imaging modality for diagnostic purposes. This article reviews the clinical applications of paediatric CT with regard to the adjustment of imaging protocols in routine clinical practice and in the emergency department, the justification of CT use in paediatric imaging, clinical awareness of CT-associated radiation risk and strategies to minimise radiation exposure to children.

MR imaging features of Nipah encephalitis.

OBJECTIVE: The newly discovered Nipah virus causes an acute febrile encephalitic illness in humans that is associated with a high mortality. The purpose of this study is to describe the MR imaging findings of Nipah encephalitis. MATERIALS AND METHODS: MR imaging of the brain was performed in 31 patients with Nipah encephalitis divided into three groups. The first group (14 patients) underwent MR imaging during the acute phase of the illness and the second group (10 patients) during the later phase of the acute illness. The third group consisted of six patients who underwent MR imaging because they experienced neurologic relapse and one patient who had late-onset encephalitis. Spin-echo T1- and T2-weighted sequences and T2-weighted fluid attenuated inversion recovery (FLAIR) sequences were performed. Contrast-enhanced MR imaging was performed in four patients. RESULTS: The FLAIR sequences revealed abnormalities in all patients studied. MR imaging findings in both the acute and later phases of encephalitis were similar; the main feature of both phases was the presence of discrete high-signal-intensity lesions, measuring 2-7 mm, disseminated throughout the brain, mainly in the subcortical and deep white matter of the cerebral hemispheres. Neither mass effect nor cerebral edema was seen. There was no correlation with the focal neurologic signs, depth of coma, and outcome of the patients. The lesions were attributed to widespread microinfarctions from underlying vasculitis of cerebral small vessels. Features found on MR imaging in relapsed and late-onset encephalitis differed from the features in acute encephalitis in that confluent cortical involvement was the prominent finding in the former, as opposed to discrete focal lesions in the subcortical and deep white matter in the latter. CONCLUSION: MR imaging is a sensitive and specific diagnostic tool for evaluating Nipah encephalitis.

Clinical features of Nipah virus encephalitis among pig farmers in Malaysia.

BACKGROUND: Between September 1998 and June 1999, there was an outbreak of severe viral encephalitis due to Nipah virus, a newly discovered paramyxovirus, in Malaysia. METHODS: We studied the clinical features of the patients with Nipah virus encephalitis who were admitted to a medical center in Kuala Lumpur. The case definition was based on epidemiologic, clinical, cerebrospinal fluid, and neuroimaging findings. RESULTS: Ninety-four patients with Nipah virus infection were seen from February to June 1999 (mean age, 37 years; ratio of male patients to female patients, 4.5 to 1). Ninety-three percent had had direct contact with pigs, usually in the two weeks before the onset of illness, suggesting that there was direct viral transmission from pigs to humans and a short incubation period. The main presenting features were fever, headache, dizziness, and vomiting. Fifty-two patients (55 percent) had a reduced level of consciousness and prominent brain-stem dysfunction. Distinctive clinical signs included segmental myoclonus, areflexia and hypotonia, hypertension, and tachycardia and thus suggest the involvement of the brain stem and the upper cervical spinal cord. The initial cerebrospinal fluid findings were abnormal in 75 percent of patients. Antibodies against Hendra virus were detected in serum or cerebrospinal fluid in 76 percent of 83 patients tested. Thirty patients (32 percent) died after rapid deterioration in their condition. An abnormal doll's-eye reflex and tachycardia were factors associated with a poor prognosis. Death was probably due to severe brain-stem involvement. Neurologic relapse occurred after initially mild disease in three patients. Fifty patients (53 percent) recovered fully, and 14 (15 percent) had persistent neurologic deficits. CONCLUSIONS: Nipah virus causes a severe, rapidly progressive encephalitis with a high mortality rate and features that suggest involvement of the brain stem. The infection is associated with recent contact with pigs.

Failed magnetic resonance imaging examinations due to claustrophobia.

A recognized cause of incomplete or cancelled MRI examinations is anxiety and claustrophobic symptoms in patients undergoing MR scanning. This appears to be a problem in many MRI centres in Western Europe and North America, where it is said to be costly in terms of loss of valuable scan time, and has led to researchers suggesting several anxiety-reducing approaches for MRI. To determine the incidence of failed MRI examination among our patients and if there are any associations with a patient's sex, age and education level, we studied claustrophobia that led to premature termination of the MRI examination in the University Malaya Medical Centre (UMMC) in 3324 patients over 28 months. The incidence of failed MRI examinations due to claustrophobia in the UMMC was found to be only 0.54%. There are associations between claustrophobia in MRI with the patients' sex, age and level of education. The majority of those affected were male patients and young patients in the 25-45-years age group. The patients' education level appears to be the strongest association with failed MRI examinations due to claustrophobia, where the majority of the affected were highly educated individuals. Claustrophobia in MRI is more of a problem among the educated individuals or patients from a higher socio-economic group, which may explain the higher incidence in Western European and North American patients.