MRI findings of orbicularis oculi hypertrophy due to heavy resistance training on the inferior orbital rim

Increase in cross-sectional muscle area of major muscle groups associated by heavy resistance training has been well documented. However, there has been no published article of changes in the inferior orbicularis oculi muscle when heavy resistance training is applied. We present a case of inferior orbicularis hypertrophy detected on MRI in a gentleman who practised heavy resistance training using his lower eyelids

A clinical and electrophysiological study of Guillain-Barré syndrome in Malaysia A clinical and electrophysiological study of Guillain-Barré syndrome in Malaysia A clinical and electrophysiological study of Guillain-Barré syndrome in Malaysia A clinical a

Abstract Guillain-Barré syndrome is now considered a heterogeneous syndrome with both demyelinating and axonal variants. A prospective study was carried out in patients with Guillain-Barré syndrome admitted to the University of Malaya Medical Centre to determine the electrophysiological subtypes as well as the relationship to antecedent Campylobacter jejuni infection, thought to be associated with a predominantly axonal and motor variant of the syndrome. Forty patients were recruited. Excluding patients with clinical Miller-Fisher syndrome, 74.2 per cent had demyelinating polyneuropathy, 12.9 per cent had primary axonopathy and 9.7 per cent were unclassifiable. There was serological evidence of antecedent C. jejuni infection in 21.1 per cent of patients as compared to 2.6 per cent of age and sex-matched hospitals (P<0.014). However, all C. jejuni positive patients had a demyelinating subtype and had good outcome. Two patients (5 per cent) had poor outcome and one (2.5 per cent) died, all of whom had evidence of axonal degeneration (primary or secondary). This study supports the heterogeneity of Guillain-Barré syndrome in Malaysia. There are differences compared with other populations (e.g. Northern China) and this may suggest differences in risk factors and pathogenetic mechanisms for the syndrome

A Giant Gastric Bezoar in Billroth II Stomach: A Case Report on Successful Endoscopic Removal via Repeated Fragmentation and Dissolution Technique Negating the Need for Surgical Intervention

A 76-year-old gentleman presented with anemia. He had a history of perforated duodenal ulcer six years ago, with Billroth II repair performed. A large gastric bezoar (8×6 cm2) with a clean base ulcer at the anastomotic junction was found during the initial oesophago- gastro-duodenoscopy (OGDS). Rapid urease test was negative. He presented with melena during the subsequent follow up (OGDS showed a Forrest Ib prepylori ulcer). We have successfully removed the gastric bezoar with dissolution therapy initially (injection of cokecola into the bezoar, followed by drinking 325 mL Coca-ColaTM twice daily), followed by four attempts of OGDS with endoscopic fragmentation. Histopathology reported as degenerated vegetable matter, acellular debris mixed with scattered fungal and bacterial colonies, which was compatible with bezoar. Follow-up OGDS showed complete clearance of the bezoar. Coca-ColaTM ingestion should be considered as initial treatment as it is non-invasive, and it enables further successful endoscopic fragmentation

Mr neurography of median nerve using diffusion tensor imaging (DTI) and its efficacy to diagnose carpal tunnel syndrome in Malaysian population

Objective: This study evaluates the feasibility of diffusion tensor imaging(DTI) in assessing median nerve by measuring diffusion parameters such as fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) at different sites of median nerve and evaluating their differences in patients with and without carpal tunnel syndrome (CTS) in local setting. Methods: A prospective cross sectional study was performed with 9 female patients diagnosed with CTS by clinical evaluation and nerve conduction study and 8 age and sex matched normal patients. Magnetic resonance imaging (MRI) wrist was performed with pre-set axial PD and DTI protocol on a 3T MRI, images post-processed using 3D SLICER software to generate median nerve tract and measure diffusion parameters FA, MD, AD and RD in segments and focal points. Results: The FA values were significantly lower in CTS patients, 0.454 (± 0.065), p< 0.002 and demonstrates negative correlation with disease severity, r = - 0.510, p = 0.002.The mean MD, 1.090 (± 0.178) and mean RD, 0.834 (± 0.128) is higher in CTS patients, p = 0.041 and p = 0.014 respectively. They show an increasing trend with increasing disease severity. Negative correlation was noted between the FA values and age groups. FA cut of value of ≤ 0.487 with sensitivity 70.6 % and specificity 76.5%, is suggested for diagnosing CTS. Conclusion: MR neurography using DTI can be utilised to detect CTS. Patients with CTS demonstrate lower FA and higher MD and RD values

The utility of Guillain‐Barré syndrome prognostic models in Malaysian patients

Guillain-Barré syndrome (GBS) is an acute immune-mediated neuropathy that has variable disease course and outcome. The Erasmus GBS outcome score (EGOS), modified EGOS (mEGOS), and Erasmus GBS respiratory insufficiency score (EGRIS) are prognostic models designed to predict the functional outcome of GBS patients at 6 months (EGOS and mEGOS) and the need for mechanical ventilation within a week of admission (EGRIS). The models were primarily developed in the Dutch GBS population, and thus the usefulness of these models in other GBS cohorts is less clear. In the current study, we aimed to validate mEGOS, EGOS, and EGRIS in Malaysian GBS patients. A total of 107 patients with GBS and its variants were consecutively recruited. Patients with GBS and Miller Fisher syndrome (MFS) were analysed separately. In the GBS cohort, high mEGOS and EGOS scores were significantly correlated with poor outcome at 6 months (mEGOS on admission: r =.381, P =.005; mEGOS at day 7 of admission: r =.507, P <.001; EGOS: r =.484, P <.001). However, there were no significant correlations between mEGOS or EGOS and outcome in patients with MFS (mEGOS on admission: r =.152, P =.523; mEGOS at day 7 of admission: r =.008, P =.973; EGOS: r =.110; P =.644). The score of EGRIS for GBS patients with mechanical ventilation was significantly higher than those patients without mechanical ventilation (4 ± 2 vs 3 ± 1; P <.001). We conclude that mEGOS and EGOS are clinically useful and relevant to the Malaysian GBS population but not in patients with classic MFS. EGRIS could be used to predict the need for mechanical ventilation in our local GBS patients. © 2019 International Society of Travel Medicin

Short-term clinical outcome of orthosis alone vs combination of orthosis, nerve, and tendon gliding exercises and ultrasound therapy for treatment of carpal tunnel syndrome

Study Design: Prospective randomized study. Introduction: Carpal tunnel syndrome (CTS) has been described as the most common compression neuropathy. Many modalities exist for conservative treatment. Efficacy of each modality has been described in the literature. However, the effectiveness of combination of these modalities is not well established. The purpose of this study is to assess the short-term clinical outcome of conservative treatment for CTS comparing orthosis alone with combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy. Methods: Forty-one patients who presented to Upper Limb Reconstructive and Microsurgery Clinic, University Malaya Medical Centre with CTS and positive electrodiagnostic study were recruited. Fifteen patients had bilateral CTS. Fifty-six wrists were equally randomized to orthosis alone and a combined therapy of orthosis, nerve/tendon gliding exercise, and ultrasound therapy. All patients were required to complete the Boston Carpal Tunnel Questionnaire during the first visit and 2 months after treatment. Results: Both the orthosis and combined therapy groups showed a significant improvement in symptoms and function after treatment. The mean difference of symptoms in the orthosis group was 0.53; 95% confidence interval [CI]: 0.23-0.83 (P = .001) and in the combined therapy group was 0.48; 95% CI: 0.24-0.72 (P < .001). Mean difference of function in the orthosis group was 0.59; 95% CI: 0.28-0.91 (P = .001) and combined group was 0.69; 95% CI: 0.49-0.89 (P < .001). However, there was no significant difference in symptom severity and functional status scores between the groups. Discussion: Our findings support other findings where orthosis and exercises improved symptom severity and functional status scores, however, there was no significant difference between orthosis alone and combined treatment. Conclusion: Patients who underwent conservative management for CTS showed improvement in symptoms and function. However, the combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy did not offer additional benefit compared to orthosis alone. © 2018 Hanley & Belfu

Clinicopathological Features of Telbivudine-Associated Myopathy.

Telbivudine, a thymidine nucleoside analog, is a common therapeutic option for chronic hepatitis B infection. While raised serum creatine kinase is common, myopathy associated with telbivudine is rare. Reports on its myopathological features are few and immunohistochemical analyses of inflammatory cell infiltrates have not been previously described. We describe the clinical, myopathological and immunohistochemical features of four patients who developed myopathy after telbivudine therapy for chronic hepatitis B infection. All four patients presented with progressive proximal muscle weakness, elevation of serum creatine kinase and myopathic changes on electromyography. Muscle biopsies showed myofiber degeneration/necrosis, regeneration, and fibers with cytoplasmic bodies and cytochrome c oxidase deficiency. There was minimal inflammation associated with strong sarcolemmal overexpression of class I major histocompatibility complex (MHC class I). Upon withdrawal of telbivudine, muscle weakness improved in all patients and eventually completely resolved in three. In our series, telbivudine-associated myopathy is characterized by necrotizing myopathy which improved on drug withdrawal. Although the occasional loss of cytochrome c oxidase is consistent with mitochondrial toxicity, the overexpression of MHC class I in all patients could suggest an underlying immune-mediated mechanism which may warrant further investigation

Heart rate variability and baroreflex sensitivity abnormalities in Guillain–Barré syndrome: a pilot study

Objective: The current study aimed to investigate autonomic dysfunction in Guillain–Barré syndrome (GBS) patients and describe the results of computational heart rate variability (HRV)/baroreflex sensitivity (BRS) and autonomic challenge tests. Methods: GBS patients were consecutively recruited and the results were compared to age- and gender-matched healthy controls. A series of autonomic function tests including computation-dependent tests (power spectrum analysis of HRV and BRS at rest) and challenge maneuvers (deep breathing, eyeball compression, active standing, the Valsalva maneuver, sustained handgrip, and the cold pressor test) were performed. Results: Ten GBS patients (six men; mean age = 40.1 ± 13.9 years) and ten gender- and age-matched healthy controls were recruited. The mean GBS functional grading scale at disease plateau was 3.4 ± 1.0. No patients required intensive care unit admission or mechanical ventilation. Low-frequency HRV (p = 0.027), high-frequency HRV (p = 0.008), and the total power spectral density of HRV (p = 0.015) were significantly reduced in patients compared to controls. The mean up slope (p = 0.034), down slope (p = 0.011), and total slope (p = 0.024) BRS were significantly lower in GBS patients. The diastolic rise in blood pressure in the cold pressor test was significantly lower in GBS patients compared to controls (p = 0.008). Interpretation: Computation-dependent tests (HRV and BRS) were more useful for detecting autonomic dysfunction in GBS patients, whereas the cold pressor test was the only reliable challenge test, making it useful as a bedside measure of autonomic function in GBS patients. © 2018, Springer-Verlag GmbH Germany, part of Springer Nature

A severe form of M-protein negative distal acquired demyelinating symmetric neuropathy

Distal acquired demyelinating symmetric neuropathy (DADS) is a variant of chronic inflammatory demyelinating polyneuropathy (CIDP) characterized by symmetrical, distal, sensory or sensorimotor involvement. DADS with M-protein (DADS-M) is less responsive to immunotherapy compared to those without M-protein (DADS-I). We report a case of DADS-I with severe clinical presentation viz. early hand involvement with marked wasting, inexcitable peripheral nerves on neurophysiology and poor response to immunotherapy. Despite the unusual presentation, ancillary tests including cerebrospinal fluid analysis, nerve biopsy and nerve ultrasound were supportive of an inflammatory demyelinating polyneuropathy. This case demonstrated the heterogeneity of the disorder and expands the clinical spectrum of DADS neuropathy. © 2019 Neurology India, Neurological Society of India