Myasthenia gravis (MG) is a rare autoimmune disorder characterised by fluctuating and variable combination of muscle weakness and fatigue. Most cases are due to T-cell mediated autoantibodies against post-synaptic acetylcholine receptors (AChR-Ab), thus preventing acetylcholine from binding and signalling skeletal muscle to contract. 1 The annual incidence is 7-23 new cases per million. 1 It can occur at any age but with two peaks; an early- onset (20-40 years) female-predominant and a late-onset (60-80 years) male-predominant peak. MG is classified into ocular and generalised (80%). More than half the patients initially present with ptosis and diplopia but half will progress to generalised disease with involvement of bulbar, limb and respiratory weakness. Those presenting as generalised MG can also develop eye signs later. 1 It is important to recognise MG early because it is highly treatable. Untreated disease leads to permanent weakness. 2 Treatment reduces mortality from life- threatening myasthenic crisis. 1,3 Misdiagnosis leads to potentially harmful interventions and inappropriate management. 4,5 Diagnosis in late-onset MG is easily missed 2,3,4,5 because of overlapping symptoms with other diseases common in the elderly. We report a case of delay and misdiagnosis in an elderly patient with co-morbidities.
Myasthenia Gravis

Background: Undergraduate medical students have been the most distressed group among the student population. Depression and anxiety have been found to be more prevalent in this group of students compared to others. Objective: This study was conducted to determine the prevalence and predictors of suicidality among undergraduate medical students in a public university. Methods: This was an analytical cross-sectional study, conducted in a public university in Selangor, Malaysia. Data were collected using self-administered questionnaires from January to February 2013, and analysed using the Statistical Package for Social Sciences Software (version 21). Results: Out of 625 undergraduate medical students, 537 (85.9%) participated in the study. The prevalence of the suicidality among undergraduate medical students was 7.0%. The significant predictors of suicidality based on multiple logistic regression were the respondent’s lifetime suicide attempts (Adjusted Odds Ratio, AOR 10.4, 95% CI 2.7 to 40.9); depression (AOR 5.9, 95% CI 1.5 to 23.0); breaking off a steady love relationship (AOR 5.4, 95% CI 1.3 to 22.4); hopelessness (AOR 4.9, 95% CI 1.1 to 21.6); and something valued being lost or stolen (AOR 4.4, 95% CI 1.2 to 15.9). Conclusion: These findings indicate that mental health care services should be strengthened at university level. The results show a need for an intervention programme to reduce suicidality among the undergraduate medical students.
Students, Medical ; Depression

Transitional cell carcinoma has rarely been reported to be associated with disseminated intravascular coagulation (DIC). We report a 55-year-old Chinese man who was diagnosed with transitional cell carcinoma with vertebral metastasis. He presented with severe anaemia and thrombocytopenia, and subsequent evaluation revealed features of DIC. Interestingly, he did not have fever, any localising symptoms or signs of infection. He was treated aggressively with transfusion of packed cells, platelets, intravenous vitamin K and fresh frozen plasma. Despite aggressive treatment, the coagulation abnormalities were resistant to correction. The patient continued to deteriorate and eventually died of cardiac arrest. This case illustrates that transitional cell carcinoma can also be associated with DIC, possibly due to the expression of certain unidentified procoagulant factors similar to the tissue factor responsible for DIC.
Anemia ; etiology ; Carcinoma, Transitional Cell ; blood ; complications ; Disseminated Intravascular Coagulation ; etiology ; Humans ; Male ; Middle Aged ; Ureteral Neoplasms ; blood ; complications

Adolescent ; Diagnosis, Differential ; Exostoses ; diagnostic imaging ; pathology ; Fingers ; diagnostic imaging ; pathology ; Humans ; Male ; Nail Diseases ; diagnostic imaging ; pathology ; Radiography

Adult ; Erythromelalgia ; pathology ; Humans ; Leg ; physiopathology ; Leprosy ; diagnosis ; pathology ; Male ; Singapore

Humans ; Male ; Middle Aged ; Prurigo ; complications ; diagnosis ; Pruritus ; Sciatica

Chickenpox may lead to several neurological complications. Optic neuritis is one of the complications which has rarely been described, especially in immunocompetent individuals. We report a case of an 11-year-old immunocompetent girl who presented with sudden onset bilateral vision loss three weeks after varicella eruption. Ophthalmic examination revealed bilateral optic disc edema. Diagnosis of bilateral optic neuritis secondary to varicella was established based upon the preceding medical history, supported with clinical and radiological fndings.

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INTRODUCTIONManaging neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. The aims of preserving kidney function by achieving safe bladder pressures with anticholinergic medication often leave a significant proportion of patients with side effects. Botulinum toxin type A has been shown to be a promising alternative.

MATERIALS AND METHODSSpinal cord injury patients who had NDO, on clean intermittent self-catheterisation, and were refractory to oral medications, were recruited. Three hundred units of botulinum toxin type A (Botox) in 30 mL NaCl solution were injected under cystoscopic guidance into the bladder.

RESULTSFifteen patients were recruited of whom 9 were tetraplegic and 6 were paraplegic. Eleven (73.3%) had complete injuries. There was a significant reduction in the mean number of leakages from 3.75 +/- 1.79 pre-injection to 0.67 +/- 1.31 and 1.5 +/- 1.5 at 6 and 26 weeks postinjection, respectively (P <0.05). Seventy-five per cent, 37.5% and 50% were completely dry at 6, 26 and 39 weeks post-injection, respectively. The mean maximal catheterisable volume increased from 312.3 +/- 145.6 mL pre-injection to 484.6 +/- 190 mL, 422.3 +/- 157.3 mL and 490.0 +/- 230.4 mL at 6, 26 and 39 weeks post-injection, respectively (P <0.005). Maximum detrusor pressure decreased significantly from 66.3 +/- 22.6 cmH2O to 21.2 +/- 23.1 cmH2O and 33.6 +/- 30.2 cmH2O at 6 and 26 weeks post-injection, respectively (P <0.05). The volume at which reflex detrusor contractions first occurred increased from 127.8 +/- 57.5 mL pre-injury to 305.7 +/- 130.8 mL at 6 weeks and 288.3 +/- 13.0 mL at 26 weeks post-injection (P <0.05). Mean cysometric bladder capacity increased from 187.8 +/- 69.2 mL to 305 +/- 136.4 mL and 288.3 +/- 13.0 mL at 6 and 26 weeks post-injury, respectively (P <0.05). Sixty per cent of patients were completely off medications at 6 and 26 weeks post-injection. One patient had urinary tract infection and 1 experienced autonomic dysreflexia during cystoscopy. Satisfaction levels increased from 4.3 +/- 2.3 pre-injury to 7.2 +/- 1.9 and 7.3 +/- 2.3 at 6 weeks and 26 weeks, respectively. This also correlated with fewer leakages.

CONCLUSIONBotulinum toxin type A injected into the detrusor is safe and efficacious for spinal cord injured patients with refractory detrusor overactivity. This effect is maintained at 26 weeks post-injection.

Adult ; Aged ; Botulinum Toxins, Type A ; therapeutic use ; Female ; Humans ; Male ; Middle Aged ; Neuromuscular Agents ; therapeutic use ; Singapore ; Spinal Cord Injuries ; complications ; physiopathology ; Urinary Bladder, Overactive ; drug therapy ; etiology ; Urodynamics