Ulnar neuropathy at the wrist is an uncommon disease and pure ulnar sensory neuropathy at the wrist is even rarer. It is difficult to diagnose pure ulnar sensory neuropathy at the wrist by conventional methods. We report a case of pure ulnar sensory neuropathy at the hypothenar area. The lesion was localized between 3 cm and 5 cm distal to pisiform using orthodromic inching test of ulnar sensory nerve to stimulate at three points around the hypothenar area. Ultrasonographic examination confirmed compression of superficial sensory branch of the ulnar nerve. Further, surgical exploration reconfirmed compression of the ulnar nerve. This case report demonstrates the utility of orthodromic ulnar sensory inching test.
Diagnosis* ; Electrodiagnosis ; Neural Conduction* ; Ulnar Nerve ; Ulnar Nerve Compression Syndromes ; Ulnar Neuropathies ; Wrist

OBJECTIVE: To identify the center of extensor indicis (EI) muscle through cadaver dissection and compare the accuracy of different techniques for needle electromyography (EMG) electrode insertion. METHODS: Eighteen upper limbs of 10 adult cadavers were dissected. The center of trigonal EI muscle was defined as the point where the three medians of the triangle intersect. Three different needle electrode insertion techniques were introduced: M1, 2.5 cm above the lower border of ulnar styloid process (USP), lateral aspect of the ulna; M2, 2 finger breadths (FB) proximal to USP, lateral aspect of the ulna; and M3, distal fourth of the forearm, lateral aspect of the ulna. The distance from USP to the center (X) parallel to the line between radial head to USP, and from medial border of ulna to the center (Y) were measured. The distances between 3 different points (M1– M3) and the center were measured (marked as D1, D2, and D3, respectively). RESULTS: The median value of X was 48.3 mm and that of Y was 7.2 mm. The median values of D1, D2 and D3 were 23.3 mm, 13.3 mm and 9.0 mm, respectively. CONCLUSION: The center of EI muscle is located approximately 4.8 cm proximal to USP level and 7.2 mm lateral to the medial border of the ulna. Among the three methods, the technique placing the needle electrode at distal fourth of the forearm and lateral to the radial side of the ulna bone (M3) is the most accurate and closest to the center of the EI muscle.
Adult ; Cadaver* ; Electrodes ; Electrodiagnosis ; Electromyography* ; Fingers ; Forearm ; Head ; Humans ; Needles* ; Ulna ; Upper Extremity

BACKGROUND: We have noticed changes in paediatric anaphylaxis triggers locally in Singapore. OBJECTIVE: We aimed to describe the demographic characteristics, clinical features, causative agents and management of children presenting with anaphylaxis. METHODS: This is a retrospective study of Singaporean children presenting with anaphylaxis between January 2005 and December 2009 to a tertiary paediatric hospital. RESULTS: One hundred and eight cases of anaphylaxis in 98 children were included. Food was the commonest trigger (63%), followed by drugs (30%), whilst 7% were idiopathic. Peanut was the top food trigger (19%), followed by egg (12%), shellfish (10%) and bird's nest (10%). Ibuprofen was the commonest cause of drug induced anaphylaxis (50%), followed by paracetamol (15%) and other nonsteroidal anti-inflammatory drugs (NSAIDs, 12%). The median age of presentation for all anaphylaxis cases was 7.9 years old (interquartile range 3.6 to 10.8 years), but food triggers occurred significantly earlier compared to drugs (median 4.9 years vs. 10.5 years, p < 0.05). Mucocutaneous (91%) and respiratory features (88%) were the principal presenting symptoms. Drug anaphylaxis was more likely to result in hypotension compared to food anaphylaxis (21.9% vs. 2.7%, Fisher's exact probability < 0.01). There were 4 reported cases (3.6%) of biphasic reaction occurring within 24 h of anaphylaxis. CONCLUSION: Food anaphylaxis patterns have changed over time in our study cohort of Singaporean children. Peanuts allergy, almost absent a decade ago, is currently the top food trigger, whilst seafood and bird's nest continue to be an important cause of food anaphylaxis locally. NSAIDs and paracetamol hypersensitivity are unique causes of drug induced anaphylaxis locally.
Acetaminophen ; Anaphylaxis ; Anti-Inflammatory Agents, Non-Steroidal ; Arachis ; Child ; Cohort Studies ; Drug Hypersensitivity ; Food Hypersensitivity ; Humans ; Hypersensitivity ; Hypotension ; Ibuprofen ; Ovum ; Retrospective Studies ; Seafood ; Shellfish ; Singapore

Sublingual immunotherapy has gained acceptance amongst the paediatric community as it is very well tolerated and is safe. The adverse effects of this therapy is minimal consisting mainly of local side effects within the oral cavity such as itching of the mouth, swelling of the lips and less frequently abdominal pain, wheezing and urticaria has been described. This report is to highlight another local side effect of sublingual immunotherapy which has been observed in 3 of our patients. This is pigmentation of the gums which can occur anytime during the course of the immunotherapy. It resolves on stopping the immunotherapy and is likely due to a local inflammatory process occurring in the gums of these children. There is no associated pain or itching with the pigmentation. It can persist as long as the child is on the immunotherapy.
Abdominal Pain ; Child ; Gingiva ; Humans ; Immunotherapy ; Lip ; Mouth ; Pigmentation ; Pruritus ; Respiratory Sounds ; Sublingual Immunotherapy ; Urticaria

BACKGROUND: Cyclooxygenase-2 (COX-2) inhibitors have been found to be safe alternatives in adults with cross-intolerant hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs). However they are usually not prescribed in children and there is little information about their tolerance in the pediatric age group. OBJECTIVE: This study aims to evaluate the tolerance to etoricoxib in children with hypersensitivity to multiple antipyretics. METHODS: A retrospective case series of children diagnosed with hypersensitivity reactions to NSAIDs and/or paracetamol who underwent a drug provocation test (DPT) with etoricoxib. Information on atopy, family history of allergic diseases, and medication usage was collected. Outcomes of the DPTs and tolerance to etoricoxib were also evaluated. RESULTS: A total of 24 children, mean age 13.5 years, had a diagnosis of cross-intolerant hypersensitivity to NSAIDs and/or paracetamol. All except one patient successfully tolerated an oral challenge with etoricoxib. Of those who passed the DPT, the majority continued to use etoricoxib with no problems. It was found to be moderately effective in reducing fever and pain. CONCLUSION: Etoricoxib can be used as a safe alternative in older children with hypersensitivity to multiple antipyretics.
Acetaminophen ; Adult ; Anti-Inflammatory Agents, Non-Steroidal ; Antipyretics ; Child ; Cyclooxygenase 2 ; Diagnosis ; Drug Hypersensitivity ; Fever ; Humans ; Hypersensitivity ; Retrospective Studies

BACKGROUND: There is limited literature in the management of chronic urticaria in children. Treatment algorithms are generally extrapolated from adult studies. OBJECTIVE: Utility of a weight and age-based algorithm for antihistamines in management of chronic spontaneous urticaria (CSU) in childhood. To document associated factors that predict for step of control of CSU and time taken to attain control of symptoms in children. METHODS: A workgroup comprising of allergists, nurses, and pharmacists convened to develop a stepwise treatment algorithm in management of children with CSU. Sequential patients presenting to the paediatric allergy service with CSU were included in this observational, prospective study. RESULTS: Ninety-eight patients were recruited from September 2012 to September 2013. Majority were male, Chinese with median age 4 years 7 months. A third of patients with CSU had a family history of acute urticaria. Ten point two percent had previously resolved CSU, 25.5% had associated angioedema, and 53.1% had a history of atopy. A total of 96.9% of patients achieved control of symptoms, of which 91.8% achieved control with cetirizine. Fifty percent of all the patients were controlled on step 2 or higher. Forty-seven point eight percent of those on step 2 or higher were between 2 to 6 years of age compared to 32.6% and 19.6% who were 6 years and older and lesser than 2 years of age respectively. Eighty percent of those with previously resolved CSU required an increase to step 2 and above to achieve chronic urticaria control. CONCLUSION: We propose a weight- and age-based titration algorithm for different antihistamines for CSU in children using a stepwise approach to achieve control. This algorithm may improve the management and safety profile for paediatric CSU patients and allow for review in a more systematic manner for physicians dealing with CSU in children.
Adult ; Angioedema ; Asian Continental Ancestry Group ; Cetirizine ; Child ; Histamine Antagonists ; Humans ; Hypersensitivity ; Male ; Pharmacists ; Prospective Studies ; Urticaria

INTRODUCTIONAwake craniotomy allows accurate localisation of the eloquent brain, which is crucial during brain tumour resection in order to minimise risk of neurologic injury. The role of the anaesthesiologist is to provide adequate analgesia and sedation while maintaining ventilation and haemodynamic stability in an awake patient who needs to be cooperative during neurological testing. We reviewed the anaesthetic management of patients undergoing an awake craniotomy procedure.

MATERIALS AND METHODSThe records of all the patients who had an awake craniotomy at our institution from July 2004 till June 2006 were reviewed. The anaesthesia techniques and management were examined. The perioperative complications and the outcome of the patients were noted.

RESULTSThere were 17 procedures carried out during the study period. Local anaesthesia with moderate to deep sedation was the technique used in all the patients. Respiratory complications occurred in 24% of the patients. Hypertension was observed in 24% of the patients. All the complications were transient and easily treated. During cortical stimulation, motor function was assessed in 16 patients (94%). Three patients (16%) had lesions in the temporal-parietal region and speech was assessed intraoperatively. Postoperative motor weakness was seen in 1 patient despite uneventful intraoperative testing. No patient required intensive care unit stay. The median length of stay in the high dependency unit was 1 day and the median length of hospital stay was 9 days. There was no in-hospital mortality.

CONCLUSIONAwake craniotomy for brain tumour excision can be successfully performed under good anaesthetic conditions with careful titration of sedation. Our series showed it to be a well-tolerated procedure with a low rate of complications. The benefits of maximal tumour excision can be achieved, leading to potentially better patient outcome.

Adult ; Aged ; Anesthesia, Local ; methods ; Anesthetics, Local ; administration & dosage ; Brain Neoplasms ; surgery ; Conscious Sedation ; Craniotomy ; Female ; Humans ; Male ; Medical Audit ; Middle Aged ; Outcome Assessment (Health Care) ; Perioperative Care ; Singapore