Toxic leucoencephalopathy (TLE) is a rare neurological complication of heroin abuse. 'Chasing the dragon' is an inhalational mode of heroin abuse that originated in Southeast Asia. Intriguingly, no cases of TLE have been reported from this region, although the inhalational mode of heroin abuse is common. We herein report the case of a middle-aged man with a history of polysubstance abuse who presented with progressive neurological symptoms and progressed to an uncommunicative state. While the initial impression was that of iatrogenic parkinsonism, diffuse leucoencephalopathy with sparing of the cerebellum was noted on magnetic resonance imaging. In view of his history of inhalational heroin abuse close to the onset of the neurological symptoms, a diagnosis of TLE was made. No clinical improvement was noted with administration of a dopaminergic agent. This is the first known case of delayed TLE following heroin inhalation from Southeast Asia with the unusual feature of cerebellar sparing.
Administration, Inhalation ; Brain ; pathology ; Disease Progression ; Heroin ; administration & dosage ; Heroin Dependence ; complications ; Humans ; Leukoencephalopathies ; chemically induced ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Nervous System Diseases ; chemically induced ; Singapore

Central pontine myelinolysis (CPM) is classically described as a demyelinating condition that results from the rapid correction of hyponatraemia. CPM has also been reported to arise from hyperglycaemia in association with concomitant acidosis, hypernatraemia and hyperosmolar syndrome. Herein, we report a rare presentation of CPM, which was purely secondary to hyperosmolar hyperglycaemia. The patient presented with ataxia and pseudobulbar affect, which evolved subacutely over a duration of two weeks. It is important to note that, in addition to acute changes in osmolality, a subacute shift secondary to hyperglycaemia may also lead to CPM.
Diagnosis, Differential ; Female ; Humans ; Hyperglycemia ; complications ; Magnetic Resonance Imaging ; Middle Aged ; Myelinolysis, Central Pontine ; diagnosis ; etiology ; Tomography, X-Ray Computed

PURPOSE: To evaluate the impact of voiding position on uroflowmetry parameters and to assess its potential clinical implications. MATERIALS AND METHODS: We conducted a prospective study from 2013 to 2015 and included men between 18 and 77 years old who were either healthy volunteers with an International Prostate Symptom Score (IPSS) ≤7 or men with benign prostate enlargement that were on alpha-blocker medication and had an IPSS <10. Participants underwent uroflowmetry and post-void residual urine (PVRU) measurements twice, once in a sitting position and once in a standing position. The participants were divided into 4 groups based on age (35 years or younger, 36 to 50 years, 51 to 60 years, and older than 60 years). RESULTS: A total of 740 men with a mean age of 40.35 years were evaluated. There was no significant difference in uroflowmetry parameters until the age of 50 years between the voiding positions. However, in those older than 50 years, PVRU volume was significantly lower in the sitting position than the standing position, whereas voiding time was significantly higher in the sitting position than the standing position. Other uroflowmetry parameters, including maximal and average urine flow rates, were non-significant. CONCLUSIONS: The voiding position plays an important role in the uroflowmetry parameters of elderly men. Voiding in the sitting position was found to be optimal for elderly men, whereas the role of the voiding position in healthy young men could not be determined. More research is needed to further study this issue.
Aged ; Flowmeters ; Healthy Volunteers ; Humans ; Lower Urinary Tract Symptoms ; Male ; Posture* ; Prospective Studies ; Prostate ; Prostatic Hyperplasia

Objective: To assess the psychological impact of suspension/postponement of various fertility treatments on infertile women during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This was a cross-sectional study conducted as an online survey among infertile women consulting either through teleconsultation or physical consultation at a fertility clinic of a tertiary care referral unit. A validated questionnaire was given as a WhatsApp link to the women who were consulting for the resumption of services. Questions asked were based on their socio-demographic parameters, fertility treatment at the time of suspension, anxiety (self-reported) and stress (perceived stress scale-4, PSS-4) due to delay in treatment, psychosocial effect of pandemic, and wishes regarding the resumption of fertility services. Results: Of 430 patients who received the questionnaire, 250 completed the survey (response rate: 58%). The mean age of participants was 29.26±4.18 years and the majority (70.4%) had lower socioeconomic status. The average PSS-4 score was 7.8±0.71, and the prevalence of self-reported anxiety was 72%. Those who suffered migration during the pandemic had significantly higher PSS-4 scores, and increasing age was associated with increased self-reported anxiety due to the suspension of fertility services. The top three priorities reported were infertility and treatment delay (48.4%), job loss (19.2%), and the risk of contracting COVID-19 infection (16%). The degree of spousal support was significantly correlated with lower PSS-4 scores (r=-0.30, P<0.01). On multivariate logistic analysis, duration of infertility, delay in treatment due to suspension of services, and fear of COVID-19 infection were significant predictors of stress and anxiety. Conclusion This study emphasizes the need to investigate psychosocial health and to provide psychological support to this vulnerable population in addition to triaging fertility treatments in a phased manner.

Objective: Indocyanine green video angiography (ICG-VA) is a routine while performing vascular surgery to assess patency of perforators, completeness of clipping and/or to assess patency of anastomosis. Its usefulness in assessing cerebral blood flow and perfusion is not well studied. This study is aimed to assess the cerebral blood flow and perfusion after temporary clipping and to correlate with the risk of ischemia. Methods: Prospective analysis of intra-operative ICG-VA performed during temporary arterial occlusion in 38 patients from January 2014 to December 2018 was conducted. Co-relation with post-operative MR diffusion weighted imaging (MR DWI) in terms of vascular territory of interest within 48 hours of surgery was performed. Clinical outcome was assessed using modified Rankin Scale (mRS) score 1-month post-surgery. Results: 43 aneurysms in 38 patients clipped using ICG-VA were included in this study. No side effect of ICG dye was seen in any patients. The number of times temporary clips applied had a direct relationship to the delay in appearance of ICG in the surgical field which became statistically significant after application of 3rd temporary clip. Nine (23.7%) patients developed ischemia following the procedure confirmed by post-operative MR DWI and all the ischemic cases had visible decrease in ICG fluorescence post-temporary clipping. Conclusions No previous study had tried to assess the intraoperative cerebral blood flow and perfusion during temporary clipping of parent vessels during aneurysm surgery. The use of ICG-VA can be extended to assess perfusion in desired territory by merely assessing the degree of opacification.

Objective: Indocyanine green video angiography (ICG-VA) is a routine while performing vascular surgery to assess patency of perforators, completeness of clipping and/or to assess patency of anastomosis. Its usefulness in assessing cerebral blood flow and perfusion is not well studied. This study is aimed to assess the cerebral blood flow and perfusion after temporary clipping and to correlate with the risk of ischemia. Methods: Prospective analysis of intra-operative ICG-VA performed during temporary arterial occlusion in 38 patients from January 2014 to December 2018 was conducted. Co-relation with post-operative MR diffusion weighted imaging (MR DWI) in terms of vascular territory of interest within 48 hours of surgery was performed. Clinical outcome was assessed using modified Rankin Scale (mRS) score 1-month post-surgery. Results: 43 aneurysms in 38 patients clipped using ICG-VA were included in this study. No side effect of ICG dye was seen in any patients. The number of times temporary clips applied had a direct relationship to the delay in appearance of ICG in the surgical field which became statistically significant after application of 3rd temporary clip. Nine (23.7%) patients developed ischemia following the procedure confirmed by post-operative MR DWI and all the ischemic cases had visible decrease in ICG fluorescence post-temporary clipping. Conclusions No previous study had tried to assess the intraoperative cerebral blood flow and perfusion during temporary clipping of parent vessels during aneurysm surgery. The use of ICG-VA can be extended to assess perfusion in desired territory by merely assessing the degree of opacification.

Male infertility is solely responsible for 20–30% of infertility cases. Oxidative damage of sperm DNA is positively linked with oligoasthenoteratozoospermia (OAT), and male infertility. The antioxidants are being explored worldwide to combat OAT, sperm DNA fragmentation and reactive oxygen species. The objective of the study was to assess the effectiveness of an antioxidant blend in improving sperm count, semen parameters and reducing DNA fragmentation index (DFI) in sub-fertile males. A prospective, double-blind, randomized, placebo-controlled trial was conducted in 300 sub-fertile males (25–45 years) from ten study sites in India. Subjects were randomized in either the antioxidant blend treatment group or placebo group. We assessed changes in sperm count, motility, normal morphology, semen volume, and percent DFI before and after treatment (90 days). To further stratify data on different criteria post hoc analysis was performed. Statistical analysis was performed using SPSS 10.0 software. There were improvements in sperm count, semen volume, sperm motility, and sperm normal morphology in the treatment group. There was improvement in sperm count in severe oligospermia subjects (sperm count < 5 million/mL, 5–10 million/mL, 10.1–15 million/mL), and high-extremely higher baseline DFI (20–30%, 31–40% and above 40%), as per post hoc analysis. There was no premature discontinuation and adverse events were reported during the study, indicating safety and well-tolerability of treatment. Study results confirmed the well-researched fact of antioxidants being effective to reduce oxidative stress and thus improve sperm DNA integrity and also improved semen parameters in males aged 40 and above.