Vitamin B12 deficiency has long been known to present with various neurological manifestations, but only rarely presents as movement disorders, especially in adults. We present the case of a 30-year-old vegan male presenting with tremors on both legs when standing which was relieved by vitamin B12 supplementation. To the best of our knowledge, this is the first documented case of slow orthostatic tremor or pseudo-orthostatic tremor caused by vitamin B12 deficiency.
Vitamin B 12 Deficiency ; Vitamin B 12 ; Vegans ; Movement Disorders ; Tremor ; Electromyography

Headaches are a common presentation in the emergency department (ED). Even though not all are potentially serious, some such as subarachnoid hemorrhage (SAH) can be more dangerous than others. SAH is a medical emergency with an almost 50% mortality rate. It is crucial not to miss the diagnosis of SAH, as a missed or delayed diagnosis can be severely detrimental. It classically presents as thunderclap headache, a severe, sudden-onset headache. There are various approaches in diagnosing or excluding SAH, which is classically done by performing a computed tomography (CT) scan followed by a lumbar puncture (LP). But with the improved sensitivity of more modern diagnostic tools, more physicians are in support of changing this classical teaching. The aim of this case report is to review the advantages and disadvantages of LP in diagnosing SAH, along with other diagnostic tools commonly used.
Subarachnoid Hemorrhage ; Spinal Puncture ; Cerebrospinal Fluid

Introduction: Rotator cuff (RC) tears account for about 20% of RC disorders and presents with severe shoulder pain that can significantly impact activities of daily life. Case report: A 34-year-old male with a history of chronic right shoulder pain presents with tenderness at the lateral shoulder, positive subacromial impingement tests, painful end range of motion and pain score of 6. Ultrasound shows a partial supraspinatus tear at the bursal side. The patient was treated with 15% dextrose to the supraspinatus tendon intrasubstance 3 times, for 4 weeks. Result: Significant pain improvement after the first treatment (VAS 1), with pain-free full range of motion until 4 weeks after treatment and sonographic evidence of supraspinatus tendon healing. Discussion: Dextrose concentrations higher than 12.5% produce an osmotic gradient which stimulates the accumulation of growth factors and inflammatory cells, which in turn can initiate the wound healing process. In this case we can find that the healing process translates to good clinical outcome by ultrasound imaging. Conclusion Dextrose prolotherapy can be used as an option for supraspinatus tendon partial tear with good results.
Rotator Cuff|prolotherapy

OBJECTIVES

To investigate and compare the morphologic effect at nerve terminals and muscle (extrafusal and intrafusal) following botulinum toxin type-A (BNTA) versus botulinum toxin-B (BNTB) among experimental rats.

Thirty experimental rats were injected with either botulinum toxin type A (Dysport®) (n=10), Botulinum toxin B (Neurobloc®) (n=10) or placebo (n=10). The following parameters were obtained at two endpoints (Day 14 and Day 28): (a) histopathological studies that determined mean diameter and percentage of muscle fibers (type 1, 2A and 2B); (b) muscle atrophy; (c) intrafusal muscle fiber diameter (Bag 1, Bag 2, chains): (d) endplate lengths and (e) terminal innervation ratios (TIA).

Degeneration, necrosis, inflammatory cell infiltration, and nuclear abnormalities were not found on haematoxylin-eosin stain. On D28, a slight increase in fibrous connective tissues (using modified Gomori-trichrome stains) as well as few focal reductions in oxidative enzyme activities (seen in NADH-TA stains) were noted in both BNTA and BNTB groups. Extrafusal muscle fiber diameter measurements (using NADH-TA and ATPase stains) indicated the following changes: (a) whichever toxin is used, there was atrophy of muscle fibers on D14 and D28, compared to controls; (b) whichever toxin is used, there was prominent atrophy of muscle fibers on the injected side compared to the minimal atrophy on the non-injected side; (c) whichever toxin is used, there was more atrophy noted on D14 compared to D28; (d) whichever time point is taken, muscle fiber type 1, followed by muscle fiber type 2A showed more vulnerability to atrophy, and (e) BNTB tended to induce more muscle atrophy than BNTA at the two time points. With regard to intrafusal muscles, the following changes were found: (a) whichever is the toxin used, atrophy of intrafusal fibers on the injected side were noted at the two time points, compared to placebo; (b) whichever is the toxin used, no significant atrophy of intrafusal fibers was noted on the non-injected side at the two time points; (c) Bag1 fibers, followed by chain fibers are more vulnerable to atrophy, and (d) BNTA tended to induce more atrophy of intrafusal fibers than did BNTB at the two time points. With regard to terminal innervation patterns using silver-cholinesterase stains (SCE), BNTA and BNTB groups had higher TIA on D14 and D28, compared to placebo.

BNTA and BNTB produce neuromuscular changes comparable with one another. Both decrease the muscle strength and induce extrafusal and intrafusal muscle changes to varying degrees when compared to placebo. Spread to the opposite corresponding limb muscles occurred to a mild degree with both BTNA and BNTB, also to varying degrees.