Julia Patrick Engkasan

Effectiveness of a Video-Based Therapy Program at Home After Acute Stroke: A Randomized Controlled Trial

OBJECTIVE To evaluate the effectiveness of an intervention using video to deliver therapy at home for patients with stroke. DESIGN Randomized controlled trial. SETTING The neurology ward and rehabilitation medicine department of a tertiary hospital. PARTICIPANTS Patients with stroke (N=90). There were 44 patients in the intervention group and 46 patients in the control group. INTERVENTIONS The intervention group received a combination of at-home rehabilitation guided by a digital videodisk containing therapy techniques and twice-monthly outpatient follow-up for 3 months. The conventional therapy group (control) attended weekly outpatient therapy sessions. MAIN OUTCOME MEASURES The primary outcome measure was the modified Barthel Index (MBI) score. The secondary measures were the incidence of poststroke complications and the Caregiver Strain Index. RESULTS At 3 months, there were no significant differences with regard to the number of patients with improved MBI score, complication rate, or Caregiver Strain Index score between the 2 groups. Both groups had significant increases in the MBI score at 3 months (P<.001 for both groups). Regression analysis revealed that only stroke severity significantly influenced the MBI score (P<.001), complication rate (P<.01), and caregiver stress level (P<.05). CONCLUSIONS Video-based therapy at home for post-acute stroke patients is safe, does not negatively impact independence, and is not stressful for caregivers.

Factors influencing bladder management in male patients with spinal cord injury: a qualitative study

Study design:Qualitative study using individual in-depth interviews.Objectives:The objective of this study was to explore the factors influencing the choice of bladder management for male patients with spinal cord injury (SCI).Setting:Public hospitals in Malaysia.Methods:Semistructured (one-on-one) interviews of 17 patients with SCI; 7 were in-patients with a recent injury and 10 lived in the community. All had a neurogenic bladder and were on various methods of bladder drainage. Interviews were audio-recorded, transcribed verbatim and analyzed using thematic analyses.Results:The choice of bladder management was influenced by treatment attributes, patients’ physical and psychological attributes, health practitioners’ influences and social attributes. Participants were more likely to choose a treatment option that was perceived to be convenient to execute and helped maintain continence. The influence of potential treatment complications on decision making was more variable. Health professionals’ and peers’ opinions on treatment options had a significant influence on participants’ decision. In addition, patients’ choices depended on their physical ability to carry out the task, the level of family support received and the anticipated level of social activities. Psychological factors such as embarrassment with using urine bags, confidence in self-catheterization and satisfaction with the current method also influenced the choice of bladder management method.Conclusion:The choice of bladder management in people with SCI is influenced by a variety of factors and must be individualized. Health professionals should consider these factors when supporting patients in making decisions about their treatment options.

A Double-Blind Randomized Controlled Trial Investigating the Most Efficacious Dose of Botulinum Toxin-A for Sialorrhea Treatment in Asian Adults with Neurological Diseases

This study aims to determine the most efficacious dose of Botulinum neurotoxin type A (BoNT-A) in reducing sialorrhea in Asian adults with neurological diseases. A prospective, double-blind randomized controlled trial was conducted over 24 weeks. Thirty patients with significant sialorrhea were randomly assigned to receive a BoNT-A (Dysport®) injection into the submandibular and the parotid glands bilaterally via an ultrasound guidance. The total dose given per patient was either BoNT-A injection of (i) 50 U; (ii) 100 U; or (iii) 200 U. The primary outcome was the amount of saliva reduction, measured by the differential weight (wet versus dry) of intraoral dental gauze at baseline and at 2, 6, 12, and 24 weeks after injection. The secondary outcome was the subjective report of drooling using the Drooling Frequency and Severity Scale (DFS). Saliva reduction was observed in response to all BoNT-A doses in 17 patients who completed the assessments. Although no statistically significant difference among the doses was found, the measured reduction was greater in groups that received higher doses (100 U and 200 U). The group receiving 200 U of Dysport® showed the greatest reduction of saliva until 24 weeks and reported the most significant improvement in the DFS score.

NEUROgENIC BOWEL MANAgEMENT AfTER SPINAL CORD INJURy: MALAySIAN ExPERIENCE

OBJECTIVES To describe the bowel programmes utilized by individuals with spinal cord injury; and to determine the association between the outcome of the bowel programmes and various interventions to facilitate defecation. STUDY DESIGN A cross-sectional study. PARTICIPANTS Individuals with spinal cord injury who have neurogenic bowel dysfunction. METHODS Face-to-face interviews were conducted using a self-constructed questionnaire that consisted of: (i) demographic and clinical characteristics of the participants; (ii) interventions to facilitate defecation; (iii) bowel care practices; (iv) outcome of the bowel programme (incidence of incontinence and duration of the evacuation procedure); and (v) participant satisfaction with their bowel programme. RESULTS The majority (79.2%) of subjects used multiple interventions for bowel care. Duration of the evacuation procedure was more than 60 min in 28.0% of participants. Water intake of more than 2 l/day was associated with longer duration of bowel care. Only 8.0% of participants had at least one episode of incontinence per month. The majority of participants (84.8%) were satisfied with their bowel programme. CONCLUSION Patients used multiple interventions to manage their bowels and spent a substantial amount of time performing bowel care. Nevertheless, the incidence of incontinence was low and satisfaction with their bowel programme was high.

Cochrane Rehabilitation: Organization and Functioning

INTRODUCTION Cochrane (www.cochrane.org) is an organization whose vision is a world of improved health where decisions about health and health care are informed by high-quality, relevant, and up-to-date synthesized research evidence. For this reason, it produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Cochrane is organized in different groups with different aims: review groups manage systematic reviews production, method groups develop the best methodology to produce evidence, centers and fields provide knowledge translation with a national/regional or topic-related focus, respectively. The knowledge translation strategy is a critical piece of work that contributes to dissemination, use, and impact of Cochrane evidence in decision-making, and is now at the center of the new developments of Cochrane. Rehabilitation is a cross-sectional topic that includes different health conditions of interest to many Cochrane Review Groups. Consequently, rehabilitation is considered by Cochrane as a “field,” a term used for groups that focus on health issues and/or interventions of importance to specific populations. The role of Cochrane Fields is to contribute to knowledge translation, as specified in Cochrane Strategy 2020, the official document that explains the future plans of Cochrane in terms of structure and function. Thus, Cochrane has created a new Cochrane Rehabilitation Field to strengthen this culture of knowledge translation.

The prevalence and distribution of spina bifida in a single major referral center in Malaysia

Background The aim of this study is to review the medical history of patients with spina bifida, encompassing both aperta and occulta types born between the years 2003 until 2016, spanning a 13-year time period. We assessed each patient and maternal parent information, details of the defects, and conditions associated with the primary defect. We also include information on patients’ ambulation and education level (where available). Methods Data from the Department of Patient Information University of Malaya Medical Centre (UMMC), Malaysia was captured from spina bifida patients (ICD10: Q05 spina bifida). Data involved patients referred to UMMC between 2003 and 2016 and/or born in UMMC within that particular time frame. We filtered and extracted the information according to the data of clinical examination, medical review, and social history provided in the medical records. Results A total of 86 patient records with spina bifida were analyzed. Spina bifida prevalence rate in this study ranged from 1.87 to 8.9 per 1,000 live births depending on weightage. We note that ethnicity was a factor whereby the highest numbers of spina bifida were from Malays (n = 36, 41.86%), followed by equal numbers of Chinese and Indians (n = 24, 27.91%). The highest number of diagnoses reported was myelomeningocele type-spina bifida (n = 39, 45.35%). The most common site of the spina bifida lesion was located at the lumbar region irrespective of aperta or occulta types (n = 23, 26.74%). Data on other associated phenotypes of spina bifida such as hydrocephalus and encephalocele was also captured at 37.21% (n = 32) and 1.16% (n = 1), respectively. In terms of mobility, 32.84% (n = 22/67) of patients between the ages 4 and 16 years old were found to be mobile. As many as 36.07% of patients ranging from 5 to 16 years of age (n = 22/61) received formal education ranging from preschool to secondary school. Conclusion The prevalence of spina bifida in UMMC is as according to international statistics which is in the range of 0.5–10 per 1,000 live births. Majority of the reported cases were males, Malays, full term babies, and of the myelomeningocele phenotype located at the lumbar region.

People with Spinal Cord Injury in Malaysia.

EPIDEMIOLOGY OF SPINAL CORD INJURY IN MALAYSIA Very little is published on the demographics or epidemiological patterns of spinal cord injury (SCI) inMalaysia. Available studies show that most persons with SCI were males, aged younger than 40 years, and had paraplegia. A related study showed a bimodal distribution of age, with peaks of incidence in the 25 to 34 and 55 to 64 age groups. The most common cause of injury was caused by motor vehicle accident followed by fall from height. Tumor-related cases made up 40% of nontraumatic causes of SCI. No data are available on the mortality and life expectancy of persons with SCI in the Malaysian population.

Asymptomatic tachycardia and acute pulmonary embolism in a case of tuberculosis spondylodiscitis

IntroductionTachycardia, or elevated heart rate is one of the important clinical parameters considered when diagnosing pulmonary embolism (PE) based on Wells’ criteria. However, tachycardia is not highly specific and commonly presents in many other conditions.Case presentationA 29-year-old female with incomplete paraplegia secondary to tuberculosis (TB) spondylodiscitis presented with asymptomatic sinus tachycardia. The related medical conditions, including anaemia, acute coronary syndrome, hyperthyroidism and other infective causes had been ruled out. Deep venous thrombosis was not on the list of differentials as she showed improvements in neurological and mobility functions with no clinical signs of calf pain or swelling. She had moderate risk of acute PE based on Wells’ criteria with positive D-dimer testing and computed tomography pulmonary angiography (CTPA) showing thrombus formation in the left-ascending pulmonary artery.DiscussionAcute PE may present solely with asymptomatic sinus tachycardia in TB spondylodiscitis. This caveat should provide a high index of suspicion to prevent delay in diagnosis and prevention of more sinister complications. Early stratification based on Wells’ criteria for a possible diagnosis of acute PE is proven to be a useful approach in conjunction with clinical features.

Characteristics of persons with spinal cord injury who drive in Malaysia and its barriers: a cross sectional study

Study designCross sectional study.ObjectivesTo determine the prevalence, characteristics of and barriers to driving among persons with a spinal cord injury (SCI).SettingSCI Rehabilitation Clinic, University Malaya Medical Centre (UMMC).MethodsThis is a questionnaire-based study on persons with SCI who attended the UMMC SCI Rehabilitation Clinic between June 2015 and November 2016. The questionnaire comprised demographic data, clinical characteristics, driving variables, Spinal Cord Independence Measure III, WHOQOL-BREF, and Craig Handicap Assessment and Reporting Technique Short Form. Malaysians aged greater than 18 years old with any etiology and levels of SCI, had no other physical disabilities and not suffering from progressive illness were recruited. A single investigator administered the questionnaire via face-to-face interviews.ResultsA total of 160 participants were included in this study. Overall, 37% of persons with SCI drove and owned a modified vehicle. Almost half of persons with paraplegia (47%) drove, but only 12% of tetraplegia did. A majority (93%) of those who drove aged below 60 years, and had higher level of independence in activity of daily living. More drivers (81%) compared to non-drivers (24%) were employed; drivers also reported better community reintegration and quality of life. Three commonest barriers to driving included medical reasons (38%), fear and lack of confidence (17%), and inability to afford vehicle modifications (13%).ConclusionsThe percentage of persons with SCI driving post injury is low. Based on the findings of this study, more efforts are needed to motivate and facilitate persons with SCI to drive.

Cranial neural tube defect after trimethoprim exposure

ObjectivesThe Neural Tube Defects Research Group of University of Malaya was approached to analyze a tablet named TELSE, which may have resulted in a baby born with central nervous system malformation at the University of Malaya Medical Centre. In this animal experimental study, we investigated the content of TELSE and exposure of its contents that resulted in failure of primary neurulation.ResultsLiquid Chromatography Tandem Mass spectrophotometry analysis of the TELSE tablet confirmed the presence of trimethoprim as the active compound. The TELSE tablet-treated females produced significant numbers of embryos with exencephaly (n = 8, 36.4%, *P < 0.0001), in all litters. The TELSE tablet-treated females subsequently given folic acid did not result in pregnancies despite there being evidence of possible resorption. Furthermore, after multiple rounds of mating which did not yield viable pregnancies, eventually, 2 embryos with exencephaly were harvested in a litter of 6 at 0.05% w/v pure trimethoprim once. The use of trimethoprim, a folic acid antagonist, peri-conceptionally increased the risk of exencephaly in the mouse.