Baby boy blue and mommy too! A rare case of methaemoglobinaemia presenting simultaneously in a mother-neonate pair.

Methaemoglobinaemia occurs when there is >1% methaemoglobin in erythrocytes. In an infant, they can present either congenitally or in an acquired form. We present a rare case of methaemoglobinaemia presenting simultaneously in a mother and infant pair. The mother and infant were discharged well on Day-4 post-delivery with both mother and baby recording oxygen saturation levels of 100%. On Day-7, during a routine clinic visit, they were incidentally found to be centrally cyanosed. There were no other abnormalities. On investigation, the methaemoglobin levels were elevated in the infant (23.9%) and mother (14.3%). Treatment with ascorbic acid normalised mother's methaemoglobin levels; but baby's levels remained high until the administration of oral methylene blue. Both baby and mother remained well and pink at last follow-up at 2 years 8 months of age. This case illustrates difficulties in ascertaining the cause of methaemoglobinaemia. Postdelivery, the mother-neonate pair were pink, and their haemoglobin electrophoresis were normal, hence it was unlikely to be congenital methaemoglobinaemia. The team could not identify any triggering factors for acquired methaemoglobinaemia. There was also the uncertainty of the necessity to treat the baby. This is because treatment is not without harmful effects and despite the high methaemoglobin levels, the infant was otherwise well. Only a single published paper recommended that high methaemoglobin levels must be treated, and the recommendation was not supported by evidence. Lessons learnt from our case are that neonates with methaemoglobinaemia can be safely treated with oral methylene blue, but more research is needed on the benefitrisk profile of treatment.

Radiologically occult hepatocellular carcinoma in a cirrhotic liver presenting with bilateral adrenal metastases.

Although it is common to have extra-hepatic metastasis of hepatocellular carcinoma (HCC) at the time of presentation, it is extremely rare to have extra-hepatic metastatic HCC without a detectable primary in the liver. We report a unique case in which a patient presented with bilateral large adrenal masses which were subsequently proven to be metastases from HCC. However, there was no tumour seen in the liver on imaging.

Patient information on breast reconstruction in the era of the world wide web. A snapshot analysis of information available on youtube.com.

Breast cancer patient's expectation and choice of reconstruction is increasing and patients often satisfy their information needs outside clinic time by searching the world wide web. The aim of our study was to analyse the quality of content and extent of information regarding breast reconstruction available on YouTube videos and whether this is an appropriate additional source of information for patients. A snapshot qualitative and quantitative analysis of the first 100 videos was performed after the term 'breast reconstruction' was input into the search window of the video sharing website www.youtube.com on the 1st of September 2011. Qualitative categorical analysis included patient, oncological and reconstruction factors. It was concluded that although videos uploaded onto YouTube do not provide comprehensive information, it is a useful resource that can be utilised in patient education provided comprehensive and validated videos are made available.

Synapsin II gene expression in the dorsolateral prefrontal cortex of brain specimens from patients with schizophrenia and bipolar disorder: effect of lifetime intake of antipsychotic drugs.

Synapsins are neuronal phosphoproteins crucial to regulating the processes required for normal neurotransmitter release. Synapsin II, in particular, has been implied as a candidate gene for schizophrenia. This study investigated synapsin II mRNA expression, using real-time reverse transcriptase-PCR, in coded dorsolateral prefrontal cortical samples provided by the Stanley Foundation Neuropathology Consortium. Synapsin IIa was decreased in patients with schizophrenia when compared with both healthy subjects and patients with bipolar disorder, whereas synapsin IIb was only significantly reduced in patients with schizophrenia when compared with healthy subjects but not in patients with bipolar disorder. Furthermore, lifetime antipsychotic drug use was positively associated with synapsin IIa expression in patients with schizophrenia. Results suggest that impairment of synaptic transmission by synapsin II reduction may contribute to dysregulated convergent molecular mechanisms, which result in aberrant neural circuits that characterize schizophrenia, while implicating involvement of synapsin II in therapeutic mechanisms of currently prescribed antipsychotic drugs.

Umbilical metastatic deposit from recurrent cholangiocarcinoma: F18-FDG PET-CT findings.

A 69-year-old woman was diagnosed with stage IIIA advanced Type IV Klatskin cholangiocarcinoma, which was treated with radical choledochectomy, extended right hepatectomy and left hepaticojejunostomy. About six months after surgery, she presented with painless jaundice. A 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (F18-FDG PET-CT) was performed, which detected an FDG-avid umbilical metastatic nodule. We describe the F18-FDG PET-CT features of umbilical metastatic nodule in recurrent cholangiocarcinoma. It is sometimes difficult to detect the lesions when they present with non-specific soft tissue thickening on routine CT imaging. F18-FDG PET-CT would probably render these lesions easier to detect and interpret.

Lower extremity amputation prevention in Singapore: economic analysis of results.

INTRODUCTION: The aim of the study was to determine the cost-effectiveness of the Lower Extremity Amputation Prevention (LEAP) strategy in comparison to standard clinical practice for treating patients with critical limb ischaemia (CLI). METHODS: A retrospective cost-effectiveness analysis of the LEAP programme relative to pre-LEAP practice was performed from the perspective of Singapore hospitals. The cost incorporated in the analysis included direct medical costs incurred during the admission. Outcomes included the number of amputations, number of deaths and length of hospital stay after the initial treatment. RESULTS: During the study period, the LEAP group had a lower amputation rate (29 percent versus 76 percent, p-value is 0.00001), lower related death rate (one percent versus 19 percent, p-value is 0.00001) and fewer in-hospital days per patient (17.8 days versus 23.16 days, p-value is 0.048) as compared to the standard clinical practice group. The implementation of the LEAP strategy generated cost savings of S$2,566 per patient during admission when compared with the pre-LEAP approach. The results were robust to variations in input parameters. CONCLUSION: The LEAP strategy dominated standard practice in the management of patients with diabetes mellitus and CLI. The implementation of the LEAP strategy significantly improved patient outcomes and reduced hospital costs.

Over-investigated and under-treated: children with febrile convulsion in a Malaysian district hospital.

INTRODUCTION: We conducted a retrospective audit on the inpatient assessment and care of children admitted with febrile convulsion to Hospital Batu Pahat, a district hospital in Malaysia, using the Malaysian national clinical practice guidelines and the American Academy of Paediatrics practice parameters on febrile convulsion as the reference standards. METHODS: The case notes of 100 consecutive children admitted in 2004 were analysed. The documentation of major clinical features, selection of investigations, the timeliness of antipyresis and frequency of parental education were evaluated. RESULTS: In general, the major clinical features that were relevant to the presenting problem were adequately documented, although fever was not mentioned as a presenting complaint in one quarter of the cases. On an average, about five investigations were ordered for every patient on admission. There was no major difference in the number of investigations conducted between children who were more severely ill and the rest of the patients. The majority of the investigations did not yield any useful diagnostic information. Only 38 percent of the children received antipyretics and 53 percent were tepid-sponged during fever, with 23 percent having received tepid-sponging without concurrently receiving antipyretics. No parental education on febrile convulsion was recorded in half of the cases. CONCLUSION: Excessive unjustified investigations, deficient antipyresis when required and inadequate communication with the family of children with febrile convulsion were observed. Awareness of such deficiencies from this audit should lead to regular staff education, monitoring and future audits in order to improve the quality of our clinical care.

Insulin resistance is associated with a metabolic profile of altered protein metabolism in Chinese and Asian-Indian men.

AIMS/HYPOTHESIS: Insulin resistance (IR) is associated with obesity, but can also develop in individuals with normal body weight. We employed comprehensive profiling methods to identify metabolic events associated with IR, while controlling for obesity. METHODS: We selected 263 non-obese (BMI approximately 24 kg/m2) Asian-Indian and Chinese men from a large cross-sectional study carried out in Singapore. Individuals taking medication for diabetes or hyperlipidaemia were excluded. Participants were separated into lower and upper tertiles of IR based on HOMA indices of < or =1.06 or > or =1.93, respectively. MS-based metabolic profiling of acylcarnitines, amino acids and organic acids was combined with hormonal and cytokine profiling in all participants. RESULTS: After controlling for BMI, commonly accepted risk factors for IR, including circulating fatty acids and inflammatory cytokines, did not discriminate the upper and lower quartiles of insulin sensitivity in either Asian- Indian or Chinese men. Instead, IR was correlated with increased levels of alanine, proline, valine, leucine/isoleucine, phenylalanine, tyrosine, glutamate/glutamine and ornithine, and a cluster of branched-chain and related amino acids identified by principal components analysis. These changes were not due to increased protein intake by individuals in the upper quartile of IR. Increased abdominal adiposity and leptin, and decreased adiponectin and IGF-binding protein 1 were also correlated with IR. CONCLUSIONS/INTERPRETATION: These findings demonstrate that perturbations in amino acid homeostasis, but not inflammatory markers or NEFAs, are associated with IR in individuals of relatively low body mass.

Pregnancy luteoma presenting as ovarian torsion with rupture and intra-abdominal bleeding.

We report a case of pregnancy luteoma, which had undergone torsion in a 33-year-old Indian woman, who presented with severe abdominal pain and decreasing haemoglobin levels at 33 weeks gestation. Ultrasonography showed a right adnexal mass, probably ovarian in origin, with suspicious intratumoral bleed. The pain was treated symptomatically, and the symptoms improved. A successful induction of labour was then performed at 36 weeks gestation. The pain recurred almost immediately after the delivery, and she experienced another intra-abdominal bleed. A diagnostic laparotomy and a right salpingo-oophorectomy were performed, and the diagnosis of luteoma was made based on histology. We discuss the clinical presentation of this unusual tumour, though often asymptomatic, can rarely present with severe abdominal pain from complications like torsion with rupture, leading to massive intra-abdominal bleeding. We also discuss the possible radiological investigations which can be done during pregnancy.

Membrane properties and firing patterns of inferior colliculus neurons: an in vivo patch-clamp study in rodents.

The inferior colliculus (IC) is a large auditory nucleus in the midbrain, which is a nearly obligatory relay center for ascending auditory projections. We made in vivo whole cell patch-clamp recordings of IC cells in young-adult anesthetized C57/Bl6 mice and Wistar rats to characterize their membrane properties and spontaneous inputs. We observed spikelets in both rat (18%) and mouse (13%) IC neurons, suggesting that IC neurons may be connected by electrical synapses. In many cells, spontaneous postsynaptic potentials were sufficiently large to contribute to spike irregularity. Cells differed considerably in the number of simultaneous spontaneous postsynaptic potentials that would be needed to trigger an action potential. Depolarizing and hyperpolarizing current injections showed six different types of firing patterns: buildup, accelerating, burst-onset, burst-sustained, sustained, and accommodating. Their relative frequencies were similar in both species. In mice, about half of the cells showed a clear depolarizing sag, suggesting that they have the hyperpolarization-activated current I(h). This sag was observed more often in burst and in accommodating cells than in buildup, accelerating, or sustained neurons. Cells with I(h) had a significantly more depolarized resting membrane potential. They were more likely to fire rebound spikes and generally showed long-lasting afterhyperpolarizations following long depolarizations. We therefore suggest a separate functional role for I(h).

Comparison of responses of neurons in the mouse inferior colliculus to current injections, tones of different durations, and sinusoidal amplitude-modulated tones.

We made in vivo whole cell patch-clamp recordings from the inferior colliculus of young-adult, anesthetized C57/Bl6 mice to compare the responses to constant-current injections with the responses to tones of different duration or to sinusoidal amplitude-modulated (SAM) tones. We observed that voltage-dependent ion channels contributed in several ways to the response to tones. A sustained response to long tones was observed only in cells showing little accommodation during current injection. Cells showing burst-onset firing during current injection showed a small response to SAM tones, whereas burst-sustained cells showed a good response to SAM tones. The hyperpolarization-activated nonselective cation channel I(h) had a special role in shaping the responses: I(h) was associated with an increased excitability, with chopper and pauser responses, and with an afterhyperpolarization following tones. Synaptic properties were more important in determining the responses to tones of different durations. A short-latency inhibitory response appeared to contribute to the long-pass response in some cells and short-pass and band-pass neurons were characterized by their slow recovery from synaptic adaptation. Cells that recovered slowly from synaptic adaptation showed a relatively small response to SAM tones. Our results show an important role for both intrinsic membrane properties -- most notably the presence of I(h) and the extent of accommodation -- and synaptic adaptation in shaping the response to tones in the inferior colliculus.

Exploring the realities of HIV/AIDS-related discrimination in Manila, Philippines.

Operating according to UNAIDS' 'Protocol for the Identification of Discrimination against People Living with HIV', this study analysed health infrastructure in Manila, Philippines and determined that despite the existence of anti-discriminatory legislation, discrimination still occurred in practice. This was attributed to an absence of written regulations and inadequate training among health staff. Discrimination associated with HIV/AIDS has been found to be a hindrance to the development of successful preventive strategies, as it discourages people living with HIV/AIDS (PLWHA) and other people from contacting health and social services. This paper argues that if the Philippines is to maintain its low prevalence rate of HIV (and even reduce it), the discrimination that PLWHA incur must be addressed taking account of their human rights.

Growth arrest and non-apoptotic programmed cell death associated with the up-regulation of c-myc mRNA expression in T-47D breast tumor cells following exposure to Epipremnum pinnatum (L.) Engl. hexane extract.

Epipremnum pinnatum (L.) Engl. hexane extract produced a significant growth inhibition against T-47D breast carcinoma cells and analysis of cell death mechanisms indicated that the extract elicited a non-apoptotic programmed cell death. T-47D cells exposed to the extract at EC(50) concentration (72 h) for 24 h failed to demonstrate typical DNA fragmentation associated with apoptosis, as carried out using a modified TUNEL assay. In addition, acute exposure to the extract produced an insignificant regulation of caspase-3 and p53 mRNA expression but increased in the c-myc mRNA expression. Ultrastructural analysis using transmission electron microscope demonstrated distinct vacuolated cells, which strongly indicated a Type II non-apoptotic cell death although the changes in chromatin were also detected. The presence of non-apoptotic programmed cell death was then reconfirmed with annexin-V and propidium iodide staining. These findings suggested that up-regulation of c-myc mRNA expression may have contributed to the growth arrest and Type II non-apoptotic programmed cell death in the Epipremnum pinnatum (L.) Engl. hexane extract-treated T-47D cells.

Methanolic extract of Pereskia bleo (Kunth) DC. (Cactaceae) induces apoptosis in breast carcinoma, T47-D cell line.

Currently, breast cancer is the leading cause of cancer-related death in women. Therefore, there is an urgent need to develop alternative therapeutic measures against this deadly disease. Here, we report the cytotoxicity activity and the mechanism of cell death exhibited by the methanol extract prepared from Pereskia bleo (Kunth) DC. (Cactaceae) plant against human breast carcinoma cell line, T-47D. In vitro cytotoxicity screening of methanol extract of Pereskia bleo plant indicated the presence of cytotoxicity activity of the extract against T-47D cells with EC50 of 2.0 microg/ml. T-47D cell death elicited by the extract was found to be apoptotic in nature based a clear indication of DNA fragmentation which is a hallmark of apoptosis. In addition, ultrastructural analysis also revealed apoptotic characteristics (the presence of chromatin margination and apoptotic bodies) in the extract-treated cells. RT-PCR analysis showed the mRNA expression levels of c-myc, and caspase 3 were markedly increased in the cells treated with the plant extract. However, p53 expression was only slightly increased as compared to caspase 3 and c-myc. Thus, the results from this study strongly suggest that the methanol extract of Pereskia bleo may contain bioactive compound(s) that caused breast carcinoma, T-47D cell death by apoptosis mechanism via the activation of caspase-3 and c-myc pathways.

Antibiotic sensitivity of Propionibacterium acnes isolates from patients with acne vulgaris in a tertiary dermatological referral centre in Singapore.

OBJECTIVES: To study the minimum inhibitory concentrations (MICs) of Propionibacterium acnes (P. acnes) isolates to selected antibiotics from patients with acne vulgaris in Singapore and determine if resistance increases with prolonged use of antibiotics. DESIGN: A single-centre prospective study. SETTING: Tertiary dermatological referral centre in Singapore. PATIENTS: One hundred and fifty patients with acne vulgaris seen at the National Skin Centre. RESULTS: In patients who had never been on antibiotics, there were no resistant isolates of P. acnes. In patients who had been on short-term antibiotics (between 6 to 18 weeks), there were 2 resistant strains among the 34 isolates (6.25%); in patients who had been on antibiotics for longer periods, there were 11 resistant strains among the 51 isolates (21.6%). The differences in the rates of isolation of resistant strains between patients who had not been on antibiotics to those that had been on long-term antibiotics were statistically significant (P = 0.015). There was also a significant difference in isolation of resistant strains from those on short-term antibiotics compared to those who had been on long-term antibiotics (P = 0.036). Resistance to erythromycin was most commonly encountered. Most of the erythromycin-resistant strains also showed cross-resistance to clindamycin. The average MICs to antibiotics such as minocycline, erythromycin and clindamycin in those on long-term antibiotics were significantly higher when compared to patients who had not been on antibiotics. CONCLUSIONS: Antibiotic resistance in P. acnes isolates in Singapore follows similar patterns to studies conducted in Europe. Resistance to erythromycin was most commonly seen, and this is associated with cross-resistance to clindamycin. Among the tetracycline group of drugs, the average MICs to tetracycline was higher than that for doxycycline, which in turn was higher than that for minocycline. Antibiotic resistance can occur with short-term antibiotic courses, and the rate of resistance increases as the duration of antibiotic consumption increases.

Survey of aerobic bacterial infections in paediatric surgical intensive care unit patients.

Infections cause a significant amount of morbidity and mortality in paediatric surgical patients requiring intensive care. The study aims to describe the epidemiology of infection among these patients, to correlate the source of infection with the underlying medical condition, and to determine the antibiotic sensitivity pattern of the organisms. Through a retrospective review over a period of one year, 133 cases were analysed. The overall incidence of infection was 35%. Those who had emergency surgery had the highest infection rate (47%). Respiratory tract infections were the commonest source of infection, and were associated with ventilator therapy rather than the underlying medical condition. The Enterobacteriaceae were the most common isolates seen. From antibiotic sensitivity tests, the empirical antibiotics of choice are gentamicin for suspected gram-negative infection and vancomycin for severe infections where methicillin-resistant Staphylococcus aureus is a likely cause. A high rate of resistance to ampicillin was seen and its use as a first-line monotherapy drug should be discontinued in our patient population.