Enterovirus 71 encephalomyelitis and Japanese encephalitis can be distinguished by topographic distribution of inflammation and specific intraneuronal detection of viral antigen and RNA

AIMS

To investigate if two important epidemic viral encephalitis in children, Enterovirus 71 (EV71) encephalomyelitis and Japanese encephalitis (JE) whose clinical and pathological features may be nonspecific and overlapping, could be distinguished.

METHODS

Tissue sections from the central nervous system of infected cases were examined by light microscopy, immunohistochemistry and in situ hybridization.

RESULTS

All 13 cases of EV71 encephalomyelitis collected from Asia and France invariably showed stereotyped distribution of inflammation in the spinal cord, brainstem, hypothalamus, cerebellar dentate nucleus and, to a lesser extent, cerebral cortex and meninges. Anterior pons, corpus striatum, thalamus, temporal lobe, hippocampus and cerebellar cortex were always uninflamed. In contrast, the eight JE cases studied showed inflammation involving most neuronal areas of the central nervous system, including the areas that were uninflamed in EV71 encephalomyelitis. Lesions in both infections were nonspecific, consisting of perivascular and parenchymal infiltration by inflammatory cells, oedematous/necrolytic areas, microglial nodules and neuronophagia. Viral inclusions were absent.

CONCLUSIONS

Immunohistochemistry and in situ hybridization assays were useful to identify the causative virus, localizing viral antigens and RNA, respectively, almost exclusively to neurones. The stereotyped distribution of inflammatory lesions in EV71 encephalomyelitis appears to be very useful to help distinguish it from JE.

Safety and tolerability of aripiprazole in the treatment of irritability associated with autistic disorder in pediatric patients: Results from a 52-week open-label study

Objective

Evaluate the time-course, severity and resolution patterns of adverse events (AEs) occurring with long-term aripiprazole treatment for irritability associated with autistic disorder.

Methods

Participants were treated with aripiprazole in a 52-week, open-label, flexibly dosed (2–15 mg/day) study. Subjects had either completed one of two 8-week randomised trials or were de novo. AEs with an incidence of ≥10% were evaluated by incidence, peak first onset, severity, percent resolved and time to resolution.

Results

A total of 330 subjects entered open-label treatment; 199 completed 52 weeks. Mean dose for the population stabilised at around 10 mg/day after approximately 4 months. Thirteen AEs had an incidence of ≥10%; most were mild or moderate in severity. Vomiting, diarrhoea and headache had an early first onset and tended to resolve fairly quickly.

Sedation, fatigue and insomnia also appeared early and resolved in a majority of cases, but not as quickly. Increased appetite appeared early (followed by increased weight) and fewer weight-related AEs resolved. More than half of the subjects increased their weight by at least one percentile category rank; nevertheless, only a small proportion of subjects with normal baseline metabolic or glucose measures had a treatment-emergent, clinically relevant laboratory abnormality. Nasopharyngitis, upper respiratory infection, cough, nasal congestion and pyrexia all had peak onset at variable times during the study, resolving in nearly all cases, with short time to resolution.

Conclusion

AEs were mostly mild or moderate and of variable duration. Increased weight was observed.

A Review of Fatal Road Traffic Accidents in Singapore from 2000 to 2004

Introduction: This retrospective study aims to assess the epidemiology of road traffic accident (RTA) fatalities in Singapore, other causes of death besides trauma in a RTA, and identify the groups at risk. Materials and Methods: Data of 1038 RTA fatalities were reported between 2000 and 2004. Analyses using the Fisher’s exact test for discrete variables and multivariate Cox regression analysis were performed to identify groups at risk. The risk of fatality was measured using the prevalence rate ratio (PRR). Results: The median age of victims in the sample was 36 years (interquartile range 24 to 55). Eight hundred and thirty six cases (78%) were in the economically productive age range of 15 to 65 years. Over the 5-year period, there was a preponderance of males. Majority of fatalities involved multiple injuries. There were also 64 (6.2%) and 25 (2.4%) cases of RTA fatalities from infective and cardiovascular (CVS) causes, respectively. Multivariate analyses showed that those ≥ 60 years were 4 (95% CI of PRR, 3.04 to 5.43) times as likely to be pedestrian fatalities. Conversely, the risk of fatalities involving pedestrians and cyclists was reduced for males (PRR = 0.58; 95% CI, 0.46 to 0.73). However, males were at increased risk of fatalities involving motorcyclists, scooter and pillion riders (PRR = 1.96; 95% CI, 1.43 to 2.70), whereas such risk was reduced for those aged 30 to 59 (PRR = 0.70; 95% CI, 0.58 to 0.85) or ≥ 60 years (PRR = 0.30; 95% CI, 0.21 to 0.42), respectively. Conclusion: As such, it appears that the groups at-risk had varying demographic characteristics. Public education could be modified to target these different groups to reduce the number of fatalities. Key words: Fatality, Motorcyclists, Pedestrians, Risk, Road traffic accident(s)

A review of fatal road traffic accidents in Singapore from 2000 to 2004

INTRODUCTION

This retrospective study aims to assess the epidemiology of road traffic accident (RTA) fatalities in Singapore, other causes of death besides trauma in a RTA, and identify the groups at risk.

MATERIALS AND METHODS

Data of 1038 RTA fatalities were reported between 2000 and 2004. Analyses using the Fisher's exact test for discrete variables and multivariate Cox regression analysis were performed to identify groups at risk. The risk of fatality was measured using the prevalence rate ratio (PRR).

RESULTS

The median age of victims in the sample was 36 years (interquartile range 24 to 55). Eight hundred and thirty six cases (78%) were in the economically productive age range of 15 to 65 years. Over the 5-year period, there was a preponderance of males. Majority of fatalities involved multiple injuries. There were also 64 (6.2%) and 25 (2.4%) cases of RTA fatalities from infective and cardiovascular (CVS) causes, respectively. Multivariate analyses showed that those > or = 60 years were 4 (95% CI of PRR, 3.04 to 5.43) times as likely to be pedestrian fatalities. Conversely, the risk of fatalities involving pedestrians and cyclists was reduced for males (PRR = 0.58; 95% CI, 0.46 to 0.73). However, males were at increased risk of fatalities involving motorcyclists, scooter and pillion riders (PRR = 1.96; 95% CI, 1.43 to 2.70), whereas such risk was reduced for those aged 30 to 59 (PRR = 0.70; 95% CI, 0.58 to 0.85) or > or = 60 years (PRR = 0.30; 95% CI, 0.21 to 0.42), respectively.

CONCLUSION

As such, it appears that the groups at-risk had varying demographic characteristics. Public education could be modified to target these different groups to reduce the number of fatalities.

Forensic Histopathology

Forensic histopathology is the application of histological techniques and examination to forensic pathology practice. It is a unique and specialised aspect of pathology practice. This chapter highlights several differences in forensic histopathology practice compared to clinical and surgical histopathology practice. The various roles of microscopic tissue examination in forensic pathology practice are categorised and discussed. These are in relation to definitive pathological diagnosis, confirmation of equivocal and occult pathology, serving as a form of permanent record, and providing invaluable material for education and research. Case examples are included to illustrate the impact of routine histological examinations, special stain techniques, as well as immunohistochemistry where appropriate, towards relevant pathological diagnoses, which may or may not be directly relevant to the establishment of the cause of death. Lastly, the chapter also aims to highlight some recent advances as well as the challenges ahead in this field.

Maternal deaths from suicide in Singapore

INTRODUCTION

Maternal mortality in Singapore, as in other developed countries, has remained low in the past decade. In the United Kingdom and Australia, maternal deaths from suicide and psychiatric causes have been the leading cause of maternal mortality, and there have therefore been comprehensive healthcare programmes to address the mental health needs of mothers.

METHODS

In this study, we looked at maternal deaths from 2000 to 2004, by linking coronial cases of female suicide in the reproductive age group 15-45 years, with the birth registration database, to identify both early and late maternal deaths.

RESULTS

There was only one identified maternal death among 589 female suicides aged 15-45 years, occurring in a teenager within the first month postpartum. There was likely also another case that was unconfirmed and unreported.

CONCLUSION

From this preliminary study, suicide and psychiatric causes are not significant causes of maternal mortality in Singapore. However, given that the epidemiology of postnatal depression statistics mirror that of the other countries, it is possible that maternal suicides have been underreported, and the load may well be higher. There is a need for a similar confidential enquiry into maternal deaths to be set up here, as is already in place in various countries, notably the United Kingdom and Australia, for the past decade.

Fatal cerebral infarction complicating therapeutic embolisation of a facial cavernous haemangioma: a case report

An eight-year-old female developed cerebral infarction, with eventual brain death, as a consequence of therapeutic embolisation of a large facial haemangioma. Post-mortem histological examination revealed the presence of identical foreign body emboli, consistent with at least one of the embolic agents used in the procedure, within the haemangioma and both cerebral hemispheres. It is possible that some of these particles might have entered the cerebral circulation through anastomoses between the right external and internal carotid arteries, and subsequently crossed over from the ipsilateral to the contralateral cerebral vasculature via the Arterial Circle of Willis.

Regulation of endogenous gene expression using small molecule-controlled engineered zinc-finger protein transcription factors

Small-molecule-regulated gene expression offers the promise of titrating the dose and duration of action of DNA-based therapies. To this end, we show that engineered zinc-finger protein transcription factors (ZFP TFs) can be coupled with a drug-inducible regulatory domain to permit small-molecule control of endogenous gene transcription. We constructed a drug-responsive ZFP TF via the fusion of a ZFP DNA-binding domain (DBD) targeting the human VEGF-A gene and an effector domain containing a truncated progesterone receptor ligand-binding domain linked to the NFkappaB p65 activation domain. Introduction of this engineered ZFP TF into human or murine cells allowed expression of the chromosomal VEGF-A gene to be induced upon addition of mifepristone, a synthetic steroid analog. Mifepristone-dependent VEGF-A induction was rapid, dose-dependent and reversible. Moreover, stable lines expressing the drug-responsive ZFP TF could be maintained in a state of continuous induction for at least 30 days without loss of viability. Potent VEGF-A induction was demonstrated using different engineered ZFP DBDs, thus this approach may represent a general solution to small-molecule regulation of targeted endogenous genes.

Out-of-hospital cardiac arrests occurring in primary health care facilities in Singapore

OBJECTIVES

To study out-of-hospital cardiac arrests (OHCA) occurring in primary healthcare facilities (HCF) in Singapore and to compare these with arrests occurring in the community.

METHODS

This prospective observational study was part of the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Included were all patients with OHCA occurring in HCF. Patient characteristics, cardiac arrest circumstances, EMS response and outcomes were recorded according to the Utstein style.

RESULTS

From 1 October 2001 to 14 October 2004, the data from 2428 subjects were received of which 138 patients were OHCA occurring in HCF. This is an incidence of 1.12/100,000 population per year and constituted 6.0% of all OHCA. Arrest occurring in HCF were more likely to be witnessed (p<0.01), or have bystander CPR (p<0.01). The HCF group was also more likely to receive CPR with both compression and ventilation (p<0.01) and have a non-trauma cause of arrest (p=0.03). HCF arrests also had a shorter collapse to call (EMS number) than the non-HCF group (HCF 1.54min versus non-HCF 5.36min, p=0.01). However, no HCF patient received defibrillation prior to EMS arrival. HCF patients were more likely to have return of spontaneous circulation at any time (p=0.05), survival to hospital admission (p<0.01) and survival to discharge (p<0.01) compared to non-HCF patients.

CONCLUSION

This study suggests that primary health care providers do have an important role locally in managing out-of-hospital cardiac arrest. We propose an initiative to encourage early defibrillation by primary health care providers.

Epidemiology of Completed Suicides in Singapore for 2001 and 2002

Abstract. This study provides an analysis of 640 completed suicide cases in Singapore for the years 2001 and 2002, compared to previous years and in relation to demographic and socioeconomic factors, as well as to the characteristics of a subgroup of suicide victims with prior psychiatric illness. There was little change in the suicide pattern over the 2 years studied compared to previous years. The sex ratio was constant at 1.5. Population-adjusted ratios were 1 for Chinese, 0.5 for Malays, and > 1 for both Indians and other ethnic groups. Falling from heights ranked first in terms of method adopted for both years. A disproportionately higher number of suicides were recorded for the 25-34 and the ≥ 75-year-old age groups. A total of 47 (17.2%) in 2001 and 74 (20.2%) in 2002 of the cases had a history of prior psychiatric illness, with psychotic disorders being the most common diagnostic category. There was also a statistically significant correlation between unemployment and incidence rates. Although the overall rate of elderly suicides had gone down since the 1990s, prevention strategy should focus on the elderly as this rate is still about 3-4 times the national average.

Post-anaesthetic maternal death in a patient with mediastinal large B-cell lymphoma: a case report

A 32-year-old female underwent laparoscopic salpingectomy of an ectopic (third) pregnancy under general anaesthesia, at approximately six weeks' amenorrhoea. She developed severe respiratory distress after extubation and died on the second postoperative day. It appears that she had a history of a mild, persistent productive cough for a period of about a month prior to the operation that was attributed to an upper respiratory tract infection. Autopsy demonstrated the presence of a large mediastinal tumour, whose existence was apparently unsuspected preoperatively, encasing the ascending thoracic aorta, aortic arch and the proximal segments of the brachiocephalic and subclavian arteries, and causing extrinsic airway compression. Subsequent microscopic examination showed histological and immunohistochemical features of a mediastinal large B-cell lymphoma. It is thought that the mechanical effects exerted by the advanced mediastinal tumour upon the airways and the thoracic cage, coupled with the pathophysiological effects of general anaesthesia on respiratory movement and airway patency, had led to the patient's unfortunate demise in early pregnancy.

Clinics in diagnostic imaging (105): Sigmoid volvulus causing intestinal obstruction, with successful endoscopic decompression

An 89-year-old woman was admitted for intestinal obstruction. Her abdominal radiograph showed typical features of sigmoid volvulus. Decompression was done successfully through careful flexible sigmoidoscopy with minimum air insufflation. The patient's symptoms were relieved and she was discharged two days post-procedure. No recurrence was noted at extended follow-up. Rapid diagnosis and early decompression are key to optimal management of sigmoid volvulus.

Clinics in diagnostic imaging (104): Gastric trichobezoar (or hairball)

A 56-year-old man underwent triphasic computed tomography (CT) of the abdomen as part of his work-up for liver transplantation. A mottled, rounded lesion with a dense rim was noted in the gastric lumen, which remained unchanged in appearance in the arterial, portal venous, and delayed phases of the CT. Gastroscopy performed three days later confirmed the presence of trichobezoar. The foreign body was broken down into smaller pieces by an endoscopic snare and was passed out spontaneously. The clinical presentation, radiological findings, and management of trichobezoars are discussed.

After the Indian Ocean tsunami: Singapore's contribution to the international disaster victim identification effort in Thailand

This paper describes the international disaster victim identification (DVI) response mounted in Thailand, with particular reference to Singapore's contribution to this process, in the wake of the Asian tsunami of 26 December, 2004, which devastated parts of more than 10 countries in and around the Indian Ocean and claimed more than 200,000 lives. Although Singapore was unscathed by this natural calamity, over 30 Singaporean visitors were counted amongst the thousands of deceased victims, mostly in Thailand. The systematic application of forensic pathology, forensic dentistry, DNA profiling, and fingerprinting to human identification, especially of the bodies of various nationalities that were in advanced states of putrefaction, was crucial to the entire DVI process. The authors perceive that the resource implications arising from such a disaster, which is unprecedented in both its scale and reach in the international history of DVI, are immense. Forward planning, adequate funding and international cooperation are essential to mounting an effective response to any major mass disaster of the future.

Pattern of injuries in helmeted motorcyclists in Singapore

BACKGROUND

Singapore has a mandatory helmet law for motorcyclists. This study aimed to determine the injuries sustained by helmeted motorcyclists presenting to the emergency Department (ED).

METHODS

Adult victims of motor vehicular incidents (MVI) who presented to an urban public hospital ED from 1 December 1998 to 31 May 1999 were interviewed. Chart reviews were done for those hospitalised. Data collected were demographic, nature of injury, ambulance care, ED and hospital care, outcome and final diagnoses.

RESULTS

Motorcyclists formed 49.1% (1018) of all MVI victims, of whom 96.1% were men. The mean age was 32.5 years (SD 13.1), significantly younger (p<0.0001) than the mean age of 36.4 years (SD 16.4) among other MVI victims. The proportions of motorcyclists and other MVI patients admitted to the hospital were not different. Among those admitted, significantly fewer (p = 0.001) motorcyclists (32.2%) sustained head injury compared with other MVI victims (46.8%) but among the motorcyclists with head injury, more than one third (34.2%) had severe head injury. The proportion of patients with thoracic injury was not different (p = 0.93) between motorcyclists (10.2%) and other MVI victims (9.9%). However, among those with thoracic injury, 79.2% of motorcyclists had severe thoracic injury, significantly more (p = 0.04) than 50% of other MVI patients. Wounds, fractures, and/or dislocations of the limbs (p<0.001) were significantly more among motorcyclists compared with other MVI patients.

CONCLUSION

Compared with other MVI victims, fewer helmeted motorcyclists sustained head injury. When head injury occurs in helmeted motorcyclists, it tends to be more severe. Motorcyclists remain vulnerable to extremity injury and to severe chest injury.

A fatal case of hepatic failure possibly induced by nitrosofenfluramine: a case report

A 42-year-old female developed fulminant hepatic failure after having ingested an undetermined quantity of a herbal product over a period of approximately four months prior to the onset of her illness. Clinically, the cause of liver failure was assessed to be drug-induced and she eventually underwent total hepatectomy, with porto-caval shunting, in anticipation of a living-unrelated liver transplant. Unfortunately, her condition deteriorated and she died less than 48 hours post-operatively, approximately three weeks post-admission. An autopsy showed that the subject was deeply jaundiced and severely obese (BMI: 47.1 kg m(-2)), with evidence of diffuse haemorrhage, including the presence of 1.35 l of blood in the peritoneal cavity. The liver had been removed and was later recovered as a formalin-fixed specimen which was markedly contracted, comprising multiple micronodules interspersed with extensive areas of dense fibrotic tissue. Histologically, there was massive necrosis of the hepatic parenchyma, such that the residual hepatocytes were disposed as nodules displaying variable cellular regeneration and ballooning degeneration, attended by florid ductal proliferation and mixed inflammatory infiltrates. Infective, autoimmune, metabolic, vascular, neoplastic and most other natural causes of massive hepatocellular necrosis were effectively excluded. Analysis of the post-mortem blood samples yielded fluconazole, metronidazole, frusemide, lignocaine and tramadol, (therapeutic agents administered to the patient during her last illness). Subsequent analysis of the residual capsules revealed that they were adulterated by fenfluramine, N-nitrosofenfluramine (1.3-1.6 mg per capsule), nicotinamide (13.3-15.6 mg per capsule) and thyroid extract. None of the herbal ingredients is currently known to be hepatotoxic and much the same applies to fenfluramine, nicotinamide (except when taken in mega-doses) and thyroid extract. However, as nitrosamines are known to be variably hepatotoxic, it would be reasonable to surmise that, in the absence of a more plausible cause of liver damage, N-nitrosofenfluramine was the likely cause of massive hepatocellular necrosis in this instance.

Victims of falls from a height surviving to hospital admission in two Singapore hospitals

Falls from a height are a common problem in Singapore. However, there has been no analysis of the injury patterns and outcomes of patients who survived initial resuscitation after falls from a height in Singapore. One hundred and thirty-nine patients admitted over a two-and-a-half year period after falls of greater than one storey were studied. The higher the fall, the greater the likelihood of hypotension and neurological injury. The length of stay in hospital, the number of operative procedures and mortality also correlated with the height of the fall. The overall mortality rate was 11% but rose to 47% among patients who were hypotensive on admission. About half of the deaths were due to head injury with haemorrhage being the second most common cause. The majority of patients who fell from five or more storeys did so intentionally, and had more severe torso and extremity injuries compared with those who fell accidentally. These findings suggest that efforts in injury prevention and aggressive evaluation and treatment of fall victims arriving alive at the hospital continue to be important.

Homicidal and dyadic falls from a height: rarities in Singapore

A review of homicidal falls from a height, over a ten-year-period (1991-2000), demonstrated the rarity of such deaths in Singapore, despite the high frequency of fatal falls from a height that prevails in the city-state. During that time, there were four cases (involving five individuals) of pure homicide and nine episodes (involving 19 individuals) of dyadic death involving vertical deceleration from a considerable height in the approximate range of 17-31 m (6-11 floors) and 17-50 m (6-18 floors), respectively. The index cases were gleaned from a total of 533 homicides and 3,963 fatal falls from a height. Hence, the corresponding ten-year prevalence rates of homicidal falls were 0.9% in terms of all homicidal deaths and 0.1% in relation to all fatal falls, and 3.6% and 0.5% for dyadic falls, respectively. The majority of victims were children, with almost equal numbers of males and females, aged between two months and six years for pure homicides and between 20 months and 13 years for homicide-suicides. Over a third (9/24) of these subjects attained the maximum Injury Severity Score (ISS) of 75. With respect to the dyadic deaths, the majority of the perpetrators (6/9) were females, comprising four mothers and two live-in maids. It would appear that strained or broken relationships, probable or actual mental illness, or a combination of both factors, had largely predisposed them to these tragic events which may, potentially, carry diplomatic implications when foreign nationals are involved.

Cholecystokinin-B receptor gene expression in cerebellum, pre-frontal cortex and cingulate gyrus and its association with suicide

Suicide is a complex behaviour. Genetic and environmental factors are implicated in suicide. Both factors require genes to exert their effects. One gene hypothesized to be involved in the pathophysiology of suicide is cholecystokinin. Alterations in cholecystokinin receptor binding have been reported to be significant in young suicide victims as compared to matched controls in the frontal and cingulate cortex. In this study we report the Cholecystokinin-B gene expression using RT-PCR, between suicide completers [(N = 10); mean age 37.2+/-12 years] and control subjects [(N = 10); mean age 37.6+/-11.9 years]. Cholecystokinin-B gene expression was significantly higher in the cerebellum (P = 0.006), cingulate gyrus (P = 0.024) and pre-frontal cortex (P = 0.017) of suicide completers when compared to their age and sex-matched controls.