Detection and distribution of anti-leptospiral antibody among dogs and their handlers

The incidence of leptospirosis seems to be on the rise and could be an alarming indirect indication of a global re-emergence. It is a potential public health threat when dogs are speculated to be involved in the transmission of leptospirosis through possible subclinical harbouring of Leptospira spp. and subsequent shedding into the environment. This study aimed to detect anti-leptospiral antibodies among dogs and their handlers using the microscopic agglutination test (MAT). Blood samples from 266 apparently healthy dogs and 194 dog handlers were collected at four working dog organisations and four dog shelters. Serum samples were tested using MAT against 20 leptospiral serovars with a cut-off titre >=1:100 (dog) and >=1:50 (dog handlers). Seventy dogs (70/266; 26.3%) were seropositive mainly against serovars Icterohaemorrhagiae, Ballum, Bataviae and Javanica (titres ranged: 1:100-1:800). Sixty-seven dog handlers (67/194; 34.5%) were seropositive mainly against serovars Grippotyphosa, Icterohaemorrhagiae and Malaysia (titres ranged: 1:50-1:200). Dogs were seropositive due to exposure, vaccination or active infection. Seropositive dog handlers could indicate exposure or active infection. This shows the potential of dogs in maintaining and spreading the infection in Malaysia. Due to the occupational risk as a result of frequent contact with dogs and exposure to contaminated environments, dog handlers should be made aware of the presence of this zoonotic disease.

Conducting a high-stakes OSCE in a COVID-19 environment

This article was migrated. The article was marked as recommended. The COVID-19 pandemic has presented significant challenges for medical schools. It is critical to ensure final year medical school students are not delayed in their entry to the clinical workforce in times of healthcare crisis. However, proceeding with assessment to determine competency for graduation from medical school, and maintaining performance standards for graduating doctors is an unprecedented challenge under pandemic conditions. This challenge is hitherto uncharted territory for medical schools and there is scant guidance for medical educators. In early March 2020, Duke-National University Singapore Medical School embraced the challenge for ensuring competent final year medical students could complete their final year of studies and graduate on time, to enter the medical workforce in Singapore without delay. This paper provides details of how the final year clinical performance examinations were planned and conducted during the COVID-19 pandemic. The aim of the paper is to provide guidance to other medical schools in similar circumstances who need to plan and make suitable adjustments to clinical skills examinations under current pandemic conditions. The paper illustrates how it is possible to design and implement clinical skills examinations (OSCEs) to ensure the validity and reliability of high-stakes performance assessments whilst protecting the safety of all participants, minimising risk and maintaining defensibility to key stakeholders.

Analgesia for Adult Distal Radius Fracture Manipulation in the Emergency Department: Demand Valve Nitrous Oxide Compared with Intravenous Regional Anaesthesia

Introduction

This study compared demand-valve nitrous oxide (Entonox) with intravenous regional anaesthesia (IVRA) as analgesia in adults with distal radius fractures requiring manipulation and reduction (M&R) in the Emergency Department.

Materials and methods

All adults presenting to the Emergency Department of Changi General Hospital, Singapore between August to December 2000 with closed distal radius fractures requiring M&R were enrolled. Five parameters were measured: pain perception using visual analogue scale (VAS), patient acceptance, procedure time, complication rate and failed manipulation.

Results

Of the 67 patients enrolled, 32 received IVRA and 35 received Entonox. The average VAS was 2.2 cm for the IVRA group and 5.8 cm for the Entonox group (p<0.0001). The average procedure time was 25.6 minutes for the IVRA group and 11.1 minutes for the Entonox group (p<0.0001). Twenty-seven IVRA patients (84.4%) and 24 Entonox patients (68.6%) would agree to the same analgesia given similar circumstances (p=0.159). Four patients who received Entonox (11.4%) experienced minor complications, while no complications were noted in the IVRA group (p=0.115). Two patients who received IVRA (6.3%) and 8 patients who received Entonox (22.9%) required more than a single attempt at M&R (p=0.086).

Conclusion

The use of Entonox, compared to IVRA, was associated with significantly shorter procedure time but significantly higher pain scores, with no significant difference in terms of patient acceptance, complication rate or failed manipulation rate. Entonox is an effective analgesic alternative to IVRA in adult patients requiring M&R for distal radius fractures in the Emergency Department. Its use is ideal in situations where IVRA is unsuitable or contraindicated.

Isolated Posterior Acute Myocardial Infarction Presenting to an Emergency Department: Diagnosis and Emergent Fibrinolytic Therapy

Objectives

Isolated posterior acute myocardial infarction (AMI) is rare and possibly underdiagnosed. The incidence of misdiagnosis in the emergency department (ED) is unknown. Delayed diagnosis may prevent timely treatment, particularly emergent fibrinolytic therapy. We describe the experience of an urban ED on this rare condition.

Methodology

A six years and seven months case series of isolated posterior AMI of initial presentation (as identified by inpatient discharge/death ICD-9-CM diagnosis code) was studied. Patients not admitted from the ED, those who developed isolated posterior AMI only after admission and/or those with concomitant ST segment elevation AMI involving other anatomical locations of the heart (e.g. inferior or lateral walls), were excluded.

Results

Eleven cases were included in the study. All the nine cases with electrocardiograms available for review demonstrated features consistent with isolated posterior AMI. Eight out of the eleven (72.7%) cases were correctly diagnosed as isolated posterior AMI in the ED. The other three cases were treated as non-ST elevation myocardial infarction (NSTEMI). Nevertheless, their lack of the typical symptoms of acute coronary syndrome and delayed presentation (more than 12 hours) precluded them from fibrinolytics. Three of the eleven cases received fibrinolytics (all streptokinase). All three cases survived to discharge and there were no haemorrhagic complications. None of the cases underwent emergent percutaneous coronary intervention.

Conclusion

The majority of cases with isolated posterior AMI (72.7%) were diagnosed in the ED. Although three cases were interpreted as NSTEMI, the use of fibrinolytic reperfusion therapy was not affected.

Isolated Clavicle Fracture with Secondary Pneumothorax: A Case Report

Clavicle fractures complicated by pneumothorax are rare. This case report describes a young man who developed pneumothorax secondary to an isolated clavicle fracture following blunt trauma to his right shoulder in an assault. The pneumothorax was diagnosed on a shoulder X-ray, and required the insertion of a chest drain. It may be prudent to specifically exclude a pneumothorax in clavicle fractures if the fractured segment is directed towards the lung.

Time Delays in Instituting Thrombolysis in Acute Myocardial Infarction - a Singapore Perspective

The reduction of mortality from acute myocardial infarction has been achieved mainly through the use of thrombolysis. In large scale studies, mortality and the extent of myocardial salvage are directly related to how early thrombolysis or reperfusion is instituted. This study was done to highlight the factors resulting in time delays that need to be targeted for change: (a) Pre-hospital delays (recognition of symptoms suggesting an acute myocardial infarction and the presentation to the A&E Department); (b) Delays that occur within the A&E Department; and (c) Delays after leaving the Accident & Emergency Department. We identified the areas contributing to significant delays in each of these areas with a view of proposing that a subgroup of these patients may be identified for a fast track approach in initiating thrombolysis within the Accident & Emergency Department.

Retention in Enhanced Team Based Learning Course: retain or refrain?

This article was migrated. The article was not marked as recommended. Background: Students' ability to retain content in medical school has always been a concern. At Duke-NUS Medical School, we modified our Team-Based Learning (TBL) classes known as TeamLEAD, a learning strategy for first year basic science content, to include an open/closed-book option in the readiness assurance phase to engage teams in deeper discussion. We hypothesize that the open-book option allows students to engage in deeper learning in their teams, which leads to an improvement in retention ability for each individual student at the end of their first year basic science curriculum. Methods: A total of 115 MCQs used throughout first year basic science courses from 2011 to 2013 were repeated during a two-week end-of-year review. We analysed the extent of students' retention by examining the influence of team's choice for open/closed-book on initial and repeated individual performance score. Results: Student's individual scores increased from 56.2% correct the first time encountering the questions to 68.7% for the second time (p<0.01). For teams that chose open-book option for group readiness assurance (GRA) test, individual students' second encounter score increased by 11.8% (p<0.01) compared to 10.3% (p<0.01) for teams that chose closed-book option. Students' retention was higher for those questions from second half of the year compared to questions from first half (p<0.01). Conclusion: Implementation of open-book component enables students to drive challenging discussion in teams. This helps individual students to consolidate, recall and retain more information over time, which results in an improved individual performance at the end-of-year review.

Student’s perspective of Residents as educators following introduction of Accreditation Council for Graduate Medical Education-International (ACGME-I) in SingHealth Residency

Introduction:

Singapore’s postgraduate medical education underwent a transition in 2010, moving away from the House staff model to the American Residency model. Teaching was defined as a core competency for SingHealth Residency programs. This study sought to determine how this transition impacted medical students’ perception of Residents as teachers.

Methods:

A 19-item Likert-type questionnaire comprising three domains—(1) quality, (2) frequency and (3) engagement—was given to all Duke-NUS medical students at the end of each clerkship from the academic year (AY) 2009–10 through 2013–14. The first two academic years were classified as the pre-initiation stage of the Residency, and the latter three, the post-initiation stage. Students rated Residents they encountered in their most recent clerkship.

Results:

Student ratings have gradually improved, with the largest improvement occurring after the initiation of Residency, and after the introduction of Residents as Future Teachers courses. Student ratings in the post-initiation Residency years combined were significantly higher than the pre-initiation of Residency years combined, for all three domains. Analysis of individual items revealed significant improvement in student ratings on all items in all domains, except for the quality of teaching in performing procedural skills.

Conclusion:

Findings from this study indicate a positive shift in the teaching culture with the transition of Singapore’s postgraduate medical education from the House staff model to the Residency program.

Chemical defense secretions of some species of Malaysian rhinotermitidae (Isoptera, Rhinotermitidae)

The defense secretions of the soldiers of the Malaysian rhinotermitid,Parrhinotermes aequalis (Havilandi) andP. pygmaeus (John),Termitogeton planus (Havilandi) andSchedorhinotermes malaccensis (Holmgren) consist mainly of vinyl ketones, whereas that ofProrhinotermes flavus (Bugnion & Popoff) gives (E)-1-nitropentadecene. The chemistry of the defense secretions ofParrhinotermes andTermitogeton is documented and based on their chemical relationships;Termitogeton shows a closer affinity to the Rhinotermitinae than Heterotermitinae.

Effectiveness of frequency mapping on 28 nm device broken scan chain failures

Frequency mapping methodology is an effective diagnostic tool for detection of manufacturing defects in scan chains. It analyses reflected laser modulations from toggling scan cells to localize defective scan path or scan cell. In this paper, we demonstrate experimentally that the use of solid immersion lens technology to enhance signal and spatial resolution is not a prerequisite for this technique up till 28 nm technology node. We present case studies to show the effectiveness of frequency mapping for detecting systematic and random broken scan chain failures on a 28 nm technology node test chip. We achieved 81% success rate in this methodology.

Bomb blast mass casualty incidents: initial triage and management of injuries

Bomb blast injuries are no longer confined to battlefields. With the ever present threat of terrorism, we should always be prepared for bomb blasts. Bomb blast injuries tend to affect air-containing organs more, as the blast wave tends to exert a shearing force on air-tissue interfaces. Commonly-injured organs include the tympanic membranes, the sinuses, the lungs and the bowel. Of these, blast lung injury is the most challenging to treat. The clinical picture is a mix of acute respiratory distress syndrome and air embolism, and the institution of positive pressure ventilation in the presence of low venous pressures could cause systemic arterial air embolism. The presence of a tympanic membrane perforation is not a reliable indicator of the presence of a blast injury in the other air-containing organs elsewhere. Radiological imaging of the head, chest and abdomen help with the early identification of blast lung injury, head injury, abdominal injury, eye and sinus injuries, as well as any penetration by foreign bodies. In addition, it must be borne in mind that bomb blasts could also be used to disperse radiological and chemical agents.

Design considerations for refractive solid immersion lens: application to subsurface integrated circuit fault localization using laser induced techniques

With fast scaling and advancement of integrated circuit (IC) technology, circuitries have become smaller and denser. New materials and more sophisticated designs have evolved. These changes reduced the effectiveness of conventional laser induced fault localization techniques. Since IC fault localization is the most critical step in failure analysis, there are strong motivations to improve both spatial resolution and sensitivity of such systems to meet the new challenges from advanced technology. Refractive solid immersion lens (RSIL) is well known to enhance the laser spot size which directly affects resolution and sensitivity in back side fault localizations. In practice, it is difficult to operate RSIL at the ideal configurations to obtain the smallest spot resolution. It is necessary to understand the resolution performance at the other design focal planes. Besides resolution, there are also other factors that affect sensitivity in a RSIL enhanced system. This paper identifies and characterizes key RSIL design parameters to optimize RSIL performance on laser induced techniques. We report that the most efficient conditions are achieved close to aplanatic RSIL design to within 20-25 microm (for a 1 mm diameter lens), and the backing objective should be the minimum numerical aperture required for optimum resolution performance. The size of the mechanical clear aperture opening should be large enough (>80%) to exploit the advantage of aplanatic RSIL. RSIL is developed on a laser scanning optical microscope in this work, and a resolution of 0.3 microm (for a wavelength of 1340 nm) was achieved over a range of operating conditions. A quantitative resolution of 0.25 microm is achieved and a pitch structure of 0.4 microm is easily resolvable. Close to 15 times enhancement in laser induced signal is obtained.

Muscarinic receptor binding activity of polyoxygenated flavones from Melicope subunifoliolata

The bark extract of Melicope subunifoliolata (Stapf) T.G. Hartley showed competitive muscarinic receptor binding activity. Six polymethoxyflavones [melibentin (1); melisimplexin (3); 3,3',4',5,7-pentamethoxyflavone (4); meliternatin (5); 3,5,8-trimethoxy-3',4',6,7-bismethylenedioxyflavone (6); and isokanugin (7)] and one furanocoumarin [5-methoxy-8-geranyloxypsoralen (2)] were isolated from the bark extract. Compounds 2 and 6 were isolated for the first time from M. subunifoliolata. The methoxyflavones (compounds 1, 3, 4, 5, 6, and 7) show moderate inhibition in a muscarinic receptor binding assay, while the furanocoumarin (compound 2) is inactive. The potency of the methoxyflavones to inhibit [(3)H]NMS-muscarinic receptor binding is influenced by the position and number of methoxy substitution. The results suggest these compounds are probably muscarinic modulators, agonists or partial agonists/antagonists.

When the stork arrives unannounced - seven years of emergency deliveries in a non-obstetric general hospital

INTRODUCTION

Emergency department deliveries are uncommon in the Singapore setting, but when they do occur, the emergency physician has to be able to deliver the child safely, perform neonatal resuscitation if needed, and try to prevent any birth trauma to the child or complications of delivery in the mother. We present our experience of emergency room deliveries spanning 7 years in a community hospital without obstetric or neonatal backup.

MATERIALS AND METHODS

This is a retrospective case series. A search was made through our electronic medical records system for patients presenting in labour or with deliveries from March 1997 to October 2004. They were studied for demographic and social factors, gravidity and parity, as well as any complications (during birth and in the immediate post-delivery period) in both parent and child.

RESULTS

Twenty-three patients presented to our emergency department with labour contractions, and 14 progressed to vaginal deliveries. Twelve were single mothers who had hidden their pregnancies, while another 2 married patients had unsuspected pregnancies. No neonate needed resuscitation or airway support, but there were 4 patients without episiotomy who sustained perineal tears, and another 2 patients in whom the placenta could not be delivered. A child (born to a single mother without antenatal care) had a low Apgar score, but improved with oxygen and suctioning.

CONCLUSIONS

An emergency department in a non-obstetric hospital should have in place adequate preparations to cater for the occasional unexpected emergency delivery and the associated need for neonatal resuscitation. In our series, there was a high proportion of concealed (hidden) and "unaware" pregnancies presenting in labour. Prompt referral to a maternity hospital with neonatal care should be made for any complications.

Electrocardiographical case. Young man with generalised myalgia

A 24-year-old man presented with generalised malaise and myalgia for three days. He presented to the Emergency Department after a fall at his workplace due to weakness. 12-lead electrocardiogram (ECG) showed normal sinus rhythm with ST depression in the leads V4 to V6, with a U wave. The tallest U wave appeared in V3. These ECG features are characteristic of hypokalaemia. ECG changes in hypokalaemia and differential diagnosis are discussed. A second case of thyrotoxic periodic paralysis with similar ECG changes of hypokalaemia is also presented.

Self perceived work related stress and the relation with salivary IgA and lysozyme among emergency department nurses

AIMS

To assess and compare the self perceived work related stress among emergency department (ED) and general ward (GW) nurses, and to investigate its relation with salivary IgA and lysozyme.

METHODS

One hundred and thirty two of 208 (63.5%) registered female ED and GW nurses participated in the study. A modified mental health professional stress scale (PSS) was used to measure self perceived stress. ELISA methods were used to determine the salivary IgA and lysozyme levels.

RESULTS

On PSS, ED nurses had higher scores (mean 1.51) than GW nurses (1.30). The scores of PSS subscales such as organisational structure and processes (OS), lack of resources (RES), and conflict with other professionals (COF) were higher in ED than in GW nurses. ED nurses had lower secretion rates of IgA (geometric mean (GM) 49.1 micro g/min) and lysozyme (GM 20.0 micro g/min) than GW nurses (68.2 micro g/min, 30.5 micro g/min). Significant correlations were observed between PSS and log IgA and lysozyme secretion rates. OS, RES, and COF were correlated with log IgA and lysozyme levels.

CONCLUSION

ED nurses, who reported a higher level of professional stress, showed significantly lower secretion rates of salivary IgA and lysozyme compared to GW nurses. Salivary IgA and lysozyme were inversely correlated with self perceived work related stress. As these salivary biomarkers are reflective of the mucosal immunity, results support the inverse relation between stress and mucosal immunity.

Use of percussion as a screening tool in the diagnosis of occult hip fractures

Traumatic hip pain is a common clinical problem in the emergency department. There is significant morbidity in discharging a patient with an undiagnosed undisplaced hip fracture. The auscultatory percussion technique is a useful method to risk stratify patients who present with traumatic hip pain and with normal radiographs. We sought to study the sensitivity and specificity of the auscultatory percussion technique in a prospective study.

The acute presentation of pulmonary thromboembolism: a retrospective viewpoint

INTRODUCTION

Acute pulmonary thromboembolism (PE) has been considered rare among Asians. We aim to describe the frequency and clinical features of this condition in a hospital in Singapore. Among patients admitted by the Emergency Department (ED), comparisons were made between those primarily diagnosed in the ED and those who were not.

MATERIALS AND METHODS

Retrospective review of all cases of radiologically proven acute PE over a 20-month period.

RESULTS

Sixty-two patients were identified. The mean age was 61.5 +/- 18.0 years with a female to male ratio of 1.8:1. There were more Malays compared to other races. There were also more Caucasians, given the proximity of the hospital to the airport and the inclusion of tourists. The commonest symptoms were dyspnoea and chest pain, while the commonest signs were tachycardia and tachypnoea. Prolonged immobilisation was the commonest risk factor. Electrocardiographic S1Q3T3 pattern was seen in more patients compared to Western studies. Cardiomegaly was the commonest chest X-ray finding. Thirty-two patients were identified to have a source of embolisation. Overall mortality rate was 21%. The ED diagnosed 36% of the cases. Alternative admitting diagnoses were predominantly ischaemic heart disease and pneumonia. The group diagnosed in the ED were notably female (P = 0.044), Caucasian (P = 0.002) and had prolonged immobilisation (P = 0.025) prior to the onset of PE.

CONCLUSION

Acute PE is not as rare here as previously thought. Clinical features reveal more similarities than differences compared to other studies in the literature. We advocate a high index of suspicion for earlier diagnosis in the ED.

Palm oil: a healthful and cost-effective dietary component

Palm oil is an excellent choice for food manufacturers because of its nutritional benefits and versatility. The oil is highly structured to contain predominantly oleic acid at the sn2-position in the major triacylglycerols to account for the beneficial effects described in numerous nutritional studies. Oil quality and nutritional benefits have been assured for the variety of foods that can be manufactured from the oil directly or from blends with other oils while remaining trans-free. The oxidative stability coupled with the cost-effectiveness is unparalleled among cholesterol-free oils, and these values can be extended to blends of polyunsaturated oils to provide long shelf-life. Presently the supply of genetic-modification-free palm oil is assured at economic prices, since the oil palm is a perennial crop with unparalleled productivity. Numerous studies have confirmed the nutritional value of palm oil as a result of the high monounsaturation at the crucial 2-position of the oil's triacylglycerols, making the oil as healthful as olive oil. It is now recognized that the contribution of dietary fats to blood lipids and cholesterol modulation is a consequence of the digestion, absorption, and metabolism of the fats. Lipolytic hydrolysis of palm oil glycerides containing predominantly oleic acid at the 2 position and palmitic and stearic acids at the 1 and 3 positions allows for the ready absorption of the 2-monoacrylglycerols while the saturated free fatty acids remain poorly absorbed. Dietary palm oil in balanced diets generally reduced blood cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides while raising the high-density lipoprotein (HDL) cholesterol. Improved lipoprotein(a) and apo-A1 levels were also demonstrated from palm oil diets; an important benefits also comes from the lowering of blood triglycerides (or reduced fat storage) as compared with those from polyunsaturated fat diets. Virgin palm oil also provides carotenes apart from tocotrienols and tocopherols that have been shown to be powerful antioxidants and potential mediators of cellular functions. These compounds can be antithrombotic, cause an increase of the prostacyclin/thromboxane ratio, reduce restenosis, and inhibit HMG-CoA-reductase (thus reducing) cholesterol biosynthesis). Red palm oil is a rich source of beta-carotene as well as of alpha-tocopherol and tocotrienols.

Minor methylated pyranoamentoflavones from Calophyllum venulosum

Two new biflavonoids, pyranoamentoflavone 7-methyl ether (1) and pyranoamentoflavone 4'-methyl ether (2), have been isolated from the leaves of Calophyllum venulosum. The structures of these two new compounds were elucidated by spectroscopic data.

Streptococcus suis serotypes characterized by analysis of chaperonin 60 gene sequences

Streptococcus suis is an important pathogen of swine which occasionally infects humans as well. There are 35 serotypes known for this organism, and it would be desirable to develop rapid methods methods to identify and differentiate the strains of this species. To that effect, partial chaperonin 60 gene sequences were determined for the 35 serotype reference strains of S. suis. Analysis of a pairwise distance matrix showed that the distances ranged from 0 to 0.275 when values were calculated by the maximum-likelihood method. For five of the strains the distances from serotype 1 were greater than 0.1, and for two of these strains the distances were were more than 0.25, suggesting that they belong to a different species. Most of the nucleotide differences were silent; alignment of protein sequences showed that there were only 11 distinct sequences for the 35 strains under study. The chaperonin 60 gene phylogenetic tree was similar to the previously published tree based on 16S rRNA sequences, and it was also observed that strains with identical chaperonin 60 gene sequences tended to have identical 16S rRNA sequences. The chaperonin 60 gene sequences provided a higher level of discrimination between serotypes than the 16S RNA sequences provided and could form the basis for a diagnostic protocol.

Xanthones from Garcinia parvifolia

Nine new xanthones, parvixanthones A-I (1-9), isolated from the dried bark of Garcinia parvifolia, were found to have a common 1,3,6,7-oxygenated pattern for their xanthone nucleus, but various oxygenated isoprenyl or geranyl substituent groups. The structures were determined by spectroscopic methods.

Novel cytotoxic, polyprenylated heptacyclic xanthonoids from Indonesian Garcinia gaudichaudii (Guttiferae)

[reaction: see text] The structures of novel gaudichaudiic acids F-I (1-4), isolated from the bark of Indonesian Garcinia gaudichaudii, have been elucidated by detailed spectral analysis. Gaudichaudiic acid I (4) is probably derived from 1 as a result of allylic oxidation at C-24 and C-21, followed by aromatization.

Gene expression profile and identification of differentially expressed transcripts during human intrathymic T-cell development by cDNA sequencing analysis

The development of immature thymocytes to mature T-lymphocytes is a central process for establishing a functional immune system. The gene regulatory events involved in this process are of outstanding interest in understanding the generation of the T-cell repertoire as well as the differentiation of lineage-specific cells, such as CD4(+) helper T-cells or CD8(+) cytotoxic T-lymphocytes. While some essential genes involved in lineage decision and thymocyte differentiation have been already identified, the exact regulatory mechanisms and differential gene expressions are still unknown. The present study was performed to analyze the gene expression profile during T-cell development, in particular, during the differentiation of immature thymocytes into CD4(+) mature T-cells by analyses of expressed sequence tags (ESTs), and to elucidate novel human genes involved in this process. Based on distinct developmental stages, three PCR-based cDNA libraries from immature CD3(-),4(-),8(-) triple-negative, CD4(+),8(+) double-positive, and mature CD4(+),8(-) single-positive thymocytes were constructed. A total of 1477 randomly selected clones were analyzed by automated single-pass sequencing, and the assembly of ESTs resulted in 1027 different species of contig sequences. Among them, 392 contig sequences were matched to known genes, and several novel transcripts were discovered. The matched clones were classified into seven categories according to their functional aspects, and the gene expression profiles of the three thymocyte subsets were compared. The information obtained in current study will serve as a valuable resource for elucidating the molecular mechanism of intrathymic T-cell development.

Identification of Enterococcus species and phenotypically similar Lactococcus and Vagococcus species by reverse checkerboard hybridization to chaperonin 60 gene sequences

Data from four recent studies (S. H. Goh et al., J. Clin. Microbiol. 36:2164-2166, 1998; S. H. Goh et al., J. Clin. Microbiol. 34:818-823, 1996; S. H. Goh et al., J. Clin. Microbiol. 35:3116-3121, 1997; A. Y. C. Kwok et al., Int. J. Syst. Bacteriol. 49:1181-1192, 1999) suggest that an approximately 600-bp region of the chaperonin 60 (Cpn60) gene, amplified by PCR with a single pair of degenerate primers, has utility as a potentially universal target for bacterial identification (ID). This Cpn60 gene ID method correctly identified isolates representative of numerous staphylococcal species and Streptococcus iniae, a human and animal pathogen. We report herein that this method enabled us to distinguish clearly between 17 Enterococcus species (Enterococcus asini, Enterococcus rattus, Enterococcus dispar, Enterococcus gallinarum, Enterococcus hirae, Enterococcus durans, Enterococcus cecorum, Enterococcus faecalis, Enterococcus mundtii, Enterococcus casseliflavus, Enterococcus faecium, Enterococcus malodoratus, Enterococcus raffinosus, Enterococcus avium, Enterococcus pseudoavium, Enterococcus new sp. strain Facklam, and Enterococcus saccharolyticus), and Vagococcus fluvialis, Lactococcus lactis, and Lactococcus garvieae. From 123 blind-tested samples, only two discrepancies were observed between the Facklam and Collins phenotyping method (R. R. Facklam and M. D. Collins, J. Clin. Microbiol. 27:731-734, 1989) and the Cpn60 ID method. In each case, the discrepancies were resolved in favor of the Cpn60 ID method. The species distributions of the 123 blind-tested isolates were Enterococcus new sp. strain Facklam (ATCC 700913), 3; E. asini, 1; E. rattus, 4; E. dispar, 2; E. gallinarum, 20; E. hirae, 9; E. durans, 9; E. faecalis, 12; E. mundtii, 3; E. casseliflavus, 8; E. faecium, 25; E. malodoratus, 3; E. raffinosus, 8; E. avium, 4; E. pseudoavium, 1; an unknown Enterococcus clinical isolate, sp. strain R871; Vagococcus fluvialis, 4; Lactococcus garvieae, 3; Lactococcus lactis, 3; Leuconostoc sp., 1; and Pediococcus sp., 1. The Cpn60 gene ID method, coupled with reverse checkerboard hybridization, is an effective method for the identification of Enterococcus and related organisms.

Cytotoxic prenylated depsidones from Garcinia parvifolia

Leaf extracts of Garcinia parvifolia provided relatively high yields of four novel, cytotoxic prenylated depsidones. The structures were determined mainly by detailed NMR spectral analysis and X-ray crystallography.

Detection of genetic alterations in the human gastric cancer cell lines by two-dimensional analysis of genomic DNA

We examined genomic DNA from each of three human-derived gastric cancer cell lines, using the technique of restriction landmark genomic scanning (RLGS) which allows monitoring of approximately 2, 000 NotI landmarks. The resulting DNA spots from cancer cell DNA were compared with those in normal mucosa or gastric primary tumor. In all, 9 intense spots were detected from two of the three cancer cell lines. Two highly intensified spots were common in the two cancer cell lines and proven to be originated from DNA region containing the human c-myc proto-oncogene on chromosome 8. The degree of amplification of c-myc DNA was similar to each other and was estimated to be 60-fold as compared to those from normal mucosa DNA. On the basis of chromosome-assigned RLGS (CA-RLGS), other spots were assigned to each chromosome, such as one on chromosome 8, two each from chromosome 20, and three on one of chromosome 9-12. The remaining spot seems to be due to demethylation of a repetitive element. Twenty-four spot that were lost due to either homozygous deletion or methylation on corresponding NotI cleavage sites were commonly observed in all cancer cells. These spots were also assigned to each chromosome: one each from chromosome 2, 6, 7, 13, 14, 16, and 20, two each from chromosome 3 and 5, and nine from chromosome 9-12 by CA-RLGS. Many of the multi-copy spots corresponding to ribosomal RNA genes were greatly decreased due mainly to methylation on CpG islands along with minor rDNA variants, indicating that only minor rRNA genes may be silenced in these cancer cells. These results show that the present alterations detected by RLGS might be useful for identification of candidate genes inactivated or expressed unexpectedly in tumor development and tumor progression in the stomach.

Four new clerodane diterpenoids from Callicarpa pentandra

Leaf extracts of Callicarpa pentandra provided four new clerodane-type diterpenoids (1-4), of which 1, 2, and 4 have ring-A-contracted structures. Their structures and stereochemistry were established by spectral data interpretation, and for 3 also by single-crystal X-ray diffraction.

Flavonol-cinnamate cycloadducts and diamide derivatives from Aglaia laxiflora

Leaf extracts of the Malaysian plant Aglaia laxiflora provided two cytotoxic compounds, a new rocaglaol rhamnoside (1), a known rocaglaol (2), new (but inactive) flavonol-cinnamaminopyrrolidine adducts (3-6), and their probable biosynthetic precursors (7 and trimethoxyflavonol). All structures were elucidated primarily by 2D NMR spectroscopy. The structure and stereochemistry of aglaxiflorin A (3) were confirmed by single-crystal X-ray crystallography.

Emergency department organisation for disasters: a review of emergency department disaster plans in public hospitals of Singapore

Disaster management plans of emergency departments (EDs) in four major public hospitals were reviewed. A comparison was made between these plans, and they were analyzed to gain an understanding of the differing objectives and doctrines behind the practices. These were summarized into five major management concepts, which are considered to be critical to the success of a disaster plan: 1) staff mobilization systems (cascading vs batch mobilization); 2) staff deployment systems; 3) team organization (surgeons vs residents); 4) area management (the role of the area manager); 5) casualty volume management (accommodation vs expansion vs extension concepts). The concepts derived should serve as a useful guide to the development of an ED disaster plan and potentially influence how new ED facilities could be planned.

5-Oxonoraporphines from Mitrephora cf. maingayi

Two new 5-oxonoraporphines, 1 and 2, together with three known compounds, ouregidione, 3-methoxycepharadione B, and isoelemicin, have been isolated from the bark of Mitrephora cf. maingayi. Structures of 1 and 2 were determined to be 1,2,3-trimethoxy-5-oxonoraporphine and 1,2-dimethoxy-3-hydroxy-5-oxonoraporphine on the basis of NMR and MS studies.

Molecular epidemiology of cryptosporidiosis outbreaks and transmission in British Columbia, Canada

Isolates from 25 (13 sporadic and 12 outbreak) cryptosporidiosis cases, 24 of which were from British Columbia, Canada, were characterized using nested polymerase chain reaction amplification of the polymorphic internal transcribed spacer 1 locus. Two predominant Cryptosporidium parvum genotypes were found. Twelve (8 sporadic and 4 outbreak) isolates amplified with the cry7/cry21 primer pair and 12 (5 sporadic and 7 outbreak) isolates amplified with the cry7/cryITS1 primer pair. Multi-locus gene analysis using sequence polymorphisms on 3 other loci, i.e., the thrombospondin-related adhesion protein gene, the dihydrofolate reductase gene, and the 18S rRNA gene on 8 (4 outbreak and 4 sporadic) isolates showed non-random association among the human and animal alleles of the 4 different C. parvum gene loci. Associations between these 2 parasite genotypes and different routes of cryptosporidiosis transmission such as zoonotic, anthroponotic, and waterborne transmission were studied using municipal population and agricultural information, as well as detection of C. parvum oocysts in municipal drinking water specimens of the residential communities of sporadic and outbreak cases.

Drowning and near-drowning--some lessons learnt

Over a period of sixteen months, 17 cases of submersion injury (encompassing victims of drowning and near-drowning) were attended to at our Accident and Emergency Department at Changi General Hospital. Most of the victims were inexperienced recreational swimmers, and in 6 of them, early bystander cardiopulmonary resuscitation enabled them to recover without severe morbidity. Non-cardiogenic pulmonary oedema with resulting chest infection was the commonest complication in survivors. Most of the episodes occurred in an urban setting in swimming pools without supervision by lifeguards. About two-thirds of the cases were adults over the age of fifteen years. In addition, there were patients in whom submersion injury was associated with more sinister conditions (fits, traumatic cervical spine injury, dysbarism, intoxication from alcohol or drugs), some of which were unsuspected by the doctors initially. Apart from the immediate threats of hypoxia and pulmonary injury, active search for any possible precipitating causes and associated occult injury should be made. In this study, the determinants of survival from near-drowning were early institution of cardiopulmonary resuscitation, presence of pupil reactivity, and presence of a palpable pulse and cardiac sinus rhythm.

Streptococcus iniae, a human and animal pathogen: specific identification by the chaperonin 60 gene identification method

It was recently reported that Streptococcus iniae, a bacterial pathogen of aquatic animals, can cause serious disease in humans. Using the chaperonin 60 (Cpn60) gene identification method with reverse checkerboard hybridization and chemiluminescent detection, we identified correctly each of 12 S. iniae samples among 34 aerobic gram-positive isolates from animal and clinical human sources.

Identification of Staphylococcus species and subspecies by the chaperonin 60 gene identification method and reverse checkerboard hybridization

A previous study (S. H. Goh et al., J. Clin. Microbiol. 34:818-823, 1996) demonstrated that a 600-bp region of the chaperonin 60 (Cpn60) genes from various bacterial isolates could be amplified by PCR with a pair of degenerate primers and that the products could be used as species-specific probes for Staphylococcus aureus, S. epidermidis, S. haemolyticus, S. lugdunensis, S. saprophyticus, and S. schleiferi. To further validate the utility of bacterial Cpn60 genes as universal targets for bacterial identification (ID), reverse checkerboard chemiluminescent hybridization experiments were performed with DNA probes from 34 different Staphylococcus species and subspecies. With the exception of probes from the Cpn60 genes of S. intermedius and S. delphini, which cross hybridized, all were species specific. Two subspecies of both S. capitis and S. cohnii were differentiated from one another, while DNAs from the two S. schleiferi subspecies cross hybridized. When 40 known Staphylococcus isolates were tested in a blind experiment by the Cpn60 gene method, 36 strains, representing six species and one subspecies (S. sciuri, S. caseolyticus, S. hominis, S. warneri, S. hyicus, S. haemolyticus, and S. capitis subsp. ureolyticus), were correctly identified. DNA from the four remaining isolates, known to be S. hyicus bovine strains, failed to hybridize to DNA from the S. hyicus target strain or any other Staphylococcus species. However, DNAs from these S. hyicus isolates did cross hybridize with each other. New DNA sequence data and evidence from previous studies suggest some genetic divergence between the two groups of S. hyicus isolates. Our results demonstrate that this Cpn60 gene-based ID method has the potential to be a basic method for bacterial ID. Studies are in progress to further validate the utility of this Cpn60 gene system for ID of Staphylococcus and other genera, including those of slow-growing microorganisms.

Spectrum of roller-blading injuries

We studied 32 patients who presented to the Accident and Emergency Department of Toa Payoh Hospital with injuries sustained while roller-blading (in-line roller skating). This sporting activity carries risk of injuries, often fractures, due to 3 principal mechanisms of injury. The first and main mechanism of injury is that of a forward fall with the arms outstretched as a protective gesture. This is associated with fractures of the distal radius in the majority of cases, although other injuries to the upper limb can occur. The second important mechanism is that of a backward fall with resulting injury to the back of the head. Lastly, the patient may fall sideways, often together with a twisting force to the lower limbs, resulting in ankle sprains and meniscus injuries to the knee. The vast majority of patients are young teenagers who are beginners and had not been properly clad in protective gear. Roller-blading therefore carries a very real risk of sporting injury.

Unplanned returns to the accident and emergency department--why do they come back?

An audit of unplanned returns by patients to the Accident and Emergency Department was carried out recently in Toa Payoh Hospital. This was done for a period of eleven months for the year 1994. A total of 166 unplanned patient returns were studied. We analysed the reasons for their return, whether there were any differences between the diagnoses made initially and at the return visit, and the outcome of these return visits. It was found that more than two-thirds of patients (72.3%) returned because of a failure to improve from their initial condition even after treatment given by the Emergency Department doctors. The six most common illnesses for which there were failure to improve were asthma, epigastric pains (including gastritis and peptic ulcer disease), gastroenteritis and food poisoning, renal and ureteric colic, minor head injury and backache. Another 14.5% of patients were found to have wrong or missed diagnoses at the initial visit, the two most important of which were appendicitis and bleeding from the gastrointestinal tract. It is hoped that such an audit will serve to identify areas for improvement in patient care. It can also be a useful tool for measuring and improving the performance of individual Emergency Room doctors, or a group of doctors.

HSP60 gene sequences as universal targets for microbial species identification: studies with coagulase-negative staphylococci

A set of universal degenerate primers which amplified, by PCR, a 600-bp oligomer encoding a portion of the 60-kDa heat shock protein (HSP60) of both Staphylococcus aureus and Staphylococcus epidermidis were developed. However, when used as a DNA probe, the 600-bp PCR product generated from S. epidermidis failed to cross-hybridize under high-stringency conditions with the genomic DNA of S. aureus and vice versa. To investigate whether species-specific sequences might exist within the highly conserved HSP60 genes among different staphylococci, digoxigenin-labelled HSP60 probes generated by the degenerate HSP60 primers were prepared from the six most commonly isolated Staphylococcus species (S. aureus 8325-4, S. epidermidis 9759, S. haemolyticus ATCC 29970, S. schleiferi ATCC 43808, S. saprophyticus KL122, and S. lugdunensis CRSN 850412). These probes were used for dot blot hybridization with genomic DNA of 58 reference and clinical isolates of Staphylococcus and non-Staphylococcus species. These six Staphylococcus species HSP60 probes correctly identified the entire set of staphylococcal isolates. The species specificity of these HSP60 probes was further demonstrated by dot blot hybridization with PCR-amplified DNA from mixed cultures of different Staphylococcus species and by the partial DNA sequences of these probes. In addition, sequence homology searches of the NCBI BLAST databases with these partial HSP60 DNA sequences yielded the highest matching scores for both S. epidermidis and S. aureus with the corresponding species-specified probes. Finally, the HSP60 degenerate primers were shown to amplify an anticipated 600-bp PCR product from all 29 Staphylococcus species and from all but 2 of 30 other microbial species, including various gram-positive and gram-negative bacteria, mycobacteria, and fungi. These preliminary data suggest the presence of species-specific sequence variation within the highly conserved HSP60 genes of staphylococci. Further work is required to determine whether these degenerate HSP60 primers may be exploited for species-specific microbic identification and phylogenetic investigation of staphylococci and perhaps other microorganisms in general.

Sebaceous carcinoma of the eyelids: a review of six cases

Sebaceous carcinoma of the eyelid, although rare, carries a grave prognosis when diagnosed late. It may be mistaken by the unsuspecting ophthalmologist for a chalazion or chronic blepharoconjunctivitis. Six cases are presented. Three patients were in their fifth decade and the remaining three were over seventy. The latter group presented with advanced local disease and had poorly differentiated tumours. The two oldest patients died of metastasis within 54 months of presentation despite total excision of the lid tumour. This review demonstrates the problems encountered in diagnosis and management.

Accident & emergency department diagnosis--how accurate are we?

An audit of the accuracy of diagnosis for admitted patients made by the medical officers of the Accident and Emergency Department was carried out recently in Toa Payoh Hospital. This was done for a period of one week lasting from 2nd to 8th February, 1994. A total of 122 admissions were studied and their diagnoses at admission compared with the diagnoses at discharge made by the doctors from the various discipliner in the wards. It was found that a high degree of accuracy of diagnosis was achieved by the medical officers of the Accident and Emergency (A&E) Department for surgical disciplines (82.9% for General Surgery, and 95.8% for Orthopaedic Surgery), and an acceptable degree of accuracy (77.6%) for General Medicine. In addition, the usage of laboratory investigations in the Accident and Emergency Department was also studied. We also assessed the performances of trainees, senior and junior medical officers as well. It is hoped that such an audit will serve to define standards for diagnostic accuracy in the Accident and Emergency Department. This can be a useful tool in the future for measuring and improving the performance of individual Emergency Room medical officers, and also the various Accident and Emergency Departments.

The scapular manipulation method for reducing anterior shoulder dislocations

Anterior dislocation of the shoulder is the most common dislocation encountered by the emergency room medical officer. Many of the present methods employed, such as Kocher's method, the Hippocratic method and distraction method, necessitate the use of both intravenous pethidine and midazolam, which prolongs the recovery time of the patient in the emergency room, as well as carrying the risk of respiratory depression. Also, such methods are associated with complications such as fractures of the humerus and injury to the axillary vessels and brachial plexus. In view of the above disadvantages, an alternative method of reducing anterior shoulder dislocations was introduced to our emergency room medical officers. For a period of 9 months, the Accident and Emergency Department of Toa Payoh Hospital assessed the method of scapular manipulation for reducing anterior shoulder dislocations. This was a descriptive study. The method was found to have a high success rate (78.4%), was easy to teach, did not rely on the use of strong intravenous sedative agents, and was free of complications. Our experience with this method compared favourably with that of another large series which had a success rate of 79%.

Oxidative susceptibility of low density lipoprotein from rabbits fed atherogenic diets containing coconut, palm, or soybean oils

The oxidative susceptibilities of low density lipoproteins (LDL) isolated from rabbits fed high-fat atherogenic diets containing coconut, palm, or soybean oil were investigated. New Zealand white rabbits were fed atherogenic semisynthetic diets containing 0.5% cholesterol and either (i) 13% coconut oil and 2% corn oil (CNO), (ii) 15% refined, bleached, and deodorized palm olein (RBDPO), (iii) 15% crude palm olein (CPO), (iv) 15% soybean oil (SO), or (v) 15% refined, bleached, and deodorized palm olein without cholesterol supplementation [RBDPO(wc)], for a period of twelve weeks. Total fatty acid compositions of the plasma and LDL were found to be modulated (but not too drastically) by the nature of the dietary fats. Cholesterol supplementation significantly increased the plasma level of vitamin E and effectively altered the plasma composition of long-chain fatty acids in favor of increasing oleic acid. Oxidative susceptibilities of LDL samples were determined by Cu2(+)-catalyzed oxidation which provide the lag times and lag-phase slopes. The plasma LDL from all palm oil diets [RBDPO, CPO, and RBDPO(wc)] were shown to be equally resistant to the oxidation, and the LDL from SO-fed rabbits were most susceptible, followed by the LDL from the CNO-fed rabbits. These results reflect a relationship between the oxidative susceptibility of LDL due to a combination of the levels of polyunsaturated fatty acids and vitamin E.

Traumatic bronchial rupture--a case report

Traumatic bronchial rupture is a rarity. Its incidence is about 1.5% to 3% in most series of blunt chest trauma. We report a patient who presented after a road traffic accident with an apparently persistent pneumothorax which failed to respond to emergency treatment. This was later discovered to be due to a traumatic bronchial rupture. It is difficult to diagnose traumatic bronchial rupture, the main reason being that it is often not considered by doctors caring for the patient with blunt chest trauma in the Accident and Emergency Department. Failure to recognise this condition contributes to its high mortality. The authors would like to recommend that emergency bronchoscopy be carried out in patients with blunt chest trauma to exclude this potentially treatable condition. This is especially so if there are suggestive clinical features, such as the presence of extensive and spreading subcutaneous emphysema, pneumomediastinum, pneumothorax, haemoptysis, fractures of the first two ribs and respiratory distress. A history of massive blunt force to the chest wall as a mechanism of injury should also prompt the trauma team to consider the need for emergency bronchoscopy.

Effect of indomethacin on blood pressure control during treatment with nitrendipine

This study tested the hypothesis that treatment with a nonsteroidal anti-inflammatory drug will not alter the hypotensive effect of a dihydropyridine calcium channel antagonist. Fifteen essential hypertensives (ages 58-80 years) had a supine diastolic blood pressure (DBP) < 100 mmHg after 4 weeks monotherapy with nitrendipine 5-20 mg twice daily. They entered a double-blind randomised crossover study in which the addition of indomethacin 25 mg three times daily was compared with placebo in treatment phases each of 4 weeks duration. Subjects were seen weekly and measurements in the last 2 weeks of each phase were compared. Supine blood pressure (mean +/- SE) was higher in the indomethacin phase (158 +/- 4/80 +/- 2) than in the placebo phase (154 +/- 4/76 +/- 3) (p < 0.01 for DBP). In 6/15 (40%) of subjects the increase in supine diastolic blood pressure with indomethacin was > 5 mmHg. Plasma urea was also increased in the indomethacin phase: 7.6 +/- 0.6 mmol/l compared with placebo: 6.3 +/- 0.5 mmol/l (p < 0.001). The study has demonstrated that concurrent treatment with the NSAID indomethacin impairs the blood pressure lowering effect of the dihydropyridine calcium channel antagonist nitrendipine. This increase in blood pressure with indomethacin in subjects treated with nitrendipine may represent either an independent pressor effect of indomethacin or a reduced vasodilator prostanoid contribution to the hypotensive effect of nitrendipine. This blood pressure increase may be sufficient to interfere significantly with clinical blood pressure control in some subjects.

Nodular skin tuberculosis with lymphatic spread--a case report

An unusual case of tuberculosis paronychia with skin infection of the big toe was recently seen in a patient returning from Kalimantan. This was complicated by inguinal lymphadenitis and tuberculosis abscess formation. The diagnosis was made on culture of the pus from the abscess and upon biopsy and histological examination of the skin lesion from the toe. The patient responded to surgical treatment and chemotherapy with ethambutol, rifampicin and isoniazid.