Tibial non-union with deformity in abnormal bone is rarely reported in literature. We report a case of a 65 years old male with a history of achondroplasia. The patient presented after a mechanical fall with an undisplaced right midshaft tibia fracture associated with pre-existing varus and procurvatum tibial deformities, which was initially managed nonoperatively. However, after nine months he developed a painful non-union. Because of the symptomatic non-union as well as the pre-existing deformities, osteotomy of the tibia and fibula was performed with the application of a TruelokHexapod (TL-Hex, Orthofix) frame. We were able to achieve compression at the fracture site, and the software guided TLHex frame enabled gradual three-dimensional correction of the deformity. At six months, bony union and simultaneous correction of the tibia deformity were achieved. At two years, the patient was able to ambulate well without pain and perform his activities of daily living. We present a case of tibial non-union with pre-existing deformity in an achondroplasia patient successfully treated with a circular frame application.

A 28-year-old Chinese man presented with acute bleeding per rectum. Computed tomography showed a posterior outpouching arising from the distal ileum. The outpouching had hyperaemic walls, but no active contrast extravasation was detected. Technetium-99m pertechnetate scintigraphy showed focal areas of abnormal uptake in the right side of the pelvis, superior and posterior to the urinary bladder. These areas of uptake appeared simultaneously with the gastric uptake and demonstrated gradual increase in intensity on subsequent images. The diagnosis of Meckel's diverticulum was confirmed on surgery and the lesion was resected. The clinical and imaging features of Meckel's diverticulum are discussed.
Abdominal Pain ; Adult ; Female ; Gastrointestinal Hemorrhage ; diagnosis ; diagnostic imaging ; Humans ; Ileum ; diagnostic imaging ; Male ; Meckel Diverticulum ; diagnosis ; diagnostic imaging ; Radionuclide Imaging ; Radiopharmaceuticals ; Sodium Pertechnetate Tc 99m ; Tomography, X-Ray Computed

PURPOSE: We investigated maternal genetic effects of four IL-4/IL-13 pathway genes as well as their interactions with the "Western or Eastern lifestyles/environments" on IgE in Karelian children. METHODS: This study included 609 children and their mothers. Total IgE levels in children and mothers were measured and 10 single nucleotide polymorphisms (SNPs) in IL-4, IL-4Ra, IL-13, and STAT6 were genotyped in mothers and their children. RESULTS: The maternal G allele of IL-13 130 (rs20541) was significantly (P=0.001) associated with decreased IgE in children in the Karelian population (Pooling Finnish and Russian children), as well as in Finnish (P=0.030) and Russian children (P=0.018). The IgE levels were significantly (P=0.001) higher in Russian children whose mothers were homozygous for the G allele of the IL-4Ra 50 (rs1805010) SNP than that in Russian children of mothers who were AG heterozygotes or AA homozygotes. After accounting for children's genotypes, we observed interactive effects on children's IgE for maternal IL-13 130 genotypes (P=0.014) and maternal IL-4Ra 50 genotypes (P=0.0003) with "Western or Eastern" lifestyles/environments. With the adjustment for multiple comparisons using a false discovery rate (FDR) of 0.05, the interactive effect of the maternal IL-4Ra50 SNP was significant. CONCLUSION: Maternal genetic variants in IL-4/IL-13 pathway genes, such as IL-13 130 and IL-4Ra50, influenced IgE levels in school children that were independent of the children's genetic effects. These effects differ in "Western or Eastern" environments.
Alleles ; Child ; Genotype ; Heterozygote ; Homozygote ; Humans ; Hypersensitivity ; Immunoglobulin E* ; Interleukin-13 ; Interleukin-4 ; Mothers ; Polymorphism, Single Nucleotide

PURPOSE: We investigated maternal genetic effects of four IL-4/IL-13 pathway genes as well as their interactions with the "Western or Eastern lifestyles/environments" on IgE in Karelian children. METHODS: This study included 609 children and their mothers. Total IgE levels in children and mothers were measured and 10 single nucleotide polymorphisms (SNPs) in IL-4, IL-4Ra, IL-13, and STAT6 were genotyped in mothers and their children. RESULTS: The maternal G allele of IL-13 130 (rs20541) was significantly (P=0.001) associated with decreased IgE in children in the Karelian population (Pooling Finnish and Russian children), as well as in Finnish (P=0.030) and Russian children (P=0.018). The IgE levels were significantly (P=0.001) higher in Russian children whose mothers were homozygous for the G allele of the IL-4Ra 50 (rs1805010) SNP than that in Russian children of mothers who were AG heterozygotes or AA homozygotes. After accounting for children's genotypes, we observed interactive effects on children's IgE for maternal IL-13 130 genotypes (P=0.014) and maternal IL-4Ra 50 genotypes (P=0.0003) with "Western or Eastern" lifestyles/environments. With the adjustment for multiple comparisons using a false discovery rate (FDR) of 0.05, the interactive effect of the maternal IL-4Ra50 SNP was significant. CONCLUSION: Maternal genetic variants in IL-4/IL-13 pathway genes, such as IL-13 130 and IL-4Ra50, influenced IgE levels in school children that were independent of the children's genetic effects. These effects differ in "Western or Eastern" environments.
Alleles ; Child ; Genotype ; Heterozygote ; Homozygote ; Humans ; Hypersensitivity ; Immunoglobulin E* ; Interleukin-13 ; Interleukin-4 ; Mothers ; Polymorphism, Single Nucleotide

Adult ; Biopsy ; Cerebral Ventricle Neoplasms ; diagnosis ; Diagnosis, Differential ; Humans ; Magnetic Resonance Imaging ; methods ; Male ; Neoplasms, Neuroepithelial ; diagnosis ; Third Ventricle ; diagnostic imaging

Humans ; Infant ; Infant, Newborn ; Male ; Mutation ; Thyroid Hormone Receptors beta ; genetics ; Thyroid Hormone Resistance Syndrome ; genetics

BACKGROUND: Breastfeeding is best for infants and the World Health Organization recommends exclusive breastfeeding for at least the first 6 months of life. For those who are unable to be breastfed, previous studies demonstrate that feeding high-risk infants with hydrolyzed formulas instead of cow's milk formula (CMF) may decrease the risk of atopic dermatitis (AD). OBJECTIVE: To estimate the economic impact of feeding high-risk, not exclusively breastfed, urban Malaysian infants with partiallyhydrolyzed whey-based formula (PHF-W) instead of CMF for the first 17 weeks of life as an AD risk reduction strategy. METHODS: A cohort Markov model simulated the AD incidence and burden from birth to age 6 years in the target population fed with PHF-W vs. CMF. The model integrated published clinical and epidemiologic data, local cost data, and expert opinion. Modeled outcomes included AD-risk reduction, time spent post AD diagnosis, days without AD flare, quality-adjusted life years (QALYs), and costs (direct and indirect). Outcomes were discounted at 3% per year. Costs are expressed in Malaysian Ringgit (MYR; MYR 1,000 = United States dollar [US $]316.50). RESULTS: Feeding a high-risk infant PHF-W vs. CMF resulted in a 14% point reduction in AD risk (95% confidence interval [CI], 3%-23%), a 0.69-year (95% CI, 0.25-1.10) reduction in time spent post-AD diagnosis, additional 38 (95% CI, 2-94) days without AD flare, and an undiscounted gain of 0.041 (95% CI, 0.007-0.103) QALYs. The discounted AD-related 6-year cost estimates when feeding a high-risk infant with PHF-W were MYR 1,758 (US $556) (95% CI, MYR 917-3,033) and with CMF MYR 2,871 (US $909) (95% CI, MYR 1,697-4,278), resulting in a per-child net saving of MYR 1,113 (US $352) (95% CI, MYR 317-1,884) favoring PHF-W. CONCLUSION: Using PHF-W instead of CMF in this population is expected to result in AD-related costs savings.
Breast Feeding ; Cohort Studies ; Cost-Benefit Analysis ; Dermatitis, Atopic ; Diagnosis ; Expert Testimony ; Health Services Needs and Demand ; Humans ; Incidence ; Income ; Infant Formula ; Infant ; Milk ; Parturition ; Quality-Adjusted Life Years ; Risk Reduction Behavior ; United States ; World Health Organization

INTRODUCTIONThe implementation of competency-based internal medicine (IM) residency programme that focused on the assurance of a set of 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies in Singapore marked a dramatic departure from the traditional process-based curriculum. The transition ignited debates within the local IM community about the relative merits of the traditional versus competency-based models of medical education, as well as the feasibility of locally implementing a training structure that originated from a very different healthcare landscape. At the same time, it provided a setting for a natural experiment on how a rapid integration of 2 different training models could be achieved.

MATERIALS AND METHODSOur department reconciled the conflicts by systematically examining the existing training structure and critically evaluating the 2 educational models to develop a new training curriculum aligned with institutional mission values, national healthcare priorities and ACGME-International (ACGME-I) requirements.

RESULTSGraduate outcomes were conceptualised as competencies that were grouped into 3 broad areas: personal attributes, interaction with practice environment, and integration. These became the blueprint to guide curricular design and achieve alignment between outcomes, learning activities and assessments. The result was a novel competency-based IM residency programme that retained the strengths of the traditional training model and integrated the competencies with institutional values and the unique local practice environment.

CONCLUSIONWe had learned from this unique experience that when 2 very different models of medical education clashed, the outcome may not be mere conflict resolution but also effective consolidation and transformation.

Accreditation ; Clinical Competence ; Curriculum ; Education, Medical, Graduate ; Internal Medicine ; education ; Internship and Residency ; Models, Educational ; Negotiating ; Singapore

INTRODUCTIONAnti-thyroid antibodies are associated with extra-thyroid diseases such as Graves' ophthalmopathy and Hashimoto's encephalopathy. Some evidence suggests that anti-thyroid antibodies are also associated with depression. Interleukin (IL)-17 appears to play an important role in autoimmune thyroid disease. This study investigated whether specific thyroid autoantibodies and IL-17 distinguished persons with depression from non-depressed controls.

MATERIALS AND METHODSForty-seven adult females with non-psychotic, current major depressive disorder and 80 healthy female controls participated in this study. Thyroid peroxidase antibodies, thyroglobulin antibodies, thyroid-stimulating hormone (TSH) receptor antibodies, free T3 and T4, TSH and IL-17 were measured from the serum. Measurements were repeated to assess test-retest reliability. Receiver operating characteristic (ROC) curves were used to estimate discriminatory values of the measurements. Differences between groups and associations between the clinical and biochemical assessments were analysed.

RESULTSMedian TSH receptor antibody concentration was significantly higher in the depressed than control group (P <0.001). Area under the ROC curve was 0.80 (95% CI, 0.73 to 0.88). Higher TSH receptor antibody titres were associated with greater depression severity scores (r = 0.33, P <0.05). IL-17 levels were not associated with TSH receptor antibody levels or depression severity scores. Thyroid function and other thyroid autoantibodies were not associated with depression severity.

CONCLUSIONTSH receptor antibodies might be a biomarker of immune dysfunction in depression.

Adult ; Autoantibodies ; blood ; Biomarkers ; blood ; Depressive Disorder, Major ; diagnosis ; immunology ; Female ; Humans ; Immunoglobulins, Thyroid-Stimulating ; blood ; Interleukin-17 ; blood ; Middle Aged ; Psychiatric Status Rating Scales ; ROC Curve ; Statistics as Topic ; Thyroid Gland ; immunology

INTRODUCTIONEnterovirus infections in childhood can be associated with significant neurological morbidity. This study aimed to describe the prevalence and range of neurological manifestations, determine the clinical characteristics and assess differences in clinical outcomes for Singaporean children diagnosed with enterovirus infections.

METHODSIn this single-centre, case-control study, clinical data was collected retrospectively from patients admitted to National University Hospital, Singapore, from August 2007 to October 2011 and diagnosed with enterovirus infection, based on the enterovirus polymerase chain reaction test, or cultures from throat and rectal swabs or cerebrospinal fluid samples. The occurrence of neurological manifestations was reviewed and clinical outcomes were assessed.

RESULTSA total of 48 patients (age range: six days-17.8 years) were included in the study. Neurological manifestations were seen in 75.0% of patients, 63.9% of whom presented with aseptic meningitis. Other neurological manifestations included encephalitis, acute cerebellitis, transverse myelitis and autonomic dysfunction. The incidence of neurological manifestations was significantly higher in patients aged > 1 year as compared to younger patients (p = 0.043). In patients without neurological manifestations, a significantly higher proportion presented with hand, foot and mouth disease and poor feeding. Long-term neurological sequelae were seen in 16.7% of patients with neurological manifestations.

CONCLUSIONA wide spectrum of neurological manifestations resulting in a relatively low incidence of long-term neurological sequelae was observed in our study of Singaporean children with enterovirus infections. As some of these neurological morbidities were severe, careful evaluation of children with neurological involvement is therefore necessary.