INTRODUCTION: In a subset of adults with non-rapid eye movement (NREM) parasomnias, clinical variants might be violent in nature and can potentially result in unintentional but considerable harm. As such, there is substantial interest on the forensic ramifications of these sleep behaviours. METHODS: This review examined the diagnostic criteria for parasomnias established in the context of international classification systems; medicolegal case reports; legal frameworks; and court cases in and outside of Singapore, to provide an overview of the implications of NREM parasomnias. RESULTS: Violent or injurious behaviours that occurred in the context of somnambulism, otherwise known as sleepwalking, have challenged traditional legal theories of criminal culpability. Yet little has changed in the application of sleep science to criminal responsibility. In Singapore, the defence of somnambulism has hitherto not been directly raised. Nonetheless, sleep medicine practitioners may increasingly be requested to render their opinions on legal issues pertaining to violent or injurious behaviours allegedly arising during sleep. Although the understanding of NREM parasomnias has improved, there is still a dearth of evidence to support both medical and legal decisions in this area. CONCLUSION NREM parasomnias come with disquieting legal and forensic implications for adjudicating criminal responsibility. There is a need to critically examine legal perspectives on behaviours occurring during sleep. More reliable empirical studies investigating the pathophysiology of NREM parasomnias can offer clearer diagnostic guidelines and address complex behaviours of NREM that often come with medicolegal implications.
Adult ; Humans ; Parasomnias/diagnosis* ; Singapore ; Sleep/physiology* ; Somnambulism/diagnosis*

Objective: To determine the risk factors for occult endometrial atypia and malignancy in patients diagnosed with non-atypical endometrial hyperplasia (NEH) on endometrial biopsy. Methods: All new cases of NEH diagnosed between April 2015 and March 2016 at KK Women’s and Children’s Hospital, who underwent hysterectomy as first-line treatment, were included in the study. Patients with a history of endometrial hyperplasia or malignancy were excluded from the study. Patient demographics (e.g., age, parity, body mass index [BMI]), medical history, and clinical presentation were obtained for analysis. Results: In total, 262 patients were diagnosed with NEH, of which 18.3% (n=48) underwent hysterectomy as first-line management. The average time to surgery was 77.0±35.7 days. All cases were diagnosed by dilation and curettage, and hysteroscopy. The mean age was 51 years, and the mean BMI was 26.9±5.8 kg/m2. Histology from the hysterectomy specimen showed 9 (18.8%) patients with atypical hyperplasia and 2 (4.2%) with grade 1, stage 1A endometrioid adenocarcinoma. Patients with higher grade final pathology had significantly lower median parity (1 vs. 2, P=0.039), higher mean BMI (30.1±6.5 vs. 25.9±5.3 kg/m2, P=0.033), and BMI ≥30 kg/m2 (54.5% vs. 13.5%, P=0.008, odds ratio 7.68), compared to patients whose final histology showed NEH or no residual hyperplasia. Conclusion Occult endometrial atypia and malignancy were found in 18.8% and 4.2% of patients with an initial diagnosis of NEH, respectively. High BMI and low parity were identified as significant risk factors for high-grade endometrial lesions in patients with NEH.

Objective: To determine the risk factors for occult endometrial atypia and malignancy in patients diagnosed with non-atypical endometrial hyperplasia (NEH) on endometrial biopsy. Methods: All new cases of NEH diagnosed between April 2015 and March 2016 at KK Women’s and Children’s Hospital, who underwent hysterectomy as first-line treatment, were included in the study. Patients with a history of endometrial hyperplasia or malignancy were excluded from the study. Patient demographics (e.g., age, parity, body mass index [BMI]), medical history, and clinical presentation were obtained for analysis. Results: In total, 262 patients were diagnosed with NEH, of which 18.3% (n=48) underwent hysterectomy as first-line management. The average time to surgery was 77.0±35.7 days. All cases were diagnosed by dilation and curettage, and hysteroscopy. The mean age was 51 years, and the mean BMI was 26.9±5.8 kg/m2. Histology from the hysterectomy specimen showed 9 (18.8%) patients with atypical hyperplasia and 2 (4.2%) with grade 1, stage 1A endometrioid adenocarcinoma. Patients with higher grade final pathology had significantly lower median parity (1 vs. 2, P=0.039), higher mean BMI (30.1±6.5 vs. 25.9±5.3 kg/m2, P=0.033), and BMI ≥30 kg/m2 (54.5% vs. 13.5%, P=0.008, odds ratio 7.68), compared to patients whose final histology showed NEH or no residual hyperplasia. Conclusion Occult endometrial atypia and malignancy were found in 18.8% and 4.2% of patients with an initial diagnosis of NEH, respectively. High BMI and low parity were identified as significant risk factors for high-grade endometrial lesions in patients with NEH.

PURPOSE: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal (GI) tract, and account for 1% of all GI malignancies. GISTs have a highly variable clinical course, and recurrent disease sometimes develops despite curative treatment. Although there are several known risk factors for recurrence, there are few adequate treatment strategies. This study evaluated the clinical behavior and clinicopathological characteristics, and examined correlation between recurrence and the prognostic factors. METHODS: From March 1999 to December 2005, 41 patients, with GISTs confirmed by a pathologic examination after a surgical resection, were enrolled. The patients were evaluated by immunohistochemical staining for CD117, CD34 and smooth muscle actin, and were classified according to the NIH criteria. RESULTS: The mean age was 58.9 years and the GISTs were mainly located in the stomach (56%) and small bowel (32%). With a median follow-up of 17.4 months, recurrence of the disease occurred in nine (22%) patients, with the liver being the main organ involved. According to the NIH criteria, there were 2 very low risk tumors, 11 low risk, 16 intermediate, and 12 high risk diagnosed. Gender was found to have predictive value for a recurrence (P=0.05). CONCLUSION: The primary site and gender have predictive value for a recurrence. Identifying the risk factors for recurrent disease may be useful for planning follow-up schedules. Further study involving more cases and a long-term follow-up will be needed. In addition, pathologic and immunohistoche-mical studies will be required to reduce the recurrence rate after a resection and to improve the patients' outcome.
Actins ; Appointments and Schedules ; Follow-Up Studies ; Gastrointestinal Stromal Tumors* ; Humans ; Liver ; Muscle, Smooth ; Recurrence* ; Risk Factors ; Stomach

Idiopathic hypertrophic pachymeningitis is a clinical disorder caused by a localized or diffuse thickening of the dura mater, with an associated chronic inflammation. This can be diagnosed when there is no evidence of other etiologies such as trauma, infection, tumors, and Wegener's disease. Clinical manifestations are chronic headache with or without neurological manifestations such as cranial nerve palsies, cerebellar ataxia, neuro-ophthalmologic complications, and rarely clinical seizures. We described a patient with simple partial seizures with focal sensory and motor symptoms in the right hand as an initial and the only clinical manifestation, accompanied by a tumor-like lesion in the left parietal convexity on brain MRI. The patient underwent a lesionectomy, and the seizures have been well controlled so far without immunosuppressant treatment.
Brain ; Cerebellar Ataxia ; Cranial Nerve Diseases ; Dura Mater ; Epilepsies, Partial ; Hand ; Headache Disorders ; Humans ; Inflammation ; Magnetic Resonance Imaging ; Meningitis* ; Neurologic Manifestations ; Rabeprazole ; Seizures*

PURPOSE: The epidermal growth factor receptor (EGFR) is a one of the transmembrane receptor proteins that play an important role in initiating tumor cell signaling and growth and is regarded as a promising target for cancer therapy. The EGFR expression rate has been reported to vary according to the detection method. The aims of this study were to evaluate the EGFR expression rate of a colorectal carcinoma by using immunohistochemical staining (IHC) and semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) and to analyze the correlation between these methods. METHODS: EGFR expression was investigated in tissue sections from 33 patients with a colorectal adenocarcinoma by using IHC and semiquantitative RT-PCR. IHC was performed with antibodies in a 1:40 dilution and a 1:80 dilution. The results of the three detection methods were compared with one another. RESULTS: The mean age of the patients was 61.9+/-12.2 years, and the male-to-female ratio was 1.2:1. The EGFR expression rates were 93.9% (31/33) in IHC with a 1:40 dilution, 87.9% (29/33) in IHC with a 1:80 dilution, and 66.7% (22/33) in RT-PCR. The result of IHC with a 1:40 dilution significantly correlated with the result of IHC with a 1:80 dilution (Pearson correlation 0.684, P<0.01). There was no correlation between semiquantitative RT-PCR and IHC (1:40 dilution, 1:80 dilution). CONCLUSIONS: The EGFR expression obtained by using IHC was consistent with different antibody dilutions. The expression rate obtained by using RT-PCR was significantly lower than that obtained by using IHC, and there was no statistical correlation between the expressions of EGFR obtained by using RT-PCR and IHC. A standardization for EGFR detection methods is needed to draw any conclusion concerning their activity in colorectal cancer.
Adenocarcinoma ; Antibodies ; Colorectal Neoplasms* ; Humans ; Immunohistochemistry ; Receptor, Epidermal Growth Factor

INTRODUCTIONThis study aimed to examine the long-term clinical outcomes of coronary fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) in a real-world population in an Asian tertiary centre.

MATERIALS AND METHODSAll patients who underwent FFR measurement for intermediate coronary lesions in our centre from June 2002 to December 2009 were enrolled. A threshold of FFR ≤0.75 was used for revascularisation. All the patients were prospectively followed-up for major adverse cardiac events (MACE) of death, myocardial infarction (MI), target vessel revascularisation (TVR) and stent thrombosis.

RESULTSBased on FFR measurement, 368 (57%) patients were treated medically while 278 (43%) underwent revascularisation. At a mean follow-up duration of 29.7 ± 16 months, 53 (14.4%) patients in the medical therapy group and 32 (11.5%) patients in the revascularised group experienced MACE (P = 0.282). There were no statistical differences in all the clinical endpoints between the 2 groups.

CONCLUSIONMedical therapy based on FFR measurement is associated with low incidences of MACE at long-term follow-up.

Adult ; Aged ; Aspirin ; therapeutic use ; Coronary Stenosis ; complications ; diagnosis ; therapy ; Drug Therapy, Combination ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Percutaneous Coronary Intervention ; methods ; Platelet Aggregation Inhibitors ; therapeutic use ; Retrospective Studies ; Ticlopidine ; analogs & derivatives ; therapeutic use ; Treatment Outcome

Toxoplasma gondii can infect humans worldwide, causing serious diseases in pregnant women and immunocompromised individuals. T. gondii rhoptry protein 13 (ROP13) is known as one of the key proteins involved in host cell invasion. In this study, we generated virus-like particles (VLPs) vaccine expressing T. gondii rhoptry ROP13 and investigated VLPs vaccine efficacy in mice. Mice immunized with ROP13 VLPs vaccine elicited significantly higher levels of T. gondii-specific IgG, IgG1, IgG2a, and IgA antibody responses following boost immunization and challenge infection, whereas antibody inductions were insignificant upon prime immunization. Differing immunization routes resulted in differing antibody induction, as intranasal immunization (IN) induced greater antibody responses than intramuscular immunization (IM) after boost and challenge infection. IN immunization induced significantly higher levels of IgG and IgA antibody responses from feces, antibody-secreting cells (ASCs), CD4⁺ T, CD8⁺ T cells and germinal center B cell responses in the spleen compared to IM immunization. Compared to IM immunization, IN immunization resulted in significantly reduced cyst counts in the brain as well as lesser body weight loss, which contributed to better protection. All of the mice immunized through either route survived, whereas all naïve control mice perished. These results indicate that the ROP13 VLPs vaccine could be a potential vaccine candidate against T. gondii infection.
Animals ; Antibody Formation ; Antibody-Producing Cells ; Body Weight ; Brain ; Feces ; Female ; Germinal Center ; Humans ; Immunization ; Immunoglobulin A ; Immunoglobulin G ; Mice ; Pregnant Women ; Spleen ; T-Lymphocytes ; Toxoplasma

Purpose: Diagnosing sarcopenia necessitates the measurement of skeletal muscle mass. However, guidelines lack a standardized imaging modality with thresholds validated among Asians. This systematic review compared ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and bioelectrical impedance analysis (BIA)/body composition monitoring in the detection of sarcopenia within Asian populations. Methods: PubMed and Embase were systematically searched for studies analyzing ultrasonography, CT, MRI, and BIA in diagnosing sarcopenia among Asians. Study quality was assessed using the Newcastle-Ottawa scale. Results: Pooled findings from 21,598 patients across 25 studies were examined. In receiver operating characteristic analysis, ultrasound displayed a pooled mean area under the curve (AUC) of 0.767 (95% confidence interval [CI], 0.709–0.806), with mean sensitivity of 81.1% (95% CI, 0.744–0.846) and specificity of 73.1% (95% CI, 0.648–0.774), for detecting sarcopenia in Asian populations. CT exhibited an AUC of 0.720 (sensitivity, 54.0%; specificity, 92.0%). MRI demonstrated an AUC of 0.839 (sensitivity, 67.0%; specificity, 66.0%). BIA displayed an AUC of 0.905 (95% CI, 0.842–0.968), 80.7% sensitivity (95% CI, 0.129–0.679), and 82.4% specificity (95% CI, 0.191–0.633). Conclusion Various modalities aid in diagnosing sarcopenia, and selection should be individualized. Although only BIA and dual-energy x-ray absorptiometry are recommended by the Asian Working Group for Sarcopenia and the European Working Group on Sarcopenia in Older People, ultrasound imaging may hold diagnostic value for sarcopenia in the Asian population. In certain groups, diagnostic use of CT and MRI is warranted. Future research can standardize and validate modality-specific thresholds and protocols within Asian populations.

Purpose: Diagnosing sarcopenia necessitates the measurement of skeletal muscle mass. However, guidelines lack a standardized imaging modality with thresholds validated among Asians. This systematic review compared ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and bioelectrical impedance analysis (BIA)/body composition monitoring in the detection of sarcopenia within Asian populations. Methods: PubMed and Embase were systematically searched for studies analyzing ultrasonography, CT, MRI, and BIA in diagnosing sarcopenia among Asians. Study quality was assessed using the Newcastle-Ottawa scale. Results: Pooled findings from 21,598 patients across 25 studies were examined. In receiver operating characteristic analysis, ultrasound displayed a pooled mean area under the curve (AUC) of 0.767 (95% confidence interval [CI], 0.709–0.806), with mean sensitivity of 81.1% (95% CI, 0.744–0.846) and specificity of 73.1% (95% CI, 0.648–0.774), for detecting sarcopenia in Asian populations. CT exhibited an AUC of 0.720 (sensitivity, 54.0%; specificity, 92.0%). MRI demonstrated an AUC of 0.839 (sensitivity, 67.0%; specificity, 66.0%). BIA displayed an AUC of 0.905 (95% CI, 0.842–0.968), 80.7% sensitivity (95% CI, 0.129–0.679), and 82.4% specificity (95% CI, 0.191–0.633). Conclusion Various modalities aid in diagnosing sarcopenia, and selection should be individualized. Although only BIA and dual-energy x-ray absorptiometry are recommended by the Asian Working Group for Sarcopenia and the European Working Group on Sarcopenia in Older People, ultrasound imaging may hold diagnostic value for sarcopenia in the Asian population. In certain groups, diagnostic use of CT and MRI is warranted. Future research can standardize and validate modality-specific thresholds and protocols within Asian populations.