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

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Emergency Service, Hospital ; Female ; Humans ; Male ; Middle Aged ; Singapore ; Skin Diseases ; diagnosis ; Tertiary Care Centers ; Young Adult

Aged ; Eccrine Porocarcinoma ; pathology ; Female ; Humans ; Sweat Gland Neoplasms ; pathology

Background and Objectives: There is a paucity of comparative studies on young strokes between populations of different ethnicities and geographical regions. The purpose of this study was to compare the patterns, risk factors and etiologies of ischaemic stroke in younger patients between stroke registries in Malaysia and Australia. Methods: From January 2007 to March 2008, all consecutive ischaemic stroke patients from the age of 18 to 49 were studied. Results: There were 67 patients for Malaysia and 61 for Australia, with 4 deaths in the Malaysian series (case-fatality of 6%), and no deaths for Australia. The mean age was 41.5±8.8 yrs for Malaysia and 40.1±8.8 years for Australia. The ethnic origin was Malays, Chinese and Indian for Malaysia, and Caucasians (85%) for Australia. The sex ratio was M : F = 1.4 : 1 for Malaysia and 1.54 :1 for Australia. The differences in risk factors for Malaysia versus Australia were: Diabetes (OR 7.25; 95% CI 2.78-19.45), hypertension (OR 6.42; 95% CI 2.75-15.22) and chronic renal disease (OR 5.2; 95% CI 1.02-35.87). Conversely, smoking was a signifi cant risk factor for Australia (OR 2.75; 95% CI 1.2-6.37). The Malaysian patients have signifi cantly higher proportions of large vessel atherosclerosis and small vessel occlusion by TOAST classifi cation, accounting for 60% of patients, while the Australian series had greater proportions of cardioembolism and patients in the determined aetiologies category, specifi cally vascular dissection. Conclusion: There were signifi cantly more large vessel atherosclerosis and small vessel occlusion among young Malaysians with ischaemic stroke as compared to Australia.

Appreciation of learning styles can be of use to help both educators and students to enhance the effectiveness of an educational experience. It has been noticed that some students at this College are not very good at expressing themselves in either written or spoken English. Our study aimed to identify the student’s learning styles; assess whether there is any correlation between learning style, baseline demographic data and self rated proficiency in English language; and assess their associations with the assessment performance. A group of third year medical students voluntarily participated in a questionnaire study to provide us with their learning styles, demographic information and self-rated proficiency in English language. This data was compared to the students’ performance in the assessment at the end of their junior clinical rotations. This cohort of students (60% Malay, 35% Chinese and 5% Indian) who were mostly visual learners, considered themselves proficient in English. Students with predominantly Visual learning styles and those with poorer English, score significantly lower during their clinical long case examinations. These two predictors appear to be independent of each other. These results may suggest that our current teaching modalities may disadvantage students with predominant visual learning styles. It also suggests that the long case clinical examination may favour those with more verbal learning styles.

INTRODUCTIONIdentifying malignancy either preoperatively or intraoperatively can have a significant impact on the management of salivary gland tumours. We review our experience with fine needle aspiration cytology (FNAC) and frozen section (FS) for salivary gland lesions. We analyse the accuracy of both modalities and their influence on management.

MATERIALS AND METHODSRetrospective review of 114 patients who underwent salivary gland surgery, 91 with intraoperative FS and 68 with preoperative FNAC. Both sets of results were compared against each other and the final histopathological diagnosis.

RESULTSThe accuracy of FS was 92.3%, with a sensitivity and specificity of 62.5% and 100%. Histologic concordance was 92.4% for benign lesions, and 100% for malignant tumours. The accuracy of FNAC was 89.7%, with a sensitivity and specificity of 100%. The non-diagnostic rate was 10.3%. Histologic concordance for FNAC was inferior to that for FS, with only 64.2% of benign lesions and 50% of malignant tumours correctly identified. FNAC did not alter the management of benign disease even when a correct diagnosis was obtained.

CONCLUSIONOur results suggest that FNAC and FS are complementary in usefulness for malignant tumours. However, FNAC does not influence the management of benign lesions and routine FNAC for every patient may not be cost-effective.

Biopsy, Fine-Needle ; standards ; Frozen Sections ; Humans ; Intraoperative Care ; Retrospective Studies ; Salivary Gland Neoplasms ; diagnosis ; pathology ; Salivary Glands ; pathology ; Sensitivity and Specificity ; Specimen Handling

Aftercare ; Coronavirus Infections ; complications ; therapy ; Critical Care ; Equipment Design ; Humans ; Lung Diseases ; etiology ; rehabilitation ; Male ; Middle Aged ; Pandemics ; Pneumonia, Viral ; complications ; therapy ; Rehabilitation ; instrumentation ; Robotics

INTRODUCTIONSevere acute respiratory syndrome (SARS) affected 8096 individuals in 29 countries, with 774 deaths. In Singapore, there were 238 cases of SARS with 33 deaths. A retrospective analysis was performed to identify predictors of poor outcome in patients with SARS locally.

MATERIALS AND METHODSClinical, laboratory and outcome data of 234 patients admitted to Tan Tock Seng Hospital and Singapore General Hospital were collected and analysed. Only data collected at the time of admission were used in the analysis for predictors of poor outcome. Adverse events were defined as admission to the intensive care unit or death.

RESULTSClinical (temperature, FiO2) and laboratory [leukocyte, lymphocyte, neutrophil, platelet, lactate dehydrogenase (LDH), albumin] trends in groups with and without an adversarial event were presented. Fifty patients experienced an adverse event. On univariate analysis, male gender, advanced age, presence of comorbidities, neutrophilia, lymphopaenia, hyponatraemia, hypoalbuminaemia, transaminitis and elevated LDH or C-reactive protein were found to be significant predictors. On multivariate analysis, predictors of poor outcome were increased age [odds ratio (OR) 1.73 for every 10-year increase; 95% CI, 1.35 to 2.21], neutrophilia (OR 1.06 for every 1 x 10(9)/L increase; 95% CI, 1.02 to 1.11) and high LDH (OR 1.17 for every 100 U/L increase; 95% CI, 1.02 to 1.34). None of the 12 paediatric patients had an adverse event.

CONCLUSIONAdvanced age, neutrophilia and high LDH predict poor outcomes in patients with SARS.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Antibodies, Viral ; analysis ; Child ; Child, Preschool ; DNA, Viral ; analysis ; Female ; Fluorescent Antibody Technique ; Humans ; Incidence ; Infant ; Male ; Middle Aged ; Retrospective Studies ; Reverse Transcriptase Polymerase Chain Reaction ; SARS Virus ; genetics ; immunology ; Severe Acute Respiratory Syndrome ; epidemiology ; virology ; Severity of Illness Index ; Singapore ; epidemiology ; Survival Rate

Livedoid vasculopathy is a rare chronic relapsing disorder characterised by recurrent painful thrombotic and vasculitic ulcers on the legs. We present the cases of two Indian women with livedoid vasculopathy that were found to be associated with an underlying factor V Leiden heterozygous mutation. There were no other thrombotic manifestations, and livedoid vasculopathy was the sole presenting feature of the factor V Leiden mutation, although this could also be coincidental. Initial treatment with high-dose immunosuppressive therapy was suboptimal, and the addition of pentoxifylline and antiplatelet therapy was crucial in achieving disease control and remission. These cases highlight the possible association with an underlying prothrombotic disorder, such as factor V Leiden mutation, in patients with livedoid vasculopathy. Although this association is relatively uncommon, it is more relevant to Indian patients, as the presence of factor V Leiden mutation is highest in this ethnicity as compared to the local Malay and Chinese populations.
Adult ; Blood Vessels ; pathology ; DNA ; genetics ; Factor V ; genetics ; metabolism ; Female ; Humans ; Leg Ulcer ; blood ; genetics ; pathology ; Livedo Reticularis ; blood ; diagnosis ; genetics ; Point Mutation ; Polymerase Chain Reaction ; Skin ; blood supply ; Skin Diseases, Vascular ; blood ; genetics ; pathology