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Varicella infection during the first and second trimester of pregnancy may increase the risk for congenital varicella syndrome 0.5-1.5% above the baseline risk for major malformation. Third trimester infection may lead to maternal pneumonia which can be life threatening if not treated appropriately. Varicella-zoster immune globulin (VZIG) should be administered as soon as possible preferably within 96 h from exposure to prevent maternal infection or subsequent complications. Later than 96 h, the effectiveness of VZIG has not been evaluated. Neonatal varicella is more severe if maternal rash appears 5 days prior to or 2 days after delivery. The newborn should be given VZIG immediately. Intravenous acyclovir is recommended for maternal pneumonia and severely affected neonate. No controlled study has yet evaluated the effectiveness of acyclovir or valacyclovir for postexposure prophylaxis to pregnant women or neonates. Unlike primary varicella infection in pregnancy, herpes zoster has not been documented to cause complications unless in the disseminated form. The advent of advanced imaging techniques and molecular biotechniques has improved prenatal diagnosis. With increase use of vaccination, the incidence of chickenpox in pregnancy is expected to decline in the future.

Background: Sentinel lymph node biopsy (SLNB), a procedure associated with low morbidity, has been shown to be an accurate technique for determining axillary lymph node status in breast cancer. It is now a standard of care in many tertiary oncology centres. The purpose of this study was to determine the feasibility of carrying out SLNB in non-tertiary centres and community practices without full nuclear medicine facilities and lower patient volume., Methods: From November 2002 to February 2005, 50 women diagnosed with clinically node-negative breast cancer underwent 52 sentinel lymph node procedures. Surgery was carried out in five hospitals with different access to nuclear medicine facilities. Lymphatic mapping was therefore carried out with blue dye only. Patients were divided into two groups: group 1 comprised those with invasive disease who went on to have an axillary clearance, and group 2 comprised those who underwent SLNB only for a negative node. Routine pathological examination was carried out for sentinel nodes., Results: There were 31 SLNB with axillary dissection and 21 SLNB only. The identification rate was 96.2%. Among those who had concomitant axillary dissection, there were no false-negative results. The overall accuracy was 94%, sensitivity was 82% and specificity was 100%., Conclusion: Consistent results in non-tertiary centres can be achieved with adequate attention to appropriate preceptorship and meticulous technique. Women who elect to have surgical treatment for breast cancer in these hospitals need not be denied the benefits of SLNB.

Falls in older people can be caused by underlying cardiovascular disorders, either because of balance instability in persons with background gait and balance disorders, or because of amnesia for loss of consciousness during unwitnessed syncope. Pertinent investigations include a detailed history, 12-lead electrocardiography, lying and standing blood pressure, carotid sinus massage (CSM), head-up tilt, cardiac electrophysiological tests, and ambulatory blood pressure and heart rate monitoring, which includes external and internal cardiac monitoring. The presence of structural heart disease predicts an underlying cardiac cause. Conversely, the absence of either indicates that neurally mediated etiology is likely. CSM and tilt-table testing should be considered in patients with unexplained and recurrent falls. Holter monitoring over 24 hours has a low diagnostic yield. Early use of an implantable loop recorder may be more cost-effective. A dedicated investigation unit increases the likelihood of achieving positive diagnoses and significantly reduces hospital stay and health expenditure.

We evaluated 26 child sexual assault cases for the incorporation of Y-STR screening in the routine detection and objective confirmation of sexual contact between the child victim and the perpetrator. Various samples, e.g. vaginal or anal swabs from patients aged 2-17 years old (25 females, 1 male), were collected 6-72 h after the incident. Due to the limited amounts of DNA in these samples, total DNA was extracted using a one-step procedure and screened with autosomal STRs to detect signs of a victim-assailant DNA mixture and with Y-STRs for assailant DNA. Autosomal STRs failed to give signs of victim-assailant DNA mixtures while Y-STRs were detected in 24 of the 26 cases corresponding to a success rate of 92.3%. With the possible presence of both male sperm and/or male epithelial cells in forensic evidence, Y-STR DNA markers were detected regardless of external ejaculation, microscopic detection of sperm and with post-coital intervals of up to 72 h. While only partial profiles were generated owing to low quantities of male DNA present, Y-STR screening results can serve as objective evidence of sexual contact in child sexual abuse cases involving victims who do not have any previous sexual history. This type of evidence can corroborate child victim testimony and spare the child victim from further trauma caused by prolonged forensic investigations and court proceedings. Alternatively, Y-STR screening can provide objective proof of non-involvement of an accused with the victim.

Objective: Ondansetron (Zofran) is a drug used for the treatment of nausea and vomiting caused by cancer chemotherapy. Despite the fact that it is not indicated, women are being prescribed this drug for the treatment of nausea and vomiting of pregnancy (NVP). There is a paucity of information on fetal safety for this indication. The objective of this study is to determine whether this drug increases the baseline rate of major malformations., Design: A prospective comparative observational study., Setting: Teratogen Information Services (TIS)., Population: Pregnant women., Methods: Our three groups included women who were exposed to ondansetron and women exposed to (1) other anti-emetics and (2) non-teratogen exposures. All of the women called either our NVP Helpline or TIS at The Motherisk Program in Toronto, Canada, or The Mothersafe Program in Sydney, Australia., Main Outcome Measure: Rates of major malformation., Results: We have completed 176 pregnancy outcomes in each group. In the ondansetron cohort, there were 169 live births, 5 miscarriages, 2 therapeutic abortions, 6 (3.6%) major malformations and the mean birthweight was 3362 g [SD 525]. There were no statistical differences in any of the study endpoints between the ondansetron and the comparison groups., Conclusions: This drug does not appear (although the sample size is limited) to be associated with an increased risk for major malformations above baseline.

The Breast Imaging Reporting And Data System (BI-RADS) categorization of mammograms is useful in estimating the risk of malignancy, thereby guiding management decisions. However, in Asian women, in whom breast density is increased, the sensitivity of mammography is correspondingly lower. We sought to determine the positive predictive value of BI-RADS categorization for malignancy in our Asian population and, hence, its value in helping us to choose between the various modalities for breast biopsy. We retrospectively reviewed all patients with occult breast lesions detected on mammography or ultrasound who underwent needle-localization open breast biopsy (NLOB) in our institution over a 6-year period. There were 470 biopsies in 427 patients; 16% of lesions were malignant. The positive predictive value of BI-RADS 4 and 5 lesions for cancer was 0.27 and 0.84, respectively. While most BI-RADS 5 mass lesions were invasive cancers, the majority of calcifications in this category were in situ carcinomas. We conclude that BI-RADS remains useful in aiding decision-making for biopsy in our Asian population. Based on positive predictive values, we recommend percutaneous breast biopsy for initial evaluation of lesions categorized as BI-RADS 4 or less. For BI-RADS 5 lesions with microcalcifications, open surgical biopsy as a diagnostic and therapeutic procedure may be more appropriate. In the case of a BI-RADS 5 lesion associated with a mass, initial percutaneous biopsy may be useful for diagnosis, followed by a planned single-stage surgical procedure as necessary.

Background: It has been stated that completion thyroidectomy for thyroid malignancy should be performed either within 10 days of the primary operation or after 3 months, to reduce the incidence of complications. The aim of this study was to review the impact of timing on the rate of complications following completion thyroidectomy., Methods: Data were obtained retrospectively from the Endocrine Surgery Thyroid Data Base, to which the records of all patients have been entered since 1957. The patients who had the last 100 consecutive completion thyroidectomies for thyroid cancer comprised the study group., Results: Sixty-three patients had the second operation performed within 10 days or more than 90 days after the initial operation (group 1). Thirty-seven patients had reoperation between 10 and 90 days after the first procedure (group 2). One patient (2 per cent) in group 1 and one patient (3 per cent) in group 2 suffered a permanent complication (P not significant)., Conclusion: There was no definite impact of the timing of surgery on the rate of complications after completion thyroidectomy.

Alternative medicine is widely publicized in Singapore. To date there are few reports of complications arising as a result of such treatments. However, there is no legislation as yet governing alternative medicine practitioners. We present an unusual case of a patient who developed life-threatening perineal gangrene as a result of rectal perforation following colonic hydrotherapy.

An 11-day-old male infant presented with subarachnoid and intraventricular haemorrhage caused by a ruptured intracranial aneurysm. Magnetic resonance (MR) angiogram and digital subtraction angiography (DSA) revealed a fusiform aneurysm 10 mm in diameter supplied by the proximal segment of the anterior cerebral artery (A1), with both distal segments (A2) arising from the aneurysm. The right A1 was aplastic. There have been 13 previous case reports of neonatal cerebral artery aneurysms, but only 1 of these has been fusiform. None of the earlier reports has mentioned dysplastic segments or other anomalies of the circle of Willis.