Impact of delayed graft function on renal function and graft survival in deceased kidney transplantation

OBJECTIVES

To define the risk factors for delayed graft function and study the impact of such delays on renal function and long-term allograft survival in renal transplant recipients.

DESIGN

Single-centre retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Records of 118 Chinese renal transplant recipients from 1 July 1997 to 31 July 2005 were reviewed, and categorised into delayed and immediate graft function groups.

RESULTS

Delayed graft function was observed in about 19% of patients, for which cold ischaemic time was an important independent predictor. For each additional hour of cold ischaemic time, the odds ratio increased for delayed function by 0.002 (95% confidence interval, 0.001-0.003; P=0.03). Multivariate analysis revealed that neither cold ischaemic time nor delayed graft function was associated with acute rejection. On the other hand, at 1 year both delayed graft function (odds ratio=18.5; 95% confidence interval, 2.6-130.5; P=0.003) and donor age (1.2; 1.1-1.3; P=0.003) were related to a glomerular filtration rate of less than 30 mL/min. When renal function between patients with and without delayed graft function during the first 3 years was compared, it was significantly better in those without delayed graft function. However, there was no significant difference in death-censored graft survival between delayed graft function and immediate graft function groups.

CONCLUSIONS

Delayed graft function has a significant adverse effect on graft function at 1 year. Limiting cold ischaemic time is important as it is an independent predictor of delayed graft function.

The association with age, human tissue kallikreins 6 and 10 and hemostatic markers for survival outcome from epithelial ovarian cancer

PURPOSE

To assess known cancer biomarkers CA-125, human tissue kallikreins KLK6 and KLK10, hemostatic markers and age with 5-year survival outcome from epithelial ovarian cancer.

METHODS

Forty-one benign cyst cohorts and 83 patients diagnosed with ovarian cancer were recruited. The following assays were performed: fibrinogen, vWF antigen, D: -dimer, ATIII activity, tPA, PAI-1, uPAR, KLK6, KLK10 and CA-125. Follow-up visits of cancer patients of more than 60 months were noted. Data between those who survived past 60 months and mortality from cancer were analyzed.

RESULTS

Only 24 patients lived past 60 months, and 31 died (advanced stage n = 27). Those living past 60 months were significantly older and associated with similar pre-operative levels seen in benign cyst cohorts especially for KLK6, fibrinogen, vWF, AT levels despite upregulation of D: -dimer, CA-125 and KLK10. Ovarian cancer cohorts living past 60 months were younger than those who died within 12 months (n = 12). Mortality within 12 months was associated with older age, upregulation of KLK6, fibrinogen, D: -dimer, vWF, tPA antigen and reduced ATIII levels. Similarly, mortality within 36 months of disease showed older age with upregulation of CA-125, KLK6 D: -dimer vWF antigen and tPA antigen levels. Late stage cancer (III/IV) showed upregulated CA-125, KLK6, KLK10, D: -dimer and reduced AT compared to early stage cancer (I/II). The 5-year survival rate for early cancer was 80%, advanced 22.9% and overall 5-year survival rate was 43.6%.

CONCLUSION

Older age together with the novel biomarkers studied and their association with adverse outcome from epithelial ovarian cancer was seen especially within 12 and 36 months of disease. Those who lived past 60 months of disease showed similar pre-operative levels seen in benign cyst cohorts despite elevated D: -dimer, CA125 and KLK 10. An enlarged study is needed to confirm these findings.

Development of quantitative-fluorescence polymerase chain reaction for the rapid prenatal diagnosis of common chromosomal aneuploidies in 1,000 samples in Singapore

INTRODUCTION

We aimed to develop a rapid quantitative-fluorescence polymerase chain reaction (QF-PCR) to detect common foetal aneuploidies in the Singapore population within 48 hours of sample collection in order to alleviate parental anxiety.

METHODS

DNA from 1,000 foetal samples (978 amniotic fluids, 14 chorion villi and eight foetal blood samples) was analysed using a QF-PCR of 19 microsatellite markers located on chromosomes 13, 18, 21, X and Y. A total of 523 samples were archived before the QF-PCR analysis (archived), while QF-PCR was performed and the results obtained within 48 hours of sample collection in the remaining 477 samples (live). The results were confirmed with their respective karyotypes.

RESULTS

In total, 47 autosomal trisomies (T) were found: 30 among the archived (three T13, 12 T18, 15 T21) and 17 among the live (four T18, 13 T21) samples. The QF-PCR results were verified with their respective karyotypes. We achieved 100 percent sensitivity (lower 95 percent confidence interval [CI], 92.8 percent) and specificity (lower 95 percent CI, 99.5 percent), and the time taken from sample collection to the obtaining of results for the 477 live samples was less than 48 hours.

CONCLUSION

Prenatal diagnostic results of common chromosomal abnormalities can be released within 48 hours of sample collection using QF-PCR. Parental anxiety is alleviated and clinical management is enhanced with this short waiting time.

Value of quantitative MRI biomarkers (Evans' index, aqueductal flow rate, and apparent diffusion coefficient) in idiopathic normal pressure hydrocephalus

PURPOSE

To define the value of Evans' index (EI), aqueductal flow rate (FR), and apparent diffusion coefficient (ADC) in the diagnosis of normal pressure hydrocephalus (NPH) and to assess the ability of these markers preoperatively to predict shunt response. To shed some light as to the mechanisms responsible for the symptoms of NPH.

MATERIALS AND METHODS

Preoperative EI, FR, and ADC readings in nine cases of clinically diagnosed NPH were compared with those of age- and gender-matched controls. Similar pre- and postoperative readings of responders and nonresponders were subsequently compared.

RESULTS

Compared with the controls, all measurements were statistically significant except for peak systolic flow rate (pSfr), which was near statistical significance. Comparison of pre- and postoperative readings of responders and nonresponders revealed a decrease in ADC in all responders (P = 0.032). Subdural hemorrhage was found in all nonresponders (P = 0.012).

CONCLUSION

For patients presenting with signs and symptoms of NPH, readings on MRI greater than 0.3, 10 mL/min, -9.0 mL/min, and 10.65 x 10(-4) mm(2)/s for EI, peak diastolic flow rate (pDfr), pSfr, and ADC, respectively, add further weight to the diagnosis. The strong correlation between shunt response and ADC decline support our hypothesis that water accumulation in the cerebrum is the major cause for the symptoms of NPH. The presence of subdural hemorrhage in all nonresponders raises suspicion of decreased compliance as the other major cause.

Quantitative analysis of the maxilla and the mandible in hyper- and hypodivergent skeletal Class II pattern

OBJECTIVES

To examine the volumetric (size) difference in the maxilla and the mandible of hyper- and hypodivergent skeletal patterns in Angle class II malocclusion.

DESIGN

Descriptive retrospective study. The hypothesis is that a hypodivergent mandible has a larger size than a hyperdivergent mandible.

SETTING AND SAMPLE POPULATION

Using cone-beam computed tomography, 20 subjects with Angle class II malocclusion were classified into two groups; 10 of 20 subjects formed a hyperdivergent group while the rest formed a hypodivergent group.

MATERIAL AND METHODS

Cone-beam computed tomography images were obtained and processed and 3D volume data was measured by one clinician. Dahlberg's technique was used to assess the measurement error and significant difference was set at p < 0.05.

RESULTS

No significant differences were found between the volumes of the maxilla and mandible in both groups. Differences were observed in the ratio of mandibular/maxillary volumes. The hypodivergent group had a significantly larger (p = 0.014) ratio than the hyperdivergent group.

CONCLUSIONS

Maxillary and mandibular volumes differ between hyper- and hypodivergent skeletal patterns.

Patients' preference for radiotherapy fractionation schedule in the palliation of symptomatic unresectable lung cancer

The palliative radiotherapeutic management of unresectable non-small-cell lung cancer is controversial, with various fractionation (Fx) schedules available. We aimed to determine patient's choice of Fx schedule after involvement in a decision-making process using a decision board. A decision board outlining the various advantages and disadvantages apparent in the Medical Research Council study of Fx schedules (17 Gy in two fractions vs 39 Gy in 13 fractions) was discussed with patients who met Medical Research Council eligibility criteria. Patients were then asked to indicate their preferred Fx schedules, reasons and their level of satisfaction with being involved in the decision-making process. Radiation oncologists (RO) could prescribe radiotherapy schedules irrespective of patients' preferences. Of 92 patients enrolled, 55% chose the longer schedule. English-speaking patients were significantly more likely to choose the longer schedule (P = 0.02, 95% confidence interval: 1.2-7.6). Longer Fx was chosen because of longer survival (90%) and better local control (12%). Shorter Fx was chosen for shorter overall treatment duration (80%), cost (61%) and better symptom control (20%). In all, 56% of patients choosing the shorter schedule had their treatment altered by the treating RO, whereas only 4% of patients choosing longer Fx had their treatment altered (P < 0.001). Despite this, all (100%) patients were satisfied with being involved in the decision-making process. The decision board was useful in aiding decision-making, with both Fx schedules being acceptable to patients. Interestingly, despite the longer average survival associated with longer Fx, nearly half of the patients believed that this was not as important as a shorter duration of treatment and lower cost. Despite patients' preferences, there were significant alterations of preferred schedules because of RO's own biases.

A rare cause of nephrotic syndrome: lipoprotein glomerulopathy

Lipoprotein glomerulopathy is a rare kidney disease in which lipoprotein thrombi are seen in the glomerular capillaries. Most of these patients are found in Japan and East Asian countries. The presenting symptoms include proteinuria, an abnormal plasma lipoprotein profile that resembles type III hyperlipoproteinaemia, and a marked increase in serum apolipoprotein E concentration. Previous studies have suggested that lipoprotein glomerulopathy might be related to APOE gene mutation. No effective therapeutic regimen has been established for lipoprotein glomerulopathy. We report the first case of biopsy-proven lipoprotein glomerulopathy in Hong Kong in a patient who presented with nephrotic syndrome and dyslipidaemia. DNA analysis revealed apolipoprotein E Kyoto together with a novel apolipoprotein E mutation, apolipoprotein E (Asp230Tyr) Hong Kong. There was significant improvement in the clinical parameters and resolution of symptoms after the introduction of statins. Further studies will be needed to clarify the role of apolipoprotein E Hong Kong and its interaction with apolipoprotein E Kyoto in the pathogenesis of lipoprotein glomerulopathy.

Prevalence of metabolic syndrome in Chinese renal transplant recipients

OBJECTIVE

To investigate the prevalence of metabolic syndrome in Chinese renal transplant recipients, using two different sets of diagnostic criteria.

DESIGN

Cross-sectional study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All Chinese patients who received solitary living-related or cadaveric kidney transplantation from 1 July 1997 to 31 December 2005 in our hospital with follow-up of more than 6 months were recruited. The diagnosis of metabolic syndrome was made according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII) criteria and the International Diabetes Federation criteria.

RESULTS

Using the modified (Asian) NCEP-ATPIII criteria, a total of 39 (32%) of 121 patients had metabolic syndrome, which included 20/69 (29%) of the males and 19/52 (37%) of the females. Using the International Diabetes Federation criteria, metabolic syndrome was diagnosed in 26% of the patients, 22% in males and 31% in females. In our patients, the most common component of metabolic syndrome was hypertension and the least common was low high-density-lipoprotein-cholesterol level. Low high-density-lipoprotein-cholesterol levels were significantly more common in female patients.

CONCLUSION

This study shows that there is a high prevalence of metabolic syndrome in our Chinese renal transplant recipients.

Diffusion-weighted MR imaging: diagnosing atypical or malignant meningiomas and detecting tumor dedifferentiation

BACKGROUND AND PURPOSE

Atypical and malignant meningiomas are uncommon tumors with aggressive behavior and higher mortality, morbidity, and recurrence compared with benign tumors. We investigated the utility of diffusion-weighted (DW) MR imaging to differentiate atypical/malignant from benign meningiomas and to detect histologic dedifferentiation to higher tumor grade.

MATERIALS AND METHODS

We retrospectively compared conventional and DW MR images (b-value 1000 s/mm(2)) acquired on a 1.5T clinical scanner between 25 atypical/malignant and 23 benign meningiomas. The optimal cutoff for the absolute apparent diffusion coefficient (ADC) and normalized ADC (NADC) ratio to differentiate between the groups was determined by using receiver operating characteristic (ROC) analysis.

RESULTS

Irregular tumor margins, peritumoral edema, and adjacent bone destruction occurred significantly more often in atypical/malignant than in benign meningiomas. The mean ADC of atypical/malignant meningiomas (0.66 +/- 0.13 x 10(-3) mm(2)/s) was significantly lower compared with benign meningiomas (0.88 +/- 0.08 x 10(-3) mm(2)/s; P < .0001). Mean NADC ratio in the atypical/malignant group (0.91 +/- 0.18) was also significantly lower than the benign group (1.28 +/- 0.11; P < .0001), without overlap between groups. ROC analysis showed that ADC and NADC thresholds of 0.80 x 10(-3) mm(2)/s and 0.99, respectively, had the best accuracy: at the NADC threshold of 0.99, the sensitivity and specificity were 96% and 100%, respectively. Two patients had isointense benign tumors on initial DW MR imaging, and these became hyperintense with the decrease in ADC and NADC below these thresholds when they progressed to atypical and malignant meningiomas on recurrence.

CONCLUSIONS

ADC and NADC ratios in atypical/malignant meningiomas are significantly lower than in benign tumors. Decrease in ADC and NADC on follow-up imaging may suggest dedifferentiation to higher tumor grade.

Bronchial artery embolisation can be equally safe and effective in the management of chronic recurrent haemoptysis

OBJECTIVE

To examine the efficacy and safety of bronchial artery embolisation in patients with acute major haemoptysis and those with chronic recurrent haemoptysis.

DESIGN

Retrospective review of clinical records.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Clinical records of 70 consecutive patients who had undergone bronchial artery embolisation in Queen Elizabeth Hospital from 1998 to 2003 were reviewed. Altogether 74 bronchial artery embolisation procedures were attempted, 46 (62%) for acute major haemoptysis, and 28 (38%) for chronic recurrent bleeding. Follow-up data were available for 32 patients.

MAIN OUTCOME MEASURES

After bronchial artery embolisation, the Kaplan-Meier method and log-rank tests were used to compare the probability of recurrence in the two patient categories.

RESULTS

Overall immediate control was attained following 99% of the procedures, with a complication rate of 13%; all complications were mild and self-limiting. For the 32 patients (19 having acute major haemoptysis and 13 having chronic recurrent bleeding) with follow-up data available, the overall recurrence rate was 36% (26% in the acute and 47% in chronic group). No statistically significant difference in recurrence probability between the two groups was observed (P=0.24). Presence of active pulmonary tuberculosis was associated with increased risk of recurrence (P=0.005).

CONCLUSION

Bronchial artery embolisation was noted to be effective and safe in both acute major and chronic recurrent haemoptysis.

Risk factors for endogenous Klebsiella endophthalmitis in patients with Klebsiella bacteraemia: a case-control study

AIM

To identify risk factors for Klebsiella endophthalmitis in patients with Klebsiella sepsis.

METHODS

This is a retrospective case-control study. The study population consisted of all patients with positive blood cultures for Klebsiella, admitted to Changi General Hospital (Singapore) from August 2004 to July 2005. The cases were patients who developed Klebsiella endophthalmitis, and the controls were those who did not. The potential risk factors analysed included age, sex, race and total white cell count at presentation, maximum temperature response, co-morbid pathologies, presence of severe infection, site of primary infection, antibiotic sensitivity of the bacterial strain, and systemic antibiotics treatment regimen.

RESULTS

133 consecutive patients with Klebsiella bacteraemia confirmed by blood culture were included. Five (3.8%) developed endophthalmitis. Klebsiella endophthalmitis was significantly associated with liver abscess as the primary site of infection (p<0.001) and disseminated intravascular coagulation (p = 0.010) on both univariate and multivariate analysis. Diabetes mellitus and other co-morbid pathologies, race and maximum temperature response were not risk factors for the occurrence of endophthalmitis.

CONCLUSIONS

Liver abscess and disseminated intravascular coagulation are risk factors for endogenous endophthalmitis in patients with Klebsiella sepsis.

Emotional and behavioural problems in Singaporean children based on parent, teacher and child reports

INTRODUCTION

This study aims to determine the prevalence of emotional and behavioural problems in a community sample of Singaporean children aged 6-12 years, and its agreement according to parent, teacher and child reports.

METHODS

The Child Behaviour Checklist (CBCL), Teacher Rating Form (TRF) and child report questionnaires for depression and anxiety were administered to a community sample of primary school children. 60 percent of the children sampled (n = 2,139) agreed to participate. Parents of a sub-sample of 203 children underwent a structured clinical interview.

RESULTS

Higher prevalence of emotional and behavioural problems was identified by CBCL (12.5 percent) than by TRF (2.5 percent). According to parent reports, higher rates of internalising problems (12.2 percent) compared to externalising problems (4.9 percent), were found. Parent-teacher agreement was higher for externalising problems than for internalising problems. Correlations between child-reported depression and anxiety, and parent and teacher reports were low to moderate, but were better for parent reports than for teacher reports.

CONCLUSION

The prevalence rates of emotional and behavioural problems in Singaporean children based on CBCL ratings are comparable to those in the West, but the low response rate and exclusion of children with special needs limit the generalisability of our findings. Singaporean children have higher rates of internalising problems compared to externalising problems, while Western children have higher rates of externalising problems compared to internalising problems.

An unusual S-adenosylmethionine synthetase gene from dinoflagellate is methylated

Background

S-Adenosylmethionine synthetase (AdoMetS) catalyzes the formation of S-Adenosylmethionine (AdoMet), the major methyl group donor in cells. AdoMet-mediated methylation of DNA is known to have regulatory effects on DNA transcription and chromosome structure. Transcription of environmental-responsive genes was demonstrated to be mediated via DNA methylation in dinoflagellates.

Results

A full-length cDNA encoding AdoMetS was cloned from the dinoflagellate Crypthecodinium cohnii. Phylogenetic analysis suggests that the CcAdoMetS gene, is associated with the clade of higher plant orthrologues, and not to the clade of the animal orthrologues. Surprisingly, three extra stretches of residues (8 to 19 amino acids) were found on CcAdoMetS, when compared to other members of this usually conserved protein family. Modeled on the bacterial AdeMetS, two of the extra loops are located close to the methionine binding site. Despite this, the CcAdoMetS was able to rescue the corresponding mutant of budding yeast. Southern analysis, coupled with methylation-sensitive and insensitive enzyme digestion of C. cohnii genomic DNA, demonstrated that the AdoMetS gene is itself methylated. The increase in digestibility of methylation-sensitive enzymes on AdoMet synthetase gene observed following the addition of DNA methylation inhibitors L-ethionine and 5-azacytidine suggests the presence of cytosine methylation sites within CcAdoMetS gene. During the cell cycle, both the transcript and protein levels of CcAdoMetS peaked at the G1 phase. L-ethionine was able to delay the cell cycle at the entry of S phase. A cell cycle delay at the exit of G2/M phase was induced by 5-azacytidine.

Conclusion

The present study demonstrates a major role of AdoMet-mediated DNA methylation in the regulation of cell proliferation and that the CcAdoMetS gene is itself methylated.

Efficacy of community-based multidisciplinary disease management of chronic heart failure

INTRODUCTION

A multidisciplinary disease management (DM) programme in chronic heart failure (CHF) improves clinical outcome. The efficacy of such a programme in a heterogeneous Asian community is not well established. Therefore, we undertook the evaluation of the efficacy of the multidisciplinary community-based DM CHF programme.

METHODS

This was a prospective study involving 154 patients (54 percent male) with a primary diagnosis of CHF, New York Heart Association functional class III/IV CHF, with left ventricular ejection fraction (LVEF) less than 40 percent. The mean age was 65 +/- 12 years and mean LVEF was 27 +/- 9 percent. We evaluated CHF hospitalisation, quality of life, activity status and quality of care (percentage of patients who received ACE inhibitors/angiotensin receptor blockers (ARB) and beta blockers after a period of six months.

RESULTS

At six months, there was improvement in the quality of life and activity status (p < 0.001). ACE inhibitors/ARB were maintained in 97 percent of the patients and there was an increased usage of beta blockers (p-value equals 0.001). The rate of CHF hospitalisation was reduced by 68 percent (p-value is less than 0.001) and there was no mortality.

CONCLUSION

The multidisciplinary DM of CHF in a heterogeneous Asian community showed significant improvement in quality of life, quality of care and reduction in CHF hospitalisation.

Seroprevalence of hepatitis C in intravenous opioid users presenting in the early phase of injecting drug use in Singapore

INTRODUCTION

All over the world, Hepatitis C virus (HCV) accounts for an estimated 130 million chronic infections. Injection drug use has become one of the most important risk factors for HCV, and within the injection drug user population, the prevalence of HCV antibody ranges from 70 to 95 percent depending on an individual's length of use and the prevalence of infection in the community. This study was undertaken to determine the prevalence of and the risk factors for Hepatitis C antibodies in injecting drug users presenting to the Community Addictions Management Programme (CAMP) in Singapore.

METHODS

Eligibility criteria for inclusion in this study were all intravenous buprenorphine users presenting to CAMP. 106 subjects, who consented to the study, completed an interviewer-administered questionnaire, and underwent a urine and blood analysis.

RESULTS

The prevalence rate for HCV was 42.5 percent among the subjects included in our study. The odds of seroprevalence in those sharing needles were 5.6 times that of those who were not, and the odds of seroprevalence among those using with others (peers or partners) were 6.3 times, as compared to among those who were individual users. Racial differences were also seen, but these could be accounted for by the sharing of needles.

CONCLUSION

This study provides important local data at the onset of an early buprenorphine-injecting epidemic in Singapore. This data is useful for disease prevention and healthcare planning.

Medial thenar recording in normal subjects and carpal tunnel syndrome

OBJECTIVE

Since little is known about the involvement of median nerve fibres to the medial thenar eminence in CTS, we determine the consistency of a motor response derived from a medial thenar motor (MTM) site. We then compare sensitivity and specificity of this novel site with other nerve conduction parameters in supporting a diagnosis of CTS.

METHODS

The motor responses over the MTM with ulnar and median stimulation were determined in healthy subjects and patients with CTS. Sensitivity and specificity of 4 motor techniques (Abductor Pollicis Brevis (APB) and median MTM latency, 2nd Lumbricales to Interossei latency difference (2-LINT), APB to Adductor Digiti Minimi (ADM) latency difference, median MTM to ulnar MTM latency difference) and the median sensory distal latency in confirming CTS were calculated using the ROC method.

RESULTS

132 hands (68 CTS, 64 controls) were examined. All but one median and ulnar nerve stimulation (both in patients with CTS) resulted in negative MTM compound muscle action potentials. Sensitivity and specificity in diagnosing CTS were 79/97% (APB) 90/98% (median MTM latency), 88/97% (2-LINT), 85/97% (APB to ADM latency difference) and 75/95% (median MTM to ulnar MTM latency difference). Median sensory latency showed 89% sensitivity and 97% specificity.

CONCLUSIONS

Median and ulnar stimulation results in consistent motor responses at the medial thenar site. Median distal motor latency to MTM is frequently abnormal in CTS showing similar sensitivity and specificity to 2-LINT and median distal sensory latency.

SIGNIFICANCE

The MTM site shows consistent responses to both median and ulnar stimulation. MTM distal latency can be considered a useful site for supporting a diagnosis of CTS.

The median palmar cutaneous nerve in normal subjects and CTS

OBJECTIVE

The neurophysiological confirmation of carpal tunnel syndrome (CTS) relies on detecting abnormal median nerve transcarpal conduction in the presence of unaffected comparator nerves. We compare the palmar cutaneous median branch (PCBm) with the ulnar sensory nerve conduction to digit 5 (US(5)) as comparator nerves for diagnosing CTS.

METHODS

In a prospective case control study of patients with clinically defined carpal tunnel syndrome and normal subjects, we determined and compared the PCBm and US(5) conduction velocity.

RESULTS

We examined 57 hands with clinically defined CTS and 59 control hands. Comparison showed highly significantly slowed PCBm conduction (p<0.0001) but not for US(5) conduction (p=0.488). Using a 3 percentile cut-off for abnormality derived from controls, PCBm conduction velocity was abnormal in 46% of CTS hands.

CONCLUSIONS

The high frequency of PCBm nerve conduction abnormality in CTS suggests that this nerve should not be used as a comparator nerve for the neurophysiological diagnosis of CTS. This finding may help explain some of the extension of sensory symptoms outside the median nerve distribution in CTS.

SIGNIFICANCE

In CTS frequent abnormality of PCBm conduction makes this a poor comparator nerve and may explain extension of sensory symptoms beyond the median nerve.

Identification of risk factors for urinary retention following total knee arthroplasty: a Singapore hospital experience

INTRODUCTION

Urinary retention is associated with an increased rate of urinary tract infections and deep sepsis following total joint arthroplasty. This study was carried out to investigate the incidence of urinary retention following total knee arthroplasty in a Singapore hospital, and to identify risk factors associated with the development of this complication in our patient population.

METHODS

The charts of 125 consecutive patients who underwent primary total knee arthroplasty between January and December 2004 were reviewed. The incidence of postoperative urinary retention was correlated with the following factors: age, gender, choice of anaesthesia, duration of surgery, and analgesic technique. Statistical analysis was performed with univariate and multivariate logistic regression models. There were 109 female and 16 male patients. The mean age of the patients was 67.5 years (range, 50-86 years).

RESULTS

Ten patients developed urinary retention, giving an overall rate of 8.0 percent (95 percent confidence interval [CI], 3.9-4.2). Male gender (odds-ratio [OR] is 5.9; 95 percent CI, 1.2-29.5; p-value is 0.03) and epidural analgesia (OR is 7.6; 95 percent CI, 1.7-35.0; p-value is 0.009) were found to be the only factors significantly associated with postoperative urinary retention. Patient age, duration of surgery and choice of anaesthesia were not found to be significantly associated with urinary retention.

CONCLUSION

In our patient population, male patients and patients receiving epidural postoperative analgesia are at increased risk of developing urinary retention following total knee arthroplasty.

Study of goldfish (Carassius auratus) growth hormone structure–function relationship by domain swapping

Using goldfish as a model, the structure-function relationship of goldfish growth hormone was studied using the strategy of homologous domain swapping. Chimeric mutants were constructed by exchanging homologous regions between goldfish growth hormone (gfGH II) and goldfish prolactin (gfPRL) with their cloned complementary DNAs. Six mutants, with their domain-swapped, were generated to have different combinations of three target regions, including the helix a, helix d and the large section in between these helices (possess the helices b, c and other random coiled regions). After expression in E. coli and refolding, these mutants were characterized by using competitive receptor binding assay (RRA) and growth hormone responding promoter activation assay. The different activity profiles of mutants in Spi 2.1 gene promoter assays from that in RRA shows that, for gfGH, receptor binding dose not confer receptor signal activations. When either helices a or d of gfGH was maintained with other helices replaced by their gfPRL counterparts, both receptor binding and hence gene activation activities are reduced. In mutants with helices b and c in gfGH maintained, containing the gfGH middle section, and helices a and d swapped with gfPRL, the had reduced RRA activities but the promoter activation activities retained. In conclusion, as in the case of human GH, the gfGH molecule possesses two functional sites: one of them is composed of discontinuous epitopes located on the target regions of this study and is for receptor binding; another site is located on the middle section of the molecule that helices a and d are not involved, and it is for activation of GH receptor and intracellular signals.

Tissue microarrays characterise the clinical significance of a VEGF-A protein expression signature in gastrointestinal stromal tumours

A tissue microarray analysis of 22 proteins in gastrointestinal stromal tumours (GIST), followed by an unsupervised, hierarchical monothetic cluster statistical analysis of the results, allowed us to detect a vascular endothelial growth factor (VEGF) protein overexpression signature discriminator of prognosis in GIST, and discover novel VEGF-A DNA variants that may have functional significance.

Uremic pruritus is associated with higher kt/V and serum calcium concentration

BACKGROUND

The prevalence and characteristics of uremic pruritus have not recently been investigated in a US dialysis cohort. This study examined uremic pruritus and associated risk factors in hemodialysis patients treated in the year 2005.

METHODS

The prevalence and characteristics of pruritus (short version McGill pain questionnaire), severity (10 cm visual analogue scale), and effect on quality of life (Skindex-16) were determined in thrice weekly hemodialysis patients. Daugirdas single-pool Kt/V, clinical and laboratory data were recorded.

RESULTS

105 of 307 screened hemodialysis patients met inclusion criteria and were evaluated, 49% (151) were excluded due to advanced age, 3% (9) other skin diseases, and 14% (42) refused. Participants were 55% male (58/105) and 65% African-American (68) with a mean +/- SD age of 48 +/- 11 years. The overall prevalence of pruritus was 57% (60/105, 95% CI 47 - 67%) and a positive correlation was observed between the presence of uremic itch and serum calcium concentration (p = 0.04). Intact PTH and serum phosphorus concentration were not associated with either the presence or intensity of itch. Intensity of pruritus was positively correlated with increasing months on dialysis (64 +/- 63 vs. 51 +/- 46 months for itch and non-itch, respectively; p = 0.02), higher Kt/V (1.82 +/- 0.7 vs. 1.70 +/- 0.56 for itch and non-itch, respectively; p = 0.01) and skin dryness (p = 0.01). Patients receiving statins were significantly less likely to report pruritus (p = 0.02) and uremic itch adversely impacted several aspects of quality of life.

CONCLUSIONS

Pruritus remains a common and significant symptom in adequately hemodialyzed patients. Higher serum calcium concentrations, longer durations of ESRD and higher Kt/V appear to be important factors associated with uremic pruritus.

Psychiatric morbidity in patients referred to an insomnia clinic

INTRODUCTION

Insomnia is a common complaint associated with psychiatric disorders. Detection and diagnosis of insomnia can be a challenge at the primary care level. Patients often present with various kinds of psychological symptoms. Therefore, a high index of suspicion and careful assessments are crucial in eliciting signs and symptoms and making an accurate diagnosis of primary insomnia or a psychiatric disorder.

METHODS

This study was undertaken at the end of 2005, and is a retrospective review of all patients referred to the Insomnia Clinic and seen by the principal author in a three-year period between 2002 and 2005. Relevant data was collected from the medical records of patients who attended the clinic during this period.

RESULTS

In this study of 141 patients seen at an Insomnia Clinic, 47.5 percent had primary insomnia, while 52.5 percent had a primary diagnosis of a psychiatric disorder. 41.1 percent of those diagnosed with a primary psychiatric disorder had comorbid psychiatric disorders and 4.3 percent had substance abuse problems.

CONCLUSION

The various psychiatric disorders present in this group of patients highlight the need for careful assessment and recognition of these associations.

Apolipoprotein E genotype affects the response to lipid-lowering therapy in Chinese patients with type 2 diabetes mellitus

OBJECTIVE

To evaluate the effect of apolipoprotein E (apoE) genotype on baseline lipid levels and the response to hydroxy-methyl glutaryl coenzyme A reductase inhibitors (statins) therapy in Chinese patients with type 2 diabetes mellitus (DM).

RESEARCH DESIGN AND METHODS

We consecutively recruited Chinese patients with type 2 DM requiring lipid-lowering therapy according to current guidelines. Patients were started on either simvastatin 10 mg daily or given an equivalent dose of lovastatin 20 mg. After 12 weeks of statin therapy, patients had fasting lipid profiles repeated. ApoE genotyping was performed by restriction fragment length polymorphism (RFLP).

RESULTS

Ninety-six patients were studied. The epsilon3/epsilon3 genotype was in 62.5%, epsilon2/epsilon3 and epsilon3/epsilon4, 16.7 and 20.8%, respectively. After adjusting for confounding variables, baseline total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels were significantly higher in those with epsilon3/epsilon4 compared with epsilon2/epsilon3 genotype (6.7 vs. 5.5 mm for TC, 4.5 vs. 3.6 mm for LDL-C; p = 0.015 and p = 0.025, respectively). With statin therapy, epsilon3/epsilon4 patients had significantly greater LDL-C lowering compared with epsilon2/epsilon3 patients (48 vs. 27.7%; p = 0.04). There was no gender difference in baseline lipid parameters or response to statin therapy.

CONCLUSIONS

ApoE genotype accounts for interindividual variability of baseline cholesterol levels, and response to statin therapy in Chinese patients with type 2 DM.

Ecthyma gangrenosum: a manifestation of Pseudomonas sepsis in three paediatric patients

Pseudomonas aeruginosa sepsis rarely occurs in healthy children. In immunocompromised children, it usually carries a high mortality rate. Ecthyma gangrenosum is a known cutaneous manifestation of Pseudomonas septicaemia. Three paediatric cases of Pseudomonas aeruginosa septicaemia with ecthyma gangrenosum were retrospectively reviewed. The three patients were aged seven years, seven months, and five months, respectively. An underlying disease of hypogammaglobulinaemia was present in the oldest patient. Blood cultures grew Pseudomonas aeruginosa in all three patients. All underwent repeated wound debridement and received intravenous ceftazidime and an aminoglycoside for a minimum of two weeks. One needed colostomy and subsequent posterior sagittal anorectoplasty as a result of complete obliteration of the anal canal from the ecthyma. There was no mortality. In conclusion, Pseudomonas aeruginosa sepsis should be treated early. Recognition of ecthyma gangrenosum as a manifestation of this problem can allow early institution of the appropriate antibiotics before culture results.

Alveolata histone-like proteins have different evolutionary origins

Prokaryotic histone-like proteins (Hlps) are abundant proteins found in bacterial and plastid nucleoids. Hlps are also found in the eukaryotic dinoflagellates and the apicomplexans, two major lineages of the Alveolata. It may be expected that Hlps of both groups were derived from the same ancestral Alveolates. However, our phylogenetic analyses suggest different origins for the dinoflagellate and the apicomplexan Hlps. The apicomplexan Hlps are affiliated with the cyanobacteria and probably originated from Hlps of the plastid genome. The dinoflagellate Hlps and the proteobacterial long Hlps form a clade that branch off from the node with the proteobacterial short Hlps.

Assessing the quality of care for patients with first-episode psychosis

INTRODUCTION

This study evaluated the quality of care in an early psychosis intervention programme (EPIP), as compared to standard treatment received by patients prior to the inception of the programme.

METHODS

The medical records of 50 patients with first-episode psychosis (FEP) who received psychiatric treatment in the calendar year of 2000, i.e. prior to the implementation of EPIP, and 87 FEP patients who were accepted in the EPIP, were reviewed for a period of one year. These patients were aged between 18 and 40 years. Each medical record was reviewed for a list of process indicators, which were identified from the published literature and other treatment guidelines, and covered different domains.

RESULTS

None of the pre-EPIP patients met all the 13 process indicators, whereas 48 percent of EPIP patients met all the indicators (p-value is less than 0.001). Using the default rate as a proxy of outcome, we found that 19 percent of EPIP patients had defaulted at the end of one year, whereas the default rate was 52 percent for the pre-EPIP patients (p-value is less than 0.001).

CONCLUSION

It is possible to improve the quality of care in patients with FEP through the use of treatment guidelines, regular monitoring of symptoms and side effects, and periodic audits.

Angular distribution of polarized photon-pairs in a scattering medium with a Zeeman laser scanning confocal microscope

A novel confocal microscope designed for use with turbid media is proposed. We use a Zeeman laser as the light source. Based on the properties of two-frequency polarized photon-pairs and the common-path feature of polarized photon-pairs with heterodyne detection employed in the proposed confocal microscope, three gatings (spatial filtering gating, polarization gating and spatial coherence gating) are thus simultaneously incorporated in the microscope. Experimental results for the angular distribution of polarized photon-pairs in a scattering medium indicate that polarization gating and spatial coherence gating preclude the detection of multiply scattered photons, whereas the pinhole selects the least scattered photon-pairs. Thus, better performance for axial resolution than can be obtained with a conventional confocal microscope is demonstrated experimentally. In addition, the proposed microscope is able to either look deeper into a turbid medium or work with a denser medium; furthermore, the axial resolution is improved.

Differential effects of isoflavones, from Astragalus membranaceus and Pueraria thomsonii, on the activation of PPARalpha, PPARgamma, and adipocyte differentiation in vitro

Compounds that target the peroxisome proliferator-activated receptors PPARalpha and PPARgamma are used to correct dyslipidemia and to restore glycemic balance, respectively. Because the majority of diabetic patients suffer from atherogenic lipid abnormalities, in addition to insulin resistance, ligands are required that can activate both PPARalpha and PPARgamma. In this study, we used chimeric PPARalpha/gamma reporter-gene bioassays to screen herbal extracts with purported antidiabetic properties. Extracts of Astragalus membranaceus and Pueraria thomsonii significantly activated PPARalpha and PPARgamma. Bioassay-guided fractionation resulted in the isolation of the isoflavones, formononetin, and calycosin from Astragalus membranaceus, and daidzein from Pueraria thomsonii as the PPAR-activating compounds. We investigated the effects of these and 2 common isoflavones, genistein and biochanin A, using chimeric and full-length PPAR constructs in vitro. Biochanin A and formononectin were potent activators of both PPAR receptors (EC50 = 1-4 micromol/L) with PPARalpha/PPARgamma activity ratios of 1:3 in the chimeric and almost 1:1 in the full-length assay, comparable to those observed for synthetic dual PPAR-activating compounds under pharmaceutical development. There was a subtle hierarchy of PPARalpha/gamma activities, indicating that biochanin A, formononetin, and genistein were more potent than calycosin and daidzein in chimeric as well as full-length receptor assays. At low doses, only biochanin A and formononetin, but not genistein, calycosin, or daidzein, activated PPARgamma-driven reporter-gene activity and induced differentiation of 3T3-L1 preadipocytes. Our data suggest the potential value of isoflavones, especially biochanin A and their parent botanicals, as antidiabetic agents and for use in regulating lipid metabolism.

Psychiatric aspects of homicide in Singapore: a five-year review (1997 - 2001)

INTRODUCTION

The association between mental illness and violent offenders is an important issue not just for psychiatrists but for the public as well. Several studies have linked an increased prevalence of psychiatric illness among offenders of violent crimes. This study seeks to update the psychiatric community in Singapore on individuals charged with murder from 1997 to 2001, all of whom received a psychiatric assessment.

METHODS

110 individuals were charged with murder from 1997 to 2001. Socio-demographical data, psychiatric diagnoses, offence and victim profiles and court outcomes were obtained from prison records and psychiatric files.

RESULTS

There were 110 individuals charged with murder between January 1, 1997 to December 31, 2001, with a total of 113 victims. In 70 of the cases, one offender killed one victim. Offenders were mostly unmarried males in the 20-39 year age group who received a secondary school level of education or less. 57 of the remandees were found not to suffer from any mental illness. Alcohol abuse and dependence disorders accounted for the largest diagnostic group. Depressive disorders accounted for 9.1 percent of the accused persons and schizophrenia, 6.4 percent. Victim profiles and court outcomes are also described. A comparison is drawn between this study and the last large report on homicides in Singapore, published in 1985. No difference is detected when the rates of schizophrenia and depression are compared between the two eras.

CONCLUSION

Perpetrators of murder have been shown to have an increased incidence of psychiatric disorders. Reduction of the rate of homicide in the country may be achievable via the reduction of controllable factors found to be linked to the aetiology of murder. Alcohol and other illicit substance use are frequently found to be associated with homicide. The authorities are encouraged to enhance campaigns to dissuade alcohol abuse.

The Clinical Predictors of Hypertension and Sleepiness in an Asian Population with Sleep-disordered Breathing

Introduction: The objective of this study was to identify the clinical predictors for hypertension and sleepiness in an Asian population with sleep-disordered breathing (SDB). Materials and Methods: This is a retrospective, consecutive case series of 228 patients with symptoms of SDB referred to a tertiary level sleep disorders unit. A full sleep history, body mass index (BMI), Epworth Sleepiness Score (ESS), apnoea-hypopnoea index (AHI) and lowest oxygen saturation were recorded. All patients had an in-hospital polysomnogram. AHI ≥5 defined SDB. ESS >8 defined sleepiness. Results: A BMI of 25 had a positive and negative predictive value of 75% and 56%, respectively, for predicting AHI ≥5, area ROC (receiver operating curve) = 0.668. Patients with AHI >5 had 3 times the risk of developing hypertension compared to the population with AHI <5. Using stepwise multivariate analyses with constant, age, BMI and lowest oxygen desaturation were predictors for hypertension. Patients with AHI ≥5 were 1.88 times more likely to have ESS >8. After stepwise multivariate analyses, the subjective complaint of sleepiness and lowest oxygen saturation during sleep were predictors of ESS >8. Conclusion: The lowest oxygen saturation attained during sleep was the common factor for hypertension and sleepiness in our Asian SDB population. Mild obesity predisposes to AHI ≥5 in our population, the threshold at which the risk of hypertension is 3-fold compared with AHI <5. The subjective complaint of sleepiness predicted an ESS of >8.

The clinical predictors of hypertension and sleepiness in an Asian population with sleep-disordered breathing

INTRODUCTION

The objective of this study was to identify the clinical predictors for hypertension and sleepiness in an Asian population with sleep-disordered breathing (SDB).

MATERIALS AND METHODS

This is a retrospective, consecutive case series of 228 patients with symptoms of SDB referred to a tertiary level sleep disorders unit. A full sleep history, body mass index (BMI), Epworth Sleepiness Score (ESS), apnoea-hypopnoea index (AHI) and lowest oxygen saturation were recorded. All patients had an in-hospital polysomnogram. AHI > or =5 defined SDB. ESS >8 defined sleepiness.

RESULTS

A BMI of 25 had a positive and negative predictive value of 75% and 56%, respectively, for predicting AHI > or =5, area ROC (receiver operating curve) = 0.668. Patients with AHI >5 had 3 times the risk of developing hypertension compared to the population with AHI <5. Using stepwise multivariate analyses with constant, age, BMI and lowest oxygen desaturation were predictors for hypertension. Patients with AHI > or =5 were 1.88 times more likely to have ESS >8. After stepwise multivariate analyses, the subjective complaint of sleepiness and lowest oxygen saturation during sleep were predictors of ESS >8.

CONCLUSION

The lowest oxygen saturation attained during sleep was the common factor for hypertension and sleepiness in our Asian SDB population. Mild obesity predisposes to AHI > or =5 in our population, the threshold at which the risk of hypertension is 3-fold compared with AHI <5. The subjective complaint of sleepiness predicted an ESS of >8.

10th Yahya Cohen Memorial Lecture: Clinical predictors in obstructive sleep apnoea patients with computer-assisted quantitative videoendoscopic upper airway analysis

AIM

To identify the clinical predictors and assist surgeons in their clinical management of obstructive sleep apnoea (OSA) - a prospective study with a new approach to analyse the static and dynamic upper airway morphology between patients with OSA and normal subjects. To introduce a new method of assessment for surgical outcome.

MATERIALS AND METHODS

Quantitative computer-assisted videoendoscopy (validated with upper airway magnetic resonance imaging) was performed in 49 (43 males, 6 females) patients with OSA and compared with 39 (22 males, 17 females) controls (apnoea-hypopnoea index <5). Absolute cross-sectional areas, transverse and longitudinal diameters at the retro-palatal and retro-lingual levels were measured during end of quiet respiration and during Mueller's manoeuvre in the erect and supine positions, allowing us to study static and dynamic morphology (collapsibility) of the upper airway. We analysed 3744 parameters.

RESULTS

In males, retro-palatal and retro-lingual areas during Mueller's manoeuvre in the supine position of 0.7981 cm2 [receiver operating characteristics (ROC) = 0.9284, positive predictive value (PPV) = 86.05%, negative predictive value (NPV) = 84.62%] and 2.0648 cm2 (ROC = 0.8183, PPV = 76%, NPV = 83.33%), respectively, were found to be good predictors/ cut-off values for OSA. Retro-palatal area measured in the supine position during Mueller's manoeuvre (AS1M) and collapsibility of retro-palatal area in the supine position calculated (CAS1) were found to have significant correlations with severity of OSA. In females, areas measured during Mueller's manoeuvre in the supine position of 0.522 cm2 at retropalatal level (ROC = 1, 100% PPV and NPV) and transverse diameter at retro-lingual level during erect Mueller's manoeuvre of 1.1843 cm (ROC = 0.9056, PPV = 100%, NPV = 83.33%) were found to be predictive. All measurements at the retro-palatal level and in the supine position had higher predictability. Area measurements obtained during Muller's manoeuvre were more predictive (ROC >0.9910) than resting measurements (ROC >0.8371). Several gender and anatomical-site specific formulas with excellent predictability (ROC close or equal to 1) were also devised. Examples of surgical outcome assessment were introduced.

CONCLUSION

Upper airway Mueller's studies are predictive and useful (independent samples t-test/Mann Whitney U test, ROC) in identifying patients with OSA. With these gender and anatomical-site specific OSA predictors/formulas and this innovative clinical method, we hope to assist other surgeons with quantitative clinical diagnosis, assessment, surgical planning and outcome assessment tools for OSA patients.

Discordant quantitative detection of putative biomarkers in nodal micrometastases of colorectal cancer: biological and clinical implications

AIMS

Nodal expression of the carcinoembryonic antigen (CEA), cytokeratin 20 (CK20), and guanylyl cyclase C (GCC) genes was measured in tandem in patients with colorectal cancer (CRC) to assess whether there would be sufficient agreement between these markers in their ability to detect micrometastasis to qualify one of them as a universal marker, and whether frozen and paraffin wax embedded tissues would yield similar results.

METHODS

One hundred and seventy five frozen lymph nodes (FT) and 158 formalin fixed, paraffin wax embedded lymph nodes (PET) from 28 CRC cases were analysed using gene specific quantitative real time polymerase chain reaction, carried out on the LightCycler system with SYBR Green chemistry.

RESULTS

There was significant disparity in positive detection of the three biomarkers in FT versus PET, with notable agreement achieved only for CEA (66.6%) in FT versus PET in Dukes' B disease, and between CK20 and GCC (44.6%) in FT, also in Dukes' B disease. One patient with full concordance in all three tumour markers with both tissue types suffered a relapse and died within two years of follow up.

CONCLUSIONS

There was considerable discordance in the positive detection of the three tumour markers in both tissue types (FT versus PET). This brings into question whether using a single tumour marker to detect micrometastasis in one tissue type (FT or PET) is adequately representative, and challenges the concept of universal markers for molecular CRC metastatic detection. Multiple tumour markers would predict more accurately the metastatic potential of Dukes' B CRCs.

Anorexia nervosa in Singapore: an eight-year retrospective study

INTRODUCTION

Information regarding the clinical features of patients with anorexia nervosa in Singapore is rare and there have not been any large studies published to date. The aims of this paper were to study the clinical characteristics and features of patients with anorexia nervosa in Singapore, and to compare the clinical features of the early versus the classical later-onset cases.

METHODS

126 cases presenting to the Child Guidance Clinic and the Eating Disorder Clinic at the Institute of Mental Health between 1994 and 2002 were identified and studied retrospectively. All presented with anorexia nervosa or had a past history of it. Subjects were further classified into early-onset (younger than 14 years) or classical later-onset (14 years and older), and a comparison was done between the two groups.

RESULTS

The large majority were female students with a mean presenting age of 17.6 years. 65.1 percent were of the restricting subtype. 84.1 percent were Chinese, 7.9 percent were Indians and 4.8 percent were Malays. Mean presenting body mass index (BMI) was 15.56. Depression was the most common co-morbid condition affecting 25.4 percent of the sample. The number of new cases increased significantly from six in 1994 to 24 in 2002 (p-value equals 0.002). Commonest precipitating factors were comments from others, school and work stress. 11.1 percent were previously members of trim and fit club in school. 42.7 percent of late-onset cases compared to 16.2 percent of the early-onset were of the binge-purge type (p-value equals to 0.005) and had a higher presenting BMI (15.91 +/- 2.90 versus 14.74 +/- 2.14, p-value equals 0.003).

CONCLUSION

The clinical characteristics of patients with anorexia nervosa in Singapore are similar to that reported in western literature. The Malay population appears to be under-represented. There was a significant increase in numbers presenting over the last two years. The early-onset cases tend to be of the restrictive-type and had a lower presenting BMI than the later-onset group.

Clinical predictors in obstructive sleep apnoea patients with calibrated cephalometric analysis - a new approach1

AIM

Utilization of a new method to accurately quantify differences in cephalometric parameters between obstructive sleep apnoea (OSA) and normal patients, and to identify good predictors for OSA. To illustrate the ethnic differences in cephalometry.

METHOD

This prospective study involves 106 South-east Asians. A calibrated catheter is inserted into the upper airway during standard cephalometry to obtain the precise magnification and allow exact measurement of anatomical parameters of cephalometry in both erect and supine positions.

RESULTS

The OSA patients have longer lower-facial length, narrower skull base, shorter and receding mandible, smaller posterior airway space (PAS), narrower retropalatal space, longer and thicker soft palate, smaller hard and soft palate angles longer tongue length and more inferiorly displaced hyoid. For the palatal level, retropalatal distance of 11.2 mm cut-off/predictive value for male (receiver operating characteristics (ROC) = 0.8414 with PPV = 77.46, NPV = 90.00) and 5.5 mm for female (ROC = 0.9180 with PPV = 100.00, NPV = 84.21) at erect position were selected. For retrolingual level, erect PAS of 10.1 mm cut-off/predictive value for male (ROC = 0.7000 with PPV = 78.38, NPV = 37.78), 5.3 mm for female (ROC = 0.7227 with PPV = 75.00, NPV = 75.00) were selected. Our study showed that South-east Asians have different cephalometric values compared with White people, Black people and Hispanics.

CONCLUSION

This new method of cephalometry using a calibrated catheter provides an accurate and simple method of obtaining precise cephalometric measurements. There is no cephalometric data on OSA from South-east Asia available. These results suggested that surgeons managing OSA patients and using cephalometry as a diagnostic method should have a set of normative and OSA cephalometric values that apply to their local populations.

Symptoms and care of dying elderly patients in an acute hospital

INTRODUCTION

We aimed to study the symptoms and the care of elderly patients dying in an acute hospital in Singapore.

METHODS

Over a one year period, we retrospectively studied all patients admitted to the Department of Geriatric Medicine and all other patients aged more than 75 years old who were admitted and died during the same admission to all other units in an acute hospital. There were 189 such patients. Demographical data, information on the patients' background and prevailing medical problems, symptoms, intervention and treatment methods were obtained from the patients' medical records and analysed.

RESULTS

The patients were frail and old. 17 percent had bedsores and 20 percent had limb contractures noted at the point of admission. 20 percent had known terminal disease. 88 percent of the deaths were expected and 12 percent unexpected. In spite of the deaths being anticipated, 25 percent of them were subjected to cardiopulmonary resuscitation and 17 percent were intubated at the point of collapse. The majority (81 percent) of relatives of the 160 patients whose deaths were anticipated and had family had no acceptance problems. 52 (31 percent) of the 167 expected deaths had input from palliative care. These patients were more dependent, (p-value equals 0.018; odds ratio [OR] = 2.5; 95 percent confidence interval [CI] 1.2-5.2), less likely to undergo resuscitation (p-value is less than 0.001; OR = 0.16; 95 percent CI, 0.06-0.44), and were more likely to be on treatment for their symptoms (p-value is equal to 0.001; OR = 7.7; 95 percent CI, 2.1-28.8).

CONCLUSION

The common symptoms experienced by the elderly at the end of life are difficulty with breathing, fever, pain and respiratory secretions. A number of patients were not on any treatment for these problems though the proportion is less where there is palliative input.

Quantitative computer-assisted digital-imaging upper airway analysis for obstructive sleep apnoea

This was a prospective study of a new objective method which quantitatively analyses the upper airways in patients with obstructive sleep apnoea (OSA). Video-nasopharyngoscopic examinations of the upper airways of 45 patients were carried out with an endoscopic calibrator. Images of the upper airway during quiet respiration and Mueller's manoeuvre in erect and supine positions were digitized by computer to generate the actual dimensions of obstructive sites. Measurements by the new method were validated by comparing 90 pairs of videoendoscopic images with upper airway magnetic resonance imaging (MRI) measurements at two identical levels. Quantitative precision is 100% for the retropalatal level and 95.6% for the retrolingual level with a tolerance of 0.5 cm(2) between the two methods. The absolute mean of the difference between the two methods of measurement is 0.08 cm(2) at the retropalatal level and 0.18 cm(2) at the retrolingual level. The agreement between the digital-imaging videoendoscopic and MRI measurements was 93.3% for the retropalatal level and 95.6% for the retrolingual level. Quantitative computer-assisted digital imaging is a reliable, cost-effective clinical method of upper airway evaluation in OSA patients. This method allows us to examine the dynamic and static morphology objectively, measure surgical outcomes of upper airway, opening up new avenues for OSA management.