First pass effect as an independent predictor of functional outcomes in medium vessel occlusions: An analysis of an international multicenter study

INTRODUCTION

First pass effect (FPE), achievement of complete recanalization (mTICI 2c/3) with a single pass, is a significant predictor of favorable outcomes for endovascular treatment (EVT) in large vessel occlusion stroke (LVO). However, data concerning the impact on functional outcomes and predictors of FPE in medium vessel occlusions (MeVO) are scarce.

PATIENTS AND METHODS

We conducted an international retrospective study on MeVO cases. Multivariable logistic modeling was used to establish independent predictors of FPE. Clinical and safety outcomes were compared between the two study groups (FPE vs non-FPE) using logistic regression models. Good outcome was defined as modified Rankin Scale 0-2 at 3 months.

RESULTS

Eight hundred thirty-six patients with a final mTICI ⩾ 2b were included in this analysis. FPE was observed in 302 patients (36.1%). In multivariable analysis, hypertension (aOR 1.55, 95% CI 1.10-2.20) and lower baseline NIHSS score (aOR 0.95, 95% CI 0.93-0.97) were independently associated with an FPE. Good outcomes were more common in the FPE versus non-FPE group (72.8% vs 52.8%), and FPE was independently associated with favorable outcome (aOR 2.20, 95% CI 1.59-3.05). 90-day mortality and intracranial hemorrhage (ICH) were significantly lower in the FPE group, 0.43 (95% CI, 0.25-0.72) and 0.55 (95% CI, 0.39-0.77), respectively.

CONCLUSION

Over 2/3 of patients with MeVOs and FPE in our cohort had a favorable outcome at 90 days. FPE is independently associated with favorable outcomes, it may reduce the risk of any intracranial hemorrhage, and 3-month mortality.

Distal medium vessel occlusions in acute ischaemic stroke - Stent retriever versus direct aspiration: A systematic review and meta-analysis

BACKGROUND

Acute ischaemic stroke due to distal medium vessel occlusion (AIS-DMVO) causes significant morbidity. Endovascular thrombectomy advancement has made treating AIS-DMVO with stent retrievers (SR) and aspiration catheters (AC) possible, however the optimal technique remains unknown. We performed a systematic review and meta-analysis to investigate the efficacy and safety of SR use compared to purely AC use in patients with AIS-DMVO.

METHODS

We systematically searched PubMed, Cochrane Library and EMBASE, from inception to 2nd September 2022, for studies comparing SR or primary combined (SR/PC) against AC in AIS-DMVO. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (modified Rankin Scale (mRS) 0-2 at 90 days), first pass effect (modified Thrombolysis in Cerebral Infarction scale (mTICI) 2c-3 or expanded Thrombolysis in Cerebral Infarction scale (eTICI) 2c-3 at first pass), successful final recanalisation (mTICI or eTICI 2b-3), and excellent final recanalisation (mTICI or eTICI 2c-3). Safety outcomes were symptomatic intracranial haemorrhage (sICH) and 90-day mortality.

RESULTS

12 cohort studies and 1 randomised-controlled trial were included, involving 1881 patients with 1274 receiving SR/PC and 607 receiving AC only. SR/PC achieved higher odds of functional independence (odds ratio (OR) 1.33, 95% confidence interval (CI) 1.06-1.67) and lower odds of mortality (OR 0.69, 95% CI 0.50-0.94) than AC. Odds of successful/excellent recanalisation and sICH were similar between both groups. Stratified to compare only SR and only AC, the use of only SR, achieved significantly higher odds of successful recanalisation as compared to only AC (OR 1.80, 95% CI 1.17-2.78).

CONCLUSION

There is potential for efficacy and safety benefits in SR/PC use as compared to AC only in AIS-DMVO. Further trials are necessary to validate the efficacy and safety of SR use in AIS-DMVO.

Simultaneous cardio-cerebral infarction: a meta-analysis

BACKGROUND/INTRODUCTION

Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse.

AIM

We aimed to summarize the reported cardio-cerebral infarction cases in the literature.

DESIGN

Meta-analysis.

METHODS

Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors.

RESULTS

A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported.

DISCUSSION/CONCLUSION

The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.

Glycoprotein IIb/IIIa inhibitors for the neurointerventionalist

Antiplatelet therapies are commonly used in neurointerventional procedures. However, specific guidelines for their use in these settings is lacking and it can often be difficult to balance the potential risks and benefits of these medications. Considering the continued growth and adoption of neurointerventional procedures, it is crucial to understand the properties of these agents in order to use them safely. Large-scale clinical trials are still needed to clarify many of these aspects for this emerging field. However, the existing literature already provides insight into which antiplatelet drugs are of benefit to the neurointerventionalist as well as their associated risks of ischemic and hemorrhagic complications. Hence, this review focuses on the applications of GPIIb/IIIA inhibitors to neurointerventional procedures.

Effects of Sodium/Glucose Cotransporter 2 (SGLT2) Inhibitors on Cardiac Imaging Parameters: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Recent studies have shown that sodium/glucose cotransporter 2 (SGLT2) inhibitors might exert favourable changes on cardiac parameters as observed on cardiovascular imaging. We conducted a systematic review and meta-analysis to determine the effects of SGLT2 inhibitors on cardiac imaging parameters. Four electronic databases (PubMed, Embase, Cochrane, Scopus) were searched for studies in which the effects of SGLT2 inhibitors on cardiac imaging parameters were examined. Studies in which a population was administered SGLT2 inhibitors and analysed by echocardiography and/or cardiac magnetic resonance (CMR) imaging were included. Random-effects pair-wise meta-analysis models were utilized to summarize the studies. A total of 11 randomized controlled trials was included with a combined cohort of 910 patients. Comparing patients receiving SGLT2 inhibitors with subjects receiving placebo, the mean change in CMR-measured left ventricular mass (LVM) was −3.87 g (95% confidence interval [CI], −7.77 to 0.04), that in left ventricular end-systolic volume (LVESV) was −5.96 mL (95% CI, −10.52 to −1.41) for combined LVESV outcomes, that in left atrial volume index (LAVi) was −1.78 mL/m² (95% CI, −3.01 to −0.55) for combined LAVi outcomes, and that in echocardiography-measured E/e′ was −0.73 (95% CI, −1.43 to −0.03). Between-group differences were not observed in LVM and LVESV after indexation. The only between-group difference that persisted was for LAVi. Treatment with SGLT2 inhibitors resulted in reduction in LAVi and E/e′ on imaging, indicating they might have an effect on outcomes associated with LV diastolic function.

Abstract P607: Interplay Between Post-Myocardial Infarction Left Ventricular Systolic Dysfunction and Atrial Fibrillation: Prognostic Implications for Post-Myocardial Infarction Acute Ischaemic Stroke

Introduction: Acute myocardial infarction (MI) and acute ischaemic stroke (AIS) are leading causes of morbidity and mortality. There is scarce data examining the interplay between post-MI left ventricular systolic dysfunction (LVSD), with or without atrial fibrillation (AF), and subsequent AIS, especially in patients with milder degrees of LVSD (ejection fraction 40-49%). Evidence of an association would be helpful in developing new strategies of reducing AIS after MI. As such, we sought to study this relationship in a real-world population-based registry.

Methods: This study involved linking national-level data from the Singapore Myocardial Infarction Registry with the Singapore Stroke Registry from 1st January 2007 to 31st December 2018. Both data sets have similar definitions for patient demographics. The ejection fraction (EF) and AF status were recorded during the MI episode. The outcome studied was the first instance of AIS that developed after the MI episode. We also studied the relationship between EF, AF and the severity of AIS as measured by the NIH Stroke Scale (NIHSS).

Results: There were 64,512 patients available for analysis. The median age was 65.7 (IQR 56.1-76.5) and 69.5% were male. The median duration post-MI to develop AIS was 16.9 (IQR 1.6-46.1) months. There was an independent association between LVSD and the outcome of AIS (adjusted HR 1.18, 95% CI 1.10-1.27); this was evident even in mild forms of LVSD (adjusted HR 1.16, 95% CI 1.06-1.27). AF was not a statistically significant predictor of AIS in post-MI patients with LVSD. Amongst patients without AF, post-MI LVSD was associated with a more severe stroke and higher NIHSS.

Conclusion: Post-MI LVSD is associated with the occurrence of subsequent AIS. Although this relationship was independent of AF status, patients with LVSD but no AF had suffered a more severe AIS. These findings support the need to develop effectives therapies to prevent AIS post-MI, especially among those with LVSD.

Significant aortic stenosis associated with poorer functional outcomes in patients with acute ischaemic stroke undergoing endovascular therapy

BACKGROUND AND AIM

Bi-directional feedback mechanisms exist between the heart and brain, which have been implicated in heart failure. We postulate that aortic stenosis may alter cerebral haemodynamics and influence functional outcomes after endovascular thrombectomy for acute ischaemic stroke. We compared clinical characteristics, echocardiographic profile and outcomes in patients with or without aortic stenosis that underwent endovascular thrombectomy for large vessel occlusion acute ischaemic stroke.

METHODS

Consecutive acute ischaemic stroke patients with anterior and posterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery and basilar artery) who underwent endovascular thrombectomy were studied. Patients were divided into those with significant aortic stenosis (aortic valve area <1.5 cm2) and without. Univariate and multivariate analyses were employed to compare and determine predictors of functional outcomes measured by modified Rankin scale at three months.

RESULTS

We identified 26 (8.5%) patients with significant aortic stenosis. These patients were older (median age 76 (interquartile range 68-84) vs. 67 (interquartile range 56-75) years, p = 0.001), but similar in terms of medical comorbidities and echocardiographic profile. Rates of successful recanalisation (73.1% vs. 78.0%), symptomatic intracranial haemorrhage (7.7% and 7.9%) and mortality (11.5% vs. 12.6%) were similar. Significant aortic stenosis was independently associated with poorer functional outcome (modified Rankin scale >2) at three months (adjusted odds ratio 2.7, 95% confidence interval 1.1-7.5, p = 0.048), after adjusting for age, door-to-puncture times, stroke severity and rates of successful recanalisation.

CONCLUSION

In acute ischaemic stroke patients managed with endovascular thrombectomy, significant aortic stenosis is associated with poor functional outcome despite comparable recanalisation rates. Larger cohort studies are needed to explore this relationship further.

Nation-Wide Observational Study of Cardiac Arrests Occurring in Nursing Homes and Nursing Facilities in Singapore

Introduction: Nursing home (NH) residents with out-of-hospital cardiac arrests (OHCA) have unique resuscitation priorities. This study aimed to describe OHCA characteristics in NH residents and identify independent predictors of survival. Materials and Methods: OHCA cases between 2010–16 in the Pan-Asian Resuscitation Outcomes Study were retrospectively analysed. Patients aged <18 years old and non-emergency cases were excluded. Primary outcome was survival at discharge or 30 days. Good neurological outcome was defined as a cerebral performance score between 1–2. Results: A total of 12,112 cases were included. Of these, 449 (3.7%) were NH residents who were older (median age 79 years, range 69–87 years) and more likely to have a history of stroke, heart and respiratory diseases. Fewer NH OHCA had presumed cardiac aetiology (62% vs 70%, P <0.01) and initial shockable rhythm (8.9% vs 18%, P <0.01), but had higher incidence of bystander cardiopulmonary resuscitation (74% vs 43%, P <0.01) and defibrillator use (8.5% vs 2.8%, P <0.01). Non-NH (2.8%) residents had better neurological outcomes than NH (0.9%) residents (P <0.05). Factors associated with survival for cardiac aetiology included age <65 years old, witnessed arrest, bystander defibrillator use and initial shockable rhythm; for non-cardiac aetiology, these included witnessed arrest (adjusted odds ratio [AOR] 3.8, P <0.001) and initial shockable rhythm (AOR 5.7, P <0.001). Conclusion: Neurological outcomes were poorer in NH survivors of OHCA. These findings should inform health policies on termination of resuscitation, advance care directives and do-not-resuscitate orders in this population. Ann Acad Med Singapore 2020;49:285–93 Key words: Advance care directives, Do-not-resuscitate orders, Geriatrics, Out-of- hospital, Palliative care

[Reduction of FXIII during myelosuppression in acute leukemia after chemotherapy and adverse relation with bleeding events]

目的

探讨急性白血病患者化疗后骨髓抑制期外周血凝血因子XIII（FXIII）浓度与出血事件的关系。

方法

纳入2017年8月至2018年3月期间55例PLT<50×10⁹/L的化疗后骨髓抑制期急性白血病患者（非急性早幼粒细胞性急性髓系白血病35例，急性淋巴细胞白血病20例），以35例非血液疾病患者作为对照组。用ELISA方法检测外周血FXIII浓度，分析急性白血病患者化疗后骨髓抑制期外周血FXIII水平与出血事件的关系。

结果

急性白血病患者化疗后骨髓抑制期FXIII水平明显低于对照组（P<0.001），FXIII水平与出血评分呈负相关（Spearman相关系数为-0.761）。当FXIII浓度的临界值为103.9 µg/L时，诊断化疗后骨髓抑制期急性白血病患者出血的敏感性为0.939，特异性为0.909。

结论

化疗后骨髓抑制期急性白血病患者外周血FXIII水平减低，且与出血事件及严重程度呈负相关，是急性白血病化疗后骨髓抑制期患者出血的独立影响因素之一。

Multi-Domains Lifestyle Interventions Reduces Depressive Symptoms among Frail and Pre-Frail Older Persons: Randomized Controlled Trial

BACKGROUND

We investigated the effect of multi-domain lifestyle (physical, nutritional, cognitive) interventions among frail and pre-frail community-living older persons on reducing depressive symptoms.

METHOD

Participants aged 65 and above were randomly allocated to 24 weeks duration interventions with nutritional supplementation (N=49), physical training (N=48), cognitive training (N=50), combination intervention (N=49) and usual care control (N=50). Depressive symptoms were assessed by the Geriatric Depression Scale (GDS-15) at baseline (0M), 3 month (3M), 6 month (6M) and 12 month (12M).

RESULTS

Mean GDS scores in the control group increased from 0.52 (0M) and 0.54 (3M) to 0.74 (6M), and 0.83 (12M). Compared to the control group, interventions showed significant differences (∆=change) at 6M for cognitive versus control (∆=-0.39, p=0.021, group*time interaction p=0.14); physical versus control (∆ =-0.37, p=0.026, group*time interaction p=0.13), and at 12M for nutrition versus control (∆ =-0.46, p=0.016, group*time interaction p=0.15). The effect for combination versus control was significant at 6M (∆ =-0.43, p=0.020) and 12M (∆ =-0.51, p=0.005, group*time interaction p=0.026). Estimated 12-month cumulative incidence of depressive symptoms (GDS≥2) relative to control were OR=0.38, p=0.037 (nutrition); OR=0.71, p=0.40 (cognitive); OR=0.39, p=0.042 (physical training) and OR=0.38, p=0.037 (combination). Changes in gait speed and energy level were significantly associated with changes in GDS scores over time.

CONCLUSION

Multi-domain interventions that reverse frailty among community-living older persons also reduce depressive symptomatology. Public health education and programmatic measures combining nutritional, physical and cognitive interventions for at-risk frail older people may likely benefit psychological wellbeing.

Stress fracture of the ulna associated with bisphosphonate therapy and use of walking aid

We report a case of a stress fracture of the ulna secondary to long-term bisphosphonate therapy and walking cane. Physicians need to have a high index of suspicion of stress fractures occurring in patients complaining of chronic upper limb pain if they are on bisphosphonate therapy and are using walking aids. Stress fractures of the upper extremities are rare and are usually associated with athletes; however, a few recent case reports have shown an association between stress fractures of the upper extremities and the use of walking aids. The association between increased incidence of upper extremity stress fractures and the use of both bisphosphonates and walking aids in patients has not been well studied, with only one previously reported case. Here, we report a case of a complete stress fracture of the ulna in a 77-year-old female, premorbidly ambulant with walking cane, on long-term bisphosphonates without any pre-existing medical conditions which could result in secondary causes of bone loss. Investigations did not reveal any causes of pathological fracture. This fracture is attributed to the use of long-term bisphosphonate therapy in conjunction with the use of a walking cane. This case highlights the importance of entertaining the possibility of such fractures occurring in any patient who is on bisphosphonate therapy presenting with stress fractures of the upper extremity.

Novel electrogram device with web-based service centre for ambulatory ECG monitoring

INTRODUCTION

Arrhythmias are often intermittent, and a normal electrocardiogram (ECG) may not be diagnostic. The purpose of this study was to evaluate the usefulness of HeartWave500 (HW), a novel web-based ambulatory ECG monitoring device.

METHODS

A total of 120 patients from the National Heart Centre, Singapore were prospectively randomised in a three to one ratio to either HW or a standard transtelephonic (TT) event recorder. HW records five leads and transmits to an internet server, while TT transmits audio data to a central station. Monitoring was conducted for two weeks. The diagnostic yield was calculated in two ways: the percentage of patients successfully diagnosed as a function of time, and the absolute number of new diagnoses per patient per week.

RESULTS

33 patients (14 male, 19 female; mean age 49.6 + or - 11.1 years) were randomised to TT. 87 patients (32 male, 55 female; mean age 43.7 + or - 12.2 years) were randomised to HW. At the end of two weeks, the percentage of patients diagnosed with any arrhythmia was similar for both groups (66.7 percent for TT versus 67.8 percent for HW). There was a trend toward significance for the number of diagnoses per patient per week for Week 2 between TT and HW (0.58 + or - 0.75 versus 0.34 + or - 0.55, p is 0.06). Transmitted ECGs were read earlier for HW (18 minutes versus 1107 minutes, Mann-Whitney non-parametric test, p is less than 0.05). Transmitted recordings that were unreadable were also significantly lower for HW (8.0 percent versus 17.6 percent, chi-square test, p is less than 0.05).

CONCLUSION

HW and TT have similar diagnostic yields. There is a trend toward a shorter monitoring time for HW. The ability of HW to record and transmit via the web, the earlier review of data and low unreadable data make HW an attractive alternative to TT.

Health Promotion Board-Ministry of Health clinical practice guidelines: functional screening for older adults in the community

The Health Promotion Board (HPB) and the Ministry of Health (MOH) publish clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HPB-MOH clinical practice guidelines on Functional Screening for Older Adults in the Community, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Health Promotion Board website (http://www.hpb.gov.sg/uploadedFiles/HPB_Online/Publications/CPGFunctionalscreening.pdf). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Myocardial infarction in Singapore: a nationwide 10-year study of multiethnic differences in incidence and mortality

INTRODUCTION AND METHODS

Cardiovascular diseases have progressively increased in importance as a major contributor of morbidity and mortality in Asia. However, many countries in Asia do not have nationwide systematically-collected and standardised data on myocardial infarction (MI). To accurately document the extent of atherosclerotic coronary heart disease in Singapore, a nationwide myocardial infarct registry was established in the mid-1986. Possible myocardial infarct events were identified through daily national lists of cardiac enzymes, hospital discharge codes, mortuary records and the national death registry. Data obtained from clinical history, cardiac enzymes and 12-lead electrocardiogram Minnesota codes were entered into an algorithm based on the WHO MONICA study. Cases identified as "definite" MI were included in the decade's review for this study.

RESULTS

From 1988 to 1997, 13,048 myocardial infarct events were diagnosed with 3367 deaths. There was a 39.1% decline in mortality, with an average decline of 6.5% per year [95% confidence intervals (CI), -3.9% to -9.1%]. However, the decline in incidence was only 20.8% with an average decline of 2.4% per year (95% CI, -6.6% to -1.2%). The highest incidence and mortality rates for both genders were seen in the Indians, followed by the Malays and the Chinese.

CONCLUSION

Over 10 years, from 1988 to 1997, we documented a significant fall in mortality from MI in Singapore. There was a smaller decline in the incidence of infarction. Singapore implemented a National Healthy Lifestyle Programme in 1992 as a 10-year effort. The disparity in the incidence and mortality may suggest that a more dramatic and immediate impact has taken place in mortality through therapeutic programmes; primary preventive programmes would be more difficult to evaluate and have a more gradual impact. Only with continual accurate data collection through the whole country, over a much longer period, can the relative value of preventive and therapeutic programmes in coronary heart disease be assessed.

A countrywide approach to the control of non-communicable diseases--the Singapore experience

INTRODUCTION

Many developed and developing countries are grappling with recent epidemics of non-communicable diseases and how to effectively control them. Singapore as a small, compact and highly urbanized country has similarly experienced a rapid increase in its chronic disease load and has adopted a national approach to control them.

METHODS

This paper traces the strategies taken in the 80s and the 90s to control non-communicable diseases and evaluates the effectiveness of the two approaches.

RESULTS

In the 80s, the control programme was largely a Ministry of Health responsibility using a persuasive approach to reach out to the target groups. This produced some results through the lowering of hypertension and cholesterol. For the 90s, the approach was one of leadership by government working with relevant agencies to reach out to all relevant sectors in the population. This National Healthy Lifestyle Programme was given top political support. The integrated and comprehensive approach used showed some improvements in health and gave the direction where efforts should be channelled.

CONCLUSION

The countrywide approach taken in Singapore for the control of non-communicable diseases illustrates a model where a national framework was adopted, harnessing health promotion and disease prevention and involving personal responsibility as a key success factor. This rides on a well-developed continuum of healthcare which aims to become an integrated and seamless one.

Risk factors and incident coronary heart disease in Chinese, Malay and Asian Indian males: the Singapore Cardiovascular Cohort Study

OBJECTIVE

This prospective study in Singapore investigated the relationships of established coronary risk factors with incident coronary heart disease (CHD) for Chinese, Malay, and Asian Indian males.

SUBJECTS

A cohort (consisting of 2879 males without diagnosed CHD) derived from three previous cross-sectional surveys.

METHODS

Individual baseline data were linked to registry databases to obtain the first event of CHD. Hazard ratios (HR) or relative risks for risk factors were calculated using Cox's proportional hazards model with adjustment for age and ethnic group and adjustment for age, ethnic group and all other risk factors (overall adjusted).

RESULTS

There were 24,986 person-years of follow-up. The overall adjusted HR with 95% CI are presented here. Asian Indians were at greatest risk of CHD, compared to Chinese (3.0; 2.0-4.8) and Malays (3.4; 1.9-3.3). Individuals with hypertension (2.4; 1.6-2.7) or diabetes (1.7; 1.1-2.7) showed a higher risk of CHD. High low density lipoprotein cholesterol (LDL-C) (1.5; 1.0-2.1), high fasting triglyceride (1.5; 0.9-2.6) and low high density lipoprotein cholesterol (HDL-C) (1.3; 0.9-2.0) showed a lesser but still increased risk. Alcohol intake was protective with non-drinkers having an increased risk of CHD (1.8; 1.0-3.3). Obesity (body mass index > or =30) showed an increased risk (1.8; 0.6-5.4). An increased risk of CHD was found in cigarette smokers of > or =20 pack years (1.5; 0.9-2.5) but not with lesser amounts.

CONCLUSIONS

The increased susceptibility of Asian Indian males to CHD has been confirmed in a longitudinal study. All of the examined established risk factors for CHD were found to play important but varying roles in the ethnic groups in Singapore.

Relationships between indices of obesity and its co-morbidities in multi-ethnic Singapore

OBJECTIVE

To investigate the effect of body mass index (BMI) and body fat distribution as measured by waist-to-hip ratio (WHR) on the cardiovascular risk factor profile of the three major ethnic groups in Singapore (Chinese, Malay and Indian people) and to determine if WHO recommended cut-off values for BMI and WHR are appropriate for the different sub-populations in Singapore.

DESIGN

Cross-sectional population study.

SUBJECTS

A total of 4723 adult subjects (64% Chinese individuals, 21% Malay individuals and 15% Indian individuals) were selected through a multi-staged sampling technique to take part in the National Health Survey in 1998.

MEASUREMENTS

Data on socio-economic status (education level, occupation, housing type) and lifestyle habits (smoking and physical activity), body weight, body height, waist and hip circumferences and blood pressure measured using standardised protocols. Fasting venous blood samples were obtained for determination of serum total cholesterol (TC), high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides (TG). Venous blood samples were taken for 2 h oral glucose tolerance test (2 h glu).

RESULTS

Absolute and relative risks for at least one cardiovascular risk factor (elevated TC, elevated TC/HDL ratio, elevated TG, hypertension and diabetes mellitus) were determined for various categories of BMI and WHR. At low categories of BMI (BMI between 22 and 24 kg/m(2)) and WHR (WHR between 0.80 and 0.85 for women, and between 0.90 and 0.95 for men), the absolute risks are high, ranging from 41 to 81%. At these same categories the relative risks are significantly higher compared to the reference category, ranging from odds ratio of 1.97 to 4.38. These categories of BMI and WHR are all below the cut-off values of BMI and WHR recommended by WHO.

CONCLUSIONS

The results show that, at relatively low BMI and WHR, Singaporean adults experience elevated levels of risks (absolute and relative) for cardiovascular risk factors. These findings, in addition to earlier reported high percentage body fat among Singaporeans at low levels of BMI, confirm the need to revise the WHO cut-off values for the various indices of obesity and fat distribution, viz BMI and WHR, in Singapore.

Diabetes mellitus abolishes ethnic differences in cardiovascular risk factors: lessons from a multi-ethnic population

AIMS

To compare cardiovascular risk factors in diabetic subjects of different ethnic groups, and between new and known diabetic subjects, in the Singapore National Health Survey '92.

METHODS

Disproportionate stratified sampling followed by systematic sampling were used in 3568 (total) respondents of whom 2743 were non-diabetics, 179 newly diagnosed diabetics and 150 known diabetics. Amongst the diabetics, there were 185 Chinese, 66 Malays and 78 Asian Indians. Diagnosis of diabetes mellitus (DM) was based on the 2 h glucose alone, after a 75 g oral glucose tolerance test. Blood pressure (BP), lipid profile, glucose, insulin and anthropometric indices were obtained from all subjects.

RESULTS

Subjects with diabetes (new and known) exhibited significantly higher triglyceride (TG), lower high density lipoprotein cholesterol (HDL-C) and low density lipoprotein (LDL)/apolipoprotein B (apo B) ratio (LDL size) compared with normoglycaemic subjects. They were more obese (generalised and central) and had higher systolic and diastolic BP. There was no difference in lipid risk factors between the two groups with diabetes although those with new diabetes were more obese whilst those with known diabetes had higher fasting glucose. Amongst subjects with diabetes, there were no significant differences between ethnic groups in TG, HDL-C, LDL/apo B ratio, or waist to hip ratio (WHR). Female Malays with diabetes had higher total cholesterol and were more obese whilst male Asian Indians with diabetes had higher fasting insulin.

CONCLUSION

Asian Indians had lower HDL-C and LDL/apo B ratio than Chinese or Malays amongst normoglycaemic subjects. However, these differences between ethnic groups were not seen in subjects with DM.

Levels of cardiovascular disease risk factors in Singapore following a national intervention programme

OBJECTIVE

To evaluate the impact of the National Healthy Lifestyle Programme, a noncommunicable disease intervention programme for major cardiovascular disease risk factors in Singapore, implemented in 1992.

METHODS

The evaluation was carried out in 1998 by the Singapore National Health Survey (NHS). The reference population was 2.2 million multiracial Singapore residents, 18-69 years of age. A population-based survey sample (n = 4723) was selected by disproportionate stratified and systematic sampling. Anthropometric and blood pressure measurements were carried out on all subjects and blood samples were taken for biochemical analysis.

FINDINGS

The 1998 results suggest that the National Healthy Lifestyle Programme significantly decreased regular smoking and increased regular exercise over 1992 levels and stabilized the prevalence of obesity and diabetes mellitus. However, the prevalence of high total blood cholesterol and hypertension increased. Ethnic differences in the prevalence of diabetes mellitus, hypertension, and smoking; and in lipid profile and exercise levels were also observed.

CONCLUSION

The intervention had mixed results after six years. Successful strategies have been continued and strengthened.

Screening for diabetes mellitus--a two-step approach in individuals with impaired fasting glucose improves detection of those at risk of complications

AIMS

To compare the new American Diabetes Association (ADA) fasting plasma glucose (FPG) criteria to the 1985 World Health Organization (WHO) 2-h post glucose (2hPG) criteria when used for screening of those with no prior history of diabetes mellitus.

METHODS

The study included 3,407 subjects without a history of diabetes in whom both FPG and 2hPG were available from the 1992 Singapore National Health Survey. The agreement (kappa) between FPG and 2hPG for the diagnosis of DM was assessed. The optimal cut-off of FPG for the detection of individuals with 2hPG > or = 11.1 mmol/l was determined by receiver-operating characteristics analysis.

RESULTS

The prevalence of diabetes diagnosed by FPG alone was 7.3% compared to 8.4% diagnosed by 2hPG. The prevalence of impaired fasting glucose was 8.0%. FPG and 2hPG showed moderate agreement (kappa = 0.646, 95% confidence interval 0.584-0.708). Age, ethnic group and obesity did not affect the degree of agreement. Of those with 2hPG > or = 11.1 mmol/l, 40.8% had FPG in the non-diabetic range while 24.8% of those with FG > or = 7.0 mmol/l had 2hPG in the non-diabetic range. The optimal FPG for the detection of 2hPG > or =11.1 mmol/l was 6.1 mmol/l. Oral glucose tolerance tests (OGTT) in those with 6.0 mmol/ < FPG < 7.0 mmol/l resulted in the diagnosis of diabetes in 90.7% of individuals at risk of microvascular complications.

CONCLUSIONS

FPG provides a simple screening test for diabetes, which shows moderate agreement with the 2hPG. A two-step strategy of OGTT in those with impaired fasting glucose improves the detection of at-risk individuals. However, diabetes should not be diagnosed on a single test. The test should be repeated on another day if an individual tests positive for diabetes.

Homeostasis model assessment in a population with mixed ethnicity: the 1992 Singapore National Health Survey

We studied insulin resistance and beta-cell function with reference to ethnic group, glucose tolerance and other coronary artery disease risk factors in a cross section of the Singapore population which comprises Chinese, Malays and Asian Indians. 3568 individuals aged 18-69 were examined. Blood pressure, anthropometric data, blood lipids, glucose and insulin were assayed in the fasting state. Glucose and serum insulin were measured 2 h after an oral glucose challenge. Insulin resistance and beta-cell function were calculated using homeostasis model assessment. Asian Indians had higher insulin resistance than Chinese or Malays. Impaired glucose tolerance (IGT) and diabetes mellitus (DM) were associated with greater insulin resistance and impaired beta-cell function compared to normal glucose tolerance (NGT). Insulin resistance was positively correlated with blood pressure in women and total cholesterol, LDL cholesterol and triglyceride in both men and women. It was negatively correlated with HDL cholesterol and LDL/apolipoprotein B ratio. beta-cell function showed no significant correlations with the cardiovascular risk factors studied. It appears that both impaired beta-cell function and insulin resistance are important for the development of hyperglycemia whereas insulin resistance alone seems more important in the development of coronary artery disease as it correlates with several known coronary artery disease risk factors.

Cardiovascular risk profile in individuals with borderline glycemia: the effect of the 1997 American Diabetes Association diagnostic criteria and the 1998 World Health Organization Provisional Report

OBJECTIVE

In 1997, the American Diabetes Association (ADA) recommended a new diagnostic category, impaired fasting glucose (IFG), to describe individuals with borderline glucose tolerance. On the other hand, the World Health Organization (WHO) suggested retaining the category of impaired glucose tolerance (IGT). We studied the prevalence of IFG and IGT in a multiethnic society and compared the cardiovascular risk profiles of subjects with IFG, IGT, or both IFG and IGT.

RESEARCH DESIGN AND METHODS

A total of 3,568 subjects were examined from the 1992 National Health Survey of Singapore, which involved a combination of disproportionately stratified sampling and systematic sampling. Anthropometric, blood pressure, insulin, lipid profile, and uric acid measurements were taken, and a standard 75-g oral glucose tolerance test was performed after a 10-h overnight fast.

RESULTS

The prevalence rates of IFG only, IGT only, and both IFT and IGT were 3.45, 10.2, and 3.4%, respectively. The degree of agreement (kappa) between the two diagnostic criteria (the ADA IFG and the WHO IGT) was only 0.25. A fasting glucose level of 5.5 mmol/l was the optimal cutoff for predicting a 2-h postload glucose level of > or =7.8 mmol/l. The following cardiovascular risk factors were higher in subjects with both IFG and IGT compared with those with either IFG or IGT alone: systolic blood pressure (131 +/- 20 vs. 125 +/- 21 and 125 +/- 19 mmHg, respectively; P < 0.05 and P < 0.001, respectively); diastolic blood pressure (77 +/- 12 vs. 73 +/- 12 and 74 +/- 12 mmHg, respectively; P < 0.05); BMI (26.2 +/- 4.2 vs. 24.4 +/- 4.0 and 24.6 +/- 4.4 kg/m2, respectively; P < 0.01 and P < 0.001, respectively); waist circumference (84.1 +/- 10.3 vs. 79.3 +/- 10.7 and 79.3 +/- 10.6 cm, respectively; P < 0.001); waist-to-hip ratio (0.84 +/- 0.08 vs. 0.82 +/- 0.09 and 0.81 +/- 0.08, respectively; P < 0.05 and P < 0.001, respectively); fasting insulin (12.1 +/- 9.7 vs. 9.2 +/- 5.3 and 9.9 +/- 7.7 mU/l; P < 0.01); insulin resistance (by homeostasis model assessment [HOMA]) (3.41 +/- 2.77 vs. 2.58 +/- 1.50 and 2.43 +/- 1.83, respectively; P < 0.01 and P < 0.001, respectively); total cholesterol (5.81 +/- 1.1 vs. 5.51 +/- 1.1 and 5.53 +/- 1.1 mmol/l, respectively; P < 0.05) and apolipoprotein(B) [apo(B)] (1.5 +/- 0.38 vs. 1.40 +/- 0.34 and 1.39 +/- 0.35 mmol/l, respectively; P < 0.01). The pattern of difference remained significant only for fasting insulin, insulin resistance (HOMA), and apo(B) (borderline) after adjustment for age, sex, and ethnic differences.

CONCLUSIONS

Obvious discordance was evident in the classification of glycemic status when applying the criteria proposed by the ADA (IFG) or WHO (IGT) in a multiethnic society like Singapore. However, subjects with either IFG or IGT had similar cardiovascular risk profiles. Therefore, both criteria identified individuals at high risk for cardiovascular disease. Individuals with both IFG and IGT had a greater incidence of the cardiovascular dysmetabolic syndrome.

Incidence of ischaemic heart disease and stroke in Chinese, Malays and Indians in Singapore: Singapore Cardiovascular Cohort Study

INTRODUCTION

This is the first prospective cohort study in Singapore to describe the incidence of ischaemic heart disease (IHD) and stroke among Chinese, Malays and Asian Indians.

MATERIALS AND METHODS

The Singapore Cardiovascular Cohort Study is a longitudinal follow-up study on a general population cohort of 5920 persons drawn from 3 previous cross-sectional surveys. Morbidity and mortality from IHD and stroke were ascertained by record linkage using a unique identification number with the death registry, Singapore Myocardial Infarct Registry and in-patient discharge databases.

RESULTS

There were 193 first IHD events and 97 first strokes during 52,806 person-years of observation. The overall incidence of IHD was 3.8/1000 person-years and that of stroke was 1.8/1000 person-years. In both males and females, Indians had the highest IHD incidence, followed by Malays and then Chinese. For males after adjusting for age, Indians were 2.78 times (95% CI 1.86, 4.17; P < 0.0001) and 2.28 times (95% CI 1.34, 3.88; P = 0.002) more likely to get IHD than Chinese and Malays respectively. For females after adjusting for age, Indians were 1.97 times (95% CI 1.07, 3.63; P = 0.03) and 1.37 times (95% CI 0.67, 2.80; P = 0.39) more likely to get IHD than Chinese and Malays respectively. For stroke, male Chinese and Indians had higher incidence than Malays (though not statistically significant). However, in females, Malays had the highest incidence of stroke, being 2.57 times (95% CI 1.31, 5.05; P = 0.008) more likely to get stroke than Chinese after adjustment for age.

CONCLUSIONS

This prospective study of both mortality and morbidity has confirmed the higher risk of IHD in Indians. It has also found that Malay females have a higher incidence of stroke, which deserves further study because of its potential public health importance.

Isolated low HDL cholesterol: an insulin-resistant state only in the presence of fasting hypertriglyceridemia

Individuals with isolated low HDL cholesterol are at increased risk of coronary artery disease. It has been reported previously that this is an insulin-resistant state. We analyzed data from the 1992 Singapore National Health Survey with the objective of defining the clinical and metabolic parameters associated with isolated low HDL cholesterol. A total of 3,568 individuals were selected by stratified random sampling. Subjects with low HDL cholesterol (<0.9 mmol/l) and "ideal" total cholesterol (<5.2 mmol/l) were identified. Data on anthropometry, blood pressure (BP), insulin resistance, glucose tolerance, sex, smoking habit, and ethnic group were examined. We found that this group was heterogeneous. Those with fasting triglyceride (TG) >1.7 mmol/l (low HDL/high TG) displayed features of the insulin resistance syndrome characterized by obesity, higher diastolic BP, greater insulin resistance, and a greater tendency to have diabetes or impaired glucose tolerance (IGT). If fasting TG was <1.7 mmol/l (isolated low HDL cholesterol), individuals were similar to the general population in terms of insulin resistance and obesity. Both groups were more commonly men and Asian Indian. The ethnic difference in prevalence could not be explained by differences in diet, exercise, alcohol ingestion, or smoking. Our data support the view that Asian Indians are genetically predisposed to isolated low HDL cholesterol as well as the insulin resistance syndrome. The higher prevalence of isolated low HDL cholesterol, the young age at which individuals exhibit this phenotype (mean age 32.5 years), along with the greater propensity for Asian Indians to develop insulin resistance and IGT contribute to the threefold increased incidence of myocardial infarction in those <65 years of age in this ethnic group.

Prevalence of diabetes and ethnic differences in cardiovascular risk factors. The 1992 Singapore National Health Survey

OBJECTIVE

The purpose of the 1992 Singapore National Health Survey was to determine the current distribution of major noncommunicable diseases and their risk factors, including the prevalence of diabetes and dyslipidemia, in Singapore.

RESEARCH DESIGN AND METHODS

A combination of disproportionate stratified sampling and systematic sampling were used to select the sample for the survey. The final number of respondents was 3,568, giving a response rate of 72.6%. All subjects fasted for 10 h and were given a 75-g glucose load, except those known to have diabetes. Blood was taken before and 2 h after the glucose load. Diagnosis of diabetes was based on 2-h glucose alone.

RESULTS

The age-standardized prevalence of diabetes in Singapore residents aged 18-69 years was 8.4%, with more than half (58.5%) previously undiagnosed. Prevalence of diabetes was high across all three ethnic groups. The prevalence of impaired glucose tolerance was 16.1%, that of hypertension was 6.5%, and 19.0% were regular smokers. The total cholesterol (mean +/- SD) of nondiabetic Singaporeans was 5.18 +/- 1.02 mmol/l; 47.9% had cholesterol > 5.2 mmol/l, while 15.4% had levels > 6.3 mmol/l. Mean LDL cholesterol was 3.31 +/- 0.89 mmol/l; HDL cholesterol was 1.30 +/- 0.32 mmol/l, and triglyceride was 1.23 +/- 0.82 mmol/l.

CONCLUSIONS

Prevalence of diabetes was high across all three ethnic groups. Ethnic differences in prevalence of diabetes, insulin resistance, central obesity, hypertension, smoking, and lipid profile could explain the differential coronary heart disease rates in the three major ethnic groups in Singapore.

Serum cholesterol and dietary fat of two populations of southern Chinese

Children in Hong Kong (HK) are the second generation of Chinese migrants from Guangdong Province and are leading a more affluent lifestyle than those in Jiangmen (JM). The association between affluence and coronary risk was investigated by comparing the serum cholesterol and dietary fat intake of children in HK and JM. Fasting serum cholesterol was examined in 94 HK children and 99 JM children, all aged seven, using the same enzymatic method by the same observer. Duplicate meals were collected in two subsamples of 20 children, one each from HK and JM and analysed for their total fat intake and fatty acid profile, again by the same observer using gravimetric methodology and gas chromatography. The mean (SD) cholesterol of HK children was 4.59 (0.83) mmol/l, significantly higher than that of JM, 4.16 (0.61) mmol/l. The daily fat intake by the HK children was 48 g, 37% higher than that of JM at 35 g. PS ratio was 0.6in HK and 0.8 in JM. Cl8-2/C14-0, the cholesterol-lowering ratio, was mostly below 10 in HK, whereas that of JM was between 10 and 40 Therefore, in order to lower the total serum cholesterol of Hong Kong children, dietary intervention to lessen total fat, in particular milk and animal fat, while moderately increasing fat consumption from vegetable sources would seem to be appropriate.

The effect of dentin bonding agents on the microleakage of porcelain veneers

OBJECTIVES

This in vitro study was conducted to investigate the effect of dentin bonding agents on the microleakage of porcelain veneers cemented on dentin margins.

METHODS

Forty human premolars were prepared on both the buccal and palatal surfaces. Each half was randomly assigned to eight groups. The veneer preparation of one group was cut entirely within enamel, to serve as controls. The remaining groups had cervical margins extending 1 mm beyond the cemento-enamel junction. Six dentin bonding agents were tested. The specimens were subjected to thermocycling and evaluated for marginal leakage using a silver nitrate stain technique. After sectioning, the extent of microleakage was measured at four interfaces: (1) incisal porcelain-composite; (2) incisal tooth-composite; (3) cervical porcelain-composite; and (4) cervical tooth-composite.

RESULTS

Statistical analysis showed that the cervical tooth-composite interface had a significantly higher leakage value (p < 0.05) than the other three interfaces when the cervical margins were in dentin.

SIGNIFICANCE

The dentin bonding agents tested did not significantly reduce the marginal leakage of the porcelain veneers cemented on dentin margins.

Ovarian cancer in Oriental women from Singapore: disease pattern and survival

A retrospective analysis of 88 ovarian tumours diagnosed over five years (1980-1984) in multi-racial Singaporean Oriental women revealed 70 (79%) epithelial tumours (ET), 17 (8%) sex cordstromal (SCS), six (7%) germ cell (GCT) and five (6%) secondary (metastatic) (SEC) cancers. The racial proportions and histological types found in the study were very similar to those of all Singaporean women in the population. Of 70 ET, 33 (47%) were stage I, five (7%) stage II, 30 (43%) stage III and two (3%) stage IV. In 97% surgical resection of primary tumour with/without removal of the uterus and opposite ovary was performed, followed by adjuvant chemotherapy in 76% and complete follow-up in 98%. The 5-year actuarial survivals in ET were in stage I 84% (low malignant potential 100% and frank carcinomas 70%), stage II 60%, stage III 29% and 0% in stage IV, whereas of the others none with SCS but four with GCT and all five with SEC died of disease. Though the incidence of ovarian cancer is much lower in Oriental than Caucasian women the proportion of different histological types, stage at presentation and survival from ovarian cancer in Oriental women does not differ from that in Caucasians.

A profile of patients with temporomandibular disorders in Singapore--a descriptive study

This is a descriptive study to establish the profile of 120 consecutive patients seeking relief from symptoms and dysfunction of the masticatory system at the Dental Clinic, Singapore General Hospital from February 1988-September 1988. The mean age of the patients was 29.4 years and females outnumber males by 2:1. The patients complained of TMJ clicking (66%), TMJ pain (55%), painful chewing (47%), headaches (42%), painful opening (37%), jaw locking (33%), and jaw muscle pain (23%). The possible etiological factors were recorded: macrotrauma (27%), stressful episodes (24%), unilateral mastication (53%), clenching (28%), grinding (26%) and excessive chewing habits (10%). Unilateral chewing was significantly associated with pain on opening (p less than 0.05) and joint pain (p less than 0.05). A statistical relationship was found between night grinding and laterotrusive wear of teeth (p less than 0.001). There was evidence that tension headache reported by TMD sufferers was related to temporalis muscle/tendon dysfunction (p less than 0.001).

Wilson's disease revisited in the tropics

The clinical features and investigations of 17 patients were analysed. Thirteen of them were Chinese and the rest Indians. Their ages at presentation ranged from 8 to 63 years (mean 18.35 years). Thirteen patients (76%) were symptomatic; 8 with predominantly hepatic manifestations and 5 with neurological features. Four were asymptomatic siblings. At diagnosis, however, 10(59%) had features of liver involvement singly, 3 (18%) had neurological involvement alone and 4 (27%) had mixed presentations. Family histories were available in 15 patients; 26.9% of siblings had Wilson's Disease. Serum ceruloplasmin was low in 82% of the patients. 24-hour urinary copper was measured in 16 patients and was raised in all of them. About half the patients (41%) had evidence of concomittant renal tubular dysfunction with hypouricaemia and aminoaciduria. Three patients (18%) had joint involvement at presentation. All 17 patients were treated with Penicillamine. Complications due to therapy included pemphigus in one and toxic epidermal necrolysis and later a lupus like syndrome in another. The features of clinical improvement included fading of K-F rings, improvement of neurological signs and the normalisation of serum transaminases. One patient developed primary hepatocellular carcinoma 5 years after presentation. Delay in diagnosis was encountered in half of the patients reviewed. Being a treatable condition, Wilson's Disease, although rare, should always be thought of in patients with haemolysis, liver diseases or extrapyramidal disorders.

Insulin secretory capacity in Singapore diabetic subjects

The determination of serum C-peptide has been found to be a sensitive indicator of endogenous insulin secretion, and serves to define diabetic patients who require insulin therapy i.e., insulin-dependent (Type I, IDDM) and those non-insulin dependent (Type II, NIDDM). The aim of our study is to establish the types of diabetes mellitus with C-peptide measurement in a group of diabetic subjects on different modes of therapy. Eighty-eight diabetic patients (60 males, 28 females) were studied. Thirty-four were on insulin (age 40 +/- 2 years; means +/- SEM), 35 on oral agents (54 +/- 1 years), and 19 on diet alone (46 +/- 3 years). Twenty healthy subjects (10 males, 10 females) serve as normal controls (37 +/- 3 years). Blood samples for serum C-peptide and blood glucose estimations were obtained after an overnight fast and one hour after a 75 grams oral glucose load. Fasting C-peptide levels obtained for the various groups were: 0.62 +/- 0.07 (nmol/L, means +/- SEM) (normal), 0.16 +/- 0.02 (insulin), 0.79 +/- 0.06 (oral), 2.15 +/- 0.15 (diet). The C-peptide values after oral glucose were 1.80 +/- 0.20 (normal), 0.23 +/- 0.05 (insulin), 1.72 +/- 0.02 (oral), 2.15 +/- 0.15 (diet). Both the fasting and post-glucose C-peptide concentrations were significantly lower (p less than 0.001) in the insulin group compared to the normals, whereas values for the diet and oral groups were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

Pyogenic hepatic abscess and diabetes mellitus--a probable association

Four patients with pyogenic hepatic abscesses are reported. There were three females and one male with an age range of 36-75 years. In all the cases, diabetes mellitus was associated. Confirmation of the abscesses was obtained by liver scanning or ultrasonography, or both. In one patient, the clinical course was complicated by sympathetic pericardial effusion with right heart failure. Two patients had percutaneous transhepatic drainage of the abscesses under fluoroscopy. All four patients eventually required laparotomy and open drainage of the abscesses. Diabetic control was achieved with insulin therapy. The common causative organism in all instances was the Klebsiella species. Three patients recovered. The remaining one developed hypotension post-operatively and died of brain-stem infarction and the hepato-renal syndrome.

Epidemiology of diabetes mellitus in Singapore: comparison with other ASEAN countries

Singapore is a tropical island city-state with a population of 2.4178 million consisting of Chinese (76.7%), Malays (14.7%), Indians (6.4%) and other races (2.2%). A diabetic survey of the adult population, aged 15 years and above, carried out in 1975, shows that the prevalence of diabetes is 1.99%; it is higher in males (2.36%) than in females (1.64%). It occurs mainly in the age group 40 years and above (5.08%) and is uncommon in the age group 15-39 years (0.40%). In males, the highest prevalence of diabetes (7.0%) is in the age group 45-49 years while in females the highest prevalence (7.2%) is in the age group 55-59 years. 43.3% of the diabetics are of normal weight while 44.3% are overweight and 12.4% are underweight. 59.6% of the diabetics are newly diagnosed while 40.4% are known diabetics; 64.3% of the newly diagnosed diabetics have no symptoms. The prevalence of diabetes among the Indians (6.07%) is significantly higher than that in Malays (2.43%) and Chinese (1.55%). Indian diabetics have a slightly higher positive family history of diabetes (12.7%) than Malays (10.9%) and Chinese (6.5%). Obesity is commoner in Malay diabetics (64.7%) than in Chinese (41.6%) and Indians (35.7%). The possible factors leading to the significantly higher prevalence of diabetes among the Indians compared to the other ethnic groups in Singapore are discussed. It is suggested that the Indian gene is susceptible to diabetes (diabetic genotype) and increased food consumption, altered lifestyle and greater obesity leads to the expression of diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

Home blood glucose monitoring, glycaemic control and diabetic complications

The aim of this study was to evaluate the effect of home blood glucose monitoring on diabetic complications and metabolic control. Forty Chinese and Indian patients participated in the Diabetic Society of Singapore National Home Blood Glucose Monitoring (HBGM) Programme. The clinical progress, the blood glucose and glycosylated haemoglobin concentrations, and the platelet aggregation of the aforementioned patients were studied over a 6-month period; the results were compared with those from a matched, albeit smaller, control group of 18 diabetic patients who were on treatment but not in the HBGM programme. At the end of the six month period, three patients in the control group showed clinical deterioration of peripheral neuropathy in contrast to one patient on HBGM. Due to the small number of patients, the difference in the findings was not statistically significant. Patients on HBGM demonstrated significant improvement in mean grouped blood glucose profile values, 135 +/- 8 to 118 +/- 5 mg/dl, p less than 0.01, and glycosylated haemoglobin levels, 10.3 +/- 0.4 to 9.3 +/- 0.3%, p less than 0.01. The platelet aggregability was unchanged. In contrast, patients in the control group developed a significant increase in platelet aggregation (30 +/- 4% to 37 +/- 5%, p less than 0.05), although the blood glucose and glycosylated haemoglobin concentrations were not significantly altered. This study demonstrated that patients on a six-month HBGM programme were able to achieve improved glycaemic control associated with a trend towards decreased deterioration of diabetic neuropathy and platelet aggregability.

Infective endocarditis in Singapore: a six year survey

Much has been written about the changing clinical spectrum of infective endocarditis. However our survey shows that the classical text book descriptions still hold good. The majority of our patients were young with 79% either 30 years or below. Fever was present in 93%, splenomegaly in 50% and cerebral embolism in 43% of our patients. Twelve patients had valvular heart disease and 2 patients had a ventricular septal defect. Eleven out of 14 patients had a positive blood culture. Echocardiography detected definite or probable vegetations in 66% of the examinations. Five patients responded satisfactorily to antibiotic therapy, 2 patients discharged themselves from hospital against medical advice, and 4 patients underwent successful cardiac surgery. Three patients died during medical therapy.