Ventilating my thoughts on severe asthma exacerbations

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A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2

SUMMARY

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death.

RECOMMENDATIONS

Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.

Parental perspectives towards sugar-sweetened beverages and polices: a qualitative study

PURPOSE

This qualitative study aimed to understand parental perception of (1) sugar-sweetened beverages (SSB) and implications of SSB on health; (2) their role in shaping their children's consumption of SSB; (3) the influences on SSB consumption of their children; and (4) potential government policies targeted at controlling SSB consumption.

METHODS

English-speaking parents of pre-schoolers aged 2-6 years were recruited. Semi-structured interviews based on the knowledge, attitude, practice framework were conducted, and transcripts were subjected to thematic analysis based on inductive approaches. Recruitment continued until data saturation was reached.

RESULTS

Twenty parents participated in the study and themes addressing the objectives identified. (1) There were misconceptions regarding the healthfulness of certain non-packaged SSB such as traditional remedies and juices. Some were unaware about the association between SSB and dental caries. (2) The need to reduce and restrict sugar consumption for overall and oral health reasons was well-recognised, but the extent of control varied. (3) Multiple stakeholders including pre-schools, grandparents and domestic helpers were involved in shaping children's diet. Children's sugar intake was also influenced by environmental factors, such as the ubiquitously available SSB, targeted marketing and high cost of healthy alternatives. (4) Participants were less accepting towards SSB taxation than the ban of SSB sales.

CONCLUSION

Despite the awareness of the types of SSBs and the general/oral health implications of sugar consumption, misconceptions exist. Although most parents possessed the knowledge and attitude, this did not translate into the practice of reducing sugar consumption in their children. There was no SSB reduction policy that had overwhelming acceptability.

Subgingival Microbiota during Healthy Pregnancy and Pregnancy Gingivitis

INTRODUCTION

Previous studies have largely explored the microbial composition and pathogenesis of pregnancy gingivitis. However, the patterns of microbial colonization during pregnancy in the absence of pregnancy gingivitis have rarely been studied. Characterization of the oral microbiome in pregnant women with healthy gingiva is an important initial step in understanding the role of the microbiome in progression to pregnancy gingivitis.

OBJECTIVES

In this study, we compared the oral microbiome of pregnant women without gingivitis (healthy pregnancy) with pregnant women having gingivitis and nonpregnant healthy women to understand how pregnancy modifies the oral microbiome and induces progression to pregnancy gingivitis.

METHODS

Subgingival plaque samples were collected from Chinese pregnant women with gingivitis (n = 10), healthy pregnant women (n = 10), and nonpregnant healthy women (n = 10). The Illumina MiSeq platform was used to perform 16S rRNA gene sequencing targeting the V4 region.

RESULTS

The alpha and beta diversity was significantly different between pregnant and nonpregnant women, but minimal differences were observed between pregnant women with and without gingivitis. Interestingly, the oral bacterial community showed higher abundance of pathogenic taxa during healthy pregnancy as compared with nonpregnant women despite similar gingival and plaque index scores. However, when compared with overt pregnancy gingivitis, pathogenic taxa were less abundant during healthy pregnancy. PICRUSt analysis (phylogenetic investigation of communities by reconstruction of unobserved states) also suggested no difference in the functional capabilities of the microbiome during pregnancy, irrespective of gingival disease status. However, metabolic pathways related to amino acid metabolism were significantly increased in healthy pregnant women as compared with nonpregnant women.

CONCLUSION

The presence of pathogenic taxa in healthy pregnancy and pregnancy gingivitis suggests that bacteria may be necessary for initiating disease development but progression to gingivitis may be influenced by the host environmental factors. More efforts are required to plan interventions aimed at sustaining health before the appearance of overt gingivitis.

KNOWLEDGE TRANSFER STATEMENT

The results of this study draw attention to the importance of oral health maintenance during pregnancy, as women without any prenatal oral conditions are predisposed to the risk of developing pregnancy gingivitis. Hence, it is important to incorporate comprehensive assessment of oral health in the prenatal health care schedules. Pregnant woman should be screened for oral risks, counseled on proper oral hygiene and expected oral changes, and referred for dental treatment, when necessary.

Short-term antidepressant treatment has long-lasting effects, and reverses stress-induced decreases in bone features in rats

Antidepressants are among the most-prescribed class of drugs in the world and though weight gain is a common outcome of antidepressant treatment, that effect is not well understood. We employed an animal model comprised of 2 weeks of chronic restraint stress with antidepressant treatment, followed by diet-induced obesity. We showed that short-term antidepressant treatment had long-lasting effects, not only leading to weight gain, but also enhancing trabecular and cortical bone features in rats; therefore, weight gain in this model was different from that of the classic diet-induced obesity. Late in the post-restraint recovery period, antidepressant-treated animals were significantly heavier and had better bone features than saline-treated controls, when assessed in the distal femoral metaphysis. The propensity to gain weight might have influenced the rate of catch-up growth and bone allometry, as heavier animals treated with fluoxetine also had enhanced bone features when compared to non-stressed animals. Therefore, short-term antidepressant treatment ameliorated the long-term effects of stress on body growth and bone. Growth and bone structural features were associated with leptin levels, and the interaction between leptin levels and antidepressant was significant for bone mineral content, suggesting that short-term antidepressants in the context of long-term diet-induced obesity modified the role of leptin in bone formation. To our knowledge this is the first study reporting that short-term antidepressant treatment has long-lasting effects in restoring the effects of chronic stress in body weight and bone formation. Our findings may be relevant to the understanding and treatment of osteoporosis, a condition of increasing prevalence due to the aging population.

APOE*E2 allele delays age of onset in PSEN1 E280A Alzheimer's disease

Alzheimer's disease (AD) age of onset (ADAOO) varies greatly between individuals, with unique causal mutations suggesting the role of modifying genetic and environmental interactions. We analyzed ~50 000 common and rare functional genomic variants from 71 individuals of the 'Paisa' pedigree, the world's largest pedigree segregating a severe form of early-onset AD, who were affected carriers of the fully penetrant E280A mutation in the presenilin-1 (PSEN1) gene. Affected carriers with ages at the extremes of the ADAOO distribution (30s-70s age range), and linear mixed-effects models were used to build single-locus regression models outlining the ADAOO. We identified the rs7412 (APOE*E2 allele) as a whole exome-wide ADAOO modifier that delays ADAOO by ~12 years (β=11.74, 95% confidence interval (CI): 8.07-15.41, P=6.31 × 10(-8), PFDR=2.48 × 10(-3)). Subsequently, to evaluate comprehensively the APOE (apolipoprotein E) haplotype variants (E1/E2/E3/E4), the markers rs7412 and rs429358 were genotyped in 93 AD affected carriers of the E280A mutation. We found that the APOE*E2 allele, and not APOE*E4, modifies ADAOO in carriers of the E280A mutation (β=8.24, 95% CI: 4.45-12.01, P=3.84 × 10(-5)). Exploratory linear mixed-effects multilocus analysis suggested that other functional variants harbored in genes involved in cell proliferation, protein degradation, apoptotic and immune dysregulation processes (i.e., GPR20, TRIM22, FCRL5, AOAH, PINLYP, IFI16, RC3H1 and DFNA5) might interact with the APOE*E2 allele. Interestingly, suggestive evidence as an ADAOO modifier was found for one of these variants (GPR20) in a set of patients with sporadic AD from the Paisa genetic isolate. This is the first study demonstrating that the APOE*E2 allele modifies the natural history of AD typified by the age of onset in E280A mutation carriers. To the best of our knowledge, this is the largest analyzed sample of patients with a unique mutation sharing uniform environment. Formal replication of our results in other populations and in other forms of AD will be crucial for prediction, follow-up and presumably developing new therapeutic strategies for patients either at risk or affected by AD.

COPD: What the anaesthetist should know

No abstract available.

Can MRI replace CT in evaluating semicircular canal dehiscence?

BACKGROUND AND PURPOSE

Patients with symptoms of semicircular canal dehiscence often undergo both CT and MR imaging. We assessed whether FIESTA can replace temporal bone CT in evaluating patients for SC dehiscence.

MATERIALS AND METHODS

We retrospectively reviewed 112 consecutive patients (224 ears) with vestibulocochlear symptoms who underwent concurrent MR imaging and CT of the temporal bones between 2007 and 2009. MR imaging protocol included a FIESTA sequence covering the temporal bone (axial 0.8-mm section thickness, 0.4-mm spacing, coronal/oblique reformations; 41 patients at 1.5T, 71 patients at 3T). CT was performed on a 64-row multidetector row scanner (0.625-mm axial acquisition, with coronal/oblique reformations). Both ears of each patient were evaluated for dehiscence of the superior and posterior semicircular canals in consensual fashion by 2 neuroradiologists. Analysis of the FIESTA sequence and reformations was performed first for the MR imaging evaluation. CT evaluation was performed at least 2 weeks after the MR imaging review, resulting in a blinded comparison of CT with MR imaging. CT was used as the reference standard to evaluate the MR imaging results.

RESULTS

For SSC dehiscence, MR imaging sensitivity was 100%, specificity was 96.5%, positive predictive value was 61.1%, and negative predictive value was 100% in comparison with CT. For PSC dehiscence, MR imaging sensitivity was 100%, specificity was 99.1%, positive predictive value was 33.3%, and negative predictive value was 100% in comparison with CT.

CONCLUSIONS

MR imaging, with a sensitivity and negative predictive value of 100%, conclusively excludes SSC or PSC dehiscence. Negative findings on MR imaging preclude the need for CT to detect SC dehiscence. Only patients with positive findings on MR imaging should undergo CT evaluation.

Theory and action for effective condom promotion: illustrations from a behavior intervention project for sex workers in singapore

Acquired immunodeficiency virus (AIDS) and sexually transmitted diseases (STD) control programs targeted at sex workers have focused on condom use. Reasons for non-condom use among female brothel-based sex workers in Singapore were found to be low self-efficacy, lack of condom negotiation skills, and barriers such as fear of annoying clients. Green's PRECEDE framework and Bandura's self-efficacy theory were applied to develop a project aimed at equipping sex workers with negotiation skills, overcoming barriers to condom use, and gathering support from brothel keepers and peers. The experimental group showed significant improvements in negotiation skills and outcome behavior of always refusing sex without a condom, that were supported by a decline in gonorrhea incidence. This article describes the application of behavior change and health education theories to achieve reduction in gonorrhea risk.

Enzyme replacement therapy for mucopolysaccharidosis VI (Maroteaux-Lamy syndrome): experience in Hong Kong

Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome) is a very rare inherited lysosomal storage disease. We evaluated the efficacy and safety of weekly infusions of recombinant human arylsulfatase B as enzyme replacement therapy for two patients in whom this condition was advanced. The primary outcome variables were the distance walked in a 6-minute walk test, forced vital capacity, and ejection fraction. The secondary outcome variables were the number of stairs climbed in a 3-minute stair climbing test, joint mobility, urinary glycosaminoglycan excretion, auto-continuous positive airway pressure study and liver size. After 24 weeks of treatment, patient A walked 40 m (36%) and patient B walked 66 m (58%) more in the walk test than at baseline. After 48 weeks, in patient A the corresponding improvements were 142 m (129%) in the walk test and 33 stairs (60%) in the 3-minute stair climbing test, and in patient B the respective improvements were 198 m (174%) and 77 stairs (140%). There was a significant decline in urinary glycosaminoglycan excretion and improvement in range of motion of joints in both patients. The auto-continuous positive airway pressure study revealed improvements in patient A, while other efficacy variables remained static. There were no drug-related adverse events or allergic reactions reported during and after the infusions of recombinant human arylsulfatase B. Recombinant human arylsulfatase B significantly improves endurance and reduces urinary glycosaminoglycan excretion. The drug is generally safe and well tolerated.

A qualitative study on HPV vaccination from a nursing perspective in Hong Kong

OBJECTIVE

To identify the perception on human papillomavirus (HPV) vaccination among female nursing students in Hong Kong.

DATA SOURCES

Data were collected through focus group discussions and semi-structured in-depth interviews. All participants (n=28) were female nursing students of a university in Hong Kong. Tape recordings of individual interviews and focus group discussions were transcribed verbatim in Chinese, translated into English, and analyzed according to Colaizzi's phenomenological analysis.

STUDY DESIGN

Four major themes emerged from the data: nursing students' understanding about HPV vaccine, nursing students' attitude on HPV vaccine, nursing students' perspective on HPV vaccination promotion, and nursing role on HPV vaccination.

CONCLUSIONS

Government should take initiative in promotion with vaccine suppliers. The awareness and knowledge of HPV and HPV vaccination among women should be increased in order to raise the positive attitude of women towards HPV vaccination and prevention of cervical cancer. Health professionals should work together on HPV promotion among women and increase the HPV vaccination rates. Moreover, further studies regarding attitude and awareness of HPV vaccination among women in different age groups are needed in order to identify more associated factors affecting their perceptions towards HPV vaccination.

Brain-derived neurotrophic factor gene polymorphisms and mirtazapine responses in Koreans with major depression

Brain-derived neurotrophic factor (BDNF) is a candidate molecule for influencing the clinical response to antidepressant treatment. The aims of this study were to determine the relationship between the Val66Met polymorphism in the BDNF gene and the response to mirtazapine in 243 Korean subjects with major depressive disorder (MDD). The reduction in the Hamilton Depression score over the 8-week treatment period was not influenced by BDNF V66M genotypes. A marginal effect of genotype on somatic anxiety score was observed at baseline (P = 0.047 in the dominant model). However, genotype-time interaction had no effect on somatic anxiety score after the 8-week a treatment period. Plasma BDNF levels tended to increase during mirtazapine treatment, although without statistical significance (P = 0.055). After 8 weeks of mirtazapine treatment, plasma BDNF levels were higher in Met allele homozygotes (1499.7 ± 370.6 ng/mL) than in Val allele carriers (649.7 ± 158.5 ng/mL, P = 0.049). Our results do not support the hypothesis that the Val66Met promoter polymorphism in the BDNF gene influences the therapeutic response to mirtazapine in Korean MDD patients. However, our data indicate that this polymorphism results in increased plasma BDNF after mirtazapine treatment.

Is the worldwide epidemic of obesity a communicable feature of globalization?

Globalization has a major impact on both economic and social determinants in public health. The current worldwide epidemic in obesity needs to be considered in the context of globalization as a communicable rather than non-communicable process. There is increasing evidence that global trends in lifestyle, eating behavior and cultural adaptation contribute to the rapid increase in obesity around the world. Thus, obesity may be defined as a "socially-contagious" feature of globalization. Furthermore, infectious agents are being identified that may cause obesity by central mechanisms or by modulating adipocyte function or at least by contributing to the chronic inflammatory milieu of the metabolic syndrome. Therefore, globalization may indeed form a critical platform for these pathogens to fuel the obesity epidemic. Understanding obesity in the light of globalization as a communicable disorder will allow outlining better avenues of prevention and treatment.

Tuberculosis culture testing at a tertiary care hospital: options for improved management and use for treatment decisions

SETTING

Chris Hani Baragwanath Hospital, a tertiary care hospital in Johannesburg, South Africa.

OBJECTIVES

To determine the proportion of patients with positive Mycobacterium tuberculosis cultures and whether those who were positive were on treatment.

DESIGN

Tuberculosis (TB) culture results were obtained from the laboratory for a 3-month period. Positive results were checked against registrations at the hospital TB Care Centre (TBCC). The treatment status of non-registered patients was obtained from various records at the hospital, district clinics and from home visits.

RESULTS

Overall, 3909 patients had 5404 samples sent for culture. Of these, 708 patients (18%) had at least one positive culture. The positive yield from 2749 adult sputum samples was 33% and ranged from 6% to 40% for different extra-pulmonary specimens. Among 1160 children, the yield varied from 0% to 12%, with 12% in sputum and gastric washing specimens. Of the 708 culture-positive patients, 429 (61%) patients were registered at the TBCC and were known to have started TB treatment. Of the 279 subjects not registered (39% overall), 100 (36%) died. Only 67 of the 179 survivors were confirmed on treatment, 40 were not on treatment and 72 could not be traced.

CONCLUSIONS

Large numbers of TB culture tests were performed, some inappropriately. Study findings highlight inadequacies in the management of culture-confirmed TB at this hospital.

Framingham Risk Scores and Anthropometric Measurements in Predicting Cardiovascular Risks among Malay Men

Framingham Risk Scores is an established method to predict an individual's 10-year risk for coronary heart disease (CHD). It provides a more precise delineation of risk which might lead to appropriate selection of therapy and opportunities for patient education and motivation. A Healthy Lifestyle Project was initiated to decrease the modifiable risk factors for CHD in a worksite in Kuala Lumpur. The participants were Malay men (n=186) working as security guards in a public university. Their mean age was 46.6 + 6.6 years. The majority had secondary education and were married. The participants' 10-year risks based on the Framingham Risk Scores were 55.4%, 39.8% and 4.8% respectively for categories of low (< 10%), intermediate (10 to 20%) and high (>20%) risk. Their Framingham Risk Scores were then correlated with anthropometric measurements such as the Body Mass Index (BMI), waist circumference and waist-hip-ratio (WHR). All the anthropometric measurements had weak but significant correlation with the Framingham Risk Scores (WHR: r=0.26; waist circumference: r=0.23; BMI: r=0.16). In conclusion, 44.6% of our participants had more than 10% risk in developing CHD in the coming ten years. Hence, they are suitable target candidates for the promotion of a healthy lifestyle such as smoking cessation, weight control, healthy dietary patterns and increased physical activities. Indicators of abdominal obesity like WHR or waist circumference may be used to complement the Framingham Risk Scores for the prediction of CHD risk in this population.

Cryptococcal pneumonia in African miners at autopsy

SETTING

Deceased miners from South Africa whose cardiorespiratory organs were submitted for autopsy for compensation for occupational lung diseases from 1996 to 2000.

OBJECTIVES

To 1) calculate the prevalence of cryptococcal pneumonia in 8421 autopsied miners, a population with a high prevalence of human immunodeficiency virus (HIV) infection; 2) document the association of cryptococcal pneumonia with other pulmonary infection; 3) document the association of cryptococcal pneumonia with a clinical diagnosis of cryptococcal meningitis; and 4) determine the accuracy of the clinical diagnosis of cryptococcal pneumonia.

DESIGN

Case series of 589 black miners with histological evidence of cryptococcal pneumonia at autopsy, defined as the presence of cryptococcal organisms in the lung parenchyma, identified by staining of the mucinous capsule.

RESULTS

The incidence of cryptococcal pneumonia at autopsy was 7%. Ninety-seven of the 589 cases (16.5%) had a concomitant respiratory infection, most commonly Pneumocystis jirovecii pneumonia (51.5%), followed by mycobacterial infection (42.3%). In life, cryptococcal meningitis was diagnosed in 46.9% and cryptococcal pneumonia in only 2.7%.

CONCLUSION

Although tuberculosis remains the most common HIV-associated respiratory disease in Africa, it is important to consider the diagnosis of cryptococcal pneumonia in acquired immune-deficiency syndrome (AIDS) patients, and to bear in mind the possibility of dual pathology.

Fetal myocardial performance in pregnancies complicated by gestational impaired glucose tolerance

OBJECTIVE

To determine fetal myocardial performance in pregnancies complicated by mild gestational impaired glucose tolerance (GIGT).

METHODS

Ultrasound examinations were performed in 37 pregnant women with mild GIGT (36 did not require insulin) and in 44 controls at 18-24, 26-30 and 34-37 weeks of gestation. The thickness of the fetal ventricular walls and interventricular septum were measured by M-mode echocardiography. Using conventional Doppler echocardiography, the mitral and tricuspid early (E) and late (A) diastolic velocities and the ventricular myocardial performance index (MPI) were determined.

RESULTS

The fetuses of women with GIGT had a greater abdominal circumference (P = 0.02), a larger amniotic fluid index (P = 0.03), and a tendency to be heavier (P = 0.058) at the third scan. There were no significant differences in myocardial thickness, mitral and tricuspid E and A velocities, and E/A ratios between study and control groups. The left and right ventricular MPIs, while similar between the two groups in the first and second scans, had decreased significantly by late gestation in the GIGT fetuses (P for trend = 0.018 and 0.014, respectively) and were significantly lower than those of the control group (P = 0.002 and 0.0008, respectively).

CONCLUSIONS

Fetuses of women with mild GIGT lack the ventricular hypertrophy and diastolic dysfunction that is common in fetuses of diabetic mothers, and they have a decreased MPI late in gestation. Published by John Wiley & Sons, Ltd.

An epidemiological and knowledge, attitudes, beliefs and practices study of sexually transmitted infections in older men

INTRODUCTION

This study was conducted to determine the disease patterns of sexually transmitted infections (STI) in older men, as well as to gather information on their knowledge, attitudes, beliefs and sexual practices.

METHODS

A prospective study was carried out from January to June 2005 in men aged 50 years or older who attended the Department of STI Control clinic.

RESULTS

There were 104 men enrolled. The majority (92.3 percent) were Chinese, and 62.5 percent were aged between 50 and 59 years, 25.9 percent between 60 and 69 years, and 11.5 percent aged 70 years or older. The patients were predominantly heterosexual, and had fairly low levels of education--85.6 percent of the patients had received primary or secondary school level of education. Majority (79.8 percent) of the men had been sexually active in the preceding six months, and 37.3 percent had paid sex during that time. 29.8 percent of men reported having taken drugs such as sildenafil (Viagra, Pfizer, New York, NY, USA) or similar drugs such as vardenafil (Levitra, Bayer, Wuppertal, Germany) or tadalafil (Cialis, Eli Lilly, Indianapolis, IN, USA). 56.7 percent of the men had active infections, with non-gonococcal urethritis (15.4 percent), genital warts (12.5 percent) and gonorrhoea (10.6 percent) being the commonest. Generally, condom usage was accepted as an effective way to prevent transmission of STI. However, many of the men surveyed felt that condom usage reduced their sexual pleasure, and 38.5 percent felt that condoms were inconvenient. There were also areas of human immunodeficiency virus (HIV) knowledge that were lacking. Most patients listed the media as their main source of knowledge about STI and HIV.

CONCLUSION

Older males attending the clinic remain at significant risk of STI and targeted educational efforts are warranted.

Tuberculosis at Chris Hani Baragwanath Hospital: an intervention to improve patient referrals to district clinics

SETTING

A study in 2001 described the process of managing tuberculosis (TB) at Chris Hani Baragwanath hospital, the numbers of patients diagnosed and poor outcomes of referring patients to clinics in the adjacent sub-districts. The present study describes and evaluates an intervention to address the problems.

OBJECTIVES

To describe the intervention process (education and referral of TB patients) and the subsequent results over a 2-year period from 2003 to 2005.

METHODS

The process of establishing the system and how it was evaluated at district clinics in Johannesburg are described.

RESULTS

In the first 2 years of operation, August 2003 to July 2005, 13,138 patients were registered. Extra-pulmonary tuberculosis (EPTB) was diagnosed in 34%. Of the 46% tested for human immunodeficiency virus (HIV), 93% were positive. Successful referral to clinics was achieved for 94% of patients.

CONCLUSIONS

Very large numbers of patients are diagnosed with TB at Chris Hani Baragwanath Hospital. A TB care centre has successfully addressed important referral, education and registration requirements for the comprehensive management of TB with links to clinics. It is suggested that this model be applied at other hospitals.

Seroprevalence of HSV-1 and 2 among sex workers attending a sexually transmitted infection clinic in Singapore

We studied the seroprevalence of herpes simplex virus (HSV)-1 and 2 in sex workers attending a sexually transmitted infection clinic in Singapore and examined their knowledge and attitudes towards HSV infection. A total of 300 participants were recruited. Questionnaires were administered and blood was taken and analysed, using the HerpeSelect 1 and 2 Elisa IgG assays (type-specific serological test). HSV-1 serology was positive in 230 (76.7%), negative in 67 (22.3%) sex workers and indeterminate in three (1.0%) sex workers. HSV-2 serology was positive in 237 (79.0%) and negative in 63 (21.0%) sex workers. On univariate analysis, there was significant association between HSV-2 seropositivity and increasing age, nationality (locals) (P<0.001) and marital status (P<0.01). Adjusting for age, marital status and condom use, HSV-2 prevalence increased significantly with duration of years of practice of sex work. Most of the respondents (86.0%) were aware that HSV could be spread through sex without a condom and about two-thirds of them were aware that HSV could be spread in the absence of symptoms. In conclusion, HSV-2 is a common infection among sex workers in Singapore with the risk increasing with years of practice.

Pneumocystis jirovecii pneumonia in African miners at autopsy

SETTING

Deceased miners from South Africa whose cardio-respiratory organs were submitted for autopsy for compensation for occupational lung diseases from 1996 to 2000.

OBJECTIVES

1) To document the incidence of Pneumocystis jirovecii pneumonia (PJP) in autopsied miners; 2) to compare the incidence of PJP over a 5-year period; 3) to record the incidence of concomitant lower respiratory tract infection in a group of PJP-infected deceased miners coming to autopsy from 1996 to 2000; and 4) to describe the accuracy of the in-life diagnosis of PJP in this group.

DESIGN

Case series of 328 deceased Black miners with histological evidence of PJP at autopsy.

RESULTS

Of the 328 miners with PJP at autopsy, 107 (32.6%) had a concomitant respiratory infection, the most common being cryptococcal pneumonia (46.7%), followed by bacterial pneumonia (34.6%) and pulmonary tuberculosis (13.1%). Overall, Pneumocystis pneumonia was unsuspected prior to death in 89% of cases; however, diagnostic accuracy in life improved from 7% in 1996 to 21% in 2000.

CONCLUSION

The high rate of undiagnosed PJP is cause for concern. Clinicians should have a heightened awareness for PJP in Africa, particularly as the disease is treatable at low cost and effective prophylaxis is available.

Teaching community, occupational and family medicine at the National University of Singapore: past, present and future

INTRODUCTION

We describe how the curriculum of community, occupational and family medicine (COFM) has evolved in response to social and educational forces and local health needs. Challenges in the teaching of the curriculum are also discussed.

CURRICULUM

The COFM Department aims to produce medical undergraduates and graduates with the skills to critically appraise evidence, prevent and manage diseases, and promote health in the community and primary healthcare setting. Its teaching programmes consist of the medical undergraduate programme and the Master of Medicine programmes in Occupational Medicine, Public Health and Family Medicine. The undergraduate modules consist of evidence-based medicine, public health in the community, disease prevention and control, occupational medicine practice, health promotion and behaviour, and communication with patients. The university's first completely online module on SARS was jointly implemented by the Department and the Centre for Instructional Technology for the entire student population last year. The COFM curriculum has shifted from giving students factual information through lectures to developing students' critical thinking and problem-solving skills through small group teaching, case studies and community health projects. Innovative assessment methods such as open-book examinations; objective structured communication stations with simulated patients; and evaluation of students' participation in group work are used to assess students' skills in problem-solving, communication and teamwork respectively.

CONCLUSION

While the Department has made significant progress in developing a relevant and updated curriculum based on appropriate learning and assessment approaches, it will strive to do more to develop students' critical thinking skills by using newer approaches.

Tuberculosis at Chris Hani Baragwanath Hospital: numbers of patients diagnosed and outcomes of referrals to district clinics

SETTING

Chris Hani Baragwanath Hospital, in Johannesburg. South Africa is experiencing a serious epidemic of tuberculosis (TB), with a measured rate of 500 cases per 100,000 population. Patients in public hospitals are referred for treatment to district clinics or to specific TB hospitals.

OBJECTIVES

To measure numbers of patients diagnosed with TB, and to describe the type of disease and referral outcomes.

METHODS

A descriptive study of patients diagnosed with TB in a tertiary hospital. Data in patient files were collected for medical and paediatric patients, and patients were interviewed by researchers who visited clinics to check if referred patients had attended.

RESULTS

In the 8-week study period, 1291 patients were diagnosed with TB: 74% had pulmonary disease and 80% of those tested for HIV were positive; 19% died in hospital, and 21% required transfer to a TB hospital. Only half of the patients referred to clinics attended within 2 weeks.

CONCLUSIONS

Patients with advanced TB are commonly seen at this hospital. Notifications were an inadequate record and an unacceptable proportion of patients were lost between hospital and clinics. This study has recommended that opportunities for education and discussion must be provided if patients are to reach clinics successfully.

Genotype C hepatitis B virus infection is associated with an increased risk of hepatocellular carcinoma

BACKGROUND

Identification of risk factors for the development of hepatocellular carcinoma (HCC) is important for HCC surveillance in chronic hepatitis B virus (HBV) infection. Our aim was to study the independent risk factors and effect of HBV genotypes on HCC development in a prospective longitudinal cohort of chronic hepatitis B patients.

PATIENTS AND METHODS

Chronic hepatitis B patients recruited since 1997 were prospectively followed up for the development of HCC. HCC was diagnosed by a combination of alpha fetoprotein, imaging, and histology. Liver cirrhosis was defined as ultrasonic features of cirrhosis together with hypersplenism, ascites, varices, and/or encephalopathy.

RESULTS

In total, 426 patients were followed up for 1664 person years; median 225 (range 12-295) weeks. Forty nine (11%) patients had underlying clinical liver cirrhosis. A total of 242 (57%) and 179 (42%) patients had HBV genotypes C and B, respectively. Twenty five patients developed HCC in a median follow up of 121 (range 14-236) weeks. The overall incidence of HCC was 1502 cases per 100 000 person years. On multivariate analysis, clinical liver cirrhosis and HBV genotype C infection were independently associated with HCC development, with an adjusted relative risk of 10.24 (95% confidence interval (CI) 4.39-23.89; p<0.001) and 2.84 (95% CI 1.05-7.72; p = 0.040), respectively. Patient age, sex, hepatitis B e antigen (HBeAg) status, alanine aminotransferase (ALT) levels, and basal core promoter mutations did not predict HCC development. Patients infected with HBV genotype C tended to have persistently positive HBeAg or fluctuating HBeAg status and higher ALT levels during the follow up period.

CONCLUSION

Genotype C HBV infection is an independent risk factor for HCC development in addition to liver cirrhosis.

Willingness to donate blood samples for genetic research: a survey from a community in Singapore

Studies on the public's willingness to donate blood specimens for genetic research are few and are conducted mainly among Western countries. Little is known about the Asian community's willingness to participate in genetic research. A community-based survey was conducted on 548 adult Singaporeans to examine their willingness to donate blood samples for genetic research and its associated factors. The response rate was 70.3%. About 49.3% (95% CI, 45.1-53.5%) were willing to donate blood for genetic research. In the multivariable Cox regression analysis, willingness was significantly associated with belief in the benefits of genetic research; intention to participate in government studies; having no fear of pain, blood, injections, and needles; and non-concern about the loss of confidentiality. Reasons against donating blood were fear of pain, blood, injections, and needles (38.1%); no self-benefits (24.8%); fear of finding out about having a disease (22.3%); fear of discrimination (18.7%); and concerns about weakness (15.1%) and weight gain (9.4%). Public education programs to promote participation in genetic research should stress its benefits and address people's fears and concerns.

Bupropion in the management of apathy

We report on three males with prominent apathy as part of the symptom complex of depression or organic brain disease. Significant clinical responses were observed following treatment with bupropion, an antidepressant with dopamine (DA) reuptake activity. We present clinical evidence in support of the hypothesis that remission in these patients occurred as a consequence of bupropion-induced increases in central DA neurotransmission.

Clinical course after stopping lamivudine in chronic hepatitis B patients with lamivudine-resistant mutants

BACKGROUND

The efficacy of lamivudine therapy in chronic hepatitis B is well established. However, drug-resistant YMDD mutants emerge with extended therapy. This may result in the resurgence of viral replication, the return of hepatitis and histological deterioration.

AIM

To study the safety of stopping lamivudine when the drug is no longer effective.

METHODS

In the 5-year Asian Lamivudine Study, 34 patients from a single centre were included in this study. They had harboured YMDD mutants for at least 2 years. Lamivudine was discontinued and they were followed up at regular intervals. Clinical symptoms, liver biochemistry and viral serology were monitored.

RESULTS

In a median follow-up of 20 months after stopping lamivudine (range, 7-39 months), 20 of the 34 patients (58.8%) had elevated alanine aminotransferase (ALT), 13 patients (38.2%) had elevated ALT one to five times the upper limit of normal and seven patients (20.6%) had an ALT flare (ALT more than five times the upper limit of normal with detectable hepatitis B virus DNA). There was no liver decompensation. ALT flare could be predicted by ALT over twice the upper limit of normal at the time of stopping lamivudine (P = 0.037).

CONCLUSIONS

It is relatively safe to stop lamivudine after YMDD mutants have emerged. ALT levels greater than or equal to twice the upper limit of normal at the time of stopping lamivudine have a higher risk for ALT flare.

The use of complementary and alternative medicine by asthma patients

BACKGROUND

Use of complementary and alternative medicines (CAM) by asthmatic patients is increasing. Data on the prevalence of CAM use in asthma are limited, and the motivation for patients to seek CAM therapy is uncertain.

AIM

To determine the prevalence and pattern of use of complementary therapies in adults treated for asthma in primary care in Singapore, and the demographic and clinical factors associated with their use.

DESIGN

Cross-sectional study.

SETTING

Five primary care clinics in Singapore.

METHODS

Adult patients with asthma (n = 802) received a structured questionnaire interview and clinical assessment that included demographic and clinical variables (clinical status, patient's knowledge, self-care and healthcare-seeking behaviour, and spirometric measurements) and detailed information on CAM use in the past one year.

RESULTS

CAM use in the past year was reported by 27.2%, including animal food products (12.3%), herbs (10.3%), herbal-based proprietary medicines (3.2%), and acupuncture or reflexology (1%). The use of CAM was significantly associated with Chinese ethnicity, longer disease duration, moderate and severe persistent asthma, FEV(1)/FVC < 80%, lack of positive response to treatment in the past year, higher patient knowledge score, and multiple sources of care providers.

DISCUSSION

The use of CAM is highly prevalent in Asian patients treated for asthma in primary care, and is associated with cultural and clinical factors reflecting a need to improve care.

Cloning and sequencing of complete cDNA of Japanese encephalitis virus YL strain in Taiwan

We determined the complete nucleotide sequence of the YL strain of Japanese encephalitis virus and its amino acid sequence was deduced. Our results displayed that the genome of YL strain contained a single open reading frame of 10,296 nucleotides (nts) which was flanked by untranslated region (UTR) containing 95 bases at the 5'-end and 586 bases at the 3'-end, respectively. Comparison of sequences showed that the overall amino acid sequence and 3' UTR of YL were similar to those of the virulent strain JaGAr0l. However, some significant amino acid differences of viral envelope (E) protein were observed between YL and JaGAr01; the amino acid sequence of E protein in YL strain possessed RGG(387-389) tripeptide instead of RGD(387-389) in JaGAr01 and in other strains; and another amino acid is K(138) in YL, not E(138) found in others. These differences suggested that the YL strain impairs in viral attachment to the cell surface and loses neuroinvasiveness, and therefore this strain was used as a live attenuated vaccine.

NOD2/CARD15 gene polymorphisms and Crohn's disease in the Chinese population

BACKGROUND

Crohn's disease affects people world-wide, but the incidence in Asia is lower than in Western countries. This difference may be due to genetic and/or environmental factors. Three single nucleotide polymorphisms (SNPs) of the NOD2/CARD15 gene have been identified to be independently associated with the development of Crohn's disease in Caucasians. Whether these SNPs are involved in the pathogenesis of Crohn's disease in the Chinese population is unknown.

AIM

To determine if NOD2/CARD15 gene polymorphisms are found in Chinese patients with Crohn's disease.

METHODS

Sixty-five consecutive Chinese Crohn's disease patients had genotyping performed using sequence-specific PCR directed against the wild-type and the Arg702Trp, Gly908Arg and 3020insC variants of the NOD2/CARD15 gene. Controls consisted of 63 patients with ulcerative colitis and 70 patients with dyspepsia.

RESULTS

None of the patients with Crohn's disease had heterozygous or homozygous SNP variants. Similarly none of the ulcerative colitis or dyspeptic controls had these SNPs.

CONCLUSION

The three previously described SNPs associated with the development of Crohn's disease in Caucasians are not found in Chinese patients with Crohn's disease.

Social and behavioural factors associated with condom use among direct sex workers in Siem Reap, Cambodia

OBJECTIVES

To determine the social and behavioural factors associated with condom use among direct sex workers in Siem Reap, Cambodia.

METHODS

Using a structured behavioural questionnaire, interviews were conducted with 140 direct sex workers attending a health centre in Siem Reap for HIV screening.

RESULTS

Consistent condom use with their clients was reported by 78% of sex workers compared to only 20% with their non-paying partners. Consistent condom use with clients was significantly higher among higher income than lower income sex workers (adjusted prevalence ratio: 1.91, 95% CI: 1.15 to 3.18) and those with good rather than poor negotiation skills (adjusted prevalence ratio: 1.51, 95% CI: 1.01 to 2.26), after adjustment for age, educational level, marital status, number of sexual encounters per week, and knowledge of AIDS/HIV and sexually transmitted infections. The most frequently reported reason for not using condoms with clients was not being able to persuade them (66.7%), while for non-paying partners, the reason was that they loved them (60.0%).

CONCLUSION

To complement the government's current programme of client education, 100% condom policy and brothel administrative measures, additional strategies to increase condom use among clients and non-paying partners should be directed at (i) the social policy and community levels to address sex workers' economic and cultural barriers to condom use, and (ii) personal level empowerment through developing sex workers' condom negotiation skills.

Awareness of glaucoma, and health beliefs of patients suffering primary acute angle closure

AIM

To evaluate the factors associated with lack of awareness of glaucoma and late presentation to the doctor in Singapore Chinese patients with acute angle closure (AAC) METHODS: A prospective, hospital based case series of 105 patients aged 35 years and above who presented with a first attack of AAC in a tertiary hospital in Singapore was conducted. A research assistant interviewed all patients face to face in clinic and recorded demographic factors, awareness of glaucoma, and subjective barriers to seeing a doctor. The time from onset of symptoms to presentation at the clinic was noted.

RESULTS

Overall, 22.9% of patients had heard of glaucoma. The multivariate adjusted odds ratio (OR) of unawareness of glaucoma in older people (> 60 years) was 1.5 (95% confidence interval (CI) 0.5 to 4.6), 3.2 (95% CI 1.1 to 9.2) for adults who were not working, and 13.8 (95% CI 1.3 to 146.7) for patients who had less than a pre-university education. A significant proportion (31.7%) of patients presented to the doctor 24 hours or more after symptoms occurred. In a multiple logistic regression model, the adjusted OR of late presentation was 8.5 (95% CI 1.04 to 69.5) if there was no car access, 5.0 (95% CI 1.0 to 24.6) if the patients spoke Chinese, and 3.3 (95% CI 0.9 to 11.9) if there was nobody to accompany to hospital.

CONCLUSION

Glaucoma awareness among patients suffering AAC was not high. Lack of awareness was associated with increasing age, lack of formal education, and unemployment. A significant proportion of patients seek medical attention late. Risk factors for late presentation include lack of car access, nobody to accompany the patient, and speaking the Chinese language primarily. Health education programmes may help increase the knowledge and awareness of glaucoma.

Erectile dysfunction in Singapore: prevalence and its associated factors--a population-based study

PURPOSE

To study the prevalence of erectile dysfunction (ED) in Singapore males aged 30 and above and its association with demographic, medical and other risk factors.

METHODOLOGY

A population based cross sectional study of 729 men aged 30 and above in Singapore was conducted using the abridged, five-item version of the International Index of Erectile Function (IIEF-5). Presence of erectile dysfunction was defined as IIEF-5 score of less than 21. Erectile dysfunction was further categorised into mild (IIEF-5: 16-20), moderate (IIEF-5: 11-15) and severe (IIEF-5: <11). A logistic regression model was used to identify significant independent risk factors for ED.

RESULTS

Overall, 51.3% of respondents (n=374) reported some degree of erectile dysfunction. Of these, 23.2% have mild ED, 8.8% have moderate ED and 19.3% had severe ED. The prevalence of ED increased from 42.8% for men in their forties to 77.4% in their sixties. The prevalence of severe ED increased from 9.1% in men in their forties to 43.5% in their sixties and 77.0% in those aged 70 and above. Age above 50 years is the single most significant risk factor on multivariate analysis when adjusted for all confounding factors. Other important risk factors include Indian ethnic group, lower household income, physical inactivity, diabetes mellitus and cardiac diseases.

CONCLUSION

Erectile dysfunction is common amongst Singaporean men. Age is the single most important physiologic factor affecting erectile function. The prevalence and severity increased significantly with age after 50 years old. With an ageing population, erectile dysfunction may become a significant health problem. Health care providers should plan their resources accordingly.

Evidence-based health promotion: applying it in practice

INTRODUCTION

In health promotion, we should use interventions established by evidence to be effective in improving the health of the community. This paper reviews the concepts, evaluation and use of evidence in health promotion.

METHODS

A literature search of evidence-based health promotion and evaluation of health promotion was conducted using Medline, Social Science Citation Index (SSCI), PsycLIT and evidence-based web sites on health promotion, health education and community preventive services. Recent issues of key journals on health promotion, health education and public health were also hand-searched.

RESULTS

The concept of evidence in health promotion interventions is complex due to its multidimensional nature. Evidence of effectiveness in health promotion is assessed by combining quantitative data on effect change in outcome measures and qualitative data on process evaluation of health promotion activities. Limitations to the use of randomised trials in community-based health promotion interventions include ethical and logistic problems in maintaining randomisation of subjects over long periods, absence of experimental conditions in the real-world setting, contamination of control subjects and the multidimensional nature of health promotion interventions.

CONCLUSION

Randomised controlled trials should be used to evaluate the effectiveness of most health education and behavioural interventions in clinical settings. When such trials are not feasible as in community-based health promotion interventions, quasi-experimental designs provide strong evidence. Multiple methods are needed to assess evidence of effectiveness of health promotion programmes. Appropriate practice of evidence-based health promotion requires consideration of quality of available evidence, local values and prevailing resources.

Effluents from a pulp and paper mill: a skin and health survey of children living in upstream and downstream villages

OBJECTIVES

A health survey of three villages (upstream village Rantau Baru and two downstream villages, Sering and Pelalawan) in the vicinity of a pulp and paper mill along the Kampar river in the province of Riau, Indonesia was conducted to find whether exposure to the effluents from the mill was related to skin conditions and ill health.

METHODS

A cross sectional survey was carried out of children living in the three villages.

RESULTS

Common skin conditions such as dermatitis, fungal infections, insect bites, and miliaria were found. No significantly increased risk of dermatitis or any illness in general was found with increasing levels of exposure to river water for downstream villages when compared with the upstream village. However, there was an increased risk of diarrhoea in Sering especially with drinking water directly from the river (prevalence rate ratio (PRR) 4.9, 95% confidence interval (95% CI) 0.4 to 63.9). An increased risk was also found within the upstream village Rantau Baru (PRR 2.3, 95% CI 0.9 to 5.8) and downstream village Sering (PRR 1.4, 95% CI 0.4 to 5.2) when children who drank water directly from the river were compared with those who never did. Analysis of the river water also showed physical and chemical variables within the acceptable range except for faecal coliforms (6 MPN/100 ml) found in the sample taken from Sering.

CONCLUSIONS

The effluent from the mill is unlikely to be causing skin conditions and ill health. Diarrhoea may be due to faecal coliform contamination of the water because all raw sewerage is deposited in the river. Community health outreach programmes are being implemented based on these findings.

Relationship of clinical and virological factors with hepatitis activity in hepatitis B e antigen-negative chronic hepatitis B virus-infected patients

To investigate the factors associated with active disease among hepatitis B surface antigen (HBsAg) positive/hepatitis B e antigen (HBeAg)-negative chronic hepatitis B virus (HBV) infection we studied chronic HBV infected patients who had undetectable HBeAg at the first visit. HBV DNA was determined by the cross-linking assay (NAXCOR) and polymerase chain reaction (PCR). Mutations in the core promoter and precore regions and viral genotypes were studied. Clinical outcome of these patients were followed and categorized as: (i) relapse (ALT > 200 IU/L or three times the previous levels); (ii) active hepatitis (elevated ALT < 200 IU/L with concomitant detectable HBV DNA); or (iii) remission. A total of eighty-five patients were followed up for 5.5 +/- 1.0 years. At first visit, 31 (36.5%) patients had elevated ALT levels, 12 (14.1%) had measurable HBV DNA by the cross-linking assay and 26 (30.6%) by PCR. Sixteen (18.8%) patients had hepatitis relapse, 13 (15.3%) had active hepatitis, and 56 (65.9%) remained in remission. Core promoter and precore stop codon mutants were found in 27 and 12 patients, respectively. Eleven and 20 had genotype B and C HBV, respectively. Initial elevated ALT and detectable HBV DNA were associated with active liver disease. Patient demographics, viral mutants or genotypes failed to predict disease activity. Hence, serum ALT and HBV DNA levels offer the best prediction of natural course of HBeAg-negative chronic HBV infection.

Cloning and sequencing of full-length cDNA of classical swine fever virus LPC strain

The cDNAs of classical swine fever virus (LPC vaccine strain) were cloned by transcriptase-polymerase chain reaction, and their nucleotide sequences were determined. In this work, we obtained the sequence information of the 786 bases of the 5'-terminal region, 6049 bases of the middle region, and 1648 bases of the 3'-terminal region. Taking our previous results and present data together, the entire genomic sequence of LPC strain was completed (12344 nucleotides in length). The genome of LPC has a large open reading frame that can encode a polypetide of 3897 amino acids, and are flanked by untranslated regions (UTR), 373 bases at the 5'-end and 278 bases at the 3'-end. Phylogenetic analysis based on genomic sequences of several viruses suggested that the LPC strain is closer to Chinese, Riems, HCLV, Alfort/187, Brescia, and Alfort strains in order. After further analysis, we found that an insertion of 13 nucleotides, TTT(C/T)CTTTTTTTT, in the 3'-UTR of LPC, Chinese, and HCLV strains. Immediately downstream to the 13 nucleotides, a unique sequence of LPC consisting of 28 thymidine was observed.

Single nucleotide polymorphism identification in candidate gene systems of obesity

We have constructed a large panel of single nucleotide polymorphisms (SNP) identified in 68 candidate genes for obesity. Our panel combines novel SNP identification methods based on EST data, with public SNP data from largescale genomic sequencing, to produce a total of 218 SNPs in the coding regions of obesity candidate genes, 178 SNPs in untranslated regions, and over 1000 intronic SNPs. These include new non-conservative amino acid changes in thyroid receptor beta, esterase D, acid phosphatase 1. Our data show evidence of negative selection among these polymorphisms implying functional impacts of the non-conservative mutations. Comparison of overlap between SNPs identified independently from EST data vs genomic sequencing indicate that together they may constitute about one half of the actual total number of amino acid polymorphisms in these genes that are common in the human population (defined here as a population allele frequency above 5%). We have analyzed our polymorphism panel to construct a database of detailed information about their location in the gene structure and effect on protein coding, available on the web at http://www.bioinformat ics.ucla.edu/snp/obesity. We believe this panel can serve as a valuable new resource for genetic and pharmacogenomic studies of the causes of obesity.

Prevalence of prostatitis-like symptoms in Singapore: a population-based study

OBJECTIVE

To study the prevalence of prostatitis-like symptoms in a generally healthy population.

SUBJECTS AND METHODS

A population-based cross-sectional survey was conducted in Singapore to evaluate "prostatitis-like symptoms" (PS), lower urinary tract symptoms (LUTS),erectile dysfunction (ED), and quality of life (QoL). Respondents with pain or discomfort in the perineum, testicles, tip of penis or bladder/suprapubic region were identified as having prostatitis-like symptoms.

RESULTS

Altogether, 1087 males aged 21 to 70 were evaluated. While at least 20% of them had some degree of LUTS, only 2.67% (29 out of 1087) had pain or discomfort suggestive of prostatitis. Six men had pain in the bladder or suprapubic region, two in the perineum, six at the tip of penis and 26 had pain during micturition (11 subjects had more than one location of pain). Only two men had severe pain while seven had moderate and the rest had mild pain. The mean age of subjects with PS was 43.14. In terms of racial distribution, 2.23% (18) of Chinese, 3.15% (4) of Malay, 4.49% (4) of Indians and 12.12% (3) of other ethnic origin had PS. Those who had PS had worse erectile function (International Index of Erectile Function (IIEF) 11.92 vs. 17.16, p < 0.003) and a worse QoL score (2.96 vs. 1.38, p < 0.001) than those without PS. Those with PS were more bothered and worried about their symptoms.

CONCLUSION

The prevalence of prostatitis-like symptoms in a largely Chinese population is 2.67%. Prostatitis-like symptoms have a negative impact on the quality of life and erectile function.

IL-1 receptor type I gene expression in the amygdala of inflammatory susceptible Lewis and inflammatory resistant Fischer rats

Lewis (LEW/N) and Fischer (F344/N) rats have different responses to inflammatory and behavioral stressors due to differences in hypothalamus-pituitary-adrenal (HPA) axis function. For example, LEW/N rats are more sensitive to restraint, inflammation and experimentally induced autoimmunity due to decreased HPA activity. The HPA axis response to peripheral inflammation is mediated, at least in part, by IL-1beta and its receptor, IL-1 type I (IL-1RI). Here, we studied the distribution of IL-1RI mRNA in the brains of LEW/N and F344/N rats, and demonstrated that IL-1RI mRNA expression has significantly increased in the basolateral nucleus (BLA) of the amygdala of LEW/N rats. These findings suggest that strain-specific HPA axis responses may be mediated by extrahypothalamic pathways.

Expression of corticotropin releasing hormone receptors type I and type II mRNA in suicide victims and controls

Corticotropin-releasing hormone (CRH) is a key neuroendocrine factor implementing endocrine, immune and behavioral responses to stress. CRH exerts its action through two major receptors, CRH-R1 and CRH-R2. Recently novel non-peptidic antagonists directed against CRH-R1 or CRH-R2 have been proposed as promising agents in the treatment of depression, anxiety and eating disorder. However, so far the CRH-receptor system has not been widely studied in humans. Therefore, we employed quantitative TaqMan PCR to analyze the expression and distribution of both CRH-R1 and CRH-R2 in human brain tissue and peripheral organs. Furthermore the expression of CRH receptors was analyzed for the first time in pituitaries of suicide victims by in situ hybridization and quantitative PCR. Our data demonstrated a different expression pattern in humans as compared to rodents. Both CRH-R1 and CRH-R2 were expressed in high amounts in the brain with the strongest expression in the pituitary. As described in rodents, however the CRH-R1 in human was the predominant receptor in the brain (82.7 +/- 11.0%), whilst CRH-R2 was the predominant receptor in peripheral organs (77.0 +/- 15.8%). There was a shift in the ratio of CRH-R1/R2 in the pituitaries of suicide victims. In conclusion, both CRH-R1 and CRH-R2 are widely expressed in human tissues with a distribution substantially different from rodents. Strong expression of both CRH-R1 and CRH-R2 in human pituitaries suggests that particularly under stress, activation of the HPA axis can be maintained through both receptors.