A review of patients managed at a combined psychodermatology clinic: a Singapore experience.

INTRODUCTION: Recognising and appropriately treating psychosomatic factors in dermatological conditions can have a significant positive impact on the outcomes of patients. Treatment of psychodermatological patients requires a multidisciplinary approach that involves dermatologists, psychiatrists and allied health professionals. METHODS: This was a retrospective case series of patients seen in our psychodermatology liaison conferences from November 2009 to July 2011. We reviewed all the case notes and analysed data such as age, gender, dermatologic and psychiatric diagnoses, treatment and outcome. RESULTS: The majority of patients in our cohort were diagnosed with either a psychophysiologic disorder or a primary psychiatric disorder. The most common diagnosis among patients with primary psychiatric disorder was delusions of parasitosis. Other common primary psychiatric disorders seen were trichotillomania and dermatitis artefacta. About a fifth of our patients had psychiatric disorders resulting from their underlying dermatological conditions. A third of our patients were lost to follow-up. CONCLUSION: Managing patients with psychocutaneous disorders can be challenging, with many patients defaulting treatments. Psychodermatology clinics will benefit both patients and their caregivers. A collaborative approach using a consultation-liaison relationship between two medical departments in a friendly environment would result in more effective, integrated and holistic treatment strategies for such patients. Further studies should be conducted to determine how beneficial such services are to patients. With more experience, we hope to improve this service.

Drug hypersensitivity syndrome with significant gastrointestinal involvement.

Drug hypersensitivity syndrome (DHS) is an idiosyncratic systemic reaction to a drug. The clinical presentation of this syndrome comprises a diverse spectrum, ranging from mild to fulminating organ failure. Nonspecific gastrointestinal symptoms are common in DHS, but severe morbidities and mortalities attributed to gut disease in DHS are rarely described. We present a case of DHS with significant gastrointestinal symptoms of prolonged profuse watery diarrhoea and persistent hypokalaemia requiring judicious intravenous water and electrolyte replacement. The symptoms resolved only after the introduction of intravenous hydrocortisone. It is important to consider intravenous corticosteroids if the gastrointestinal system is involved, as accelerated gut motility and mucosal damage would affect absorption of oral medications. Supportive treatment with the monitoring of fluid and electrolytes status and judicious replacement remains fundamental in the management of DHS patients with gut involvement.

Validating the ABCD(2) Score for predicting stroke risk after transient ischemic attack in the ED.

OBJECTIVES: The aim of the study was to validate the use of the ABCD(2) score for the prediction of stroke after transient ischemic attack (TIA) in patients presenting to the emergency department (ED). The ABCD(2) scoring is based on 5 factors as follows: age of at least 60 years; blood pressure of at least 140/90 mm Hg; clinical features such as unilateral weakness and speech impairment alone; duration of at least 60 minutes or 10 to 59 minutes; and diabetes. METHODS: The authors conducted a retrospective observational study of all patients presented to the ED for TIA, as diagnosed by the attending emergency physicians, for a 2-year period. Sensitivity, specificity, and negative predictive value (NPV) were calculated for risk of stroke at 2, 7, 30, and 90 days after presentation. RESULTS: From January 1, 2005, to December 31, 2006, there were 470 patients diagnosed with TIA at the ED. Mean age was 61.0 years (SD, 13.2), with 63.3% males. Age of at least 60 years, unilateral weakness, and duration of at least 60 minutes were found to be significant predictors of stroke at 2 days. An admission rule based on an ABCD(2) score of at least 4 showed sensitivity of 86.4% and NPV of 91.7% for stroke at 7 days. Admission based on a score of at least 3 showed sensitivity of 96.6% and NPV of 96.1%. Admission rate was 69.1% and. 83.6%, respectively. CONCLUSION: The ABCD(2) rule showed good sensitivity and NPV for stroke at 7 days. However, NPV was not 100%, and there would still be patients being discharged from the ED and returning with a stroke if this cutoff was implemented in our setting.

Characteristics, and disease control and complications of hypertensive patients in primary-care - a community-based study in Singapore.

INTRODUCTION: Hypertension is a common chronic condition usually managed by primary-care practitioners in Singapore. This study assessed the characteristics, control and complications of non-diabetic hypertensive patients managed at government primary healthcare clinics. MATERIALS AND METHODS: A cross-sectional study involving 9 clinics was conducted over 1-week in 2006. Five hundred and six non-diabetic hypertensive patients were systematically sampled from all clinic attendees. Data relating to socio-demographic, lifestyle factors, treatment and complications were collected by interviewer-administered questionnaires and review of clinic medical records. Blood pressure (BP) measurements were taken with validated automated sets following a standard protocol. RESULTS: The prevalence of good BP control (<140/90 mmHg) was 37.7% (95% CI: 33.6% to 41.8%). Ninety seven percent were on medication with about half on monotherapy. Seventy percent of patients had a body mass index (BMI) of 23.0 kg/m(2) or higher, 64% did not exercise regularly and 8% were current smokers. After adjusting for age and lifestyle factors, male hypertensive patients had poorer BP control compared to females. Nineteen percent of patients reported at least 1 complication of hypertension, especially cardiac disease. After multivariate analysis and duration of disease, age and the male gender were associated with the presence of hypertensive complications. CONCLUSIONS: More than half of the patients were not controlled to target levels. Male patients were more likely to have poorer control of hypertension and significantly higher risks of complications. Control of BP could be further improved by lifestyle modifications - weight reduction, promotion of physical activity, healthier eating habits and smoking cessation.

Discovery of 2-[5-(4-chloro-phenyl)-1-(2,4-dichloro-phenyl)-4-ethyl-1H-pyrazol-3-yl]-1,5,5-trimethyl-1,5-dihydro-imidazol-4-thione (BPR-890) via an active metabolite. A novel, potent and selective cannabinoid-1 receptor inverse agonist with high antiobesity efficacy in DIO mice.

By using the active metabolite 5 as an initial template, further structural modifications led to the identification of the titled compound 24 (BPR-890) as a highly potent CB1 inverse agonist possessing an excellent CB2/1 selectivity and remarkable in vivo efficacy in diet-induced obese mice with a minimum effective dose as low as 0.03 mg/kg (po qd) at the end of the 30-day chronic study. Current SAR studies along with those of many existing rimonabant-mimicking molecules imply that around the pyrazole C3-position, a rigid and deep binding pocket should exist for CB1 receptor. In addition, relative to the conventional carboxamide carbonyl, serving as a key hydrogen-bond acceptor during ligand-CB1 receptor interaction, the corresponding polarizable thione carbonyl might play a more critical role in stabilizing the Asp366-Lys192 salt bridge in the proposed CB1-receptor homology model and inducing significant selectivity for CB1R over CB2R.

Bioisosteric replacement of the pyrazole 5-aryl moiety of N-(piperidin-1-yl)-5-(4-chlorophenyl)-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide (SR141716A). A novel series of alkynylthiophenes as potent and selective cannabinoid-1 receptor antagonists.

Replacing the conventional pyrazole 5-aryl substituent of 1 (SR141716A) with the 2-thienyl moiety appended with an appropriate alkynyl unit, a novel class of 5-(5-alkynyl-2-thienyl)pyrazole derivatives, behaving as highly potent CB1 receptor antagonists with good CB1/2 selectivity, was discovered, many of which, as typified by compound 18, showed significant weight reduction in diet-induced obese mouse model, thus pharmacologically validating that the bioisosteric replacement described above is viable. Also encouraging was the finding that a subtle structural modification of the newly developed series could result in a distinct difference in the intrinsic property, as demonstrated by compounds 12 (NA) and its methylated structural isomers 15 (PA) and 18 (IA). Moreover, current structure-activity relationship studies revealed that around the pyrazole 5-position of 1, a deep and flat crevice surrounded by a sequence of hydrophobic/aromatic residues as indicated by the CB1-receptor homology model might exist in the binding site.

Effect of brain DHA levels on cytoskeleton expression.

Brain docosahexaenoic acid (DHA, 22:6n-3) levels are associated with learning memory performance, but it is not known the mechanism of DHA on enhancing memory effect. The aim of this study was to examine effect of brain DHA levels on cytoskeleton expression. Rats were fed a chow or sunflower oil-based n-3 fatty acid-deficient diet supplemented with or without fish oil starting from embryo and through postnatal day 140. The various DHA levels were from 5.0% to 15.6% of total fatty acids in hippocampus, 3.9% to 13.7% in visual cortex, and 5.3% to 14.4% in olfactory bulbs. The expression of the cytoskeleton markers tyrosine tubulin, acetylated tubulin, and beta-actin in the hippocampus, visual cortex and olfactory bulb was not affected by brain DHA levels.

Fish oil supplementation of control and (n-3) fatty acid-deficient male rats enhances reference and working memory performance and increases brain regional docosahexaenoic acid levels.

Most previous studies have focused on improved reference memory and recovery of whole brain docosahexaenoic acid [DHA, 22:6(n-3)] levels in DHA-deficient animals supplemented with fish oil (FO) or switched to an adequate DHA-enriched diet. The aims of this study were to determine whether reference and working memory performance can be enhanced in control male rats and improved in (n-3) fatty acid-deficient male rats given an FO supplement and whether brain DHA accumulation, deficiency, and recovery are region specific. From the embryo to postnatal d 140, 4 groups of rats were fed a nonpurified or sunflower oil-based (n-3) fatty acid-deficient diet alone or supplemented with (n-3) fatty acids from FO representing approximately 0.3% of the energy source. The male rats were tested at postnatal d 102-130 for spatial learning memory performance in the Morris water maze. The fatty acid composition of different brain regions was analyzed by GC. Rats fed the (n-3) fatty acid-deficient diet showed significantly poorer reference and working memory, and FO supplementation partially rescued both memory performances. Furthermore, FO supplementation during brain development and adulthood in normal rats resulted in significant enhancement of both memories. Following dietary DHA repletion, the hippocampus and olfactory bulbs accumulated more DHA, were more resistant to dietary DHA deprivation, and showed better DHA recovery than the visual cortex, frontal cortex, and cerebellum. These results suggest that DHA is critical for the development and maintenance of learning memory performance.

Comparing attitudes of the public and medical staff towards witnessed resuscitation in an Asian population.

AIM: To compare the attitudes of the public attending at a local Emergency Department and the medical staff towards witnessed resuscitation. METHODS: Over a 2-week period in April 2006, we conducted an interview survey on the relatives of patients attending at the Emergency Department of Singapore General Hospital (SGH) via a convenience sampling. We approached 156 people with a response rate of 93.5%. We compared the results with a similar study conducted on the medical staff in the Emergency Department in the same hospital. RESULTS: Should relatives be present during resuscitation? We found that 73.1% of the public supported witnessed resuscitation compared to only 10.6% of the medical staff (P<0.001). The most frequently deemed advantage for witnessed resuscitation cited by both groups was that relatives would then have assurance that everything possible had been done for the patient. While 68.8% of the public felt that being allowed into the resuscitation area would help in their grieving processes, only 35.6% of the medical staff shared the same point of view (P<0.001). Medical staff were less likely to agree that witnessed resuscitation would strengthen the bonds between themselves and the public (P<0.001). Medical staff were however, more inclined towards the opinion that relatives would have a traumatic experience in witnessing resuscitation of their loved ones (P<0.001) and that the presence of relatives would cause stress to the medical staff performing resuscitation (P<0.001). CONCLUSION: Locally, we find a discrepancy between healthcare workers and the public towards the concept of witnessed resuscitation. More research is needed on the attitudes of the Asian public and medical staff.