First toddler mesenteric lymphatic malformation in Malaysia - A case report.

This is the first reported case of a mesenteric lymphatic malformation in a toddler in Malaysia. It is a rare benign condition with incidence of 1 in 250,000 populations. Our patient presented to us at 2 years 11months old complaining of abdominal distension for 6 months without obstructive symptoms. Clinically there was a vague soft central abdominal mass. CT abdomen done revealed a large multiloculated intraperitoneal mesentery cystic mass within the central abdomen extending to pelvis. A semi-emergency laparotomy was performed. Intra-operatively the multiloculated mesenteric cyst measured 20cm x 30cm, adherent to the small bowel beginning at 12cm from duodeno-jejunal junction. Resection of the mesenteric cyst with adherent small bowel and primary anastomosis was done. Histopathological examination revealed multiple large lymphatic channels of various sizes in the mucosa and submucosa. Our patient has no signs of recurrence and remains symptom-free after 1 year since his surgery. Surgery with clear margins of resection is the recommended gold standard based on available literature. Type of surgical resection required will depend on the type of mesenteric lymphatic malformation. An awareness of this rare pathology is required to ensure proper management is given to these patients.

HLA-DQ A1, -DQB1 and -DRB1 gene polymorphism--in Malay type 1 diabetes mellitus patients and their use for risk prediction.

HLA-DQA1, -DQB1, and -DRB1 gene polymorphism were analyzed to study type 1 DM susceptibility in Malay patients from Southeast Asia (Malaysia and Singapore). Patients showed significant increases in the occurrence of DQA1*0501 (50.7% vs. 20.4%; RR = 3.97; Pc < 0.01), DQB1*0201 (48% vs. 19.1%; RR = 3.86; Pc < 0.05), and DRB1*0301 (38.7 vs. 6.8%; RR = 8.36; 95% Pc < 0.05). Conversely, significant decreases were noted in the occurrence of DQA1*0601 (14.7% vs. 35.2%; RR = 0.33; Pc = 0.008) and DQB1*0601 (4% vs. 23.5%; RR = 0.16; Pc < 0.05) in type 1 DM patients. Using a logistic regression model, we derived a risk prediction model for type 1 DM in our indigenous Malay population based on the identified HLA genotypes. The RR for type 1 DM increases by a factor of 5.68 for every unit increase in the number of DRB1*0301 allele (P < 0.001), and decreases by a factor of 0.18 per unit increase in the number of DQB1*0601 allele (P < 0.001). After adjusting for these two HLA genotypes, DQA1*0501, DQB1*0201 and DQA1*0601 were not statistically significant as risk predictors. The lower incidence of type 1 DM in the Malay population may be contributed by the genotypic combinations of DR and DQ genes as well as the linkage disequilibria between susceptible and protective alleles.

Clinical predictors of acute respiratory acidosis during exacerbation of asthma and chronic obstructive pulmonary disease.

Mechanical ventilation (MV) during exacerbation of asthma or chronic obstructive pulmonary disease (COPD) is unequivocally needed when apnoea, cardiorespiratory arrest, coma, hypoxia or treatment failure is present. The need is less clear when the patient can respond, has intact airway reflexes and spontaneous respiration. In this situation, acidosis is an important factor in the decision to institute MV. This study aimed to provide a clinical means of identifying patients with acute respiratory acidosis (ARA) in a setting where blood gas analysis is unavailable. We undertook a prospective, observational study of consecutive patients who presented to two emergency departments with severe and life-threatening exacerbation of asthma or COPD. Each underwent clinical assessment, treatment and blood gas analysis. The outcome measure was ARA or mixed ARA and metabolic acidosis. A total of 127 episodes in patients aged 15-90 years (65.3% males and 34.7% females) were included in the study. Of these, 62.2% had asthma and 37.8% had COPD; 71.7% had life-threatening and 28.3% had severe attacks. Overall, the adjusted odds ratio (and 95% confidence intervals) for predictors of ARA were 7.09 (1.79-28.06) for drowsiness, 4.11 (1.31-12.88) for flushing, 3.34 (1.01-11.02) for having COPD and 2.86 (1.01-8.07) for intercostal retractions. In conclusion, with drowsiness, the likelihood of ARA is about seven times higher. The presence of flushing, COPD and intercostal retractions also increase the risk of ARA.

Improving the diagnosis related grouping model's ability to explain length of stay of elderly medical inpatients by incorporating function-linked variables.

INTRODUCTION: This study first aimed to determine the adequacy of the Diagnosis Related Grouping (DRG) model's ability to explain (1) the variance in the actual length of stay (LOS) of elderly medical inpatients and (2) the LOS difference in the same cohort between the departments of Geriatric Medicine (GRM) and General Medicine (GM). We then looked at how these explanatory abilities of the DRG changed when patients' function-linked variables (ignored by DRG) were incorporated into the model. MATERIALS AND METHODS: Basic demographic data of a consecutively hospitalised cohort of elderly medical inpatients from GRM and GM, as well as their actual LOS, discharge DRG codes [with their corresponding trimmed average length of stay (ALOS)] and selected function-linked variables (including premorbid functional status, change in functional profile during hospitalisation and number of therapists seen) were recorded. Beginning with ALOS, function-linked variables that were significantly associated with LOS were then added into two multiple liner regression models so as to quantify how the functional dimension improved the DRGs' abilities to explain LOS variances and interdepartmental LOS differences. Forward selection procedure was employed to determine the final models. For the interdepartmental analysis, the study sample was restricted to patients who shared common DRG codes. RESULTS: 114 GRM and 118 GM patients were studied. Trimmed ALOS alone explained 8% of the actual LOS variance. With the addition of function-linked variables, the adjusted R2 of the final model increased to 28%. Due to common code restrictions, the data of 79 GRM and 78 GM patients were available for the analysis of interdepartmental LOS differences. At the unadjusted stage, the median stay of GRM patients was 4.3 days longer than GM's and with adjustments made for the DRGs, this difference was reduced to 3.9 days. Additionally adjusting for the patients' functional features diminished the interdepartmental LOS discrepancy even further, to 2.1 days. CONCLUSION: This study demonstrates that for elderly medical inpatients, the incorporation of patients' functional status significantly improves the DRG model's ability to predict the patients' actual LOS as well as to explain interdepartmental LOS differences between GRM and GM.

Measuring health-related quality of life in Singapore: normal values for the English and Chinese SF-36 Health Survey.

OBJECTIVE: To determine norms for assessing Health-related Quality of Life (HRQOL) in Singapore using the Short Form 36 Health Survey (SF-36). MATERIALS AND METHODS: Mean SF-36 scores were calculated for 24 population subgroups (categorised by age, gender, ethnicity and questionnaire language) and for subjects with self-reported co-morbid conditions using data from a community-based survey in Singapore. RESULTS: The English and Chinese SF-36 was completed by 4122 and 1381 subjects, respectively, 58% (n = 3188) of whom had self-reported co-morbid conditions. SF-36 scores varied in subgroups differing in age, gender and ethnicity. In general, subjects with self-reported co-morbid conditions had lower SF-36 scores than those without these conditions, the magnitude of which exceeded 20 points in several instances. A method for calculation of SF-36 scores adjusted for age, gender, ethnicity and questionnaire language is described. CONCLUSION: We present norms for English and Chinese SF-36 versions in Singapore and describe potential uses for these data in assessing HRQOL in Singapore.

Validation of the Western Ontario and Mcmaster University osteoarthritis index in Asians with osteoarthritis in Singapore.

OBJECTIVE: To assess the reliability and validity of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) as an outcome measure in Asian patients with knee or hip osteoarthritis (OA) in Singapore. DESIGN: The WOMAC was administered twice 7 days apart to 66 consecutive English-speaking Chinese, Malay or Indian inpatients and outpatients with knee or hip OA seen at a tertiary referral centre through a structured interview, which also assessed demographic and other characteristics. Internal consistency was assessed using Cronbach's alpha, reliability using Spearman's correlations, intraclass correlations and repeatability coefficients, and relationships between WOMAC domains and known determinants of function using Spearman's correlations and the Mann-Whitney U-test. RESULTS: The WOMAC showed good internal consistency (alpha=0.70 to 0.93) and good reliability, with intraclass correlations of 0.83 to 0.90 and mean test-retest score differences of 0.02 to 0.13 points (possible range 4 points). Results of Likert scoring assessment supported the validity of the WOMAC when interpreted in the context of the close association between pain and physical function. Eight of nine a priori hypotheses relating WOMAC Pain and Physical Function scores to known determinants of function were present, supporting construct validity of this scale. CONCLUSION: The WOMAC is a valid and reliable outcome measure in Asian patients with OA in Singapore.

Synthesis of New Abscisic Acid (ABA) Analogs Possessing a Geometrically Rigid Cyclized Side Chain.

In a solution, cis-abscisic acid (ABA) isomerizes into the trans-isomer which is physiologically inactive, and this structural instability is regarded as a reason for insuitability of ABA in agricultural applications. The side chain of ABA, the 2-cis-4-trans-3-methyl-2,4-pentadienoic acid moiety, was replaced with various substituted phenyl groups to examine biological effects of the inflexibility of the part. Construction of the phenyl moiety was achieved by cyclizing the ionone derivatives and subsequent aromatization. Some of those new compounds showed ABA-like activity in both seed germination and transpiration assays.

Validation of a Chinese version of the Medical Outcomes Study Family and Marital Functioning Measures in patients with SLE.

The objective was to validate a Chinese translation of the Medical Outcomes Study Family and Marital Functioning Measures (FFM and MFM) in patients with systemic lupus erythematosus (SLE). Chinese-speaking SLE patients (n = 69) completed a self-administered questionnaire containing the FFM and MFM and assessing demographic and socio-economic status twice within a 2 week period. SLE activity, disease-related damage and quality of life were assessed using the BILAG, SLICC/ACR Damage Index and SF-36 Health Survey, respectively. Scale psychometric properties were assessed through factor analysis, Cronbach's alpha, quantifying test-retest differences and known-groups construct validity. Factor analysis identified 1 factor corresponding to the FFM and 2 factors corresponding to the MFM. Internal consistency for the FFM was excellent (alpha = 0.92) while that for the MFM was acceptable (alpha = 0.62). Mean (s.d.) test-retest differences were 0.06 (1.54) points for the FFM and 0.03 (2.08) points for the MFM. 11 and 10 of 13 a priori hypotheses relating the FFM and MFM, respectively, to demographic, disease and quality of life variables were confirmed, supporting the construct validity of these scales. The Chinese FFM and MFM are valid and reliable measures of family and marital functioning in Chinese-speaking SLE patients, with psychometric properties very similar to the source English version.

Validation of the Chinese SF-36 for quality of life assessment in patients with systemic lupus erythematosus.

We studied the reliability and validity of the Chinese Short-Form 36 Health Survey (SF-36) in a cross sectional study of patients with systemic lupus erythematosus (SLE). Sixty-nine consecutive subjects completed a questionnaire containing the Chinese SF-36 twice within 14 d. Disease activity and damage were assessed using the British Isles Lupus Activity Group (BILAG) and SLICC/ACR Damage Index (DI) scales, respectively. Internal consistency was assessed using Cronbach's alpha, reliability using Spearman's correlation and repeatability coefficients, and relationships between SF-36, BILAG and DI scores using Spearman's correlation. The Chinese SF-36 showed high internal consistency (alpha = 0.72-0.91) and good reliability, with correlations exceeding 0.70 for 7 scales and mean scale score differences of < 2 points for 6 scales. SF-36 scores correlated weakly with BILAG scores (-0.27 to -0.41) and DI scores (-0.24 to -0.35), and subjects' mean SF-36 scores were 6-24 points lower than the general population, supporting construct validity of the SP-36. These data suggest that the Chinese SF-36 is a reliable and valid measure of quality of life in patients with SLE.

Interpretation of the tuberculin skin test in Mycobacterium bovis BCG-vaccinated Singaporean schoolchildren.

Tuberculin skin test (TST) interpretation in Singapore is confounded by universal BCG vaccination at birth and by a revaccination policy for schoolchildren who are tuberculin nonreactors (TST < 10 mm, using 1 TU PPD RT 23) at 12 or 16 yr old, with not more than two BCG vaccinations given to any child. School health records for birth cohorts 1978 to 1984 indicate that 82.8% were revaccinated at age 12 yr. By collation with the national database of tuberculosis (TB) notifications, we examined the risk of TB disease in these cohorts for the 4 yr subsequent to TST reading at ages 12 and 16 yr respectively, in intervals of 0-4, 5-9, 10-14, 15-17, and >/= 18 mm. Receiver-operating curves (ROCs) were constructed to ascertain the optimum TST cutoffs in screening for the likelihood of development of TB disease. A cutoff of 10 mm performed best for the group tested at age 12 yr, whereas 16 mm was found to be optimum in those tested at age 16 yr (> 80% of whom were BCG revaccinated 4 yr earlier). We have extrapolated these findings to the screening of contacts, and utilized these cutoff points to guide the treatment of latent TB infection in this high-risk group.