Developing item banks to measure three important domains of health-related quality of life (HRQOL) in Singapore.

OBJECTIVES: To develop separate item banks for three health domains of health-related quality of life (HRQOL) ranked as important by Singaporeans - physical functioning, social relationships, and positive mindset. METHODS: We adapted the Patient Reported Outcomes Measurement Information System Qualitative Item Review protocol, with input and endorsement from laymen and experts from various relevant fields. Items were generated from 3 sources: 1) thematic analysis of focus groups and in-depth interviews for framework (n = 134 participants) and item(n = 52 participants) development, 2) instruments identified from a literature search (PubMed) of studies that developed or validated a HRQOL instrument among adults in Singapore, 3) a priori identified instruments of particular relevance. Items from these three sources were "binned" and "winnowed" by two independent reviewers, blinded to the source of the items, who harmonized their selections to generate a list of candidate items (each item representing a subdomain). Panels with lay and expert representation, convened separately for each domain, reviewed the face and content validity of these candidate items and provided inputs for item revision. The revised items were further refined in cognitive interviews. RESULTS: Items from our qualitative studies (51 physical functioning, 44 social relationships, and 38 positive mindset), the literature review (36 instruments from 161 citations), and three a priori identified instruments, underwent binning, winnowing, expert panel review, and cognitive interview. This resulted in 160 candidate items (61 physical functioning, 51 social relationships, and 48 positive mindset). CONCLUSIONS: We developed item banks for three important health domains in Singapore using inputs from potential end-users and the published literature. The next steps are to calibrate the item banks, develop computerized adaptive tests (CATs) using the calibrated items, and evaluate the validity of test scores when these item banks are administered adaptively.

Calibration of a physical functioning item bank for measurement of health-related quality of life in Singapore.

PURPOSE: We aimed to develop and calibrate an item bank to measure physical function (PF) in Singapore, a multi-ethnic city in Southeast Asia. METHODS: We recruited participants from community and hospital settings stratified for age and gender, with and without medical conditions to administer candidate pool of 61-items derived from the people's perspectives. We calibrated their responses using Samejima's graded response model of item response theory (IRT), including model assumptions, model fit, differential item functioning (DIF), and concurrent and known-groups validity. RESULTS: 496 participants (50% male; 41% above 50 years old; 33.3% Chinese, 32.7% Malay and 34.1% Indian; 35% without chronic illness) were included in the calibration of item bank. 6 items were excluded due to mis-fit and local dependence. Redundancies in the response level was collapsed and re-scoring, while preserving the 5-level response structure. We found the final 55-item PF bank had adequate fit to IRT assumptions of unidimensionality, local independence and monotonicity. Items generally showed discernible ceiling effects with latent scores between - 3.5 to + 1.5. We found no DIF with gender, ethnicity or education. The PF scores correlated in the hypothesized direction with self-reported global health (Spearman's rho = - 0.35, 95% confidence intervals - 0.43 to - 0.27) and discriminated between groups stratified by age, gender and medical conditions. CONCLUSION: The 55-item Singapore PF item bank provides an adequate tool for measuring the lower end of PF, with greatest potential utility in healthcare settings where restoration to normal physical functioning is the goal of intervention.

Development and calibration of a novel social relationship item bank to measure health-related quality of life (HRQoL) in Singapore.

BACKGROUND: Social relationships (SR) is an important domain of health-related quality of life. We developed and calibrated a novel item bank to measure SR in Singapore, a multi-ethnic city in Southeast Asia. METHODS: We developed an initial candidate pool of 51 items from focus groups, individual in-depth interviews and existing instruments that had been developed and/or validated for use in Singapore. We administered all items in English to a multi-stage sample of subjects, stratified for age and gender, with and without medical conditions, recruited from community and hospital settings. We calibrated their responses using Samejima's Graded Response Model (SGRM). We evaluated a final 30-item bank with respect to Item Response Theory (IRT) model assumptions, model fit, differential item functioning (DIF), and concurrent and known-groups validity. RESULTS: Among 503 participants (47.7% male, 41.4% above 50 years old, 34.0% Chinese, 33.6% Malay and 32.4% Indian), bi-factor model analyses supported essential unidimensionality: explained common variance of the general factor was 0.805 and omega hierarchical was 0.98. Local independence was deemed acceptable: the average absolute residual correlations were < 0.06 and 1.8% of the total item-pair residuals were flagged for local dependence. The overall SGRM model fit was adequate (p = 0.146). Five items exhibited DIF with respect to age, ethnicity and education, but were retained without modification of scores because they measured important aspects of SR. The SR scores correlated in the hypothesized direction with a self-reported measure of global health (Spearman's rho = - 0.28, p < 0.001). CONCLUSION: The 30-item SR item bank has shown acceptable psychometric properties. Future studies to evaluate the validity of SR scores when items are administered adaptively are needed.

Traditional Chinese herbal medicine for vascular dementia.

BACKGROUND: Traditional Chinese herbal medicine (TCHM) is widely used for treating vascular dementia (VaD) in China. Recent studies of a number of TCHMs have demonstrated in vitro biological activity and therapeutic effects in animals, but the published clinical evidence has not been systematically appraised. OBJECTIVES: To evaluate the efficacy and safety of TCHMs listed in either the Chinese Pharmacopoeia (CP) or the Chinese National Essential Drug List (NEDL) that are used to treat VaD. A secondary aim was to identify promising TCHMs for further clinical research. SEARCH METHODS: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialised Register (on 14 March 2018) and also several Chinese biomedical databases: the Chinese Biological Medicine Database (January 1979 to May 2015), Wanfang database (January 1998 to May 2015), Chongqing VIP Information Co. Ltd or Weipu (January 1998 to May 2015) and the Chinese National Knowledge Infrastructure (January 1979 to May 2015). SELECTION CRITERIA: We included randomised controlled trials (RCTs) of TCHMs compared to placebo, to Western medicine (WM) or to routine therapy for VaD risk factors. Eligible participants were men and women aged 18 years and above, diagnosed with VaD by any of the following four criteria: (1) Diagnostic and Statistical Manual of Mental Disorders (DSM) versions III, III-R, IV, IV-TR; (2) National Institute of Neurological Disorders and Stroke (NINDS-AIREN); (3) International Classification of Diseases 9 or 10; (4) the Hachinski or the Modified Hachinski Ischaemic Score. We required the use of an imaging technique to differentiate VaD from other dementias. We excluded (1) trials with participants diagnosed with mixed dementia or those that did not use an imaging technique to ascertain VaD; (2) trials of NEDL-listed Gingko biloba or Huperzine A as experimental interventions, to avoid duplication of existing Cochrane Reviews; (3) trials using acupuncture alone as the experimental intervention; (4) trials using another CP- or NEDL-listed TCHM (except for Huperzine A and Gingko which are popular in Western practice) as the control intervention; and (5) trials using purely non-pharmacological interventions as the control intervention unless explicitly described as 'routine therapy for VaD risk factors'. DATA COLLECTION AND ANALYSIS: We assessed the risks of bias using the Cochrane 'Risk of bias' tool and adapted the Outcome Reporting Bias in Trials (ORBIT) classification system for outcome reporting bias. We assessed TCHM effects on five clinically important outcomes: cognition, global performance, safety, activities of daily living and behaviour and summarised the effects using mean differences for continuous outcomes and risk ratios or risk differences for binary outcomes. We stratified the studies into those that estimated the TCHM versus 'no treatment' effect and those that estimated the TCHM versus the WM effect, with further stratification by the specific TCHM tested or by one of the four modes of action. We pooled using a random-effects model. Due to substantial clinical and design heterogeneity, we did not estimate an 'overall TCHM effect'. MAIN RESULTS: We only found studies (47 studies, 3581 participants) for 18 of the 29 eligible TCHMs as defined by our inclusion criteria. All were superiority trials conducted in China between 1997 and 2013, with most employing a two-arm parallel design with sample sizes ranging from 26 to 240 and a median treatment duration of 12 weeks (range: 2 to 24 weeks).We found that reporting and trial methodology were generally poor; in particular, there was a lack of information on randomisation, an absence of blinding of participants and outcome assessors and incomplete reporting of adverse events (AEs). None of the 30 trials published from 2007 onwards adopted the CONSORT recommendations for reporting RCTs of herbal interventions.We found seven TCHMs which each had potentially large benefits in studies estimating the TCHM versus 'no treatment' effect and in studies estimating the TCHM versus the WM effect. Two TCHMs (NaoXinTong and TongXinLuo) were common to both groups. Three of these TCHMs - Nao XinTong, NaoMaiTai and TongXinLuo - had the strongest evidence to justify further research. Two TCHMs (NaoMaiTai and TongXinLuo) had a 5% or more increased risk of AEs compared to the 'no Treatment' control, but the quality of this evidence was poor. AUTHORS' CONCLUSIONS: We found moderate- to very low-quality evidence of benefit and harm of TCHMs for VaD. Methodological inadequacies need to be addressed by better conducted and reported trials. We identified NaoMaiTai, NaoXinTong and TongXinLuo as warranting special research priority.

Clinical and socio-demographic correlates of anxious distress in Asian outpatients with major depressive disorder.

BACKGROUND: Anxious distress in major depressive disorder (MDD) is common and associated with poor outcomes and management difficulties. AIMS: This post hoc analysis aimed to examine the socio-demographic and clinical correlates of anxiety distress in Asian outpatients with MDD. METHODS: Instead of two out of five specifiers defined by the Diagnostic and Statistical Manual Version-5, anxious distress defined in this study was operationalized as the presence of at least two out of four proxy items drawn from the 90-item Symptom Checklist, Revised (SCL-90-R). Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Fatigue Severity Scale, the Sheehan Disability Scale and the Multidimensional Scale of Perceived Social Support. RESULTS: The data of 496 patients with MDD were included. Anxious distress was found in 371 participants (74.8%). The binary logistic regression analysis found that anxious distress was independently and significantly correlated with working status, higher MADRS scores, severe insomnia and functional impairment. CONCLUSIONS: Three-fourths of Asian patients with MDD in tertiary care settings may have DSM-5 anxious distress of at least moderate distress. Its prevalence may vary among working groups. The specifier was associated with greater depressive symptom severity, severe insomnia and functional impairment.

Early detection of dementia in multilingual populations: Visual Cognitive Assessment Test (VCAT).

BACKGROUND: Early diagnosis of cognitive impairment allows timely intervention with pharmacological and non-pharmacological measures. However, current cognitive evaluation tools do not cater for multilingual populations. OBJECTIVE: To develop and validate a visual-based cognitive evaluation tool, the Visual Cognitive Assessment Test (VCAT), which can be administered to multilingual populations without the need for translation or adaptation. METHOD: We designed a battery of tests to evaluate the domains of memory, executive function, visuospatial function, language and attention. Pilot testing of individual test items, followed by test refinement and development of a field version was performed. We subsequently validated VCAT for the diagnosis of mild cognitive impairment (MCI) and mild Alzheimer's disease (AD). Diagnostic performance was assessed by the area under the curve (AUC), sensitivity (Se) and specificity (Sp). RESULTS: VCAT was validated in a sample of 206 participants. The sample comprised 53.9% males; mean age (SD) was 67.8 (8.86) years; mean years of education was 10.5(6.0). AUC of VCAT for detection of cognitive impairment was found to be 93.3 (95% CI 90.1 to 96.4). Also, the Se and Sp of VCAT for the diagnosis of cognitive impairment (MCI and mild AD) were 85.6% and 81.1%, respectively. VCAT's diagnostic Se and Sp comparable to those of the Montreal Cognitive Assessment in the same cohort. Mean time-to-complete VCAT was 15.7 ± 7.3 min. CONCLUSIONS: The VCAT has good Se and Sp for the diagnosis of MCI and mild AD. The visual-based test paradigm allows easy application to multilingual populations without the need for translation or adaptation.

Inferior Alveolar Nerve Injury in Trauma-Induced Mandible Fractures.

PURPOSE: This prospective observational cohort study sought to determine the prevalence of inferior alveolar nerve (IAN) injury after mandibular fractures before and after treatment and to elucidate factors associated with the incidence of post-treatment IAN injury and time to normalization of sensation. MATERIALS AND METHODS: Consenting patients with mandibular fractures (excluding dentoalveolar, pathologic, previous fractures, or mandibular surgery) were prospectively evaluated for subjective neurosensory disturbance (NSD) and underwent neurosensory testing before treatment and then 1 week, 1.5, 3, 6, and 12 months after treatment. RESULTS: Eighty patients (men, 83.8%; mean age, 30.0 yr; standard deviation, 12.6 yr) with 123 mandibular sides (43 bilateral) were studied. Injury etiology included assault (33.8%), falls (31.3%), motor vehicle accidents (25.0%), and sports injuries (6.3%). Half the fractures (49.6%) involved the IAN-bearing posterior mandible; all condylar fractures (13.0%) had no NSD. Treatment included open reduction and internal fixation (ORIF; 74.8%), closed reduction and fixation (22.0%), or no treatment (3.3%). Overall prevalence of IAN injury was 33.7% (95% confidence interval [CI], 24.8-42.6) before treatment and 53.8% (95% CI, 46.0-61.6) after treatment. In the IAN-bearing mandible, the prevalence was 56.2% (95% CI, 43.2-69.2) before treatment and 72.9% (95% CI, 63.0-82.7) after treatment. In contrast, this prevalence in the non-IAN-bearing mandible was 12.6% (95% CI, 4.1-21.1) before treatment and 31.6% (95% CI, 20.0-43.3) after treatment. Factors associated with the development of post-treatment IAN injury included fracture site and gap distance (a 1-mm increase was associated with a 27% increase in odds of post-treatment sensory alteration). Time to normalization after treatment was associated with type of treatment (ORIF inhibited normalization) and fracture site (IAN-bearing sites took longer to normalize). CONCLUSION: IAN injury was 4 times more likely in IAN-bearing posterior mandibular fractures (56.2%) than in non-IAN-bearing anterior mandibular fractures (12.6%). After treatment, IAN injury prevalence (in 12 months) was higher (72.9% in posterior mandible, 31.6% in anterior mandible).

Diagnosing paediatric myocarditis: what really matters.

OBJECTIVE: Paediatric myocarditis has remained a diagnostic challenge. We aim to identify distinct characteristics and derive a scoring system that will trigger further investigations to be performed among paediatric patients presenting to the emergency department (ED) with clinically suspected myocarditis. DESIGN: We performed an age-matched case-control study of children seen in a large tertiary institution. Cases and controls were patients less than 16 years' old who presented to the ED over a 10-year period from Jan 2001 to Dec 2010. Cases were identified with a final discharge or postmortem diagnosis of acute myocarditis. Controls were those who presented to the ED in the same period and were initially diagnosed with acute myocarditis, but who were later found to have other diagnoses. We compared their vital signs, presenting symptoms, physical examination findings, electrocardiogram and chest radiograph findings. RESULTS: Based on domain-specific stepwise conditional logistic regression analyses, five characteristics were found to be potentially discriminating: respiratory distress, poor perfusion, hypotension, an abnormal chest radiograph and any electrocardiogram abnormalities. Satisfactory discrimination was attained using these five parameters. The estimated area under receiver operating characteristic curve was 90% (95% CI 0.83 to 0.97). A cut-off score of 3 would give a positive likelihood ratio of 13 (95% CI 3.31 to 51.06) and a negative likelihood ratio of 0.35 (95% CI 0.22 to 0.55). CONCLUSIONS: A cut-off risk score of 3, though not yet validated, may be potentially useful in future to trigger further investigations for children with suspected myocarditis. It allows for the appropriate use of resources, while minimising on misdiagnosis.

Comparative efficacy and tolerability of topical prostaglandin analogues for primary open-angle glaucoma and ocular hypertension.

OBJECTIVE: To systematically review the efficacy and tolerability of 4 prostaglandin analogues (PGAs) as first-line monotherapies for intraocular pressure (IOP) lowering in adult patients with primary open-angle glaucoma or ocular hypertension. DATA SOURCES: A literature search was performed in PubMed (1965-June 2013) and the Cochrane Library (1980-June 2013) using the search terms ocular hypertension, open-angle glaucoma, prostaglandin analogues, bimatoprost, latanoprost, tafluprost, and travoprost. Additional studies were searched from the reference lists of identified publications. STUDY SELECTION AND DATA EXTRACTION: In all, 32 randomized controlled trials comparing between PGAs (bimatoprost 0.03%, latanoprost 0.005%, tafluprost 0.0015%, and travoprost 0.004%) or PGA with timolol were selected. DATA SYNTHESIS: A network meta-analysis was conducted. Using timolol as reference, the relative risks (RRs) of achieving treatment success, defined as the proportion of patients achieving at least 30% IOP reduction, with 95% CIs, were as follows: bimatoprost, 1.59 (1.28-1.98); latanoprost, 1.32 (1.00-1.74); travoprost, 1.33 (1.03-1.72); and tafluprost, 1.10 (0.85-1.42). The mean IOP reductions after 1 month were 1.98 (1.50-2.47), 1.01 (0.55-1.46), 1.08 (0.59-1.57), and 0.46 (-0.41 to 1.33) mm Hg, respectively, and the results were sustained at 3 months. Bimatoprost was associated with the highest risk of developing hyperemia, whereas latanoprost had the lowest risk, with RRs (95% CI) of 4.66 (3.49-6.23) and 2.30 (1.76-3.00), respectively. CONCLUSIONS: Bimatoprost achieved the highest efficacy in terms of IOP reduction, whereas latanoprost had the most favorable tolerability profile. This review serves to guide selection of the optimal PGA agent for individual patient care in clinical practice.

Clinical and sociodemographic correlates of suicidality in patients with major depressive disorder from six Asian countries.

BACKGROUND: East Asian countries have high suicide rates. However, little is known about clinical and sociodemographic factors associated with suicidality in Asian populations. The aim of this study was to evaluate the factors associated with suicidality in patients with major depressive disorder (MDD) from six Asian countries. METHODS: The study cohort consisted of 547 outpatients with MDD. Patients presented to study sites in China (n = 114), South Korea (n = 101), Malaysia (n = 90), Singapore (n = 40), Thailand (n = 103), and Taiwan (n = 99). All patients completed the Mini-International Neuropsychiatric Interview (MINI), the Montgomery-Asberg Depression Rating Scale (MADRS), the Global Severity Index(SCL-90R), the Fatigue Severity Scale, the 36-item short-form health survey, the Sheehan Disability Scale, and the Multidimensional Scale of Perceived Social Support (MSPSS). Patients were classified as showing high suicidality if they scored ≥ 6 on the MINI suicidality module. Multivariate logistic regression analysis was used to examine sociodemographic and clinical factors related to high suicidality. RESULTS: One hundred and twenty-five patients were classed as high suicidality. Unemployed status (adjusted odds ratio [OR] 2.43, p < 0.01), MADRS score (adjusted OR 1.08), p < 0.001, and GSI (SCL-90R) score (adjusted OR 1.06, p < 0.01) were positively related to high suicidality. Hindu (adjusted OR 0.09, p < 0.05) or Muslim (adjusted OR 0.21, p < 0.001) religion and MSPSS score (adjusted OR 0.82, p < 0.05) were protective against high suicidality. CONCLUSIONS: A variety of sociodemographic and clinical factors were associated with high suicidality in Asian patients with MDD. These factors may facilitate the identification of MDD patients at risk of suicide.

Differences in psychiatric symptoms among Asian patients with depression: a multi-country cross-sectional study.

AIM: The aim of this study was to compare the symptomatic and clinical features of depression among five groups of patients with major depressive disorder (MDD) living in China, Korea, Malaysia/Singapore, Taiwan, and Thailand. METHODS: Consecutive consenting adults (aged 18-65) who met DSM-IV criteria for non-psychotic MDD ­ based on the Mini International Neuropsychiatric Interview ­ and who were free of psychotropic medication were evaluated in a cross-sectional study. Depressive symptoms were evaluated using the 10-item Montgomery­Asberg Depression Rating Scale (MADRS) and the 13-item depression subscale of the Symptoms Checklist 90-Revised (SCL-90-R). In addition, the 10-item SCL-90-R Anxiety Subscale was completed. ancova were conducted, adjusting for confounders: age, completion of secondary education, marital status, work status, religion, index episode duration, and depressive severity. For the magnitude of differences, a threshold of 0.10 was taken as the minimum effect size representing clinical significance, and an effect size of 0.25 was considered moderate. RESULTS: Four MADRS symptoms differentiated these five groups, the most prominent being 'lassitude' and 'inner tension'. Nine SCL-90-R depression items also differentiated the groups, as did eight SCL-90-R Anxiety Subscale items. The MADRS lassitude item had the largest effect size (0.131). The rest of those statistically significant differences did not exceed 0.10. CONCLUSION: MDD is more similar than different among outpatients in these diverse Asian countries. The between-country differences, while present and not due to chance, are small enough to enable the use of common clinician and self-report rating scales in studies involving Asians with MDD from various ethnic backgrounds.

Evaluation of three paediatric weight estimation methods in Singapore.

AIM: Rapid paediatric weight estimation methods in the emergency setting have not been evaluated for South East Asian children. This study aims to assess the accuracy and precision of three such methods in Singapore children: Broselow-Luten (BL) tape, Advanced Paediatric Life Support (APLS) (estimated weight (kg) = 2 (age + 4)) and Luscombe (estimated weight (kg) = 3 (age) + 7) formulae. METHODS: We recruited 875 patients aged 1-10 years in a Paediatric Emergency Department in Singapore over a 2-month period. For each patient, true weight and height were determined. True height was cross-referenced to the BL tape markings and used to derive estimated weight (virtual BL tape method), while patient's round-down age (in years) was used to derive estimated weights using APLS and Luscombe formulae, respectively. The percentage difference between the true and estimated weights was calculated. For each method, the bias and extent of agreement were quantified using Bland-Altman method (mean percentage difference (MPD) and 95% limits of agreement (LOA)). The proportion of weight estimates within 10% of true weight (p10) was determined. RESULTS: The BL tape method marginally underestimated weights (MPD +0.6%; 95% LOA -26.8% to +28.1%; p10 58.9%). The APLS formula underestimated weights (MPD +7.6%; 95% LOA -26.5% to +41.7%; p10 45.7%). The Luscombe formula overestimated weights (MPD -7.4%; 95% LOA -51.0% to +36.2%; p10 37.7%). CONCLUSIONS: Of the three methods we evaluated, the BL tape method provided the most accurate and precise weight estimation for Singapore children. The APLS and Luscombe formulae underestimated and overestimated the children's weights, respectively, and were considerably less precise.

Germline variation controls the architecture of somatic alterations in tumors.

Studies have suggested that somatic events in tumors can depend on an individual's constitutional genotype. We used squamous cell carcinomas (SCC) of the skin, which arise in high multiplicity in organ transplant recipients, as a model to compare the pattern of somatic alterations within and across individuals. Specifically, we performed array comparative genomic hybridization on 104 tumors from 25 unrelated individuals who each had three or more independently arisen SCCs and compared the profiles occurring within patients to profiles of tumors across a larger set of 135 patients. In general, chromosomal aberrations in SCCs were more similar within than across individuals (two-sided exact-test p-value<1x10(-7)), consistent with the notion that the genetic background was affecting the pattern of somatic changes. To further test this possibility, we performed allele-specific imbalance studies using microsatellite markers mapping to 14 frequently aberrant regions of multiple independent tumors from 65 patients. We identified nine loci which show evidence of preferential allelic imbalance. One of these loci, 8q24, corresponded to a region in which multiple single nucleotide polymorphisms have been associated with increased cancer risk in genome-wide association studies (GWAS). We tested three implicated variants and identified one, rs13281615, with evidence of allele-specific imbalance (p-value=0.012). The finding of an independently identified cancer susceptibility allele with allele-specific imbalance in a genomic region affected by recurrent DNA copy number changes suggest that it may also harbor risk alleles for SCC. Together these data provide strong evidence that the genetic background is a key driver of somatic events in cancer, opening an opportunity to expand this approach to identify cancer risk alleles.

Diagnostic evaluation of pediatric myocarditis in the emergency department: a 10-year case series in the Asian population.

OBJECTIVES: Pediatric myocarditis is a known cause of dilated cardiomyopathy and is associated with significant mortality. Our primary objective was to describe the frequency of presenting symptoms, signs, and investigation results among children diagnosed with acute myocarditis. Our secondary objective was to review these patients' initial diagnoses by the emergency physicians. METHODS: This was a retrospective chart review of all patients younger than 16 years who were diagnosed with acute myocarditis in our hospital over a 10-year period (January 2001 to December 2010). The symptoms and signs were stratified according to age (infants, 1-5 years, 6 years or older). RESULTS: Thirty-nine children met the search criteria, of whom 10 patients (25.6%) were definite cases proven by myocardial biopsy. The average age was 5.4 years (SD, 4.3 years). The most common symptom complex was that of hypoperfusion (61.5%), which consisted of lethargy (53.8%), syncope (23.1%), and seizure (23.1%). Only 4 patients had cardiac symptoms, and all were older than 6 years old. Hepatomegaly was present in 16 patients (41.0%), whereas gallop rhythm or cardiac murmur was heard only in 5 patients (12.8%), Chest radiographs showed abnormalities in only 21 cases (53.8%), whereas all had abnormal electrocardiogram findings. Fifteen cases (38.5%) were diagnosed correctly at initial presentation, whereas the most common misdiagnosis was that of respiratory tract infections (20.5%). CONCLUSIONS: Pediatric myocarditis rarely presents with specific cardiac symptoms in the younger population. Any child with symptoms and signs of hypoperfusion, especially unexplained seizure or syncope, should have an electrocardiogram performed.

Factors affecting fetal bradycardia following combined spinal epidural for labor analgesia: a matched case-control study.

PURPOSE: The combined spinal epidural (CSE) technique for labor analgesia has become increasingly popular owing to its rapid onset of analgesia. However, incidences of fetal bradycardia following CSE have been reported. This study aimed to identify predictors of fetal bradycardia post CSE, such as a decrease in pain scores, the block height, Prostin (dinoprostone; Pfizer) use, and dosage of oxytocin. METHODS: From May 2008 to October 2008, 29 patients were identified to have had an episode of fetal bradycardia. Each case was then matched to three controls, according to age and American Society of Anesthesiology status, selected from 2345 parturients who received a CSE during this period. RESULTS: A unit improvement in the pain score was associated with an increase in the odds of fetal bradycardia by 1.28 (95 % confidence interval [CI]: 1.02-1.60). In a second logistic regression model including sensory level higher than T9, the effect size remained consistent with an odds ratio of 1.22 (95 % CI: 0.97-1.53), supporting the theory that a higher level of sympathetic block (with a higher sensory block taken as a surrogate marker) results in an increased risk of fetal bradycardia. The dosage of oxytocin and the quantity of Prostin used were not found to be risk factors. CONCLUSION: The difference between pre- and post-CSE pain scores, and a higher sensory block height, which are surrogates for a greater degree of sympatholysis, were found to be risk factors for fetal bradycardia post CSE.

Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review.

BACKGROUND: Corticosteroid injections can be performed blind (landmark-guided) or with image guidance, and this may account for variable clinical outcomes. The objective of this study was to assess the effectiveness and safety of image-guided versus blind corticosteroid injections in improving pain and function among adults with shoulder pain. METHODS: MEDLINE, the Cochrane Controlled Trials Register and EMBASE were searched to May 2010. Additional studies were identified by searching bibliographies of shortlisted articles. Search items included blind, landmark, anatomical, clinical exam, image-guided, ultrasound, fluoroscopy, steroid injection, frozen shoulder, random allocation, randomized controlled trial (RCT) and clinical trial.Randomized controlled studies comparing image-guided versus blind (landmark-guided) corticosteroid shoulder injections that examined pain, function and/or adverse events were included. Independent extraction was done by two authors using a form with pre-specified data fields, including risk of bias appraisal. Conflicts were resolved by discussion. The decision to pool data was based on assessment of clinical design homogeneity. When warranted, studies were pooled under a random-effects model. RESULTS: Two RCTs for pain, function and adverse events (n = 101) met eligibility criteria. No serious threats to validity were found. Both trials compared ultrasound-guided versus landmark-guided injections and were judged similar in clinical design. Low to moderate heterogeneity was observed: shoulder pain I2 = 60%, function I2 = 22%. A meta-analysis demonstrated greater improvement with ultrasound-guided injections at 6 weeks after injection in both pain (mean difference = 2.23 [95% CI: 1.27, 3.18]), as assessed with a 0 to 10 visual analogue scale, and shoulder function (standardised mean difference = 1.09 [95% CI: 0.61, 1.57]) as assessed with shoulder function scores. Although more adverse events (all mild) were reported with landmark-guided injections, the difference was not statistically significant (risk ratio = 0.20 [95% CI: 0.04, 1.13]).This review was only based on two moderate-sized trials. Blinding of patients was not performed in both trials, causing some risk of bias in outcome assessment since primary endpoints were wholly or partially patient-reported. CONCLUSION: There is a paucity of RCTs on image-guided versus landmark-guided corticosteroid shoulder injections examining pain, function and adverse events. In this review, patients who underwent image-guided (ultrasound) injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection. Image-guided (ultrasound) corticosteroid injections potentially offer a significantly greater clinical improvement over blind (landmark-guided) injections in adults with shoulder pain. However, this apparent benefit requires confirmation from further studies (adequately-powered and well-executed RCTs).

The Health and Well-Being of Caregivers of Technologically Dependent Children.

Caregivers of technology-dependent children face considerable responsibilities. This study examined the association of 2 child-related stressors-functional status and use of mechanical ventilator-with 2 domains of family caregiver well-being-depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D]) and health-related quality of life (HRQOL) and family function (PedsQL Family Impact Module). The secondary objective was to determine whether these associations were moderated by caregiver-perceived social support. Structured interviews were conducted with 88 primary family caregivers of technology-dependent children in Singapore. Hierarchical multiple regression was used to assess the primary and secondary objectives. A total of 44.3% of caregivers were at high risk of clinical depression. Moderately poor child functional status was associated with more caregiver depressive symptoms. Perceived social support moderated this association. Family caregivers of technology-dependent children have high levels of depressive symptoms and relatively poor HRQOL and family functioning. Enhancing caregivers' social support is important for their well-being.

A randomized controlled trial of a brain-computer interface based attention training program for ADHD.

OBJECTIVE: The use of brain-computer interface in neurofeedback therapy for attention deficit hyperactivity disorder (ADHD) is a relatively new approach. We conducted a randomized controlled trial (RCT) to determine whether an 8-week brain computer interface (BCI)-based attention training program improved inattentive symptoms in children with ADHD compared to a waitlist-control group, and the effects of a subsequent 12-week lower-intensity training. STUDY DESIGN: We randomized 172 children aged 6-12 attending an outpatient child psychiatry clinic diagnosed with inattentive or combined subtypes of ADHD and not receiving concurrent pharmacotherapy or behavioral intervention to either the intervention or waitlist-control group. Intervention involved 3 sessions of BCI-based training for 8 weeks, followed by 3 training sessions per month over the subsequent 12 weeks. The waitlist-control group received similar 20-week intervention after a wait-time of 8 weeks. RESULTS: The participants' mean age was 8.6 years (SD = 1.51), with 147 males (85.5%) and 25 females (14.5%). Modified intention to treat analyzes conducted on 163 participants with at least one follow-up rating showed that at 8 weeks, clinician-rated inattentive symptoms on the ADHD-Rating Scale (ADHD-RS) was reduced by 3.5 (SD 3.97) in the intervention group compared to 1.9 (SD 4.42) in the waitlist-control group (between-group difference of 1.6; 95% CI 0.3 to 2.9 p = 0.0177). At the end of the full 20-week treatment, the mean reduction (pre-post BCI) of the pooled group was 3.2 (95% CI 2.4 to 4.1). CONCLUSION: The results suggest that the BCI-based attention training program can improve ADHD symptoms after a minimum of 24 sessions and maintenance training may sustain this improvement. This intervention may be an option for treating milder cases or as an adjunctive treatment.

Development and calibration of a novel positive mindset item bank to measure health-related quality of life (HRQoL) in Singapore.

BACKGROUND: Positive mindset (PM) is an important domain of health-related quality of life in Singapore, a multi-ethnic urban city state in Southeast Asia. We therefore developed and calibrated a novel item bank to measure and improve PM. METHODS: We developed an initial candidate pool of 48 items from focus groups, in-depth interviews and existing instruments locally developed and validated for use in Singapore. We administered all items in English to a multi-stage sample stratified for age and gender, of subjects with and without medical conditions recruited from the community and a hospital, and calibrated their responses using Samejima's Graded Response Model. We evaluated a final 36-item bank with respect to Item Response Theory (IRT) model assumptions, model fit, differential item functioning (DIF), concurrent and known-groups validity. RESULTS: Among 493 participants (49.3% male, 41.6% above 50 years old, 33% Chinese, Malay and Indian), bifactor model analyses supported unidimensionality: explained common variance of the general factor was 0.86 and omega hierarchical was 0.97. Local independence was deemed acceptable: the average absolute residual correlations were <0.06 and 3.3% of the total item-pair residuals were flagged for local dependence. The overall model fit was adequate and provided good coverage of the PM construct (theta range: -3.6 to +2.4). Five items exhibited DIF with respect to ethnicity and gender, but were retained without modification of scores because they measured important aspects of PM. Scores correlated in the hypothesized direction with a self-reported measure of global health (Spearman's rho = -0.28, p<0.001) and discriminated between groups of participants with and without a self-reported diagnosis of a mood disorder (p = 0.007) adjusting for age, gender, ethnicity, education and marital status. CONCLUSION: The 36-item PM item bank demonstrated satisfactory psychometric properties for the English-speaking Singaporean population. IRT model assumptions were sufficiently met and scores showed concurrent and known-groups validity. Future studies to evaluate the validity of PM scores when items are administered adaptively are needed.

Perception of Stigma and Its Associated Factors Among Patients With Major Depressive Disorder: A Multicenter Survey From an Asian Population.

Stigma of major depressive disorder (MDD) is an important public health problem. This study aimed to examine the level of perceived stigma and its associated factors in MDD patients in five Asian countries, including China, Korea, Malaysia, Singapore, and Thailand. A total of 547 outpatients with MDD were included from Asian countries. We used the stigma scale of the Explanatory Model Interview Catalogue (EMIC) to assess stigma. The Montgomery-Asberg Depression Rating Scale (MADRS), Symptoms Checklist 90-Revised (SCL-90-R), Fatigue Severity Scale (FSS), Sheehan Disability Scale (SDS), 36-Item Short-Form Health Survey (SF-36), and Multidimensional Scale of Perceived Social Support (MSPSS) were used to assess symptoms, clinical features, functional impairment, health status, and social support. The stigma scores of patients under 55 years old were significantly higher than those equal to or greater than 55 years old (P < 0.001). The stigma scores exhibited significant negative correlation with age; MSPSS scores of family, friends, and others; and SF-36 subscale of mental health, but significant positive correlation with MADRS, FSS, SDS, and SCL-90-R subscale scores of depression, interpersonal sensitivity, obsession-compulsion, psychoticism, and somatization. Multivariate regression analysis revealed that age, SCL-90-R interpersonal sensitivity, obsession-compulsion, psychoticism, MSPSS scores of friends and others, and SF-36 of mental health were significantly associated with the level of perceived stigma. These findings suggest that MDD patients who are young, have a high degree of interpersonal sensitivity and psychoticism, have low health-related quality of life, and have low social support are the target population for stigma interventions in Asia.