Machine-learning model derived gene signature predictive of paclitaxel survival benefit in gastric cancer: results from the randomised phase III SAMIT trial.

OBJECTIVE: To date, there are no predictive biomarkers to guide selection of patients with gastric cancer (GC) who benefit from paclitaxel. Stomach cancer Adjuvant Multi-Institutional group Trial (SAMIT) was a 2×2 factorial randomised phase III study in which patients with GC were randomised to Pac-S-1 (paclitaxel +S-1), Pac-UFT (paclitaxel +UFT), S-1 alone or UFT alone after curative surgery. DESIGN: The primary objective of this study was to identify a gene signature that predicts survival benefit from paclitaxel chemotherapy in GC patients. SAMIT GC samples were profiled using a customised 476 gene NanoString panel. A random forest machine-learning model was applied on the NanoString profiles to develop a gene signature. An independent cohort of metastatic patients with GC treated with paclitaxel and ramucirumab (Pac-Ram) served as an external validation cohort. RESULTS: From the SAMIT trial 499 samples were analysed in this study. From the Pac-S-1 training cohort, the random forest model generated a 19-gene signature assigning patients to two groups: Pac-Sensitive and Pac-Resistant. In the Pac-UFT validation cohort, Pac-Sensitive patients exhibited a significant improvement in disease free survival (DFS): 3-year DFS 66% vs 40% (HR 0.44, p=0.0029). There was no survival difference between Pac-Sensitive and Pac-Resistant in the UFT or S-1 alone arms, test of interaction p<0.001. In the external Pac-Ram validation cohort, the signature predicted benefit for Pac-Sensitive (median PFS 147 days vs 112 days, HR 0.48, p=0.022). CONCLUSION: Using machine-learning techniques on one of the largest GC trials (SAMIT), we identify a gene signature representing the first predictive biomarker for paclitaxel benefit. TRIAL REGISTRATION NUMBER: UMIN Clinical Trials Registry: C000000082 (SAMIT); ClinicalTrials.gov identifier, 02628951 (South Korean trial).

Reasonable Risk Ratio of Palate Surgery: A New Critical Analysis.

OBJECTIVE.: A new critical complication risk analysis, the reasonable risk ratio (RRR or R3) for palate surgeries in obstructive sleep apnea patients. METHODS.: Analysis from published meta-analyses, systematic reviews on success rates, and complications encountered for 3 palate surgeries, expansion sphincter pharyngoplasty (ESP), barbed repositioning pharyngoplasty (BRP) and modified uvulopalatopharyngoplasty (mUPPP), over 20 years. The RRR is derived from a ratio of the percentage of each respective complication over the success rate of that particular surgical procedure. The benchmark RRR of tonsillectomy is set at 0.035 to 0.078. An RRR below this benchmark value is more favorable as tonsillectomy is a widely accepted ENT procedure with risks to benefit well accepted. RESULTS.: The RRR for foreign body (FB) sensation (BRP) ranged from 0.03 to 0.23 (mean RRR of 0.14), FB sensation (ESP) 0.01, FB sensation (mUPPP) ranged from 0.33 to 0.55 (mean RRR of 0.44). The RRR for swallowing difficulties (BRP) ranged from 0.04 to 0.23 (mean RRR of 0.11), mUPPP, was 0.37; no reported swallowing difficulties with the ESP. The RRR for velopharyngeal insufficiency (VPI) (BRP) ranged from 0.009 to 0.18 (mean RRR of 0.07), and RRR VPI (mUPPP) was 0.14. The RRR (BRP) for dry throat was 0.06 and the mUPPP was 0.35, with no reported VPI or dry throat for ESP. The overall RRR for the BRP was 0.09, ESP was 0.01 and mUPPP was 0.29. CONCLUSION.: RRR provides a summarized data-driven, statistical guide to aid decision-making, and helps in patient counseling. BRP and ESP have been shown to have less complications compared to mUPPP.Level of evidence: IV.

Baveno-VII criteria to predict decompensation and initiate non-selective beta-blocker in compensated advanced chronic liver disease patients.

BACKGROUND/AIMS: The utility of Baveno-VII criteria of clinically significant portal hypertension (CSPH) to predict decompensation in compensated advanced chronic liver disease (cACLD) patient needs validation. We aim to validate the performance of CSPH criteria to predict the risk of decompensation in an international real-world cohort of cACLD patients. METHODS: cACLD patients were stratified into three categories (CSPH excluded, grey zone, and CSPH). The risks of decompensation across different CSPH categories were estimated using competing risk regression for clustered data, with death and hepatocellular carcinoma as competing events. The performance of "treating definite CSPH" strategy to prevent decompensation using non-selective beta-blocker (NSBB) was compared against other strategies in decision curve analysis. RESULTS: One thousand one hundred fifty-nine cACLD patients (36.8% had CSPH) were included; 7.2% experienced decompensation over a median follow-up of 40 months. Non-invasive assessment of CSPH predicts a 5-fold higher risk of liver decompensation in cACLD patients (subdistribution hazard ratio, 5.5; 95% confidence interval, 4.0-7.4). "Probable CSPH" is suboptimal to predict decompensation risk in cACLD patients. CSPH exclusion criteria reliably exclude cACLD patients at risk of decompensation, regardless of etiology. Among the grey zone, the decompensation risk was negligible among viral-related cACLD, but was substantially higher among the non-viral cACLD group. Decision curve analysis showed that "treating definite CSPH" strategy is superior to "treating all varices" or "treating probable CSPH" strategy to prevent decompensation using NSBB. CONCLUSION: Non-invasive assessment of CSPH may stratify decompensation risk and the need for NSBB in cACLD patients.

Factors Associated With Hope and Quality of Life in Patients With Coronary Artery Disease.

BACKGROUND: Psychological resources such as hope have been suggested to affect quality of life (QoL) positively in patients with heart disease. However, little information regarding the relationship between these two constructs is available. PURPOSE: This work was aimed at examining the factors associated with hope and QoL in patients with coronary artery disease. METHODS: In this descriptive work, perceived QoL and hope were assessed in 500 patients with heart disease. The information was collected using the McGill QoL Questionnaire, demographic variables, and the Herth Hope Index. The Pearson correlation test and general linear model were used to examine correlations through SPSS Version 22. RESULTS: A considerable correlation was discovered between QoL and hope (r = .337, p < .001). Multivariate analyses with regression revealed that religious beliefs and social support both had significant and positive effects on the total perceived hope of patients and that patient age had a considerable negative impact on QoL (p < .05). None of these factors had a significant impact on hope (p < .05). In addition, the total QoL had a significant and positive effect on patient feelings and thoughts, whereas the physical problems component of QoL had a significant and negative effect on hope (p < .05). Participants with higher levels of education reported more hope. CONCLUSIONS: QoL relates significantly to self-perceived hope in patients. Understanding QoL and hopefulness in patients with coronary artery disease has implications for nurses and other healthcare professionals.

The road to achieving herd immunity: factors associated with Singapore residents' uptake and hesitancy of the COVID-19 vaccination.

OBJECTIVE: Achieving high vaccination rates is key to containing the coronavirus disease 2019 (COVID-19). This study evaluated the factors associated with uptake of the COVID-19 vaccine. METHODS: Six hundred and seventy-six respondents were surveyed online between May and June 2021. Data on demographics, perception of the COVID-19 pandemic, and vaccine willingness and hesitancy factors were collected. RESULTS: Approximately 54.6% of the respondents had received the COVID-19 vaccination. Age (p = 0.001), males (OR 1.7, 95% CI 1.1-2.6, p = 0.026), ethnicity (p = 0.004), occupation (p = 0.003)), working in healthcare (OR 6.1, 95% CI 2.8-13.2, p < 0.001), smoking (OR 3.3, 95% CI 1.3-8.8, p = 0.014), seeing vaccination as a social responsibility (OR 3.8, 95% CI 1.2-12.0, p = 0.022) and believing the vaccine is important to end the COVID-19 pandemic (OR 2.7, 95% CI 1.1-6.1, p = 0.020) were associated with greater vaccination uptake. CONCLUSION: Social responsibility and well-being of collective society are important values associated with vaccine uptake in an Asian society. Understanding factors behind vaccine uptake can help advise public health measures and strategies to achieve high levels of vaccination.

Morphologic quantification of the maxilla and the mandible with cone-beam computed tomography.

INTRODUCTION: The purpose of this pilot study was to use cone-beam computed tomography (CBCT) to determine the volumes of the maxilla and the mandible in subjects with skeletal Class I, Class II, and Class III malocclusions. Hypothesis 1 was that the volume (size) of a skeletal Class II maxilla is larger than those of Class I and Class III. Hypothesis 2 was that the volume of a skeletal Class III mandible is larger than those of Class I and Class II. METHODS: Thirty women patients were classified into 3 groups according to their skeletal pattern: skeletal Class I (0 degrees < or =ANB <6 degrees ), Class II (ANB > or =6 degrees ) and Class III (ANB <0 degrees ). The volumes of the maxilla and the mandible were measured with CBCT. CB MercuRay (Hitachi Medico, Tokyo, Japan) and CB works software (CyberMed, Seoul, Korea) were used to process the images. RESULTS: There was a trend that skeletal Class III subjects might have significantly greater mandibular volume compared with Class II subjects (P = 0.089). The ratios of maxilla-to-mandible volumes between the skeletal Class II and Class III groups were significantly different (P = 0.005). Differences were observed in the ratios of maxillary and mandibular volumes across the 3 groups. CONCLUSIONS: Hypotheses 1 and 2 were rejected; there was no trend for Class III subjects to have larger mandibles (P = 0.089) compared with Class II subjects. The ratio of the maxilla and mandible volumes in skeletal Class III subjects was significantly larger (P = 0.005) compared with Class II subjects.

Head-to-head evaluation on diagnostic accuracies of six SARS-CoV-2 serological assays.

In this study, we evaluated and compared six SARS-CoV-2 serology kits including the Abbott SARS-CoV-2 IgG assay, Beckman Access SARS-CoV-2 IgG assay, OCD Vitros OCD Anti-SARS-CoV-2 Total antibody assay, Roche Elecsys Anti SARS-CoV-2 assay, Siemens SARS-CoV-2 Total assay, and cPass surrogate viral neutralising antibody assay. A total of 336 non-duplicated residual serum samples that were obtained from COVID-19 confirmed patients (n=173) on PCR and negative controls (n=163) obtained pre-December 2019 before the COVID-19 pandemic were used for the study. These were concurrently analysed on the different immunoassay platforms and correlated with clinical characteristics. Our results showed all assays had specificity ranging from 99.3% to 100.0%. Overall sensitivity across all days of symptoms, in descending order were OCD (49.1%, 95% CI 41.8-56.5%), cPass (44.8%, 95% CI 37.5-52.3%), Roche (41.6%, 95% CI 34.5-49.0%), Siemens (39.9%, 95% CI 32.9-47.3%), Abbott (39.8%, 95% CI 32.9-47.3%) and Beckman (39.6%, 95% CI 32.5-47.3%). Testing after at least 14 days from symptom onset is required to achieve AUCs greater than 0.80. OCD and cPass performed the best in terms of sensitivity for >21 days symptoms with 93.3% (95% CI, 73.5-99.2%) and 96.7% (95% CI, 82.8-99.9%), respectively. Both also shared the greatest concordance, kappa 0.963 (95% CI 0.885-1.0), p<0.001, and had the lowest false negative rates. Serology results should be interpreted with caution in certain cases. False negatives were observed in a small number of individuals with COVID-19 on immunosuppressive therapy, pauci-symptomatic or who received antiretroviral therapy. In conclusion, all assays exhibited excellent specificity and total antibody assays with spike protein configurations generally outperformed nucleocapsid configurations and IgG assays in terms of diagnostic sensitivity.

Generalised convulsive status epilepticus in Singapore: clinical outcomes and potential prognostic markers.

PURPOSE: To study the characteristics, outcomes and prognostic markers of convulsive status epilepticus (SE) in Singapore. METHODS: 62 adult admissions to the National University Hospital Singapore from 2002 to 2005 were studied. Ethnicity, history of epilepsy, educational subnormality, neuroimaging, seizure duration, length of stay, Modified Rankin Scale (MRS) pre and post discharge, blood glucose, creatine kinase, potassium, white cell and platelet count were recorded. An MRS> or =3 at discharge was defined as a poor outcome. ROCs of significant variables were plotted to identify the best test cut-offs. RESULTS: Mean age was 59.2 years (range 20-94). 75.9% patients had epilepsy. Mean length of stay was 14 days (range 1-75). Univariate analyses revealed age (p=0.01, OR 1.075, 95% CI 1.030-1.122), length of stay in ICU (p=0.03, OR 1.299, 95% CI 1.014-1.665) and hospital (p=0.014, OR 1.203, 95% CI 1.038-1.393) and hyperglycemia (p=0.045, OR 1.327, 95% CI 1.007-1.750) associated with poor outcome. Test cut-off values for prognostic markers were established: age> or =55 years (ROC 0.790, sensitivity 72.3, specificity 85.7, PPV9 4.4%, NPV 48.8%) and serum glucose> or =7 mmol/L (ROC 0.737, sensitivity 72.3, specificity 80.0, PPV 93.5%, NPV 36.4%). A discriminant model using these variables was then constructed with probability scores for poor outcome. DISCUSSION: Age, hyperglycemia and length of stay in hospital influenced outcome from convulsive SE in the local population with hyperglycemia being a novel prognostic marker. Some prognostic markers cited in the literature differed, highlighting the possibility that these indicators may vary across population groups.

Motivation, study habits, and expectations of medical students in Singapore.

OBJECTIVES: To determine the motivation and incentives in education, learning experience and teaching techniques, and expectations about future careers among medical students from a multi-ethnic Asian country. METHODS: Pre-validated questionnaire-based survey with stratified random sampling among medical students. The questionnaire combined qualitative responses with semi-quantitative measures of available alternatives. RESULTS: The response rate was 83.1%. The most important factor for pursuing university study was 'prospect of finding an interesting challenging job' (rank 1-75%). Family made a significant contribution in decision making. Given the chance, a majority (67.2%) of respondents would prefer to study overseas. The main deterring factors were cost (67.7%), distance from home (28%), and local opportunity for post-graduation (23.4%). Despite their inclination of study overseas, the majority (73.9%) of the respondents indicated they were either very satisfied or satisfied with their current choice of university study. Only 20% of students were comfortable in asking questions in classroom as asking questions was deemed 'too risky' and 'unnecessary to get better grades'. Students adopted strategies related to assessment and competition to monitor their study. Senior students reported university education as less relevant to their future careers as compared to junior students (p = 0.002). CONCLUSIONS: Students' learning behaviour is determined by complex factors such as educational incentives, learning support, assessment and competition. Among several external factors, family, job prospects and expectations about the future play a critical role in education.

Epidemiology of diabetic foot problems and predictive factors for limb loss.

OBJECTIVES: The aim of this study was to evaluate the epidemiology of diabetic foot problems (DFP) and predictive factors for major amputations (below- and above-knee). METHODS: This is a prospective study of 202 patients treated in National University Hospital (NUH) during the period of January 2005 to May 2006. A protocol was designed for documentation including patient profile, type of DFP, presence of risk factors, comorbidities and complications, clinical presentation, investigations, treatment given, and final outcome. The predictors for limb loss were determined using univariate and stepwise logistic regression analysis. RESULTS: One hundred ninety-two patients had Type 2 diabetes. Mean age of cohort was 60 years, with male to female ratio of 1:1. Incidence of DFP was significantly higher in Malays (P=.0015) and Indians (P=.036) and significantly lower in Chinese (P<.05). Of patients, 72.8% had poor endocrine control (GHb level >7%), and 42.1% of patients had sensory neuropathy based on 5.07 Semmes-Weinstein Monofilament test. Common DFP included gangrene (31.7%), infection (abscess, osteomyelitis) (28.7%), ulcer (27.7%), cellulitis (6.4%), necrotizing fasciitis (3.5%) and Charcot's osteoarthropathy (2.0%). Surgery was performed in 74.8% of patients and major amputation in 27.2% of patients (below-knee in 20.3% and above-knee in 6.9%). CONCLUSIONS: This is the first detailed prospective study evaluating predictive factors for major amputations in patients with DFP. Significant univariate predictive factors for limb loss were age above 60 years, stroke, ischaemic heart disease, nephropathy, peripheral vascular disease (PVD), sensory neuropathy, glycosylated haemoglobin level, Ankle Brachial Index (ABI) <0.8, gangrene, infection, and pathogens such as methicillin-resistant Streptococcus aureus (MRSA) and Staphylococcus aereus. Upon stepwise logistic regression analysis, only PVD and infection were significant.

Intra-operative cerebrospinal fluid sampling versus post-operative lumbar puncture for detection of leptomeningeal disease in malignant paediatric brain tumours.

INTRODUCTION: Leptomeningeal disease is a feared sequelae of malignant paediatric brain tumours. Current methods for its detection is the combined use of cranio-spinal MRI, and CSF cytology from a post-operative lumbar puncture. In this study, the authors hypothesize that CSF taken at the start of surgery, either from an external ventricular drain or neuroendoscope will have equal sensitivity for positive tumour cells, in comparison to lumbar puncture. Secondary hypotheses include positive correlation between CSF cytology and MRI findings of LMD. From a clinical perspective, the key aim of the study was for affected paediatric patients to avoid an additional procedure of a lumbar puncture, often performed under anaesthesia after neurosurgical intervention. METHODS: This is single-institution, retrospective study of paediatric patients diagnosed with malignant brain tumours. Its main aim was to compare cytological data from CSF collected at the time of surgery versus data from an interval lumbar puncture. In addition, MRI imaging of the same cohort of patients was examined for leptomeningeal disease and corroborated against CSF tumour cytology findings. RESULTS: Thirty patients are recruited for this study. Data analysis demonstrates a statistically significant association between our intra-operative CSF and LP sampling. Furthermore, our results also show for significant correlation between evidence of leptomeningeal disease on MRI findings versus intra-operative CSF positivity for tumour cells. CONCLUSION: Although this is a retrospective study with a limited population, our data concurs with potential to avoid an additional procedure for the paediatric patient diagnosed with a malignant brain tumour.

The estimate of average age at the onset of acute myocardial infarction in Iran: A systematic review and meta-analysis study.

BACKGROUND: Research indicates that the age of onset of first acute myocardial infarction (AMI) is an essential element in the life expectancy that has been decreasing in developing countries. There are various studies performed in Iran reporting a range of ages at time of AMI. Thus, this meta-analysis study is designed to determine the mean age at first AMI in the Iranian population. METHODS: All studies that met the inclusion and exclusion criteria were reviewed using standard keywords in the databases from 2000 to 2016. Two raters verified a total of 658 articles. Sixteen studies met the inclusion criteria of this study for meta-analysis. Cochran test and I-squared (I2) were used for samples' homogeneity. Pooled estimates of mean were calculated using the random effects inverse-variance model. RESULTS: The mean age of AMI varied between 55.9 to 62.9 years among the primary studies. The pooled mean age of first AMI with a 95% confidence interval (CI) for the total sample, men, and women were 59 (58.9, 60.4), 58.7 (58.3, 59.2), and 64.2 (63.5, 64.8), respectively. CONCLUSION: Our meta-analysis shows that the mean age of first onset of AMI in Iranian people is slightly lower than that reported elsewhere; and it is lower for men than for women.

Assessment criteria for compliance with oral hygiene: application of ROC analysis.

PURPOSE: Diabetes is an established risk factor for periodontal disease. Management of periodontal disease is highly dependent upon effective oral hygiene. Assessment of plaque and gingivitis has been commonly used and arbitrarily set in clinical practice to evaluate patients' adherence with oral hygiene recommendations. This study aims to determine an objective cut-off criterion for assessing oral hygiene compliance utilising a combination of plaque and bleeding scores. MATERIALS AND METHODS: 161 patients with diabetes, from a prospective clinical trial, provided the clinical periodontal parameters at baseline to be used to determine the oral hygiene compliance criterion in relation to a composite score of pocket depth, subgingival calculus and supragingival calculus. A sequence of different combinations of plaque and gingival bleeding scores were used. Receiver operator characteristic (ROC) curve assessment, sensitivity, specificity, and predictive values were utilised for the determination of the criterion. RESULTS: The combination of 25% plaque scores and 15% gingival bleeding scores obtained the highest ROC value (using a probability cut-off of 0.5) of 0.868 with sensitivity 98.6%, specificity 75.0%, positive predictive value (PPV) 97.3% and negative predictive value (NPV) 85.7%. According to this criterion, amongst the cohort of subjects examined, 145 (90.1%) were categorised as non-compliant, and only 16 (9.9%) were considered compliant with oral hygiene at baseline. CONCLUSIONS: Based upon the clinical periodontal parameters of subjects from this study, a combination of 25% plaque score and 15% bleeding score appears to be a valid target for determining compliance with oral hygiene in oral health programmes.

Defining negative symptoms remission in schizophrenia using the Brief Negative Symptom Scale / Criterios de remisión de síntomas negativos utilizando la Escala Breve de Síntomas Negativos (BNSS)

Introduction: This study aimed to propose criteria for negative symptoms remission (NSR) in schizophrenia using the Brief Negative Symptom Scale (BNSS).Material and methods: 274 participants were assessed on the Positive and Negative Syndrome Scale (PANSS), BNSS and Social and Occupational Functioning Assessment Scale (SOFAS). Two criteria for NSR on the BNSS were proposed – NSR based on the BNSS domains scores (NSRBNSS_DOMAINS) and NSR based on 5 key items of the BNSS (NSRBNSS_5ITEMS). A SOFAS score of 61 and above was considered as functional remission (FR). Logistic regressions were run to examine the association between FR and NSR. Receiver operating characteristic (ROC) curve analysis was performed for the NSR criteria on FR. Kappa agreement statistic was used to evaluate the agreement between the two NSR criteria.Results: Eighty-nine (32.5%) participants fulfilled NSRBNSS_DOMAINS criterion whereas 70 (25.6%) participants fulfilled NSRBNSS_5ITEMS criterion. The two NSR criteria had substantial agreement (Kappa statistic=0.797) with each other. Sixty-one (25.3%) participants were in FR. FR was significantly associated with NSR, irrespective of the criterion used. To predict FR, the Area Under the Curve for NSRBNSS_DOMAINS and NSRBNSS_5ITEMS were 0.761 (CI: 0.696–0.826, p<0.001) and 0.723 (CI: 0.656–0.790, p<0.001), respectively. Hence, both NSR criteria demonstrated a fair ability to discriminate between functional remitters and non-remitters. Conclusions: Depending on the setting and needs, clinicians and researchers might employ either the full BNSS or an abbreviated 5-item BNSS scale to identify NSR in schizophrenia. More research is needed to further examine the validity of these criteria in schizophrenia. (AU)

Introducción: El objetivo de este estudio fue proponer criterios para la remisión de síntomas negativos (NSR) en la esquizofrenia utilizando la Escala Breve de Síntomas Negativos (BNSS). Material y métodos: 274 participantes fueron evaluados con la Escala de Síndrome Positivo y Negativo (PANSS), BNSS y la Escala de Evaluación del Funcionamiento Social y Ocupacional (SOFAS). Se propusieron dos criterios para NSR en el BNSS: NSR basado en las puntuaciones de los dominios BNSS (NSRBNSS_DOMAINS) y NSR basado en 5 elementos clave del BNSS (NSRBNSS_5ITEMS). Una puntuación SOFAS de 61 y superior se consideró como remisión funcional (FR). Se realizaron regresiones logísticas para examinar la asociación entre FR y NSR. El análisis de la curva de características operativas del receptor (ROC) se realizó para los criterios NSR en FR. Se utilizó la estadística de concordancia Kappa para evaluar la concordancia entre los dos criterios de NSR.Resultados: Ochenta y nueve (32,5%) participantes cumplieron el criterio NSRBNSS_DOMAINS mientras que 70 (25,6%) participantes cumplieron el criterio NSRBNSS_5ITEMS. Los dos criterios de NSR tuvieron un acuerdo sustancial (estadística Kappa = 0,797) entre sí. Sesenta y un (25,3%) participantes estaban en FR. La FR se asoció significativamente con la NSR, independientemente del criterio utilizado. Para predecir la FR, el área bajo la curva para NSRBNSS_DOMAINS y NSRBNSS_5ITEMS fueron 0,761 (IC: 0,696-0,826, p <0,001) y 0,723 (IC: 0,656-0,790, p <0,001), respectivamente. Por lo tanto, ambos criterios NSR demostraron una capacidad adecuada para discriminar entre remitentes funcionales y no remitentes. Conclusiones: Dependiendo del entorno y las necesidades, los médicos e investigadores pueden emplear la BNSS completa o una escala BNSS abreviada de 5 ítems para identificar la NSR en la esquizofrenia. Se necesita más investigación para examinar a fondo la validez de estos criterios en la esquizofrenia. (AU)

Migration psychosis and homicide in Singapore: a five year study.

Psychiatric research into violent offences, particularly murder, have been scant in the South East Asian region, with the last major review of homicides in Singapore and their association with psychiatric disorders being as far back as 1985. This study seeks to update the psychiatric community on individuals charged with murder in Singapore from 1997 to 2001 and particularly to further investigate the phenomenon of 'migration psychosis' in relation to foreigners in this sample who have committed homicide. One hundred and ten individuals in Singapore were charged with murder between 1997 and 2001. Socio-demographic data, psychiatric diagnoses, offence and victim profiles and court outcomes were obtained. The group consisting of offenders who were Singapore citizens or permanent residents was compared with those offenders who were foreigners. Analysis was done using the statistical package, SPSS. The proportion of foreigners in this study who committed homicide is significantly higher than the proportion of citizens/permanent residents in the general population. Foreigners who commit homicide also appear to (i) suffer from the more serious psychiatric illnesses of mood and psychotic disorders compared with locals, (ii) be less likely to have a known history of violence or a past forensic history and (iii) be more likely to be new to psychiatric services compared with the local homicide offenders. Compared with locals, foreigners appear to have a higher risk for committing homicide. Yet, they are less likely to appear early enough before mental health services. Some form of basic education to employers of foreigners as well as to the foreigners themselves on the early signs of mental illness is recommended.

Assessment of colour differences in silicone hand and digit prostheses: perceptible and acceptable thresholds for fair and dark skin shades.

This study addresses the dilemma of initial clinical and social acceptance of a newly fabricated silicone prosthesis in relation to its colour match to the natural skin. This was achieved by derivation of specific colour difference thresholds defining perceptible and acceptable levels of colour sensitivity. Two separate sets of 10 fair and dark shade digit prosthesis samples were each fabricated with a stepped increase in colour difference (deltaE) against the baseline hand prosthesis. Ninety individuals with normal colour vision scores were selected as colour assessors. The colour difference of each prosthesis in the two series was evaluated visually against the baseline by the assessors, using defined scores. The thresholds for perceptible and acceptable colour difference determined in this study were deltaE= 0.8 and deltaE= 1.8 for the fair series and deltaE = 1.3 and deltaE = 2.6 for the dark series, respectively. The acceptable threshold values differed from the perceptible threshold values by deltaE= 1.0 for the fair-shade samples and deltaE= 1.3 for the dark-shade samples. This study demonstrated that subjective visual assessment is positively correlated with deltaE values computed from colorimetric measurements for both fair and dark-shade silicone samples (p<0.001). This results shows that human subjects with normal colour vision are capable of accurately assessing colour differences. These observations emphasize the importance of subjective feedback on colour by the patient, provided the latter has perfect colour-tested vision. The study also showed that human subjects were less sensitive to perceived colour differences in darker-shade than fairer-shade samples (p < 0.001). This finding seems relevant in a clinical setting involving a multi-ethnic patient population.

A pilot study of the impact of the Asian Tsunami on a group of Asian media workers.

The Asian Tsunami that struck on December 26, 2004, claimed tens of thousands of lives. To bring up-to-date news to the public, many media workers raced to the frontline. Singapore journalists were among the first to arrive at the devastated scenes of the affected countries. Critical Incident Stress Debriefing (CISD) was offered to these media personnel about a week after they returned from assignment. Twelve of the media workers participated in the CISD and also completed the General Health Questionnaire (GHQ-28), The Impact of Events Scale (IES), and a feedback questionnaire on what was helpful to them during the debriefing. Twenty-five percent of the respondents displayed psychiatric symptoms (GHQ-28 score > or = 5) with highest scorings being in the somatic domain. One third had IES > 30 with higher scores on the avoidance scale. Seventy-five percent of the participants indicated moderate (8.6-19) to high (> 19.0) total scores on the IES. All the participants reported that CISD was valuable. This pilot study provides support for the need to address the emotional aftermath of impacted media workers in the wake of disasters.

Combined panel of serum human tissue kallikreins and CA-125 for the detection of epithelial ovarian cancer.

OBJECTIVE: To determine the predictive accuracy of the combined panels of serum human tissue kallikreins (hKs) and CA-125 for the detection of epithelial ovarian cancer. METHODS: Serum specimens collected from 5 Indonesian centers and 1 Vietnamese center were analyzed for CA-125, hK6, and hK10 levels. A total of 375 specimens from patients presenting with ovarian tumors, which include 156 benign cysts, 172 epithelial ovarian cancers (stage I/II, n=72; stage III/IV, n=100), 36 germ cell tumors and 11 borderline tumors, were included in the study analysis. Receiver operating characteristic analysis were performed to determine the cutoffs for age, CA-125, hK6, and hK10. Sensitivity, specificity, negative, and positive predictive values were determined for various combinations of the biomarkers. RESULTS: The levels of hK6 and hK10 were significantly elevated in ovarian cancer cases compared to benign cysts. Combination of 3 markers, age/CA-125/hk6 or CA-125/hk6/hk10, showed improved specificity (100%) and positive predictive value (100%) for prediction of ovarian cancer, when compared to the performance of single markers having 80-92% specificity and 74-87% positive predictive value. Four-marker combination, age/CA-125/hK6/hK10 also showed 100% specificity and 100% positive predictive value, although it demonstrated low sensitivity (11.9%) and negative predictive value (52.8%). CONCLUSION: The combination of human tissue kallikreins and CA-125 showed potential for improving prediction of epithelial ovarian cancer in patients presenting with ovarian tumors.

Predictive factors for lower extremity amputations in diabetic foot infections.

The objective of this study was to evaluate the epidemiology of diabetic foot infections (DFIs) and its predictive factors for lower extremity amputations. A prospective study of 100 patients with DFIs treated at the National University Hospital of Singapore were recruited in the study during the period of January 2005-June 2005. A protocol was designed to document patient's demographics, type of DFI, presence of neuropathy and/or vasculopathy and its final outcome. Predictive factors for limb loss were determined using univariate and stepwise logistic regression analysis. The mean age of the study population was 59.8 years with a male to female ratio of about 1:1 and with a mean follow-up duration of about 24 months. All patients had type 2 diabetes mellitus. Common DFIs included abscess (32%), wet gangrene (29%), infected ulcers (19%), osteomyelitis (13%), necrotizing fasciitis (4%) and cellulitis (3%). Thirteen patients were treated conservatively, while surgical debridement or distal amputation was performed in 59 patients. Twenty-eight patients had major amputations (below or above knee) performed. Forty-eight percent had monomicrobial infections compared with 52% with polymicrobial infections. The most common pathogens found in all infections (both monomicrobial and polymicrobial) were Staphylococcus aureus (39.7%), Bacteroides fragilis (30.3%), Pseudomonas aeruginosa (26.0%) and Streptococcus agalactiae (21.0%). Significant univariate predictive factors for limb loss included age above 60 years, gangrene, ankle-brachial index (ABI) <0.8, monomicrobial infections, white blood cell (WBC) count ≥ 15.0×10(9)/L, erythrocyte sedimentation rate ≥100 mm/hr, C-reactive protein ≥15.0 mg/dL, hemoglobin (Hb) ≤10.0g/dL and creatinine ≥150 µmol/L. Upon stepwise logistic regression, only gangrene, ABI <0.8, WBC ≥ 15.0×10(9)/L and Hb ≤10.0g/dL were significant.

Efficacy of metered-dose inhalers for children with acute asthma exacerbations.

OBJECTIVE: To compare the effectiveness of the administration of inhaled beta-agonists delivered via a metered-dose inhaler (MDI) with spacers--as part of an evidence-based asthma pathway developed to manage acute asthma exacerbations in children at the emergency room level and in inpatient management--against administration via nebulization. DESIGN: Case with historical control. SETTING: KK Women's and Children's Hospital (Singapore). PARTICIPANTS: A total of 19,951 children (infants to older children) aged 18 years and younger who attended the emergency room for asthma exacerbations. MAIN OUTCOME MEASURES: Average length of stay, proportion admitted to high dependency or intensive care, proportion readmitted for unresolved symptoms within 72 hr, cost per patient and overall. RESULTS: There was no increase in the mean proportion of emergency room attendances admitted to inpatient care with use of an MDI (mean difference 0.97%, 95% CI: -1.6-3.5%, P = 0.447), nor of children admitted to intensive care (0.21 vs. 0.20 pre- and post-pathway, P = 0.827) or to high dependency units (2.21 vs. 1.37 pre- and post-pathway, P = 0.200) but a significant reduction in the within 72 hr re-attendance rate (mean difference 1.4%, 95% CI: 0.78-2.0%, P < 0.001) with use of an MDI. The average length and cost per patient for an inpatient stay for acute asthma exacerbations was reduced with use of an MDI. CONCLUSIONS: The use of an MDI with spacer as part of an evidence-based asthma pathway was effective in the management of acute asthma exacerbations in the emergency room setting and for inpatient management.