This paper presents the results of a clinical study of 150 patients in Singapore with ankylosing spondylitis (AS) and reviews recent developments locally with regards to the disease. The patients were predominantly males (ratio 7:1) and Chinese (n = 147). The onset of disease is usually in the early twenties and there was a mean delay of 6.3 years before diagnosis was made. Peripheral joint involvement is common but apart from uveitis (17%), extra-articular manifestations are rare. AS patients have abnormal lipid profiles and lower bone mineral density compared to healthy controls. HLA*B2704 is the predominant subtype in our Chinese patients whilst HLA*B2706 was found only in healthy controls. Intensive group physiotherapy is beneficial for patients with spondyloarthropathy.
Low molecular weight IgM (LMW IgM) is the monomeric subunit of the naturally occurring pentameric IgM. It is not seen in health but has been previously observed in systemic lupus erythematosus (SLE) particularly in those patients with active disease and may reflect an adverse prognostic finding. We have therefore studied the presence of LMW IgM in 33 Chinese or Malay SLE patients (Singapore) and 21 Caucasian patients (Adelaide). LMW IgM was measured using filtration chromatography or by a sensitive immunoblotting technique. LMW IgM was observed in all patients in the Adelaide group and in 32 patients in the Singapore group with slightly greater quantities being seen in the Adelaide group. LMW IgM constituted up to 15.3% of the total IgM and was frequently associated with the presence of other low molecular weight IgM oligomers. In both groups LMW IgM correlated significantly with the total IgM levels (P less than 0.01). In a more detailed study in the Singapore group LMW IgM also correlated significantly with the IgM anticardiolipin levels (P = 0.02) but not with IgG anticardiolipin or with IgG or IgM anti-DNA levels or with rheumatoid factor. Patients with more extensive organ involvement had higher levels of LMW IgM but not at a significant level. We conclude that circulating LMW IgM occurs almost universally in SLE, is closely related to the total IgM levels and appears independent of ethnic background. The significance of LMW IgM in this disorder is unclear.
OBJECTIVE: To determine the effects of ethnicity on disease manifestations in Oriental patients with systemic lupus erythematosus (SLE) and to describe the risk of developing renal or central nervous system (CNS) involvement with time.
METHODS: A retrospective study of 472 patients with SLE seen at the only Rheumatology Unit in Singapore. The effect of ethnicity on selected disease manifestations at diagnosis was assessed after adjusting for demographic variables using multiple logistic regression. The probability of developing selected disease manifestations with time was determined using the Kaplan-Meier product limit method.
RESULTS: At diagnosis, Malays had a higher risk of renal or CNS involvement than Chinese (OR 2.26, 95% CI 1.21 to 4.21, and OR 3.07, 95% CI 1.01 to 9.34, respectively), and Indians a lower risk of malar rash and a higher risk of oral ulcers than Chinese (OR 0.30, 95% CI 0.13 to 0.68, and OR 2.90, 95% CI 1.45 to 7.34, respectively). The prevalence of renal or CNS involvement in the entire cohort increased with time, reaching 75.6% (95% CI 66.1% to 85.0%) and 16.7% (95% CI 11.7% to 21.6%), respectively, after 18 years of disease.
CONCLUSION: Ethnicity influenced disease manifestations at diagnosis in this cohort of Oriental patients with SLE. Renal or CNS involvement developed in previously unaffected patients up to 18 years after diagnosis, highlighting the need for continued vigilance in patients with lupus.
OBJECTIVE: To determine the clinical features of psoriatic arthritis (PsA) in a multiethnic Oriental population and to study the effect of ethnicity on disease patterns.
METHODS: A retrospective study of 80 patients with PsA seen at either a rheumatology or dermatology referral center. Patients and case records were reviewed and data abstracted according to a standard protocol. Eighty consecutive patients with psoriasis without PsA seen at the dermatology center were recruited as controls.
RESULTS: Asymmetric polyarthritis developing in the 4th decade with an equal male to female ratio was the commonest pattern of arthritis among Chinese, Indians, and Malays. Clinically apparent lumbar spondylitis was significantly more common in Indians than Chinese (10/11 vs 11/20, respectively; p = 0.046), although the prevalence of lumbar spondylitis was similar in all ethnic groups. Eighty-nine percent of subjects required nonsteroidal antiinflammatory drugs and 51% required disease modifying antirheumatic drugs at some time for control of joint disease. PsA was significantly more common among Indians compared to the ethnic distribution of the Singapore population (p < 0.000001). Multiple logistic regression identified Indian ethnicity as a risk factor for the development of PsA (OR 2.39, 95% confidence interval 1.02 to 5.60).
CONCLUSION: The commonest pattern of PsA in all ethnic groups was asymmetric polyarthritis. Ethnicity affected the development and presentation of PsA in our series: Indians with psoriasis had double the risk of developing PsA compared to Chinese with psoriasis, and lumbar spondylitis when present in Chinese subjects was asymptomatic in 45%, being detectable only on radiological examination.
The indirect hemagglutination test was used to study antibody titers to Entamoeba histolytica in different Malaysian populations. Eighty-seven percent of Orang Asli (western Malaysian aborigines) adults and 79% of Orang Asli children with acute amebic dysentery were seropositive. However, significantly fewer children (39%) with amebic dysentery had high titer responses (titer greater than or equal to 1:1,280) than did adults with amebic dysentery (76%). No correlation between proctoscopic severity and amebic titer was found. Forty-four percent of asymptomatic family members were seroresponders. Satak, an Orang Asli village located near towns, had significantly more seroresponders (32%) than did the isolated, deep jungle village, Belatim (4%).
A prospective study was carried out in the Maternity Hospital, Kuala Lumpur in 1989 to determine the morbidity and mortality of infants of diabetic mothers. Out of 24,856 neonates born during the study period, 54 neonates (2.2 per 1000 livebirths) were born to mothers who were diagnosed to have diabetes mellitus before the current pregnancy or who had impaired glucose tolerance test during the current pregnancy. Almost a third (29.6 percent) of these infants of diabetic mothers had birthweight of 4000 grams and above, and 37.0 percent of the 54 babies were large-for-gestational age. Hypoglycemia occurred in 9/54 (16.7 percent) of the neonates, respiratory distress syndrome in 5/54 (9.3 percent), shoulder dystocia in 7/54 (13.0 percent), and congenital abnormalities in 4/54 (7.4 percent). Three (5.6 percent) neonates died during the neonatal period. The results of this study suggest a need to intensify control of maternal diabetes mellitus during pregnancy in order to reduce the rates of morbidity and mortality of their infants.
An association of idiopathic systemic lupus erythematosus (ISLE) with genetically determined N-acetylation polymorphism has been suspected from previous studies, mainly on Caucasian populations in which there is an approximate incidence of 50% of slow and rapid acetylators. The present study is of the incidence of ISLE and acetylator status in a mixed population of Malaysia. The results did not support an association between ISLE and acetylator status: the frequencies of slow acetylators in the ISLE patients who were Malaysian Chinese and Malay were 13 and 38% respectively. This did not differ significantly from the respective healthy groups (20 and 29%). The small number of Indians in the survey did not allow a valid comparison, but the figures did suggest a lack of association between ISLE and acetylator status.
The neutrophil antigen (NA)1 and 2 is coded by two recognized allelic forms of Fc gamma receptor IIIB (FcgammaRIIIB). FcgammaRIIIb is a low affinity receptor and preferentially removes immune complexes from the circulation. Systemic lupus erythematosus (SLE) is an autoimmune and polygenic disorder characterized by accumulation of autoimmune complexes. The majority of SLE patients in our medical center are of Chinese ethnicity, followed by Malay and Indian. Recently, studies have focussed on the Fc receptors in different ethnic groups and their relation to SLE. We chose to study the gene distribution of this receptor in the Chinese and Malays population in Malaysia. We designed a polymerase chain reaction allele specific primers (PCR-ASP) method to distinguish the two allelic forms. Genomic DNA was isolated from the peripheral blood of 183 Chinese and 55 Malays SLE patients as well as 100 Chinese and 50 Malays healthy controls. Genotyping of Chinese SLE patients revealed that the gene frequencies for FcgammaRIIIB-NA1 and FcgammaRIIIB-NA2 were 0.648 and 0.347, while in the ethnically matched healthy controls they were 0.68 and 0.32, respectively. One out of the 183 Chinese SLE patients was identified as a NA-null due to the absence of PCR product for both alleles. The FcgammaRIIIB-NA1 and FcgammaRIIIB-NA2 allele frequencies for both the Malays SLE and healthy controls were 0.62 and 0.38.
The human sex test in forensic multiplexes is based on the amelogenin gene on both the X and Y chromosomes commonly used in sex genotyping. In this study of 338 male individuals in a Malaysian population comprising Malays, Chinese and Indians, using the AmpFlSTR Profiler Plus kit, the amelogenin test gave a significant proportion of null alleles in the Indian ethnic group (3.6% frequency) and 0.88% frequency in the Malay ethnic group due to a deletion of the gene on the Y chromosome. This sex test also failed in a forensic casework sample. Failure of the amelogenin test highlights the need for more reliable sex determination than is offered by the amelogenin locus in the Malay and Indian populations. The gender of the Indian-Malay amelogenin nulls was confirmed by the presence of three Y-STR alleles (DYS438, DYS390 and DYS439). For the Indian ethnic group, one of the Y-STR forms a stable haplotype with the amelogenin null. The amelogenin-deletion individuals also showed a null with a male-specific minisatellite MSY1, indicating that a very large deletion was involved that included the amelogenin and the MSY1 loci on the short arm of the Y chromosomes (Yp).
Vital statistics in Malaya are of limited value but annual reports show that the infant mortality in Penang Municipality is 125, in Singapore Municipality 172.2, in the Straits Settlements 165.28, and in the State of Kedah 137 per thousand births. The tables show a similarity to those of large English towns fifty years ago.
Poverty, ignorance and superstition account for many of these deaths and much maternal ill-health. Children are seldom taken out in infancy and houses are frequently dark, stuffy and closely-shuttered. Solid carbohydrate food is given to infants even during the first month. Congenital Syphilis causes a number of deaths and in an investigation in Singapore of mothers whose infants died in the first year of life 30.9 per cent. were Wassermann-positive.
Increasing use is made of maternity wards in the Hospitals and in Kuala Lumpur there is a Chinese maternity hospital with a Chinese woman doctor on the staff. The infant death-rate among Malays is much higher than that of other races, who are more willing to make use of the hospitals.
In the rural areas labour commonly takes place under the most primitive conditions with no help except that of an untrained handy-woman (bidan). A better midwifery service for these areas is gradually being developed and Malay women are being trained to replace the old "bidan" in the villages.
Education is doing something to inculcate modern views on the bringing up of children. The teaching of personal hygiene to teachers and pupils in the vernacular girls' schools is proving of value, and the Girl Guide movement has given an added interest to this.
Medical inspection of school children is more complete in the towns than in the rural areas. Dental caries, skin conditions, intestinal worms, and enlarged tonsils are common in the junior schools.
Tables are given of vital statistics and records of school medical inspection from the reports of the health officers of the Straits Settlements, Singapore, and Kedah. W. H. Peacock.
Merital is a recently introduced antidepressant agent which is structurally unrelated to the traditional antidepressant agents and which is reported to have minimal side effects. This study aimed to establish the olerance of a single compared to a spaced dose .schedule of Merital. It was found that a single morrung dose of Merital 100 mgs compared to a similar dose of the drug given in two divided doses did not appreciably increase the frequency or severity of side effects.
Numerous studies with compelling evidence had shown a clear relationship between dyslipidaemia and cardiovascular (CV) events in patients with diabetes mellitus. This was an observational study based on secondary data from the online registry database Adult Diabetes Control and Management (ADCM) looking into the determinants of uncontrolled dyslipidaemia in type 2 diabetes mellitus patients. Independent predictors were identified using multivariate logistic regression. A total of 303 centres (289 health clinics, 14 hospitals) contributed a total of 70,889 patients (1972 or 2.8% patients were from hospital). About thirty eight percent were reported to have dyslipidaemia. There were 40.7% patients on lipid-lowering agents and of those above age 40 years old, only 38.1% of them were on a statin. Malay ethnicity and younger age groups (<50 years old) were two major determinants of uncontrolled LDL-C, TG and HDL-C. Female gender and uncontrolled blood pressure were determinants of uncontrolled LDL-C, and poor glycaemic control was related independently to high TG. This study has highlighted the suboptimal management of diabetic dyslipidaemia in Malaysia. Pharmacological treatment of dyslipidaemia could be more effective. Healthcare stakeholders in this country, especially in the primary care, have to recognize these shortfalls and take immediate remedial measures.
To determine the prevalence, distribution, severity and treatment need of enamel opacities among 11-12 year-old school children in a fluoridated urban community.
This paper presents evidence from the Malaysian Family Life Survey that mothers' reports of their babies' birthweights, including reports of unweighed babies' approximate size at birth, can be used to examine many biological and socioeconomic correlates of birthweight. The study uses a sample of 5583 singleton births that occurred between 1945 and 1976. In these data, the frequency distribution of birthweights and their bivariate and multivariate relationships with the biological correlates of mother's age, baby's sex, first parity and infant mortality are consistent with those found in prospective studies. A new biological correlate, mother's age at menarche, is introduced as a proxy for the mother's nutrition during childhood. Late age at menarche is associated with lower birthweight. Other results show mothers younger than 20 years and older than 35 appear to be at greater risk of bearing small babies, but the former effect is no longer important when parity is controlled. Short interbirth intervals are associated with small babies. We attempt to distinguish whether this is due to prematurity or to maternal nutritional depletion; both effects appear to be operating. Higher income appears to mitigate the pernicious effect of short interbirth intervals. Indian babies weigh significantly less than those of other ethnic groups. Furthermore, birthweights have increased since the 1950s for Malays and Chinese, but not for Indians. The lower birthweights and lack of improvement over time for Indians appear to be due to close birthspacing, lack of access to medical care and falling incomes.
Three different ethnic groups from Singapore comprising 79 Chinese, 34 Malays and 23 Indians of Dravidian origin, were investigated for the HindIII RFLP at the DNF15S2 locus. The three populations had very similar allele frequencies and the frequency of rarer(S) allele was significantly (p less than 0.01) lower (0.21) in these ethnic groups compared to that in Caucasians (0.41). The phenotypic distributions were at Hardy-Weinberg equilibrium.
The objective of this study was to determine the prevalence of diabetic retinopathy in a primary care setting using digital retinal imaging technology and to quantify the degree of diabetic retinopathy using internationally accepted severity scales. Two hundred patients with type 2 diabetes were evaluated clinically followed by fundus photography. The prevalence of retinopathy and maculopathy was 47.4% and 59.2% respectively (both retinopathy and maculopathy 34.7%). The high prevalence of retinal abnormality in this study is a cause for concern as most patients had diabetes for only 5 years or less.
Tumour necrosis factor superfamily 4 (TNFSF4) gene has been reported to be associated with systemic lupus erythematosus (SLE) susceptibility due to its encoding for OX40L protein that can increase autoantibody production and cause imbalance of T-cell proliferation. The purpose of this study was to investigate the association of TNFSF4 rs2205960, rs1234315, rs8446748 and rs704840 with SLE in the Malaysian population. A total of 476 patients with SLE and 509 healthy controls were recruited. Real-time polymerase chain reaction (PCR) was applied to genotype the selected single nucleotide polymorphisms (SNPs). Allelic and genotypic frequencies of each SNP were calculated for each ethnic group, and association test was performed using logistic regression. The overall association of each SNP in Malaysian patients with SLE was determined with meta-analysis. The frequency of minor T allele of TNFSF4 rs2205960 was significant in Chinese and Indian patients with SLE, with P values of 0.05 (OR = 1.27, 95% CI: 1.00-1.61) and 0.004 (OR = 3.16, 95% CI: 1.41-7.05), respectively. Significant association of minor G allele of rs704840 with SLE was also observed in Chinese (P = 0.03, OR = 1.26, 95% CI: 1.02-1.56). However, after Bonferroni correction, only T allele of rs2205960 remained significantly associated with Indian cohort. Overall, minor G allele of rs704840 showed significant association with SLE in the Malaysian population with P values of 0.05 (OR = 1.20, 95% CI: 1.00-1.43). We suggested TNFSF4 rs704840 could be the potential SLE risk factors in the Malaysian population.