Quality-of-life assessment has become an accepted method of evaluation in clinical medicine. The technique is based on a patient's self-assessment of physical, psychological, and social function, as well as the effects of distressing physical symptoms. The most important aspect of quality-of-life assessment is that it brings into focus a patient-centred view of health outcome, which is broader than the physiologic measures which predominate in Western medicine. Strategies for the development and use of assessment questionnaires have evolved over the past 15 years, and numerous questionnaires have been created. Most originate in Western societies, with English as the most common language of development. Adapting such questionnaires for use in other language and cultural settings is an imprecise practice. Language translation and equivalent cultural meaning must both be addressed. This paper reports on the language translation process and results for the Functional Living Index for Cancer (FLIC) as translated into Chinese and Malay in Singapore. We employed a step-wise process beginning with translation/back translation, followed by structured pilot field trials and population sampling. Taped versions of the questionnaire were devised to meet illiteracy problems in the sample population. Paired comparisons of the Chinese and Malay versions of individual questions with their English counterparts show good correlations and similar means most of the time. Factor analysis on a population sample of 246 (112 Chinese, 35 Malay and 98 English speaking) with cancers of minimal, extensive or palliative extent is convergent with that obtained on a North American population. However, a separate analysis of the Chinese questionnaires showed some differences in factor pattern. Specific language and cultural translation difficulties are discussed. Of note is the predicted significant decrease in total FLIC scores with extent of disease within each of the language preference populations, which provides some evidence for the validity for each language version in the Singapore culture(s). Thus, the FLIC translations into Malay and Chinese in Singapore can be considered for use in local trials, subject to ongoing evaluation.
A study to determine the prevalence of goitre and abnormal thyroid status during pregnancy in Malaysian women was conducted. Two hundred and three women (Malay = 85, Chinese = 47 and Indian = 71) in the third trimester and with no known thyroid disease were studied. There was a marked racial disparity in the prevalence of goitre: Indian 61%, Malay 28% and Chinese 29% (p = 0.001). The serum thyrotropic hormone (TSH) was significantly higher in Indians (median: 1.36 uIU/ml) compared to Malays (1.14 uIU/ml, p = 0.009). The serum albumin was also significantly lower in Indians (mean +/- sd; 36.12 +/- 3.9 mmol/l) compared to Malays (39.3 +/- 4.8 mmol/l) or Chinese (39.1 +/- 5.2) (p < 0.001). Thyroid antibody was detected in 14.6% of these women with no significant racial difference in its prevalence. Three women were found to be thyrotoxic but none were hypothyroid. This study found a high prevalence of goitre among the pregnant Indian women, probably related to the protein malnutrition state. The high prevalence of positive thyroid antibody in our population indicates that a high percentage of women are at risk of developing postpartum thyroiditis.
Serum concentrations of thyroid stimulating hormone (TSH) and thyroid autoantibodies in pregnant patients with thyroid disease at various stages of pregnancy were determined by in-house ELISAs. In normal pregnancy, serum TSH levels were significantly elevated (p < 0.05) from 13 weeks of gestation. The normal reference ranges for TSH for the second (0.6-5.0 mIU/l) and third trimester (0.6-5.6 mIU/l) were significantly higher (p < 0.05; p < 0.01 respectively) compared to 0.4-4.5 mIU/l for the first trimester. In pregnant thyroid patients, serum TSH levels correlated highly (p < 0.001) to T4 (r = 0.740), FT4I (r = 0.683) and MicAb (microsomal antibodies) (r = 0.825) but weaker (p < 0.01) to T3 (r = -0.512), FT3I (r = 0.520) and TgAb (thyroglobulin antibodies) (r = 0.618). Thus, measurement of TSH with the highly sensitive ELISA (enzyme linked immunosorbent assay) would form a useful first line test for thyroid dysfunction in pregnancy while measurement of thyroid autoantibodies would aid in the diagnosis of autoimmune hypothyroidism.
We evaluated the usefulness of sensitive thyrotrophin hormone (TSH) measurements in determining the thyroid status in the follow-up of Graves' patients undergoing medical treatment with thionamides. Out of a total of 186 serum samples tested, TSH levels were suppressed in 123 (66.1%), normal in 32 (17.2%) and elevated in 31 (16.7%) cases. Total T4, or T3 or both were elevated only in 97 (74.8%) cases of TSH-suppressed patients, indicating that TSH is less discriminatory as a first-line test for patients under treatment due to the hypothalamic-pituitary lag period. No comparisons with free T4 or free T3 were done in this study. Both total T4 (120 +/- 28 nmol/l) and TBII (23 +/- 21%) levels were significantly greater (p < 0.02) in the euthyroid group with suppressed TSH. This may suggest that persistence of a thyrotoxic state may still be present.
Cardiac arrhythmias are common in patients with thyrotoxicosis. Conduction abnormalities have been seen in a few thyrotoxic patients, but these, in particular high grade atrioventricular (AV) block, often occur in the presence of other conditions. Three thyrotoxic patients with conduction abnormalities are described: two were associated with severe hypokalaemia and the third had congestive cardiac failure. Conditions predisposing to conduction abnormality should be identified when this occurs in a thyrotoxic patient as their correction may help resolve or explain the conduction abnormality.
Two patients, members of one family, with Peutz-Jeghers syndrome are described who underwent surgery for bowel obstruction. Both had multiple polyps in the gastrointestinal tract. Severe dysplasia and adenomatous change were present in two hamartomatous polyps adjacent to a stenosing colonic carcinoma in one patient and moderate dysplasia and adenomatous change were observed in two hamartomatous rectal polyps in his son. These changes support recent reports in the literature of progression towards neoplasia in these lesions.
Pyomyositis, purportedly a common tropical infection affecting mainly healthy adults and children, appears to be most uncommon in this region. We report a case of pyomyositis caused by a Methicillin-resistant Staphylococcus aureus (MRSA) in a previously healthy army officer. This case serves to illustrate the difficulty in recognising this disease entity, which is why many cases may have been missed. With the increasing incidence of MRSA nosocomial infections, the emergence of MRSA in a hitherto community-acquired infection poses a major concern especially since intravenous drug abuse and acquired immune deficiency syndrome (AIDS) are on the rise in our country. We hope to inculcate greater awareness of this infection.
A review of consecutive biopsies of adnexal tumours from 112 patients, received by the Department of Pathology, University of Malaya, over a 13-year period was undertaken. The age range of the patients was from 1 to 84 years, with a mean of 29.8 years. Thirty-three (32%) patients were under 20 years of age. There were 68 females with a male to female ratio of 1.0:1.5. In 105 cases (93.7%), the neoplasm was solitary. The tumour measured less than 2 cm in the largest dimension in 103 cases (92%). The common sites of occurrence were the head and neck region (59%) and extremities (25%). Neoplasms of hair follicle origin accounted for 63.4% (71 cases) of all lesions. Intra-tumour deposition of amyloid was noted in one of the 14 cases of trichoepithelioma.
General life tables for the 1990 Singapore resident population are given in this paper. Analyses were carried out separately for males and females for all ethnic groups as well as for Chinese, Malays and Indians. Average fractions of the last age interval lived were used to give a more precise derivation of the life table death rates from their corresponding age-specific death rates. The results show that in 1990, Singapore males had achieved a life expectancy at birth of 73.7 years while the females had attained a level of 78.6 years. These levels were comparable to those of many developed countries. Other interesting features include higher differentials in the life expectancies between sexes among the Chinese and the Indians taking over the Malays for second placing in terms of life expectancy at birth for both sexes. As a result, the Indians registered a 12% gain in life expectancy at birth for males for the decade 1980 to 1990, compared to only 7.1% for Chinese and 4.4% for Malays as well as nearly 10% for females compared to only 6.2% for Chinese and 6.3% for Malays. A subsequent paper will highlight the results of multiple-decrement life table analyses which will summarise the mortality of the 1990 Singapore resident population for various component causes of death rather than for all causes combined.
Drug-induced agranulocytosis is a potentially fatal complication despite advances in supportive care. A patient with carbimazole-induced agranulocytosis associated with marked depletion of granulocytic precursors in the marrow was treated with granulocyte-macrophage colony stimulating factor (GM-CSF) at a dose of 5 micrograms/kg subcutaneously daily for one week. The absolute neutrophil count rose above 1 x 10(9)/L after one week of GM-CSF therapy. The GM-CSF probably expedited the recovery of the neutrophil count. Further studies are warranted to delineate the role of GM-CSF in the treatment of drug-induced agranulocytosis.
A typical case of chronic pericardial effusion resulting in cardiac tamponade is presented. A pericardiocentesis was done for diagnosis and drainage, followed by a pleuro-pericardial window as definitive therapy. The minimal cumulative dose expected to produce pericardial disease is about 4000 rads, and the disease usually manifests within 12 months of such radiation exposure, as in this patient. It is concluded that for symptomatic pericardial effusions, available evidence justifies a subtotal pericardiectomy, a window procedure being reserved to tide over ill patients as in this patient. No strong evidence exists for the efficacy of steroid therapy; such therapy is reserved for asymptomatic mild effusions, which may also resolve spontaneously.
A systematic collection of fetal morphometric measurements was started seven years ago in 1987 with the prospective entry of data into personal computer-based stations in the Department of Obstetrics and Gynaecology, Singapore General Hospital. A cross-sectional study was done, comparing 2392 Chinese fetuses with 2117 Malay fetuses and 459 Indian fetuses from 18 to 40 weeks. The mean values of the head circumference (HC), abdominal circumference (AC) and femur length (FL) of the 3 ethnic groups were analysed. There were no statistical significant differences in the head circumference and abdominal circumference of Chinese, Malay and Indian fetuses in Singapore. The Chinese and Malay fetal femur length appeared similar but were apparently shorter than the Indian femur length. Nomograms of head circumference, abdominal circumference and femur length were constructed for application to fetuses of all 3 ethnic groups.
A cross-sectional survey of 568 married women aged 21-65 years in the Pasir Panjang Constituency was conducted to determine the prevalence of cervical cancer screening in the community and the factors affecting acceptance of this screening test. Results show that 309 (54.4%) of the respondents had ever had a Pap smear. The women who reported having had a smear were more likely to be below 45 years of age (prevalence ratio 1.47, 95% confidence interval 1.15 to 1.88), Chinese and of a higher socioeconomic status (1.68, 1.33 to 2.12). They were also more likely to have married at a later age (1.68, 1.21 to 2.31) than women who had not had a smear. Age and socioeconomic status remained independent predictors on multivariate analysis. The findings suggest that an important task of public health practitioners is to increase the uptake of screening among older and socially disadvantaged women who are known to be at the highest risk of cervical cancer. In addition, strategies to encourage younger women to continue regular attendance at screening clinics beyond their childbearing years will be important for the future.
The Programme on Prevention and Management of Obesity in Preschool Children, aged three to six years, was implemented in 17 Primary Health Clinics in November 1991. The study sample comprised 1128 preschool children who qualified to enter the obesity register, using the defined criteria for obesity of 2 standard deviations above the normal weight for height and age. This group was divided into three categories, namely, mildly overweight (120% to below 140%), moderately overweight (140% to below 160%), and severely overweight (above 160%). The severely overweight category was referred to dietitians for follow-up management, while the other two categories were managed by the clinic staff through pre-planned nurse-conducted counselling sessions. In this paper, we analysed the first 1128 preschool children aged three to six years on the Programme with respect to their demographic characteristics; medical conditions; family history of obesity, diabetes, hypertension and ischaemic heart disease; number of siblings and parents' educational and occupational status. The Malay children showed significantly more severe grades of obesity compared to the Chinese and Indian children. A family history of obesity and hypertension among the three groups were significant (P < 0.001). After one year of follow-up with the intervention programme, the following were found: 40.4% (456) of the children improved in their obesity status and 20.2% (228) reached normal status. The severe, moderate and mild categories reduced from 6.3% to 5.9%, 29.3% to 23.2% and 64.4% to 50.7% respectively and was found to be statistically significant (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
We present a 64-year-old Malay lady who had undergone a choledochoduodenostomy (CDD) two years ago for obstructive jaundice. She was admitted with jaundice and underwent ultrasonography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio pancreatography (ERCP) and computed tomographic (CT) scanning of the liver and biliary tree. All the investigations confirmed a type IVa choledochal cyst. At operation, the grossly dilated biliary system was packed with a thick mucoid material and the mucosa of the bile ducts was visibly abnormal with scattered nodules. This mucoid material had caused occlusion of the entire biliary tree resulting in obstructive jaundice. To the best of our knowledge, this is probably the first report of obstructive jaundice caused by thick mucus. The peculiar management problems of this case and the risk of malignant change in choledochal cysts are discussed.
Significant advances in diagnosis and management have cured the majority of children with cancer. In the leukaemias, the commonest childhood malignancy, intensive induction-consolidation is important to ensure a lasting cure in about 65-80% and to eliminate the traditionally bad prognostic risk factors associated with less intensive treatment. Bone marrow transplantation (BMT) has a curative role in the minority who relapse particularly while on treatment. With few exceptions, most paediatric solid tumours are curable. Although the multimodal approach is responsible for the progress made, chemotherapy has emerged to play a dominant role. It has, in several tumours, obviated or reduced the need for radiotherapy and/or surgery. In Wilms' tumour and Hodgkin's disease, refinement of treatment is now in progress to reduce therapy-related morbidity while not sacrificing efficacy.
Amiodarone, a commonly used antiarrhythmic agent, has numerous adverse effects. The purpose of this case report is to highlight its hepatotoxicity, an unusual complication of long term amiodarone therapy. Our patient is a 76-year-old man with underlying ischaemic heart disease and recurrent ventricular tachycardia. Eleven months after commencing amiodarone, he developed asymptomatic raised aminotransferases which resolved following drug withdrawal. Amiodarone was then reintroduced and four years later, the patient developed hepatomegaly, worsening liver biochemistry and histopathological changes consistent with early cirrhosis. His symptoms improved following discontinuation of amiodarone. However, hepatomegaly and a low serum albumin still persist four years later.
This is a retrospective study of 525 posterior chamber implants in diabetics performed by A S M Lim and B C Ang of Singapore. The patients were reviewed by visiting ophthalmologists--J E Kennedy (Sydney), M Ngui (East Malaysia) and P M Hart (Belfast). This study did not show any significant difference in the complication of post-operative visual acuity between diabetics and non-diabetics. 95% obtained 6/12 vision or better when pre-existing disease was excluded. It also showed that posterior chamber implants can be inserted in eyes with maculopathy or proliferative retinopathy if laser treatment was effectively done before or after surgery.
410 cases of psoriasis [282 males (68%) and 127 females (31%)] were interviewed and examined to study the nail changes. The prevalence of nail changes was 78.0% (males = females). Common changes were pitting (67.5%) and onycholysis (67.2%). Dystrophy of varying degrees occurred in 35.0%, subungual hyperkeratosis in 24.7%, discoloration in 18.4%, loss of nails in 2.8% and pustulation in 1.3%. Pitting and onycholysis was the most common combination (45.6%). Nail changes were significantly more common in patients who have moderate to severe psoriasis as compared with patients with mild psoriasis; in patients who have psoriasis for greater than 5 years as compared with patients who have psoriasis for less than 5 years; and in patients older than age 50 as compared with those aged less than 50. A definite correlation was found between the prevalence of nail changes and the presence of scalp and periungual psoriasis, and the presence of joint involvement.
Drug eruptions from indeginous medicine is often difficult to diagnosis and confirm. It is known that a number of these now supplied by bomohs and Chinese sinsehs contain known drugs and are dispensed as tablets and capsules. We report 3 cases of adverse drug eruption to "Jamu", a Malay herb. A particular brand, "Jamu Indonesia, Toko Air Pancur", from Johor Bahru, Malaysia, is especially recommended for "sakit pinggang" or backache. The cases occurred between January and February 1985, and all had taken brown kidney shaped tablets. The adverse reactions were moderately severe. Two had erythroderma with hepatitis, and one, Steven Johnson Syndrome. Analysis of this jamu for analgesics led to the discovery of adulteration with phenylbutazone and diazepam. Records from local cases from 1974-1984 showed that 8 other patients, all Chinese had adverse cutaneous eruptions from phenylbutazone, oxybutazone and propyphenazone. The skin manifestations were erythroderma (2 cases), vasculitis (2 cases) and toxic epidermal necrolysis (4 cases). Those with toxic epidermal necrolysis had 100% mortality.