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Restless legs syndrome: pathophysiology and modern management

Nagandla K, De S

Postgrad Med J, 2013 Jul;89(1053):402-10.
PMID: 23524988 DOI: 10.1136/postgradmedj-2012-131634

Restless legs syndrome (RLS) is a common sensory motor neurological disorder that is characterised by an irresistible urge to move the legs that significantly affects the quality of life of the patient. Prevalence in the general population is 5-25% and it is twice as prevalent in women as in men. RLS is the most common movement disorder in pregnancy with a fourfold increased risk of developing this disorder later in life. The pathophysiology of RLS is centred on dopaminergic dysfunction, reduced central nervous system iron, genetic linkages, or alteration in neurotransmitters such as hypocretins, endorphins levels and immune dysfunction and inflammatory mechanisms. With the emergence of new evidence, there are changes to the previous treatment recommendations for RLS. There is sufficient evidence to conclude that dopamine agonists such as rotigotine transdermal patch, pramipexole, ropinirole, gabapentin enacarbil, pregabalin and gabapentin are effective in the short-term treatment of RLS and rotigotine, followed by gabapentin enacarbil, ropinirole, pramipexole and gabapentin for long-term treatment. Based on expert consensus, the recommendation for daily RLS is dopamine agonists or gabapentin or low-potency opioids. Levodopa is less preferred for treating daily RLS due to its high risk of augmentation. For intermittent RLS, it is levodopa or dopamine agonists or low-potency opioids or benzodiazepines. For refractory RLS, the choice is to change to gabapentin or a different dopamine agonist, addition of a second agent like gabapentin or benzodiazepine to the existing drug or changing to a high-potency opioid or tramadol. Medications with safety record in pregnancy include opioids and antiepileptics such as carbamazepine and gabapentin. There are concerns that patients with RLS are at risk for metabolic deregulation, autonomic dysfunction and cardiovascular morbidity. However, a recent study concluded that RLS is not associated with increased risk of cardiovascular complications.
Fulltext Acceptability of Just-in-Time Teaching amongst medical students: a pilot study

De S, Nagandla K, Kanagasabai S

Education in Medicine Journal, 2014;6(1):11-19.
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Introduction: Just-in-Time Teaching (JiTT) is a novel method of teaching-learning used in various disciplines of science and humanities. It is a technique that scaffolds the students learning process by reducing the cognitive load which is the load related to the executive control of working memory. Just in time teaching underpins the concept that expertise in learning originates from the knowledge already stored in long term memory and with subsequent interaction between the learner and teacher motivates enhanced active learning and optimizes the intellectual performance.
Objective: The objective of the study is to assess the acceptability of JiTT over traditional lecture teaching among the medical students.
Method: In a cross sectional pilot study, three hundred thirty five students participated in a questionnaire based study that grades the various aspects of the traditional lecture series. After the implementation of JiTT method for a period of four months, three hundred two students completed the questionnaire, grading the same variables for JiTT. The analysis was done by using SPSS version 11 applying Paired t test and McNemar's Test.
Result: The results of our study highlighted that JiTT technique was perceived superior to traditional teaching with statistically significant outcomes in the clarity of the topic (p=0.003,) duration of the session (p=0.002), knowledge gained and orientation for exams (p=0.044). The students perceived JiTT method as less monotonous (p=0.005) increasing their alertness during these sessions (p=0.002).
Conclusion: We therefore propose that Just-in-Time Teaching method is a more interactive and acceptable teaching-learning tool shifting the nature of teaching to a more student-centric approach as perceived by the medical students. This is the first pioneer study on JiTT to be performed on undergraduate medical students so far.
Fulltext Oral Hypoglycemic Agents in pregnancy: An Update

Kavitha N, De S, Kanagasabai S

J Obstet Gynaecol India, 2013 Apr;63(2):82-7.
PMID: 24431611 DOI: 10.1007/s13224-012-0312-z

INTRODUCTION: Traditionally, insulin has been the gold standard in the management of Type 2 diabetes in pregnancy and gestational diabetes. However, insulin therapy can be inconvenient because of the needs for multiple injections, its associated cost, pain at the injection site, need for refrigeration, and skillful handling of the syringes. This has led to the exploration of oral hypoglycemic agents as an alternative to insulin therapy.
OBJECTIVES: This review examines and evaluates the evidences on the efficacy, safety, and current recommendations of oral hypoglycemic agents.
CONCLUSION: The evidence of this study supports the use of glyburide and metformin in the management of Type 2 diabetes and gestational diabetes with no increased risk of neonatal hypoglycemia or congenital anomalies. The safety of these oral hypoglycemic agents are limited to the prenatal period and more randomized controlled trials are required to provide information on the long-term follow up on neonatal and cognitive development.
Comprehensive management of Jehovah's Witness in pregnancy

Pang FS, Liaw EYF, De S

Postgrad Med J, 2023 Sep 21;99(1176):1068-1075.
PMID: 37334974 DOI: 10.1093/postmj/qgad047

Jehovah's Witness (JW) is a denomination of Christianity which has many-fold higher morbidity and mortality compared to the general population as they refuse blood transfusion. Information is scanty regarding guidelines on the optimal approach to pregnant ladies of JW faith. In this review we have attempted to analyse the ways and techniques available which can be used to reduce the morbidity and mortality of these women. In antenatal care, haematological status can be optimised to reduce modifiable risk factors, namely anaemia by parenteral iron therapy from the second trimester onwards especially in patients who do not respond to oral iron therapy. In severe cases, erythropoietin serves as an effective alternative to blood transfusion. During the intrapartum period, using antifibrinolytics, cell salvage, bloodless surgical techniques, and uterine cooling for patients undergoing caesarean delivery have been proven effective. To conclude, complications of pregnant JW patients may be reduced if they comply with the preventives and targeted monitoring during the various phases of pregnancy. Further studies are warranted as this population exists as a minor group but is growing worldwide.
Bone mineral density and hip axis length in Singapore's multiracial population

Goh JC, Low SL, Das De S, DasDe S

J Clin Densitom, 2004;7(4):406-12.
PMID: 15618601

Ethnic differences in bone density and hip geometry are known to exist, even within the same population. A recent study in Singapore showed that there were significant racial differences in hip fracture rates, with Chinese having the highest incidence of hip fractures. The aim of this study was to compare the bone mineral density (BMD) and hip axis length in Chinese, Malay, and Indian women. A total of 1575 women aged 20-59 yr were recruited, of which 77.6% (1222) were Chinese, 7.7% (122) Malays, and 14.7% (231) Indians. There was no significant difference in peak BMD of both lumbar spine and femoral neck among the three ethnic groups. However, in the older age group (50-59 yr), both Chinese and Malay women had significantly lower femoral neck BMD compared to Indian women. There was no significant loss in BMD of the lumbar spine between the second and fifth decades in all the three races. Between the second and fifth decade, Chinese and Malay women had significant bone loss in the femoral neck of 6.6% and 8.2%, respectively, whereas Indian women did not show any significant bone loss. Chinese women had significantly longer hip axis length compared to either Malay or Indian women (9.87 +/- 0.52 cm vs 9.67 +/- 0.49 cm; p < 0.005; and 9.69 +/- 0.55 cm, p < 0.05, respectively). The initial findings suggest racial differences in bone density and hip geometry exist in the local community. Future research should include prospective, longitudinal studies to determine the age-related bone loss in these three racial groups. It is also important to investigate the differences of spine and hip fracture rates and their relationship with bone density and hip axis length.
Fulltext Risk factors for hip fracture in Asian men and women: the Asian osteoporosis study

Lau EM, Suriwongpaisal P, Lee JK, Das De S, Festin MR, Saw SM, et al.

J. Bone Miner. Res., 2001 Mar;16(3):572-80.
PMID: 11277276 DOI: 10.1359/jbmr.2001.16.3.572

The objectives of the Asian Osteoporosis Study (AOS) were to determine risk factors for hip fracture in men and women in four Asian countries, that is, Singapore, Malaysia, Thailand, and the Philippines. A total of 451 men and 725 women (aged 50 years and over) with hip fractures were compared with an equal number of community controls. A standardized questionnaire was administered by interview. The following relative risks (RRs) were found in women and men by multiple logistic regression: dietary calcium intake < 498 mg/day, 2.0 for women (95% CI, 1.5-2.8) and 1.5 for men (95% CI, 1.0-2.2); no load bearing activity in the immediate past, 2.0 for women (95% CI, 1.4-2.7) and 3.4 for men (95% CI, 2.3-5.1); no vigorous sport activities in young adulthood, 7.2 for women (95% CI, 4.0-13.0) and 2.4 for men (95% CI, 1.6-3.6); cigarette smoking, 1.5 for men (95% CI, 1.0-2.1); alcohol consumption 7 days a week, 2.9 for women (95% CI, 1.0-8.6) and 1.9 for men (95% CI, 1.1-3.2); fell twice or more in the last 12 months, 3.0 for women (95% CI, 1.8-4.8) and 3.4 for men (95% CI, 1.8-6.6); a history of fractures after 50 years of age, 1.8 for women (95% CI, 1.1-2.9) and 3.0 for men (95% CI, 1.6-5.6); a history of stroke, 3.8 for women (95% CI, 2.0-7.1) and 3.6 for men (95% CI, 1.8-7.1); use of sedatives, 2.5 for women (95% CI, 1.0-6.3) and 3.0 for men (95% CI, 1.0-9.7); and use of thyroid drugs, 7.1 for women (95% CI, 2.0-25.9) and 11.8 for men (95% CI, 1.3-106.0). Women who were 1.56 m or taller had an RR of 2.0 (95% CI, 1.3-3.0) for hip fracture and men who were 1.69 m or taller had an RR of 1.9 (95% CI, 1.2-3.1) for hip fracture. Based on these findings, primary preventive programs for hip fracture could be planned in Asia.
The incidence of hip fracture in four Asian countries: the Asian Osteoporosis Study (AOS)

Lau EM, Lee JK, Suriwongpaisal P, Saw SM, Das De S, Khir A, et al.

Osteoporos Int, 2001;12(3):239-43.
PMID: 11315243 DOI: 10.1007/s001980170135

The Asian Osteoporosis Study (AOS) is the first multicenter study to document and compare the incidence of hip fracture in four Asian countries. Hosital discharge data for the year 1997 were obtained for the Hong Kong SAR, Singapore, Malaysia and Thailand (Chiang Mai). The number of patients who were 50 years of age and older and who were discharged with a diagnosis of hip fracture (ICD9 820) was enumerated. The age-specific incidence rates were deduced and were directly adjusted to the US white population in 1989. The age-adjusted rates for men and women (per 100,000) are as follows: Hong Kong, 180 and 459; Singapore, 164 and 442; Malaysia, 88 and 218; Thailand, 114 and 289; compared with US White rates of 187 in men and 535 in women, published in 1989. We conclude that there is moderate variation in the incidence of hip fracture among Asian countries. The rates were highest in urbanized countries. With rapid economic development in Asia, hip fracture will prove to be a major public health challenge.
Fulltext Awareness of cancer cervix and its prevention among students in Melaka, Malaysia

De S, Selvan VT, Tan J, Soe HHK, Sahoo S, Sahoo R

J Educ Health Promot, 2019;8:231.
PMID: 31867395 DOI: 10.4103/jehp.jehp_379_19

BACKGROUND: Cancer cervix is caused by human papillomavirus (HPV), oncogenic virus and has vaccines and screening as its preventive measures. This study analyzes the change in awareness and attitudes of nonmedical students toward the condition following the use of an educational module.
METHODOLOGY: The study design was quasi-experimental. The interprofessional (IP) team implemented an educational module and analyzed the difference in awareness of young individuals toward the cancer cervix. A pretest and posttest written questionnaire, customized for both genders, was administered with the intervention of the educational module in between. The module consisted of a short educational presentation along with a group activity. A follow-up survey was also done after 2 months to check the attrition of awareness. The statistical analysis was done using MacNemar test using SPSS 12 IBM software and significance of differences were determined.
RESULTS: There was a significant improvement of knowledge and awareness on linkage between HPV and cervical cancer (P < 0.001). There was also significant change with regard to attitudes toward cervical cancer vaccination (P = 0.004). The knowledge of HPV linkage to the malignancy was maintained after 2 months of gap. The subjects also wished for more future awareness program.
CONCLUSIONS: There is improved awareness in the dental and foundation in science students, and this improved awareness will ensure favorable attitudes toward cervical cancer vaccines or will attend regular screening programs. Awareness program must be held at regular intervals at different locations to enhance the knowledge dissemination of this common yet preventable genital malignancy of females. The IP collaboration and practices will help in reducing the disease burden of the society in future.
Associations between ethnicity, body composition, and bone mineral density in a Southeast Asian population

Yang PL, Lu Y, Khoo CM, Leow MK, Khoo EY, Teo A, et al.

J Clin Endocrinol Metab, 2013 Nov;98(11):4516-23.
PMID: 24037892 DOI: 10.1210/jc.2013-2454

Chinese men in Singapore have a higher incidence of hip fractures than Malay and Indian men. We investigated whether there were corresponding ethnic differences in peak bone mineral density (BMD) in young men and whether differences in body composition influenced peak BMD.