Middle-aortic syndrome is a surgically curable cause ofchildhood hypertension. Open surgery is traditionallyoffered but with the advance of medical technology,endovascular approached is available in many country.Failure to control BP in open surgery is as low as 4.1%compares to 13% in endovascular approaches. However,mortality is 4% in open surgery almost 2 times higher than2.3% in endovascular approach. This article presents a caseof 10 years old child treated successfully withoutcomplication with endovascular balloon dilatation, as a firstcase of such disease in East Malaysia.

INTRODUCTIONThe Multiple Sclerosis International Quality of Life questionnaire (MusiQoL) is a self-administered, multi-dimensional, patient-based health-related quality of life (HRQoL) instrument. With increasing prevalence of multiple sclerosis (MS) in Asian countries, a valid tool to assess HRQoL in those patients is needed. The aim of this study was to evaluate patient acceptability, content validity and psychometric properties of an Asian version of the English MusiQoL in Singapore, Malaysia and India.

MATERIALS AND METHODSEnglish speaking patients older than 18 years of age with a defi nite diagnosis of MS were included. The self-administered survey material included the adapted HRQoL questionnaire, a validated generic HRQoL questionnaire: the short-form 36 (SF-36), as well as a checklist of 14 symptoms. We assessed the internal and external validity of the adapted MusiQoL.

RESULTSA total of 81 patients with MS were included in the study. The questionnaire was generally well accepted. In the samples from Malaysia and Singapore, all scales exhibited good internal consistency (Cronbach's alpha >0.70). Correlation to SF-36 was generally good, demonstrating high construct validity (P <0.001) in some aspects of the MusiQoL.

CONCLUSIONThe Asian adaptation of the English version of the MusiQoL in evaluating HRQoL seems to be a valid, reliable tool with adequate patient acceptability and internal consistency.

Activities of Daily Living ; Asia ; Female ; Health Surveys ; Humans ; India ; Language ; Malaysia ; Male ; Multiple Sclerosis ; drug therapy ; psychology ; Outcome Assessment (Health Care) ; Psychometrics ; standards ; Quality of Life ; psychology ; Singapore ; Statistics, Nonparametric ; Surveys and Questionnaires

Brain ; blood supply ; diagnostic imaging ; Brain Ischemia ; blood ; diagnosis ; diagnostic imaging ; Combined Modality Therapy ; methods ; Humans ; Male ; Middle Aged ; Monitoring, Physiologic ; Stroke ; drug therapy ; physiopathology ; Tomography, X-Ray Computed

INTRODUCTIONThis study aims to study how the effect of the location of patient collapses from cardiac arrest, in the residential and non-residential areas within Singapore, relates to certain survival outcomes.

MATERIALS AND METHODSA retrospective cohort study of data were done from the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Out-of- hospital cardiac arrest (OHCA) data from October 2001 to October 2004 (CARE) were used. All patients with OHCA as confirmed by the absence of a pulse, unresponsiveness and apnoea were included. All events had occurred in Singapore. Analysis was performed and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI).

RESULTSA total of 2375 cases were used for this analysis. Outcomes for OHCA in residential areas were poorer than in non-residential areas-1638 (68.9%) patients collapsed in residential areas, and 14 (0.9%) survived to discharge. This was significantly less than the 2.7% of patients who survived after collapsing in a non-residential area (OR 0.31 [0.16 - 0.62]). Multivariate logistic regression analysis showed that location alone had no independent effect on survival (adjusted OR 1.13 [0.32 - 4.05]); instead, underlying factors such as bystander CPR (OR 3.67 [1.13 - 11.97]) and initial shockable rhythms (OR 6.78 [1.95 - 23.53]) gave rise to better outcomes.

CONCLUSIONEfforts to improve survival from OHCA in residential areas should include increasing CPR by family members, and reducing ambulance response times.

Adult ; Aged ; Aged, 80 and over ; Ambulances ; Cardiopulmonary Resuscitation ; statistics & numerical data ; Cohort Studies ; Emergency Medical Services ; statistics & numerical data ; Female ; Geography ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Out-of-Hospital Cardiac Arrest ; mortality ; Residence Characteristics ; statistics & numerical data ; Retrospective Studies ; Singapore ; epidemiology ; Time-to-Treatment ; statistics & numerical data ; Treatment Outcome

INTRODUCTIONVenous thromboembolism (VTE), including its most serious clinical subtype, pulmonary embolism (PE), is a potentially preventable disease. While current assessment tools do not include ethnicity as a risk factor, studies suggest that Asians have lower risk of VTE compared to Caucasians. This study aims to describe 2006 in-hospital and projected population based incidence rates of VTE and PE in Singapore.

MATERIALS AND METHODSData on 2006 admissions at 3 major NHG hospitals, cases of VTE and their demographics were obtained from the ODS, a large administrative database of the National Healthcare Group (NHG). Demographic characteristics of the 2006 Singapore resident population were obtained from the 2006 Singapore Statistics website.

RESULTSIn 2006, there were 860 cases of VTE out of 98,121 admissions in these 3 hospitals. Overall and secondary VTE age adjusted in-hospital burden was 73 and 54 per 10,000 patients, respectively. Caucasians and Eurasians had VTE rates in excess of 100 per 10,000 while Chinese, Malays and Indians each had rates below 100 per 10,000. Assuming that 42.5% of the 2006 Singapore population was served by NHG, the estimated population-based incidence of VTE and PE is 57 and 15 per 100,000, respectively.

CONCLUSIONSAs patterns across ethnic groups point to lower VTE rates among Asians compared to Caucasians and Eurasians, analytic studies should be considered to test this hypothesis. There may be a need to develop locally applicable risk assessment tools which can be used to support local guidelines for VTE prophylaxis, thus leading to more acceptable and cost-effective care.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Child ; Child, Preschool ; Databases, Factual ; Female ; Humans ; Infant ; Infant, Newborn ; Inpatients ; Male ; Middle Aged ; Pulmonary Embolism ; epidemiology ; prevention & control ; Singapore ; epidemiology ; Venous Thromboembolism ; epidemiology ; ethnology ; prevention & control ; Young Adult

BACKGROUNDComputer-based testing (CBT) has become increasingly popular as a testing modality in under- and postgraduate medical education. Since 2004, our medical school has utilised CBT to conduct 2 papers for the third- and final-year assessments - Paper 3, with 30 multiple choice questions featuring clinical vignettes, and the modified essay question (MEQ) paper.

AIMSTo obtain feedback from final-year students on their preferred mode of testing for Paper 3 and MEQ components of the Medicine track examination, and the reasons underlying their preferences.

METHODSAn online survey was carried out on 213 final-year undergraduates, in which they were asked to provide feedback on Paper 3 and MEQ papers. Students were asked if they thought that the CBT format was preferable to the pen-and-paper (PNP) format for Paper 3 and the MEQ, and why.

RESULTSOne hundred and fourteen out of 213 (53.5%) students completed the online survey. For Paper 3, 91 (79.8%) felt that CBT was preferable to PNP, 11 (9.6%) preferred the PNP format and 12 (10.5%) were unsure. For the MEQ, 62 (54.4%) preferred CBT over PNP, 30 (26.3%) preferred the PNP format and 22 (19.3%) were unsure. Reasons given to explain preference for CBT over PNP for Paper 3 included independence from seating position, better image quality (as images were shown on personal computer screens instead of projected onto a common screen) and the fact that CBT allowed them to proceed at their own pace. For the MEQ, better image quality, neater answer scripts and better indication of answer length in CBT format were cited as reasons for their preference.

CONCLUSIONSOur survey indicated that whereas the majority of students preferred CBT over PNP for Paper 3, a smaller margin had the same preference for the MEQ.

Clinical Competence ; Computers ; Education, Medical ; methods ; standards ; Educational Measurement ; methods ; Humans ; Students, Medical

BACKGROUND AND AIMIntravenously-administered tissue plasminogen activator (IV-TPA) induces thrombolysis and remains the only FDA-approved therapy for acute ischaemic stroke. IV-TPA thrombolysis has been approved recently in Singapore for acute stroke. Continuous exposure of clot to 2-MHz pulsed-wave transcranial Doppler (TCD) ultrasound during IV-TPA infusion is known to augment thrombolysis. We aimed to determine the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore.

SUBJECTS AND METHODSConsecutive patients with acute ischaemic stroke due to intracranial arterial-occlusions were treated with standard IV-tPA and continuously monitored with 2-MHz TCD according to the CLOTBUST-trial protocol. Arterial recanalisation was determined with Thrombolysis in Brain Ischemia (TIBI) flow-grading system. Safety and efficacy of ultrasoundassisted thrombolysis were assessed by rates of symptomatic intracranial haemorrhage (sICH) and functional recovery at 1 month, respectively.

RESULTSFive consecutive patients (mean age 58 years, 3 men and 3 of Chinese ethnicity) were included. Mean time elapsed between symptom onset and presentation to emergency room was 98 minutes (range, 50 to 135 minutes) while the mean time interval between symptom onset to IV-TPA bolus was 144 minutes (range, 125 to 180 minutes). Partial or complete recanalisation with reduction in the stroke severity was noted in 4 out of the 5 patients during IV-TPA infusion (mean change in NIHSS = 4 points; range 2 to 8 points). None of our patients developed sICH while 4 patients demonstrated good functional outcome at 1 month.

CONCLUSIONSOur preliminary study demonstrates the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore. Continuous TCD-monitoring during IV-TPA infusion provides real-time information, enhances thrombolysis and improves functional outcomes in acute ischaemic stroke.

Aged ; Brain Infarction ; diagnostic imaging ; Female ; Fibrinolytic Agents ; administration & dosage ; Humans ; Infusions, Intravenous ; Male ; Middle Aged ; Thrombolytic Therapy ; methods ; Tissue Plasminogen Activator ; administration & dosage ; Ultrasonography, Interventional ; methods

INTRODUCTIONTranscranial Doppler (TCD) is an established tool for the non-invasive assessment of cerebral blood flow. Since TCD results vary with the skills and experience of the sonographer, it requires validation against contrast angiography. We evaluated the diagnostic accuracy of TCD against computed tomography angiography (CTA) and the feasibility of the latter as an additional screening tool in our acute ischaemic stroke patients.

MATERIALS AND METHODSOur stroke unit manages about 700 patients annually. Acute stroke patients undergo TCD for vascular assessment of major arteries of the circle of Willis. Randomly selected acute stroke patients with significant stenosis on TCD underwent high-resolution cranial CTA with multidetector helical scanner. CTA was performed within 24 hours of TCD and images were interpreted by a neuroradiologist blinded to TCD findings. An independent neurosonologist reevaluated TCD if CTA findings were contradictory. Additional information by either modality was also noted.

RESULTSFifteen patients (12 men, mean age 61 +/- 15years) with cerebral ischaemia and moderate (>50%) stenosis in > or =1 large intracranial arterial segment on routine TCD were evaluated by CTA. Compared with 21 segments of significant stenosis on CTA, TCD showed 16 true-positive, 3 false-positive and 5 false-negative results (sensitivity: 76.2%, positive predictive value: 84.2%). In 3 cases, TCD showed findings complementary to CTA (real-time embolisation, collateral flow patterns, evidence of distal M2 branch occlusion).

CONCLUSIONTCD in our neurovascular laboratory shows a satisfactory agreement with cranial CTA in evaluating patients with cerebral ischaemia. TCD can provide additional real-time dynamic findings complementary to information provided by CTA.

Aged ; Brain Ischemia ; diagnosis ; Cerebral Angiography ; Female ; Humans ; Male ; Middle Aged ; Pilot Projects ; Singapore ; Tomography, X-Ray Computed ; Ultrasonography, Doppler, Transcranial

INTRODUCTIONThe aim of this study was to assess the sensitivity of McDonald's magnetic resonance imaging (MRI) criteria for the diagnosis of multiple sclerosis (MS) in a group of Asian patients diagnosed with clinically definite MS, based on lesion characterisation on MRI scans.

MATERIALS AND METHODSForty-nine patients from 3 major neurological institutions were classified as having Asian- or Western-type MS based on clinical assessment. Each MRI scan was reviewed by 2 neuroradiologists for the presence and characteristics of brain and spinal lesions. The McDonald's MRI criteria were then applied and its sensitivity evaluated.

RESULTSNine patients were excluded, leaving 34 females and 6 males who were dominantly Chinese (90%), with a mean age of 36.2 years. The MRI brain and spinal findings were detailed and tabulated. Statistically significant differences (P <0.01) in MRI brain findings and sensitivity of McDonald's MRI criteria were found between our Asian- and Western-type MS patients. The diagnostic yield of McDonald's MRI criteria increased by 20% when we substituted a cord for a brain lesion, and applied the substitution for enhancing cord lesions as well.

CONCLUSIONThe diagnosis is more likely to be made when using McDonald MRI criteria based on brain findings, in a patient who presents clinically with Western-type MS. The provision for substitution of "one brain for a spinal lesion" is helpful in Asian-type MS, where there is preponderance of spinal lesion load. Our findings suggest that minor modifications in the interpretation of McDonald's MRI criteria have significant impact on the diagnosis in patients clinically presenting as Asian-type MS, with potential bearing on their subsequent management.

Adult ; Brain Injuries ; diagnosis ; pathology ; Diagnosis, Differential ; Female ; Humans ; Magnetic Resonance Imaging ; Male ; Medical Audit ; Multiple Sclerosis ; classification ; diagnosis ; Retrospective Studies ; Sensitivity and Specificity ; Singapore ; Spinal Cord Injuries ; diagnosis ; pathology