Depression is a complex disabling condition that is common in primary care. Mr. X was previously diagnosed with depression but had defaulted treatment. It was through an extended consultation that we could unmask the diagnosis and initiate the therapeutic process. ObjectivesTo use the model of an extended consultation to both diagnose depression and to formulate the psycho-social factors that predispose, precipitate and perpetuate the depression as well as the positive factors that ameliorate it (4 Ps). MethodsAn example of an extended consultation with Mr. X. was videotaped with his permission. Excerpts from the video transcript are reproduced to demonstrate the 4 Ps formulation and how the pattern approach of narrative therapy was employed to help Mr. X. ResultsMr. X. gained insight into his condition. He was hence agreeable to initiate anti-depressant medication and continued to follow up for his depression.ConclusionThe extended consultation can be used to uncover therapeutic opportunities when engaging patients with depression, and to formulate the 4 Ps in order to complement pharmacotherapy for holistic management.

INTRODUCTIONThis study records the prevalence and patterns of breastfeeding in Singaporean Chinese mothers who gave birth between 2000 and 2008.

MATERIALS AND METHODSThe Strabismus, Amblyopia and Refractive Error in Singaporean Children (STARS) study is a population-based survey conducted in South-Western Singapore. Disproportionate random sampling by 6-month age groups of Chinese children born from 2000 to 2008 was performed. The mothers (n = 3009) completed a standard questionnaire which recorded the initiation, content, method and duration of breastfeeding. World Health Organization (WHO) definitions for feeding content were used: Replacement (exclusive commercial formula or any liquid or solid/semi-solid food, excluding breast milk), Complementary (breast milk, solid/semi-solid foods, and any non-human liquid), and Exclusive (breast milk only, without additional food, drink or water). STARS-specific definitions for feeding method were used: Expressed (breast milk only fed via bottle, with no additional food or non-human liquid), Combination (breast milk and non-breast milk, fed via bottle and breast), and Direct (breast milk only fed via breast).

RESULTSBreastfeeding initiation (overall prevalence 77.0%) and duration increased over time, and were independently associated with higher maternal education: in 2000 and 2001, 68.6% of mothers initiated breastfeeding and 12.9% breast fed for or=6 months, vs 90.9% and 35.3%, respectively, of university-educated women (P <0.001). Expressed, Combination and Complementary feeding also increased, while Replacement feeding decreased (P <0.001). There was no difference in breastfeeding patterns by the child's gender.

CONCLUSIONSIn a population-based sample of Singaporean Chinese mothers giving birth from 2000 to 2008, breastfeeding initiation and duration increased over time and were independently associated with higher maternal education. This increase was associated with increased milk expression and complementary feeding. Thus awareness of breastfeeding benefits is rising in Singapore, but future health policies may need to target less-educated mothers.

Breast Feeding ; epidemiology ; ethnology ; Child ; Child, Preschool ; China ; ethnology ; Educational Status ; Female ; Humans ; Infant ; Male ; Mothers ; Singapore ; epidemiology ; Surveys and Questionnaires

INTRODUCTIONHuman immunodeficiency virus type 1 (HIV-1) genotyping resistance test (GRT) is essential for monitoring HIV-1 drug resistance mutations (DRMs). High cost and HIV-1 genetic variability are challenges to assay availability in Singapore. An in-house Sanger sequencing-based GRT method was developed at the Communicable Disease Centre (CDC), Singapore's HIV national treatment reference centre for both subtype B and non-subtype B HIV-1.

MATERIALS AND METHODSThe in-house GRT sequenced the fi rst 99 codons of protease (PR) and 244 codons of reverse transcriptase (RT) in the pol gene. The results were compared with the Food and Drug Administration (FDA)-approved ViroSeq™ HIV-1 Genotyping System.

RESULTSSubtype assignment for the 46 samples were as follows: 31 (67.4%) CRF01_AE, 14 (30.5%) subtype B and 1 (2.1%) subtype C. All 46 samples had viral load of ≥500 copies/mL, and were successfully amplified by the in-house primer sets. Compared to the ViroSeq™ test, our in-house assay showed drug-resistance conferring codon concordance of 99.9% at PR and 98.9% at RT, and partial concordance of 0.1% at PR and 1.1% at RT. No discordant result was observed.

CONCLUSIONThe assay successfully identified DRMs in both subtype AE and B, making it suitable for the efficient treatment monitoring in genetically diverse population. At less than half of the running cost compared to the ViroSeq™ assay, the broadly sensitive in-house assay could serve as a useful addition to the currently limited HIV genotyping assay options for resource-limited settings, thereby enhancing the DRM surveillance and monitoring in the region.

Anti-Retroviral Agents ; pharmacology ; Drug Resistance, Viral ; genetics ; Genes, pol ; genetics ; Genotyping Techniques ; methods ; HIV Infections ; drug therapy ; virology ; HIV-1 ; drug effects ; genetics ; Humans ; Mutation ; Sequence Analysis, DNA ; methods ; Singapore

Background: Tuberculous meningitis is a life-threatening manifestation resulting from infection by Mycobacterium tuberculosis, especially in the developing countries. The molecular aspects of pathogenesis of tuberculous meningitis remain poorly understood. We evaluated the correlation of cerebrospinal fluid (CSF) and serum cytokine levels with the clinical outcome of 15 HIV-negative patients with tuberculous meningitis. We also assessed the association of CSF and serum cytokines with neuroimaging of brain findings in the patients. Methods: The prospective longitudinal study was conducted at the University Malaya Medical Centre between 2012 and 2014. Neuroimaging of the brain was performed and the findings of leptomeningeal enhancement, hydrocephalus, tuberculoma, infarcts and vasculopathy were recorded. The CSF and serum specimens were analyzed for IL-1ß, IL-8, IL-10, IL-18, IP-10, IFN-γ, MCP-1, TGF-ß, VEGF, TNF- α, IL-18BPa and MMP-9. The clinical outcome was graded at 3 months based on Modified Rankin scale (mRS). Results: On admission and at one month of anti-tuberculosis treatment, the CSF levels of IL-8, IL-1β, IP-10, IFN-γ and VEGF were elevated in all of the patients. Serum IP-10, MCP-1, IL-1β and IL-8 levels were increased on admission and at one month of anti-tuberculosis treatment. There were statistically significant differences between good and poor outcome (mRS at 3 months) for CSF IFN-γ (p=0.033), CSF IL-10 (p=0.033) and serum VEGF (p=0.033) at one month of treatment. None of the patients showed any association between CSF and serum cytokines on admission and at one month of anti-tuberculosis treatment with neuro-radiological findings. Conclusion: The CSF cytokine levels were not related to TBM disease severity on admission, and changes on MRI/CT scans. CSF levels of IFN-γ and IL-10 at one month of anti-tuberculosis treatment were associated with clinical outcome at 3 months. CSF cytokine levels on admission were not associated with the clinical outcome.
Tuberculosis, Meningeal

INTRODUCTION: There is an increasing reliance on informal caregivers to continue the care of patients after discharge. This is a huge responsibility for caregivers and some may feel unprepared for the role. Without adequate support and understanding regarding their needs, patient care may be impeded. This study aimed to identify the needs valued by caregivers and if there was agreement between acute care nurses and caregivers in the perception of whether caregiver needs were being met. METHODS: We conducted face-to-face interviews with 100 pairs of acute care nurses and caregivers. Participants were recruited from inpatient wards through convenience sampling. Questionnaires included demographic data of nurses and caregivers, patients' activities of daily living, and perception of caregiver needs being met in six domains of care. Independent t-test was used to compare mean values in each domain, and intraclass correlation coefficient was used to compare agreement in perception. RESULTS: Caregivers valued reassurance the most. Three domains of care needs showed significant differences in perception of caregiver needs being met:reassurance (p = 0.002), honesty and timeliness (p = 0.008), and kindness and genuine care (p = 0.026). There was poor agreement in all six domains of caregiver needs being met between nurses and caregivers. CONCLUSION Although caregivers valued reassurance the most, there was poor agreement between acute care nurses and caregivers in the perception of caregiver needs being met. Hence, more attention should be paid to the caregiver's needs. Further studies can examine reasons for unmet caregiver needs and interventions to improve support for them.

Objective: The primary objective of this study was to describe the neuroimaging changes of tuberculous meningitis (TBM), and to determine the role of neuroimaging in the diagnosis of TBM. Methods: Between January 2009 and July 2015, we prospectively recruited TBM patients in two hospitals in Malaysia. Neuroimaging was performed and findings were recorded. The control consists of other types of meningo-encephalitis seen over the same period. Results: Fifty four TBM patients were recruited. Leptomeningeal enhancement was seen in 39 (72.2%) patients, commonly at prepontine cistern and interpeduncular fossa. Hydrocephalus was observed in 38 (70.4%) patients, 25 (46.3%) patients had moderate and severe hydrocephalus. Thirty four patients (63.0%) had cerebral infarction. Tuberculoma were seen in 29 (53.7%) patients; 27 (50.0%) patients had classical tuberculoma, 2 (3.7%) patients had “other” type of tuberculoma, 18 (33.3%) patients had ≥5 tuberculoma, and 11 (20.4%) patients had < 5 tuberculoma. Fifteen (37.2%) patients had vasculitis, 6 (11.1%) patients had vasospasm. Close to nine tenth (88.9%) of the patients had ≥1 classical neuroimaging features, 77.8% had ≥ 2 classical imaging features of TBM (basal enhancement, hydrocephalus, basal ganglia / thalamic infarct, classical tuberculoma, and vasculitis/vasospasm). Only 4% with other types of meningitis/encephalitis had ≥1 feature, and 1% had two or more classical TBM neuroimaging features. The sensitivity of the imaging features of the imaging features for diagnosis of TBM was 88.9% and the specificity was 95.6%. Conclusion: The classic imaging features of basal enhancement, hydrocephalus, basal ganglia/thalamic infarct, classic tuberculoma, and vasculitis are sensitive and specific to diagnosis of TBM.
Tuberculosis, Meningeal

Background: The PLASMIC score is a convenient tool for predicting ADAMTS13 activity of ＜10%.Lactate dehydrogenase (LDH) is widely used as a marker of haemolysis in thrombotic thrombocytopenic purpura (TTP) monitoring, and could be used as a replacement marker for lysis. We aimed to validate the PLASMIC score in a multi-centre Asia Pacific region, and to explore whether LDH could be used as a replacement marker for lysis. Methods: Records of patients with thrombotic microangiopathy (TMA) were reviewed. Patients’ ADAMTS13 activity levels were obtained, along with clinical/laboratory findings relevant to the PLASMIC score. Both PLASMIC scores and PLASMIC-LDH scores, in which LDH replaced traditional lysis markers, were calculated. We generated a receiver operator characteristics (ROC) curve and compared the area under the curve values (AUC) to determine the predictive ability of each score. Results: 46 patients fulfilled the inclusion criteria, of which 34 had ADAMTS13 activity levels of ＜10%. When the patients were divided into intermediate-to-high risk (scores 5‒7) and low risk (scores 0‒4), the PLASMIC score showed a sensitivity of 97.1% and specificity of 58.3%, with a positive predictive value (PPV) of 86.8% and negative predictive value (NPV) of 87.5%. The PLASMIC-LDH score had a sensitivity of 97.1% and specificity of 33.3%, with a PPV of 80.5% and NPV of 80.0%. Conclusion Our study validated the utility of the PLASMIC score, and demonstrated PLASMIC-LDH as a reasonable alternative in the absence of traditional lysis markers, to help identify high-risk patients for treatment via plasma exchange.

Growing Up in Singapore Towards healthy Outcomes (GUSTO) is Singapore's largest birth cohort study to date. The main aim of GUSTO is to evaluate the role of developmental factors in the early pathways to metabolic compromise. Detailed data is collected for a range of environmental exposures in the parents and offspring, and allergic disorders are among a number of outcomes assessed in infancy and childhood. Under the Allergy domain of GUSTO, this integrated study will describe the epidemiology of allergic manifestations and different phenotypes in the Asian context and help shed light on the association of metabolic disease to allergy. Epigenetic mechanisms and associations with other childhood disorders will also be explored. The aim of this report is to focus on methodology of GUSTO, and to suggest similar approaches (i.e., integrated cohort studies on pediatric allergy) worldwide. Recruitment commenced in 2009 with a cohort of 1,163 pregnant mothers in their first trimester. The mothers and children were followed throughout pregnancy and follow-up will continue until the child reaches 3 years of age. Preliminary results showed that 39.8% of the mothers had a personal history of having at least one allergic disease, which included asthma, eczema and allergic rhinitis. Further data collection and analyses are still ongoing. Allergy is a complex spectrum of disorders with numerous poorly-understood aspects. The ongoing GUSTO cohort study, with its longitudinal design and multi-disciplinary nature, may provide new insights into developmental influences on allergy. As a Singapore-based study, it will be the first integrated allergy cohort in Southeast Asia, of which recruitment started during pregnancy.
Asia, Southeastern ; Asian Continental Ancestry Group ; Asthma ; Child ; Cohort Studies ; Data Collection ; Eczema ; Environmental Exposure ; Epidemiology ; Epigenomics ; Female ; Follow-Up Studies ; Humans ; Hypersensitivity ; Metabolic Diseases ; Mothers ; Parents ; Parturition ; Phenotype ; Pregnancy ; Pregnancy Trimester, First ; Rhinitis, Allergic ; Singapore

BACKGROUND: Studies have reported that early febrile episodes and febrile episodes with infections are associated with a decreased risk of developing atopy. OBJECTIVE: To examine further the association between presence of and number of febrile episodes are with atopy and atopic diseases and if there was a difference between all fevers and fever after vaccination. METHODS: We studied 448 infants in a Singapore mother-offspring cohort study (Growing Up in Singapore Towards Healthy Outcomes) which had complete data for the exposures and outcomes of interest. Fever was defined as more than 38.0℃ and was self-reported. The presence of and number of febrile episodes were examined for association with outcome measures, namely parental reports of doctor-diagnosed asthma and eczema, and rhinitis, which was evaluated by doctors involved in the study at 18 and 36 months. These outcomes were considered atopic if there were 1 or more positive skin prick tests. RESULTS: The presence of all fevers from 0–6 months of age was associated with reduced odds of having atopy at 36 months of age (unadjusted odds ratio [OR], 0.628; 95% confidence interval [CI], 0.396–0.995). The presence of fever after vaccination from 0–24 months of age was associated with reduced odds of having atopy at 36 months of age (OR, 0.566; 95% CI, 0.350–0.915). The presence of all fevers from 0–6 months of age was associated with reduced odds of having atopic eczema at 36 months (OR, 0.430; 95% CI, 0.191–0.970). Fever was associated with increased odds of having doctor-diagnosed asthma and rhinitis. CONCLUSION: There was an inverse relationship between the presence of all fevers from 0–6 months of age and the development of atopy and eczema at 36 months of age. Fever after vaccination might be considered a subclinical infection that did not show the same effect in early life.
Asthma ; Asymptomatic Infections ; Cohort Studies ; Dermatitis, Atopic ; Eczema ; Fever ; Humans ; Infant ; Odds Ratio ; Outcome Assessment (Health Care) ; Parents ; Rhinitis ; Singapore ; Skin ; Vaccination