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Adrenal and renal surgery by the laparoscopic and/or retroperitoneoscopic approach.

Annals of the Academy of Medicine, Singapore.1997;26(3):336-343.

Since its introduction 6 years ago, almost all abdominal procedures have been attempted laparoscopically. Despite their retroperitoneal location, kidneys and adrenals have also been reached by the blitz of endoscopic surgery since 1992. We present here the techniques, indications, advantages or disadvantages of the videoscopic approach-either laparoscopic or retroperitoneoscopic- of those solid retroperitoneal organs. Preliminary results of the international literature are presented, while objectively comparing currently available data about the efficacy and cost of endoscopic versus open procedure. Despite the time-consuming nature and high operative cost of the endoscopic approach, decreased convalescence and better patient comfort are evident. Furthermore videoendoscopic adrenal surgery performed, even sporadically, by surgeons experienced in laparoscopic surgery is as safe as the open approach, provided that those surgeons are also familiar with the rules and potential drawbacks of adrenal surgery for endocrine disorders.
Adrenalectomy ; economics ; methods ; Cost-Benefit Analysis ; Endoscopy ; economics ; methods ; Humans ; Laparoscopy ; economics ; methods ; Nephrectomy ; economics ; methods ; Retroperitoneal Space

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Angioedema and systemic lupus erythematosus--a complementary association?

Manjari LAHIRI ; Anita Y N LIM

Annals of the Academy of Medicine, Singapore.2007;36(2):142-145.

INTRODUCTIONWe report angioedema as a rare presentation leading to a diagnosis of systemic lupus erythematosus (SLE).

CLINICAL PICTUREA diagnosis of angioedema was delayed in a patient presenting with limb and facial swelling until she developed acute upper airway compromise. After excluding allergic and hereditary angioedema, acquired angioedema (AAE) was suspected, possibly precipitated by respiratory tract infection. Associated clinical and laboratory features led to a diagnosis of SLE.

TREATMENTManagement proved challenging and included high dose steroids and immunosuppressants.

OUTCOMEThe patient responded to treatment and remains in remission without recurrence of the angioedema.

CONCLUSIONAAE occurs due to the acquired deficiency of inhibitor of C1 component of complement (C1 INH). Lymphoproliferative disorders and anti-C1 INH antibodies are well-described associations. However, one should also consider the possibility of SLE.

Angioedema ; blood ; etiology ; physiopathology ; therapy ; Antiphospholipid Syndrome ; diagnosis ; etiology ; Brain ; pathology ; Complement C1 Inactivator Proteins ; analysis ; deficiency ; Female ; Humans ; Lupus Erythematosus, Systemic ; complications ; diagnosis ; etiology ; Magnetic Resonance Imaging ; Middle Aged ; Respiration, Artificial ; Respiratory Insufficiency ; etiology ; therapy

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Seronegative spondyloarthropathy--studies from the Asia Pacific region.

Hwee Siew HOWE ; Like ZHAO ; Yeong Wook SONG ; Lauren SPRINGER ; John EDMONDS ; Jieruo GU ; David T Y YU

Annals of the Academy of Medicine, Singapore.2007;36(2):135-141.

Recent therapeutic advances, in particular the use of anti-tumour necrosis factor (anti-TNF) agents, have revived interest in the seronegative spondyloarthropathies (SpA), a group of arthritides characterised by axial skeletal involvement and the absence of rheumatoid factor. The purpose of this article is to review the studies that have been done in the Asia Pacific region, as a broad understanding of the scope and severity of this group of diseases would enable rheumatologists and physicians in this part of the world to better manage their patients. The majority of genetic studies have focused on the associations of HLA-B27 with ankylosing spondylitis (AS) and SpA, while a few studies examined the associations of the CARD, IL-1, LMP2, TAP and TGF with AS. There are a handful of studies on the immunological responses to bacteria and cytokine levels in AS. The onset and clinical features of SpA have been reported from most countries in the region, but no data on patient outcomes, using current measurement tools such as the Bath Ankylosing Spondylitis Disease Activity index (BASDAI), is available. Validation of these instruments of measurement as well as classification criteria in different ethnic populations is necessary where no prior data exist. Future studies will likely be focused on better clinical characterisation of patient cohorts, particularly with regard to the use of currently used measurement tools for disease activity and spinal function and mobility, and the identification of the need for biologic therapy in each country.
Arthritis ; epidemiology ; genetics ; immunology ; therapy ; Asian Continental Ancestry Group ; Genetic Predisposition to Disease ; HLA-B27 Antigen ; genetics ; Humans ; Sensitivity and Specificity ; Spinal Diseases ; epidemiology ; genetics ; immunology ; therapy ; Spondylitis, Ankylosing ; genetics ; immunology ; Transforming Growth Factor beta1 ; immunology

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The use of biological agents in the treatment of rheumatoid arthritis.

Peng Thim FAN ; Keng Hong LEONG

Annals of the Academy of Medicine, Singapore.2007;36(2):128-134.

Rheumatoid arthritis is a common and potentially devastating condition which did not have good treatment options until recently. Pharmacological treatment should not just comprise antiinflammatory agents and corticosteroids. The current therapeutic approach is to start a disease modifying agent early in the illness to prevent eventual joint damage. Older disease modifying anti-rheumatic drugs (DMARDs) include methotrexate, sulphasalazine and hydroxychloroquine. Newer ones such as leflunomide and cyclosporine are also used. A recent advance in the management of rheumatoid arthritis is the use of biological agents which block certain key molecules involved in the pathogenesis of the illness. They include tumour necrosis factor (TNF)- blocking agents such as infliximab, etanercept and adalimumab, the anti-CD 20 agent rituximab and CTLA-4 Ig abatacept. Other agents which are in development include anti-IL6 tocilizumab, anti-CD22 and anti-lymphostat B. In this review, the efficacy and side effects of these agents, their impact on current clinical practice and future trends are discussed.
Abatacept ; Antibodies, Monoclonal ; therapeutic use ; Antibodies, Monoclonal, Humanized ; Antirheumatic Agents ; therapeutic use ; Arthritis, Rheumatoid ; immunology ; therapy ; Drug Therapy, Combination ; Humans ; Immunoconjugates ; therapeutic use ; Immunologic Factors ; adverse effects ; therapeutic use ; Immunosuppressive Agents ; therapeutic use ; Methotrexate ; therapeutic use ; Remission Induction ; Tumor Necrosis Factor-alpha ; antagonists & inhibitors

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Computational immunology--from bench to virtual reality.

Cliburn CHAN ; Thomas B KEPLER

Annals of the Academy of Medicine, Singapore.2007;36(2):123-127.

Drinking from a fire-hose is an old cliché for the experience of learning basic and clinical sciences in medical school, and the pipe has been growing fatter at an alarming rate. Of course, it does not stop when one graduates; if anything, both the researcher and clinician are flooded with even more information. Slightly embarrassingly, while modern science is very good at generating new information, our ability to weave multiple strands of data into a useful and coherent story lags quite far behind. Bioinformatics, systems biology and computational medicine have arisen in recent years to address just this challenge. This essay is an introduction to the problem of data synthesis and integration in biology and medicine, and how the relatively new art of biological simulation can provide a new kind of map for understanding physiology and pathology. The nascent field of computational immunology will be used for illustration, but similar trends are occurring broadly across all of biology and medicine.
Allergy and Immunology ; Computational Biology ; Flow Cytometry ; Humans ; Medical Informatics ; Models, Biological ; Software

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Julian THUMBOO ; Vibeke STRAND

Annals of the Academy of Medicine, Singapore.2007;36(2):115-122.

With improvements in mortality in systemic lupus erythematosus (SLE), the functional status of these patients, assessed using health-related quality of life (HRQoL) instruments, is increasingly being recognised as an important outcome measure in clinical research. Domains of HRQoL of particular importance to SLE patients include fatigue, ability to work, good health, independence, social and family life, learned helplessness (reflecting the unpredictability of lupus), pain and the home environment. The SF-36 currently appears to be the best available generic instrument for the assessment of HRQoL in SLE, and is likely to be complemented by several newly-developed disease-specific HRQoL instruments. It has been shown that SLE patients have poorer functional status than the general population, and that specific manifestations of SLE (disease activity, previous renal involvement and fibromyalgia) may influence HRQoL. HRQoL in SLE patients has been improved by (1) psycho-educational interventions including telephone counselling, a self-help course, group psychotherapy; (2) therapies including Riquent, belimumab, mycophenolate mofetil, dehydroepiandrosterone, oestrogen therapy and a cholesterol- lowering diet. Additional research is needed to identify strategies which can improve HRQoL in SLE patients.
Health Status Indicators ; Humans ; Lupus Erythematosus, Systemic ; psychology ; Outcome Assessment (Health Care) ; Quality of Life ; Sensitivity and Specificity

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Patient satisfaction with rheumatology practitioner clinics: can we achieve concordance by meeting patients' information needs and encouraging participatory decision making?

Anita Y N LIM ; Corinne ELLIS ; Alan BROOKSBY ; Karl GAFFNEY

Annals of the Academy of Medicine, Singapore.2007;36(2):110-114.

INTRODUCTIONThe objective of this study was to determine if patient information needs are being met and the level of patient satisfaction with rheumatology practitioners in participatory decision-making and thereby indirectly explore whether concordance was achieved.

MATERIALS AND METHODSThe design was a cross-sectional postal questionnaire survey of 420 patients attending outpatient clinics at the Norfolk and Norwich University Hospital who were taking disease modifying anti-rheumatic drugs (DMARDs) or a biological treatment. The population served is ethnically homogeneous and predominantly Caucasian.

RESULTSThe response rate was 76%. Most respondents (79%) had inflammatory arthritis while 66% had rheumatoid arthritis. Seventy-seven per cent of patients reported that the rationale behind commencing treatment was explained and that they were given ample opportunities to ask questions. Eighty-two per cent said they were given an appropriate amount of information. Sixty-four per cent of patients were satisfied with their level of participation in the decision-making process, although a substantial number (25%) said that information from different sources was conflicting. There was no correlation between concern about side effects and patients' perceptions of the effectiveness of medication. Females were more concerned than males about possible side effects; P =0.009, using the Mann-Whitney U test. One third of the patients altered their medication in response to whether their arthritis felt better or worse.

CONCLUSIONThe majority of patients were satisfied that their information needs were met and with the care provided in the practitioner clinic. Participatory decision-making was sub-optimal despite patient satisfaction with the amount of time allocated to meeting their information needs. We found that patients exercise autonomy in managing their arthritis by regulating their medications through an active decision-making process, which is informed by their previous experience of medication, and how well controlled they felt their arthritis was. Research into this decision-making process may hold the key to achieving concordance.

Antirheumatic Agents ; therapeutic use ; Arthritis ; drug therapy ; psychology ; Decision Making ; Female ; Health Care Surveys ; Humans ; Male ; Outpatient Clinics, Hospital ; Pain Measurement ; Patient Education as Topic ; standards ; Patient Participation ; Patient Satisfaction ; statistics & numerical data ; Rheumatology ; standards ; Singapore

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The value of joint aspirations in the diagnosis and management of arthritis in a hospital-based rheumatology service.

Yong Yeow CHONG ; Kok Yong FONG ; Julian THUMBOO

Annals of the Academy of Medicine, Singapore.2007;36(2):106-109.

INTRODUCTIONAlthough joint aspiration with synovial fluid analysis is useful in the diagnosis of crystal or septic arthritis, the frequency with which it provides a diagnosis or aids subsequent management of patients with arthritis has not been well quantified. We therefore evaluated the usefulness of joint aspiration in the diagnosis and management of patients with arthritis in a hospital-based rheumatology service.

MATERIALS AND METHODSWe reviewed records of all patients with joint aspiration performed by an inpatient rheumatology service in a tertiary referral hospital from November 2003 to December 2004. Data were extracted on the frequency with which joint aspiration provided a diagnosis or aided management.

RESULTSAmong 76 patients [mean +/- standard deviation (SD), 60.9 +/- 15.9 years; 41 males, 35 females, Chinese (50), Malay (20), Indian (4) and others (2)] with 86 joint aspirations, a definitive diagnosis was obtained in 44% of procedures which showed gout (n = 28), septic arthritis (n = 8) or pseudogout (n = 2). In another 47% of procedures, joint aspiration aided diagnosis by allowing categorisation of synovial fluid as inflammatory (n = 25), non-inflammatory (n = 16) or blood-stained (n = 2). Joint(s) aspirated were knees (71%), ankles (15%), elbows (8%), shoulders (2%) and wrists, metacarpo-phalangeal and metatarso-phalageal (approximately 1% each).

CONCLUSIONJoint aspiration provides a definitive diagnosis or information that aids diagnosis in a significant number of patients in a hospital-based rheumatology service.

Aged ; Arthritis ; diagnosis ; therapy ; Arthritis, Infectious ; diagnosis ; Chondrocalcinosis ; diagnosis ; Female ; Gout ; diagnosis ; Hospital Departments ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Rheumatology ; Singapore ; Synovial Fluid ; chemistry

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Outcomes of chronic hepatitis B infection in Oriental patients with rheumatic diseases.

Bernard Y H THONG ; Ee Tzun KOH ; Hiok Hee CHNG ; Wan Cheng CHOW

Annals of the Academy of Medicine, Singapore.2007;36(2):100-105.

INTRODUCTIONThe aim of this study was to ascertain the outcomes of chronic hepatitis B (CHB) infection following immunosuppressive therapy in 38 consecutive oriental patients with systemic rheumatic diseases.

MATERIALS AND METHODSThis is a retrospective consecutive, non-comparative study.

RESULTSThe majority of patients were female (26, 68.4%), predominantly Chinese (92.1%), with a mean age 54 +/- 14 years (range, 16 to 87). The mean duration of rheumatic disease was 9 +/- 11 years (range, 0.1 to 48), with rheumatoid arthritis (52.6%) and systemic lupus erythematosus (23.7%) being the most common. The mean duration of CHB infection was 6 +/- 5 years (range, 0.1 to 17), with the majority diagnosed during pre-methotrexate screening (50.0%) and asymptomatic transaminitis following initiation of immunosuppressive therapy (23.7%). Upon diagnosis of rheumatic disease, all patients had normal alanine aminotransferase (ALT). Of these, 18.2% were positive for hepatitis B e antigen (HBeAg) and 78.1% were positive for anti- HBe antibody. Twenty (52.6%) developed ALT elevation, which was more than twice the upper limit of normal in 12 patients. ALT normalised spontaneously in 12 patients without hepatic decompensation or change in therapy. Seven (18.4%) patients received lamivudine for 18 +/- 22 months (range, 2 to 61). Two patients developed YMDD mutation subsequently treated with adefovir (1) and adefovir/lamivudine (1). There were 3 (7.9%) hepatitis B virus (HBV)-unrelated deaths [infection (2), genitourinary malignancy (1)], and 1 from HBV-reactivation complicated by septicaemia. None have developed hepatocellular carcinoma.

CONCLUSIONElevated ALT occurred in 52.6% of patients, with only 18.4% requiring anti-viral therapy for HBV reactivation. HBV-related mortality was low. With the appropriate precautionary measures, prednisolone and immunosuppressants (except methotrexate and leflunomide) may be used safely in patients where clinically indicated.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Alanine Transaminase ; blood ; Antiviral Agents ; therapeutic use ; Asian Continental Ancestry Group ; Comorbidity ; Female ; Glucocorticoids ; therapeutic use ; Hepatitis B, Chronic ; epidemiology ; Humans ; Immunosuppressive Agents ; therapeutic use ; Lamivudine ; therapeutic use ; Lupus Erythematosus, Systemic ; drug therapy ; Male ; Middle Aged ; Prednisolone ; therapeutic use ; Retrospective Studies ; Rheumatic Diseases ; epidemiology ; Treatment Outcome ; Virus Activation

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In vivo pro- and anti-inflammatory cytokines in normal and patients with rheumatoid arthritis.

Suppiah Paramalingam SIVALINGAM ; Julian THUMBOO ; Sheila VASOO ; Szu Tien THIO ; Connie TSE ; Kok Yong FONG

Annals of the Academy of Medicine, Singapore.2007;36(2):96-99.

INTRODUCTIONRheumatoid arthritis (RA) is a chronic, deforming arthritis that can lead to disabilities and poor quality of life. Cytokines are protein mediators of inflammation and are produced as a result of the activation of various cellular reactions. They are the final mediators and/or regulators of the inflammatory process.

MATERIALS AND METHODSThe sera from 64 RA patients were assayed for both Th-1 and Th-2 related cytokines and soluble TNF-alpha receptors (IFN-gamma, TGF-beta, TNF-alpha, IL-1beta, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-18, sTNF-R1 and sTNFR2) using ELISA.

RESULTSThe pro-inflammatory cytokines (IL-1, IL-6, IL-8, IL-18 and TNF- alpha) were significantly elevated in RA patients, while TGF-beta, an immunomodulatory cytokine, was elevated in control individuals. When the RA patients were categorised as active or inactive based on DAS scores, similar cytokines profiles were observed in both RA sub-groups. However, assays of sTNF-R1 and sTNFR-2 were noted to be significantly elevated in inactive RA patients when compared to active patients.

CONCLUSIONOur findings indicate that local production of cytokine inhibitors is capable of diminishing disease activity and cytokine activity.

Adult ; Aged ; Arthritis, Rheumatoid ; blood ; pathology ; Cell Differentiation ; Cytokines ; blood ; Female ; Humans ; Male ; Middle Aged ; Receptors, Tumor Necrosis Factor, Type I ; chemistry ; Receptors, Tumor Necrosis Factor, Type II ; chemistry ; Transforming Growth Factor beta ; chemistry

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