Multiple Biomarkers Improved Prediction for the Risk of Type 2 Diabetes Mellitus in Singapore Chinese Men and Women

Background@#Multiple biomarkers have performed well in predicting type 2 diabetes mellitus (T2DM) risk in Western populations. However, evidence is scarce among Asian populations. @*Methods@#Plasma triglyceride-to-high density lipoprotein (TG-to-HDL) ratio, alanine transaminase (ALT), high-sensitivity Creactive protein (hs-CRP), ferritin, adiponectin, fetuin-A, and retinol-binding protein 4 were measured in 485 T2DM cases and 485 age-and-sex matched controls nested within the prospective Singapore Chinese Health Study cohort. Participants were free of T2DM at blood collection (1999 to 2004), and T2DM cases were identified at the subsequent follow-up interviews (2006 to 2010). A weighted biomarker score was created based on the strengths of associations between these biomarkers and T2DM risks. The predictive utility of the biomarker score was assessed by the area under receiver operating characteristics curve (AUC). @*Results@#The biomarker score that comprised of four biomarkers (TG-to-HDL ratio, ALT, ferritin, and adiponectin) was positively associated with T2DM risk (P trend <0.001). Compared to the lowest quartile of the score, the odds ratio was 12.0 (95% confidence interval [CI], 5.43 to 26.6) for those in the highest quartile. Adding the biomarker score to a base model that included smoking, history of hypertension, body mass index, and levels of random glucose and insulin improved AUC significantly from 0.81 (95% CI, 0.78 to 0.83) to 0.83 (95% CI, 0.81 to 0.86; P=0.002). When substituting the random glucose levels with glycosylated hemoglobin in the base model, adding the biomarker score improved AUC from 0.85 (95% CI, 0.83 to 0.88) to 0.86 (95% CI, 0.84 to 0.89; P=0.032). @*Conclusion@#A composite score of blood biomarkers improved T2DM risk prediction among Chinese.

Sugar-sweetened beverages consumption in midlife and risk of late-life cognitive impairment in Chinese adults / 中华流行病学杂志

Objective@#To evaluate whether midlife consumption of sugar-sweetened beverages (SSBs), including juices and soft drinks, were associated with late-life cognitive impairment in Chinese adults.@*Methods@#Follow up was conducted for participants from Singapore Chinese Health Study, a population-based prospective cohort, for 16-23 (mean 20) years. The information about their SSBs consumption were collected at baseline survey from 1993 to 1998 by using a validated food frequency questionnaire and their cognition status were evaluated by using a Singapore-modified Mini-Mental State Examination Scale in the 3rd follow-up visit during 2014- 2016. Multivariable logistic regression models were used to estimate the ORs and 95%CIs.@*Results@#A total of 16 948 participants were included in the analysis and 2 443 of them were identified as cognitive impairment using education-specific cutoffs. Sex, age, ancestral home, education level, physical activity level, total diet fiber intake level, BMI, alcohol drinking were significantly associated with cognitive impairment (P<0.05). After adjusted the above variables, potential dietary variables and disease status, no significant association was observed between SSBs consumption and cognitive impairment (P>0.05). Compared with those who never or hardly ever drank soft drinks, no significant differences in cognitive impairment risk were observed for those who drank soft drinks 2 or more times a week (OR=0.91, 95%CI: 0.77-1.08), those who drank 1 time a week (OR=1.00, 95%CI:0.82-1.23) and those who drank 1-3 times a month (OR=0.94, 95%CI: 0.80-1.09) (trend P=0.306). Compared with those who never or hardly ever drank juices, no significant differences in cognitive impairment risk were observed for those who drank juices 2 or more times a week (OR=1.03, 95%CI:0.88-1.20), those who drank 1 time a week (OR=0.96, 95%CI: 0.82-1.12) and those who drank 1-3 times a month (OR=0.94, 95%CI: 0.82-1.08) (trend P=0.930). No significant interactions were found with age, sex, and BMI status.@*Conclusion@#SSBs consumption in midlife was not significantly associated with risk of late-life cognitive impairment in Singaporean Chinese adults with relatively low consumption levels. Further researches are needed to verify the results.

Sugar-sweetened beverages consumption in midlife and risk of late-life cognitive impairment in Chinese adults / 中华流行病学杂志

To evaluate whether midlife consumption of sugar-sweetened beverages (SSBs), including juices and soft drinks, were associated with late-life cognitive impairment in Chinese adults. Follow up was conducted for participants from Singapore Chinese Health Study, a population-based prospective cohort, for 16-23 (mean 20) years. The information about their SSBs consumption were collected at baseline survey from 1993 to 1998 by using a validated food frequency questionnaire and their cognition status were evaluated by using a Singapore-modified Mini-Mental State Examination Scale in the 3(rd) follow-up visit during 2014- 2016. Multivariable logistic regression models were used to estimate the and 95s. A total of 16 948 participants were included in the analysis and 2 443 of them were identified as cognitive impairment using education-specific cutoffs. Sex, age, ancestral home, education level, physical activity level, total diet fiber intake level, BMI, alcohol drinking were significantly associated with cognitive impairment (0.05). Compared with those who never or hardly ever drank soft drinks, no significant differences in cognitive impairment risk were observed for those who drank soft drinks 2 or more times a week (=0.91, 95: 0.77-1.08), those who drank 1 time a week (=1.00, 95:0.82-1.23) and those who drank 1-3 times a month (=0.94, 95: 0.80-1.09) (trend =0.306). Compared with those who never or hardly ever drank juices, no significant differences in cognitive impairment risk were observed for those who drank juices 2 or more times a week (=1.03, 95:0.88-1.20), those who drank 1 time a week (=0.96, 95: 0.82-1.12) and those who drank 1-3 times a month (=0.94, 95: 0.82-1.08) (trend =0.930). No significant interactions were found with age, sex, and BMI status. SSBs consumption in midlife was not significantly associated with risk of late-life cognitive impairment in Singaporean Chinese adults with relatively low consumption levels. Further researches are needed to verify the results.

Plasma Fetuin-A Levels and Risk of Type 2 Diabetes Mellitus in A Chinese Population: A Nested Case-Control Study

BACKGROUND: Fetuin-A is a hepatokine that involved in the pathogenesis of insulin resistance. Previous epidemiological studies have found a positive association between blood fetuin-A and type 2 diabetes mellitus (T2DM) risk among Caucasians and African Americans. We aimed to investigate the prospective relationship between fetuin-A and T2DM in an Asian population for the first time. METHODS: A nested case-control study was established within a prospective cohort of Chinese living in Singapore. At blood collection (1999 to 2004), all participants were free of diagnosed T2DM and aged 50 to 79 years. At subsequent follow-up (2006 to 2010), 558 people reported to have T2DM and were classified as incident cases, and 558 controls were randomly chosen from the participants who did not develop T2DM to match with cases on age, sex, dialect group, and date of blood collection. Plasma fetuin-A levels were measured retrospectively in cases and controls using samples collected at baseline. Conditional logistic regression models were used to compute the odds ratio (OR) and 95% confidence interval (CI). Restricted cubic spline analysis was used to examine a potential non-linear association between fetuin-A levels and T2DM risk. RESULTS: Compared with those in the lowest fetuin-A quintile, participants in the highest quintile had a two-fold increased risk of developing T2DM (OR, 2.06; 95% CI, 1.21 to 3.51). A non-linear association was observed (P nonlinearity=0.005), where the association between fetuin-A levels and T2DM risk plateaued at plasma concentrations around 830 µg/mL. CONCLUSION: There is a positive association between plasma fetuin-A levels and risk of developing T2DM in this Chinese population.

An 11-year review of dermatomyositis in Asian patients

<p><b>INTRODUCTION</b>Dermatomyositis (DM) is a multisystem inflammatory disease with a strong association with malignancy. We aimed to describe a series of Asian patients with DM and identify any significant clinical factors associated with malignancy.</p><p><b>MATERIALS AND METHODS</b>This was a retrospective review of a multi-racial cohort of 69 Asian patients diagnosed with DM over an 11-year period from 1996 to 2006.</p><p><b>RESULTS</b>Malignancy was detected in 15 out of 68 patients (22%), the most common of which was nasopharyngeal carcinoma (7 cases). Compared to the non-malignancy group, the malignancy-associated group was older and had more male patients. There were no statistically significant clinical, serological or laboratory factors associated with a higher risk of malignancy.</p><p><b>CONCLUSION</b>This study highlights the importance of ongoing malignancy screening especially for nasopharyngeal carcinoma in Asian patients with DM.</p>

Peripheral arterial disease in community-based patients with diabetes in Singapore: Results from a Primary Healthcare Study

<p><b>INTRODUCTION</b>Peripheral arterial disease (PAD) is an important complication of diabetes mellitus (DM), significantly associated with increased morbidity and mortality secondary to amputations, strokes and coronary artery disease. Information on DM patients with PAD is limited in our ethnically diverse population in Singapore. We aimed to determine the prevalence, risk factors and co-morbidities of PAD in patients managed for DM in the primary care setting.</p><p><b>MATERIALS AND METHODS</b>A cross-sectional study was conducted among 521 diabetics in 9 of the 18 government-aided clinics in the community. Data including demographics, presence of co-morbidities and vascular risk factors were collected using an interviewer-administered questionnaire, and Ankle-Brachial Index (ABI) was calculated from systolic ankle and brachial pressure measurements.</p><p><b>RESULTS</b>The prevalence of PAD, defi ned as resting ABI of <0.9 on either leg and/or a history of gangrene or non-traumatic amputation was 15.2% [95% confidence interval (CI), 12.3-18.5]. This prevalence of PAD was higher in patients with pre-existing microvascular and other macrovascular complications. In multivariate analysis, prevalence of PAD was positively associated with increasing age (OR, 1.08; 95% CI, 1.05-1.12), Malay versus Chinese ethnicity (OR, 2.27; 95% CI, 1.09-4.70), low HDL-cholesterol (OR, 1.87; 95% CI, 1.04- 3.37), and insulin treatment (OR, 2.98; 95%CI, 1.39-6.36).</p><p><b>CONCLUSION</b>PAD is an important cause of concern among patients with diabetes, with a high prevalence which further increases with increasing age and duration of DM, and exhibits ethnic variation. Risk factors identified in this study may improve early identification of PAD, allowing for prompt interventions, with a potential to reduce long-term morbidity and mortality.</p>

Acceptance of information and communication technologies for healthcare delivery: a SingHealth Polyclinics study

<p><b>OBJECTIVE</b>This study aimed to determine the prevalence of short message system (SMS) and internet usage in patients visiting the SingHealth Polyclinics and to measure patients' acceptance of using these technologies in healthcare delivery.</p><p><b>MATERIALS AND METHODS</b>A representative sample of patients visiting the 9 SingHealth Polyclinics were interviewed in-person by trained medical students. Collected information included demographic characteristics, access to and usage of mobile phone/SMS and internet, as well as acceptance and concerns on using these technologies in primary healthcare delivery.</p><p><b>RESULTS</b>Among 705 patients surveyed (mean age: 54.6 years, female: 50.6%, response rate: 92%), 407 (57.7%) were SMS users and 158 (22.4%) were internet users. Two hundred and eighty-four of 412 SMS and/or internet users (40.3% of the entire sample) were comfortable with the use of these technologies in healthcare delivery. Malay or Indian ethnicity, better education, and visiting the clinic for acute symptoms or screening were factors positively associated with willingness to use such technologies. The main concerns associated with the use of SMS and internet in healthcare delivery were preference for in-person consultation with a doctor (23.5%), reduced patient-doctor interaction (23.0%), and increased healthcare cost (20.8%).</p><p><b>CONCLUSION</b>The present prevalence of SMS and internet usage among patients visiting the SingHealth Polyclinics and their concerns towards use of these technologies in healthcare delivery do not support current widespread implementation of services entailing SMS and internet in the study sites.</p>

New hope for an old cure: a pilot animal study on selective venesection in attenuating the systemic effects of ischaemic-reperfusion injury

<p><b>INTRODUCTION</b>Reperfusion of acutely ischaemic tissue may, paradoxically, lead to systemic complications. This phenomenon is believed to be initiated by humoral factors that have accumulated in the ischaemic tissue. The ancient art of venesection may reduce the load of these mediators at the point of reperfusion. The aim of this study is to test if selective venesection, by removing the initial venous return from the ischaemic tissue, can attenuate the systemic effects of the ischaemic-reperfusion injury using a porcine model of acute limb ischaemia.</p><p><b>MATERIALS AND METHODS</b>The right femoral arteries of anaesthetised female pigs were clamped. Twelve pigs were divided into 2 groups (n = 6 per group). In the treatment group, 5% of blood volume was venesected from the ipsilateral femoral vein upon reperfusion; the other arm served as control. The animals were sacrifi ced after 4 days for histological examination. A pathologist, blinded to the experimental groups, graded the degree of microscopic injury.</p><p><b>RESULTS</b>For the control group, the kidneys showed glomeruli and tubular damage. The livers demonstrated architectural distortion with cellular oedema. There was pulmonary oedema as well as extensive capillary congestion and neutrophil infiltration. Such findings were absent or reduced in the venesected animals. Consequently, the injury scores for the kidney, lung, liver and heart were significantly less for the venesected animals.</p><p><b>CONCLUSION</b>Selective venesection reduces the remote organ injuries of the ischaemic-reperfusion phenomenon.</p>

Characteristics, and disease control and complications of hypertensive patients in primary-care - a community-based study in Singapore

<p><b>INTRODUCTION</b>Hypertension is a common chronic condition usually managed by primary-care practitioners in Singapore. This study assessed the characteristics, control and complications of non-diabetic hypertensive patients managed at government primary healthcare clinics.</p><p><b>MATERIALS AND METHODS</b>A cross-sectional study involving 9 clinics was conducted over 1-week in 2006. Five hundred and six non-diabetic hypertensive patients were systematically sampled from all clinic attendees. Data relating to socio-demographic, lifestyle factors, treatment and complications were collected by interviewer-administered questionnaires and review of clinic medical records. Blood pressure (BP) measurements were taken with validated automated sets following a standard protocol.</p><p><b>RESULTS</b>The prevalence of good BP control (<140/90 mmHg) was 37.7% (95% CI: 33.6% to 41.8%). Ninety seven percent were on medication with about half on monotherapy. Seventy percent of patients had a body mass index (BMI) of 23.0 kg/m(2) or higher, 64% did not exercise regularly and 8% were current smokers. After adjusting for age and lifestyle factors, male hypertensive patients had poorer BP control compared to females. Nineteen percent of patients reported at least 1 complication of hypertension, especially cardiac disease. After multivariate analysis and duration of disease, age and the male gender were associated with the presence of hypertensive complications.</p><p><b>CONCLUSIONS</b>More than half of the patients were not controlled to target levels. Male patients were more likely to have poorer control of hypertension and significantly higher risks of complications. Control of BP could be further improved by lifestyle modifications - weight reduction, promotion of physical activity, healthier eating habits and smoking cessation.</p>

Does team learning motivate students' engagement in an evidence-based medicine course?

<p><b>INTRODUCTION</b>Small group-based instructional methods such as team learning have been shown to produce positive educational outcomes. To motivate students' learning in an evidence-based medicine course, we explore team learning as a teaching strategy, and describe students' engagement and preference for this mode of learning.</p><p><b>MATERIALS AND METHODS</b>An adaptation of team learning was implemented in September 2007 for all Year 2 Medical undergraduates attending the Principles in Evidence-Based Medicine course at the National University of Singapore. First, each student attempted a multiple-choice question individually. Next, the student discussed the same question with his/her team and provided a group response. Individual and group answers were recorded using keypads and Turning Point software. Students' engagement and preference for team learning were measured using a self-reported Likert Scale instrument. The pattern of engagement in team learning was compared with conventional tutorial involving the same cohort of students using chi2 trend test.</p><p><b>RESULTS</b>A total of 224 (88%) and 215 (84%) students responded to the surveys on team learning and conventional tutorial respectively. Overall, students reported a higher level of engagement with team learning than conventional tutorial. However, regardless of the mode of instruction, the students were equally likely to pay attention in class. Sixty-nine per cent of students found team learning more enjoyable than conventional tutorial, with 73% preferring this mode of learning. There was a tendency for the percentage of correct responses to improve after group discussion.</p><p><b>CONCLUSIONS</b>Team learning is the preferred mode of learning by Year 2 students attending the evidence-based medicine course. It promoted a high level of students' engagement and interaction in class.</p>