Assessment of Human Health Risks in Tropical Environmental Waters with Microbial Source Tracking Markers.

Human specific microbial source tracking (MST) markers which are highly specific to human waste contamination offer the advantage of better association with human pathogens than traditional microbial indicators. However, the performance of these MST markers may vary across different geographical regions. The magnitude of MST markers also plays an important role in interpreting the health risks. This study aims to (i) validate the specificity and sensitivity of human markers for tropical urban catchments; (ii) identify the threshold concentrations of MST markers, i.e. human polyomaviruses (HPyVs), Bacteroides thetaiotaomicron (B. theta) and Methanobrevibacter smithii (M. smithii), that correspond to the acceptable gastrointestinal (GI) illness risks associated with swimming using the QMRA approach; and (iii) validate the threshold concentrations of MST markers using the surveillance data obtained from the tropical urban environment. Among the three MST markers, HPyVs showed the highest specificity (100%) to sewage samples, followed by M. smithii (97%) and B. theta (90%). All MST markers showed 100% sensitivity towards sewage contamination, with B. theta present in highest abundance in sewage, followed by HPyVs and M. smithii. This study demonstrates a risk-based framework to identify the threshold concentrations of MST markers associated with GI illness risks in environmental waters by considering two main influencing factors (i.e. decay and dilution factors). This study successfully validated the B. theta threshold concentration range (581 to 8073 GC/100 mL) with field data (370 to 6500 GC/100 mL) in estimating GI illness risks with an Enterococcus model. Field data showed that the MST markers at threshold concentrations were able to classify the safe level in more than 83% of the samples, according to GI illness risks from Enterococcus and adenovirus. The study also highlighted the lack of associations between MST markers and GI illness risks from norovirus. With comprehensive information on specificity, sensitivity and threshold concentrations of MST markers, increasing confidence can be placed on identifying human source contamination and evaluating the health risks posed in environmental waters in Singapore.

The SAD-MEN questionnaire: a new and reliable questionnaire for assessing sexual dysfunction in Asians with diabetes.

AIM: The aim of this study is to construct a new tool for the assessment of sexual dysfunction among men with diabetes that is valid and reliable across different ethnicities, languages and socio-economic backgrounds in South East Asia. METHODS: Focus group interviews were conducted to determine the construct of the questionnaire. Content and face validity were assessed by a panel of experts. A pilot study was conducted to validate the Sexual Dysfunction in Asian Men with Diabetes (SAD-MEN) questionnaire in English and Malay. The International Index of Erectile Function-5 (IIEF-5) was used for comparison. Construct validity was assessed using exploratory factor analysis, reliability was determined using Cronbach's α (> 0.700), and test-retest reliability using Spearman's rank correlation coefficient. RESULTS: The SAD-MEN questionnaire yielded moderate face and content validity, with high reliability as shown by Cronbach's α values of 0.949 for sexual performance and 0.775 for sexual desire for the English version. The Malay language questionnaire had a Cronbach's α value of 0.945 for sexual performance and 0.750 for sexual desire. Test-retest reliability using Spearman's test gave correlation coefficients of r = 0.853, P = 0.000 for the English language questionnaire and r = 0.908, P = 0.000 for the Malay language questionnaire. CONCLUSION: The SAD-MEN questionnaire is a valid and reliable tool by which to assess sexual dysfunction in English- and Malay-speaking Malaysian and South East Asian men with diabetes.

Miniaturized versus conventional cardiopulmonary bypass and acute kidney injury after cardiac surgery.

INTRODUCTION: Acute kidney injury (AKI) is a serious complication after coronary artery bypass grafting (CABG). There are conflicting reports whether a miniaturized cardiopulmonary bypass (MCPB) system is associated with a lower AKI incidence compared with conventional cardiopulmonary bypass (CCPB). It is unknown if AKI risk factors differ between the two groups. We assessed if MCPB decreases AKI after CABG and compared the risk factors between both groups. METHODS: Sixty-eight Asian patients presenting for elective CABG at a tertiary heart centre were enrolled. They were randomly assigned to MCPB (n=34) or CCPB group (n=34) and followed up in a single-blinded, prospective, randomized, controlled trial. The primary outcome was Acute Kidney Injury Network stage 1 AKI. RESULTS: The AKI incidence was 21.5% and was not significantly different between patients undergoing MCPB versus CCPB (21.9% versus 21.2%, p=0.948). The first CPB haematocrit was independently associated with AKI in the MCPB group (Relative Risk [RR]=0.484, 95% Confidence Interval [CI]=0.268-0.876, p=0.016); post-operative blood loss and inflammation were independently associated with AKI in the CCPB group (RR=1.005, 95%CI=1.003-1.007, p<0.001; RR=1.018, 95%CI=1.010-1.028, p<0.001). CONCLUSION: The MCPB system is not associated with a lower incidence of AKI in Asian patients undergoing CABG. Risk factors for AKI differed between patients using the MCPB and CCPB systems.

Evaluation of FRNA coliphages as indicators of human enteric viruses in a tropical urban freshwater catchment.

This study aimed to evaluate the relationship between FRNA coliphages (FRNA GI to GIV) and human enteric viruses (human adenoviruses, HAdV, astroviruses, AstV, noroviruses, NoV, and rotaviruses, RoV) in a tropical urban freshwater catchment. Positive associations between human-specific coliphages and human viral pathogens substantiate their use as viral indicators and in microbial source tracking. Reverse transcription qPCR was used to measure the concentrations of viruses and FRNA coliphages in concentrated water samples. Environmental water samples were also analyzed for male-specific (F+) and somatic (Som) coliphages using plaque assay. The most abundant enteric virus was NoV (55%) followed by HAdV (33%), RoV (33%), and AstV (23%), while the most abundant FRNA genogroup was GI (85%) followed by GII (48%), GIV (8%) and GIII (7%). Concentrations of human-specific coliphages FRNA GII were positively correlated with NoV, HAdV, RoV, AstV, F+ and Som (τ = 0.5 to 0.3, P < 0.05) while concentrations of animal-specific coliphages FRNA GI were negatively correlated with HAdV and RoV (τ = -0.2, P < 0.05). This study demonstrates statistical relationships between human-specific coliphages and a suite of human enteric viruses in the environment.

Development and validation of the Asian Diabetes Quality of Life (AsianDQOL) Questionnaire.

AIM: To construct a type-2 diabetes specific quality of life (QOL) tool for Asian populations that is valid and reliable across different ethnicities, languages, and socio-economic backgrounds. METHODS: A focus group determined the domains affecting QOL in consultation with an expert group. A pilot study was conducted to validate the Asian Diabetes QOL (AsianDQOL) in English, Malay and Chinese-Mandarin. The World Health Organization Brief Quality of Life Questionnaire (WHOQOL-BREF) was used for comparison. Exploratory factor analysis (EFA), reliability analysis (RA) using Cronbach's alpha, test-retest reliability, and confirmatory factor analysis (CFA) using structural equation modeling (SEM) was undertaken using the statistical software IBM SPSS Statistics version 20. RESULTS: EFA with eigenvalues (>1) and factor loadings ≥0.3 for English and Malay language demonstrated 21 items (5 components). CFA (English version) confirmed the model (CMIN 201.08, p-value 0.071, GFI 0.88, RMSEA 0.036, CFI 0.978). CFA (Malay version) confirmed the 5-factor model (CMIN 189.39, p-value 0.085, GFI 0.937, RMSEA 0.025, CFI 0.987). The Cronbach's alpha scores (English version) were 0.917, 0.818, 0.816, 0.749 and 0.719, respectively. The Malay version scored 0.833, 0.819, 0.816, 0.775, 0.673, respectively, whilst the Chinese/Mandarin version scored 0.890, 0.719, 0.826, 0.862 and 0.759, respectively. Test-retest reliability showed Pearson correlation of 0.600 (English version), 0.700 (Malay version) and 0.500 (Chinese-Mandarin version). A scoring system was generated based on the 25th, 50th and 75th centiles for all the three languages. CONCLUSION: The AsianDQOL is a valid, reliable and stable tool for assessing QOL in multi-ethnic and multi-lingual T2DM Asian populations.

Alternative fecal indicators and their empirical relationships with enteric viruses, Salmonella enterica, and Pseudomonas aeruginosa in surface waters of a tropical urban catchment.

The suitability of traditional microbial indicators (i.e., Escherichia coli and enterococci) has been challenged due to the lack of correlation with pathogens and evidence of possible regrowth in the natural environment. In this study, the relationships between alternative microbial indicators of potential human fecal contamination (Bacteroides thetaiotaomicron, Methanobrevibacter smithii, human polyomaviruses [HPyVs], and F+ and somatic coliphages) and pathogens (Salmonella spp., Pseudomonas aeruginosa, rotavirus, astrovirus, norovirus GI, norovirus GII, and adenovirus) were compared with those of traditional microbial indicators, as well as environmental parameters (temperature, conductivity, salinity, pH, dissolved oxygen, total organic carbon, total suspended solids, turbidity, total nitrogen, and total phosphorus). Water samples were collected from surface waters of urban catchments in Singapore. Salmonella and P. aeruginosa had significant positive correlations with most of the microbial indicators, especially E. coli and enterococci. Norovirus GII showed moderately strong positive correlations with most of the microbial indicators, except for HPyVs and coliphages. In general, high geometric means and significant correlations between human-specific markers and pathogens suggest the possibility of sewage contamination in some areas. The simultaneous detection of human-specific markers (i.e., B. thetaiotaomicron, M. smithii, and HPyVs) with E. coli and enterococcus supports the likelihood of recent fecal contamination, since the human-specific markers are unable to regrow in natural surface waters. Multiple-linear-regression results further confirm that the inclusion of M. smithii and HPyVs, together with traditional indicators, would better predict the occurrence of pathogens. Further study is needed to determine the applicability of such models to different geographical locations and environmental conditions.

Diabetes quality of life perception in a multiethnic population.

AIM: The aim of this study was to determine ethnic differences and predictors of the perception of quality of life (QOL) in a multiethnic Malaysian population with type 2 diabetes. METHODS: A population-based cross-sectional study was done in three different states in Malaysia. The Asian Diabetes Quality of Life (AsianDQOL) tool specific for type 2 diabetes is the primary outcome tool. One-way analysis of covariance was undertaken to examine ethnic differences on the total and component AsianDQOL scores controlling for important covariates. Stepwise multiple linear regression models were used for selecting predictors for the AsianDQOL score with stratification for ethnicity and language. RESULTS: A total of 647 subjects (338 Malays, 160 Chinese and 149 Indians) were recruited. Chinese scored significantly lower (78.1 ± 11.6) on the AsianDQOL (total) score compared to Malays (81.4 ± 9.0) and Indians (81.5 ± 9.2) (F = 3.060, p = 0.049, η (2) = 0.02). Likewise, Chinese scored significantly lower (21.0 ± 4.3) on the AsianDQOL (diet) score compared to Malays (22.8 ± 3.6) and Indians (22.5 ± 3.7) (F = 4.96, p = 0.008, η (2) = 0.04). The main predictors of AsianDQOL (total) score for the English language group of different ethnicities were sexual dysfunction (-4.5), having visual problems (-3.7), female (-2.8) and glycemic control (-1.6). Sexual dysfunction was negatively correlated with QOL in Malay, Chinese ethnic group and Indian ethnic groups. CONCLUSION: The perception of AsianDQOL is different across ethnic groups and languages spoken. Significant differences in the English-speaking group and the non-English-speaking group are detected within the same ethnicity. Sexual dysfunction severely impacts AsianDQOL in a multiethnic Asian population and remains an important determinant regardless of ethnicity and language.

A mobile-health application to detect wandering patterns of elderly people in home environment.

Wandering is a common and risky behavior in people with dementia (PWD). In this paper, we present a mobile healthcare application to detect wandering patterns in indoor settings. The application harnesses consumer electronics devices including WiFi access points and mobile phones and has been tested successfully in a home environment. Experimental results show that the mobile-health application is able to detect wandering patterns including lapping, pacing and random in real-time. Once wandering is detected, an alert message is sent using SMS (Short Message Service) to attending caregivers or physicians for further examination and timely interventions.

Prevalence and quantification of Listeria monocytogenes in chicken offal at the retail level in Malaysia.

A total of 216 chicken offal samples (chicken liver = 72; chicken heart = 72; chicken gizzard = 72) from wet markets and hypermarkets in Selangor, Malaysia, were examined for the presence and density of Listeria monocytogenes by using a combination of the most probable number and PCR method. The prevalence of L. monocytogenes in 216 chicken offal samples examined was 26.39%, and among the positive samples, the chicken gizzard showed the highest percentage at 33.33% compared with chicken liver (25.00%) and chicken heart (20.83%). The microbial load of L. monocytogenes in chicken offal samples ranged from <3 to 93.0 most probable number per gram. The presence of L. monocytogenes in chicken offal samples may indicate that chicken offal can act as a possible vehicle for the occurrence of foodborne listeriosis. Hence, there is a need to investigate the biosafety level of chicken offal in Malaysia.

Listeria monocytogenes in retailed raw chicken meat in Malaysia.

This study aimed to determine the prevalence Listeria monocytogenes in raw chicken meat samples at hypermarkets and wet markets. Chicken drumsticks, breasts, and thighs were randomly selected. The most probable number (MPN) PCR method was used to quantify the L. monocytogenes in the samples. Listeria monocytogenes was detected in 20% of the samples. Occurrence of L. monocytogenes was highest in breast (42.03%) followed by drumstick (11.27%) and thigh (7.14%). Samples from hypermarkets showed higher occurrence (25.71%) of L. monocytogenes compared with wet markets (14.29%). The density of L. monocytogenes found in samples ranged from <3.0 to 16 MPN•g(-1). The presence of L. monocytogenes in raw chicken meat is unwanted but unpreventable. Thus, further research on the processing method to reduce and eliminate this kind of bacteria in chicken meat before consumption is necessary. The presence of L. monocytogenes in chicken samples suggests the importance of this pathogen in chicken. Thus, more study is needed to find ways to eliminate this pathogen from poultry.

Acute generalised exanthematous pustulosis and toxic epidermal necrolysis induced by carbamazepine.

Acute generalised exanthematous pustulosis and Stevens-Johnson syndrome (toxic epidermal necrolysis spectrum of severe cutaneous drug reactions) are believed to have distinct underlying pathophysiologies. Our patient, a 28-year-old Chinese woman, represents the first known reported case of clinically-consistent and histologically-proven acute generalised exanthematous pustulosis and toxic epidermal necrolysis overlap induced by carbamazepine in the English literature.

Cutaneous vascular tumours: an update.

This review evaluates changes in vascular nomenclature particularly in the category of vascular tumours of intermediate malignancy that includes the various haemangioendotheliomas, Kaposi's sarcoma and giant cell angioblastoma. Recently described entities in this category, including the latter tumour and composite haemangioendothelioma, are described. Several newly characterized vascular tumours not included in recent classifications of vascular tumours are also summarized. These include acquired elastotic haemangioma, symplastic haemangioma, cutaneous epithelioid angiomatous nodule and cutaneovisceral angiomatosis with thrombocytopenia. The newly introduced clinical classification of congenital haemangiomas into non-involuting and rapidly involuting variants and radiation-induced atypical vascular lesions are also reviewed.

Sarcomatoid basal cell carcinoma--predilection for osteosarcomatous differentiation: a series of 11 cases.

Primary cutaneous carcinomas rarely show heterologous malignant mesenchymal differentiation. We report 11 cases of sarcomatoid basal cell carcinoma (BCC) with osteosarcomatous differentiation. The patients (7 men and 4 women) ranged in age from 61 to 92 years (median 75 y). The tumors presented as exophytic nodules (0.3 to 7 cm) on the head (n=6), upper limb (n=3), and lower limb (n=2). All lesions were completely excised. Seven patients were alive without evidence of disease (follow-up interval 5 to 24 mo) and 1 patient died of unrelated causes at 7 months without evidence of disease. On histology, the tumors were dermal in location with 2 cases showing focal subcutaneous involvement. Ten tumors were well-circumscribed and 1 tumor showed focally infiltrative edges. Ten tumors revealed conventional BCC associated with varying proportions of osteosarcomatous and undifferentiated sarcomatous stroma. Transition from neoplastic epithelial to mesenchymal cells was seen in 8 cases. One case showed a purely osteoclastic giant cell rich malignant mesenchyme, interpreted as representing early stages of osteosarcomatous transformation. Previously unreported in sarcomatoid BCC, the mesenchymal component of another two cases displayed predominant malignant giant cell tumor like areas and 1 further case disclosed areas reminiscent of telangiectatic osteosarcoma. Pancytokeratins (AE1/3 and MNF116) and smooth muscle actin stained occasional undifferentiated sarcomatous cells in 2 and 3 tumors, respectively. MNF116 and EMA were focally positive in osteosarcomatous tumor cells of 1 case. Although the follow-up interval is short, our data suggest an excellent prognosis for polypoid and exophytic sarcomatoid BCC after complete surgical resection.

An unusual cause of granulomatous inflammation: eosinophilic abscess in Langerhans cell histiocytosis.

Eosinophilic abscess inciting a granulomatous response has rarely been reported and appears not to have been described in the setting of a neoplasm. In this report, a case is described where a granulomatous response occurred around eosinophilic abscesses in a patient with Langerhans cell histiocytosis, an association which has not previously been documented. On histology, the excised lymph node showed the presence of eosinophilic abscess and necrosis surrounded by granulomas, which in turn were surrounded by Langerhans cells, a feature confirmed on immunohistochemistry. Although rare, this case highlights the importance of careful examination of eosinophilic abscess with granulomatous inflammation in order to exclude an underlying neoplasm.

Pineal yolk sac tumour with a solid pattern: a case report in a Chinese adult man with Down's syndrome.

Intracranial germ cell tumours are rare. The incidence of primary intracranial yolk sac tumour is even more uncommon, with only two reported cases being associated with Down's syndrome in the English literature. This report details the findings of yolk sac tumour in the pineal region affecting a 22 year old Chinese man with Down's syndrome. Histology revealed yolk sac tumour with only a solid pattern, potentially mimicking the more common germinoma in the pineal region. No other germ cell components were identified. This is the third report of intracranial yolk sac tumour manifesting in a patient with trisomy 21. The pathology of this tumour and its differential diagnoses are discussed.

Pseudodicentric (16;12)(q11;p11.2) in a type AB (mixed) thymoma.

Genetic alterations of thymomas are rarely described in the literature. In this study, a previously unreported instance of aberrant karyotypic change consisting of 45,XX,pseu dic(16;12) (q11;p11.2) [cp23]/87-90,idemx2[cp4] in a Masaoka Stage II mixed thymoma or type AB thymoma affecting a 56-year-old Chinese woman is detailed. Abnormalities involving 12p containing important tumor suppressor-like genes have been documented especially in hematological malignancies. Recently, recurrent losses involving 16q, a locus known to harbor several tumor suppressor genes, have been described in type C thymomas (squamous cell carcinoma), suggesting a possible relationship between type AB thymoma and type C thymoma. Whether these genes are involved in the pathogenesis of type AB thymoma remain to be clarified and it is currently unclear if cytogenetic studies may eventually play a role in the classification of thymic tumors.

Leiomyomatosis-like lymphangioleiomyomatosis of the colon in a female with tuberous sclerosis.

Smooth muscle lesions of the large bowel, excluding the rectum, are generally rare, and diffuse smooth muscle lesions, termed leiomyomatosis, are even rarer. In this report, we document, for the first time, leiomyomatosis-like lymphangioleiomyomatosis (LAM) of the ascending, transverse, and descending colon in association with bilateral renal angiomyolipoma (AML) in a 30-year-old Chinese female with tuberous sclerosis complex (TSC). She presented with protracted constipation for which a colectomy was performed. Histology disclosed multiple confluent nodular CD34 and CD117 negative smooth muscle proliferation within the large bowel wall, whereas the renal biopsy revealed typical features of AML. Interestingly, the epithelioid smooth muscle cells of both the colonic and renal lesions were HMB45 positive, suggesting that leiomyomatosis-like LAM of the colon, pulmonary LAM and AML are closely related entities. The patient remained free of complications for the last five years after surgery. Leiomyomatosis-like LAM of the large bowel probably represents another manifestation of the tendency of TSC to be associated with proliferative lesions.

Riboflavin, folate and vitamin C status of Gambian women during pregnancy: a comparison between urban and rural communities.

Anthropometric, haematological and vitamin status indices were measured in a group of pregnant women living in the urban community of Bakau in The Gambia, West Africa. Their haematological and anthropometric indices were generally within normal limits. Vitamin C status was also acceptable and was similar to values observed in rural Gambian women sampled at the same time of year. Folate status was similar to that seen previously in rural Gambian communities, and there was a strong intrasubject correlation between plasma and red cell folate levels, together with a trend towards higher values as pregnancy progressed. This was consistent with probable compliance with local recommendations for folate supplementation during pregnancy. The urban Gambian women also resembled their rural counterparts in having very poor biochemical riboflavin status, which deteriorated as pregnancy progressed. In this respect they differed markedly from UK women, who had satisfactory riboflavin status even in late pregnancy. The existence of severe biochemical riboflavin deficiency, even in urban Gambian women, whose anthropometric indices are not compatible with severe general malnutrition, suggests that a deficiency of this vitamin may be widespread in Sahelian West Africa. Measures to improve maternal vitamin status during pregnancy would therefore be equally appropriate in both rural and urban communities.

Epidemiological aspects of rotavirus infection in young Gambian children.

Rotavirus gastro-enteritis in young Gambian children has its maximum impact on infants after the age of one month, in whom it produces short, well-defined annual winter epidemics with clinical dehydration in up to 18% of those infected. Sporadic infection was observed in neonates who were often asymptomatic, throughout one year but not in the subsequent year. In two consecutive years studied there was a major change from subgroup I, serotype 2 to subgroup II, serotypes 1 and 3. This could have contributed to the failure of children to develop protective immunity against sequential disease following an infection during infancy. If rotavirus morbidity in this community is to be notably reduced by a vaccination programme it would need to be carried out in early infancy prior to the winter season. Evaluation of a type-specific vaccine should include monitoring secular changes in rotavirus serotypes throughout subsequent epidemics.

Food and water hygiene and diarrhoea in young Gambian children: a limited case control study.

During the annual rainy season epidemic of diarrhoea in The Gambia, two groups of urban children were identified, one of which remained completely free of diarrhoea and another in which diarrhoeal prevalence exceed 30% over a period of three months. Microbiological studies on the food and water consumed by these children during one day showed widely varying degrees of contamination in both groups. No difference was observed in levels of contamination, faecal or otherwise, between the two groups. The real problem seemed to lie in accounting for the freedom from diarrhoea of some children rather than explaining possible causes of morbidity in others.

PIP: During the annual rainy season epidemic of diarrhea in the Gambia, 2 groups of urban children were identified, 1 of which remained completely free of diarrhea and another in which diarrheal prevalence exceeded 30% over a period of 3 months. Microbiological studies on the food and water consumed by these children during 1 day showed widely varying degrees of contramination in both groups. No difference was observed in levels of contamination, fecal or otherwise, between the 2 groups. The real problem seems to lie in accounting for the freedom from diarrhea seen in some children rather than in explaining the possibel causes of morbidity in others.