Smartphone electrocardiogram for QT interval monitoring in Coronavirus Disease 2019 (COVID-19) patients treated with Hydroxychloroquine.

INTRODUCTION: The global pandemic of Corona Virus Disease 2019 (COVID-19) has led to the re-purposing of medications, such as hydroxychloroquine and lopinavir-ritonavir in the treatment of the earlier phase of COVID-19 before the recognized benefit of steroids and antiviral. We aim to explore the corrected QT (QTc) interval and 'torsadogenic' potential of hydroxychloroquine and lopinavir-ritonavir utilising a combination of smartphone electrocardiogram and 12-lead electrocardiogram monitoring. MATERIALS AND METHODS: Between 16-April-2020 to 30-April- 2020, patients with suspected or confirmed for COVID-19 indicated for in-patient treatment with hydroxychloroquine with or without lopinavir-ritonavir to the Sarawak General Hospital were monitored with KardiaMobile smartphone electrocardiogram (AliveCor®, Mountain View, CA) or standard 12-lead electrocardiogram. The baseline and serial QTc intervals were monitored till the last dose of medications or until the normalization of the QTc interval. RESULTS: Thirty patients were treated with hydroxychloroquine, and 20 (66.7%) patients received a combination of hydroxychloroquine and lopinavir-ritonavir therapy. The maximum QTc interval was significantly prolonged compared to baseline (434.6±28.2msec vs. 458.6±47.1msec, p=0.001). The maximum QTc interval (456.1±45.7msec vs. 464.6±45.2msec, p=0.635) and the delta QTc (32.6±38.5msec vs. 26.3±35.8msec, p=0.658) were not significantly different between patients on hydroxychloroquine or a combination of hydroxychloroquine and lopinavir-ritonavir. Five (16.7%) patients had QTc of 500msec or more. Four (13.3%) patients required discontinuation of hydroxychloroquine and 3 (10.0%) patients required discontinuation of lopinavirritonavir due to QTc prolongation. However, no torsade de pointes was observed. CONCLUSIONS: QTc monitoring using smartphone electrocardiogram was feasible in COVID-19 patients treated with hydroxychloroquine with or without lopinavir-ritonavir. The usage of hydroxychloroquine and lopinavir-ritonavir resulted in QTc prolongation, but no torsade de pointes or arrhythmogenic death was observed.

Phenotypic variation among siblings with arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is primarily a familial disease with autosomal dominant inheritance. Incomplete penetrance and variable expression are common, resulting in broad disease spectrum. Three patterns of phenotypic expression have been described: (1) "classic" subtype, with predominant right ventricle involvement, (2) "left dominant" subtype, with early and dominant left ventricle involvement, and (3) "biventricular" subtype, with both ventricles equally affected. Genotypephenotype associations have been described, but there are other genetic and non-genetic factors that can affect disease expression. We describe two different phenotypic expressions of ARVC in a family.

Real-world experiences of folic acid supplementation (5 versus 30 mg/week) with methotrexate in rheumatoid arthritis patients: a comparison study.

The objective of this study was to compare the tolerability of methotrexate in two different regimes of folic acid (FA) supplementation in rheumatoid arthritis (RA). We performed a multicenter, cross-sectional observational cohort study on 240 RA patients with 120 patients each in 5 mg of FA weekly and 30 mg of FA weekly supplementation. There were no significant differences for side effects (14.2 versus 22.5%, P=0.523) and discontinuation of methotrexate (3.6 versus 13.3%, P=0.085). RA patients given 5 mg of FA weekly supplementation had a lower disease activity score 28 compared to 30 mg of FA weekly supplementation [3.44 (1.10) versus 3.85 (1.40), P=0.014]. FA supplementation of 5 mg per week and 30 mg per week was associated with similar tolerability of methotrexate in RA patients.

Risk factors associated with low birth weight infants in the Malaysian population.

This study aimed to identify the risk factors which were significantly associated with low birth weight (LBW, <2500 g) infants among the Malaysian population. This was a case-control study carried out at the Tuanku Jaafar Hospital, Seremban, Malaysia over a five-month period. Cases were all infants born with birth weight less than 2500 g. Control infant were selected with the help a random sampling table from among infants with birth weight of > or =2500 g born on the same day in the hospital. Of 3341 livebirths delivered in the hospital, 422 (12.6%) were LBW infants. Logistic regression analysis showed that, after controlling for various potential confounders, the only significant risk factors associated with infants of LBW were gestational age (adjusted odds ratio (OR)=0.6, 95% C.I.: 0.5, 0.6; < 0.0001), maternal pre-pregnancy weight (adjusted OR = 0.97, 95% C.I.: 0.95, 0.99; p < 0.0001), nulliparity (adjusted OR = 3.4, 95% C.I.: 2.2, 5.1; p < 0.0001), previous history of LBW infants (adjusted OR = 2.3, 95% C.I.: 1.4, 3.8; p=0.001) and PIH during current pregnancy (adjusted OR=3.3, 95% C.I.: 1.6, 6.6; p = 0.001). A number of potentially preventable or treatable risk factors were identified to be associated with LBW infants in Malaysia.

The use of complementary and alternative medicine by asthma patients.

BACKGROUND: Use of complementary and alternative medicines (CAM) by asthmatic patients is increasing. Data on the prevalence of CAM use in asthma are limited, and the motivation for patients to seek CAM therapy is uncertain. AIM: To determine the prevalence and pattern of use of complementary therapies in adults treated for asthma in primary care in Singapore, and the demographic and clinical factors associated with their use. DESIGN: Cross-sectional study. SETTING: Five primary care clinics in Singapore. METHODS: Adult patients with asthma (n = 802) received a structured questionnaire interview and clinical assessment that included demographic and clinical variables (clinical status, patient's knowledge, self-care and healthcare-seeking behaviour, and spirometric measurements) and detailed information on CAM use in the past one year. RESULTS: CAM use in the past year was reported by 27.2%, including animal food products (12.3%), herbs (10.3%), herbal-based proprietary medicines (3.2%), and acupuncture or reflexology (1%). The use of CAM was significantly associated with Chinese ethnicity, longer disease duration, moderate and severe persistent asthma, FEV(1)/FVC < 80%, lack of positive response to treatment in the past year, higher patient knowledge score, and multiple sources of care providers. DISCUSSION: The use of CAM is highly prevalent in Asian patients treated for asthma in primary care, and is associated with cultural and clinical factors reflecting a need to improve care.

Understanding asthma: patient survey.

Eight hundred and two adult patients attending five randomly selected polyclinics in Singapore were interviewed to assess their understanding of asthma. Knowledge of asthma mechanism and its medications was poor with a mean score of 1.4 (median: 1) out of a total score of 6. About a third knew that asthma is due to narrowing of airways and a quarter knew the action of bronchodilators. Only 4.4% (27) knew that steroids decrease airway swelling or inflammation. The best knowledge score was associated with subjects who had the highest education, who had a family history and who had been exposed to pamphlets and books. Incorrect use of prophylaxis was also evident with only one-third (37%) using steroid inhalers regularly as prescribed. Only half (54.5%) of those with no schooling used the correct inhaler technique. Doctors were a source of information for only 49.9% (400) of the patients and it was those with the highest education who were most likely to get information from the doctors. Pamphlets were a source of information for less than one-fifth (16.2%) of the subjects. Greater emphasis should be given to patient education by doctors to help patients understand asthma and its treatment. Important target groups are the older, lesser educated and the moderate or severe patients on steroid inhalers.

Lifestyle and behavioural risk factors associated with asthma morbidity in adults.

We studied the association between morbidity and personal lifestyle/behavioural factors that predispose to exposure to known environmental precipitants of asthma, in a group of asthmatics (n = 787) in primary-care clinics. Clinical severity of asthma was determined by questions regarding the frequency of daytime or nocturnal attacks, the number of visits to primary care or hospital emergency departments for treatment of acute attacks, and the number of hospitalizations, as well as the amount of sick leave in the past year. Questions concerning risk factors included ethnicity, clinical atopic status (current rhinitis/eczema), smoking, occupation, keeping of pets, rugs and carpets, use of brooms, burning of mosquito coils or incense, and outdoor air pollution, as well as the patient's knowledge of asthma care. The most significant independent predictors of asthma morbidity, identified from multivariate logistic regression analyses, were current keeping of either pets or rugs/carpets (OR 1.49; 95% CI 1.12-1.99), and current high-risk occupations (OR 0.59, 95% CI 0.40-0.89). A multiplicity of interacting factors and behavioural responses appear to influence the effects of allergens and other environmental precipitants on asthma morbidity in patients.

The family doctor's role in the care of the elderly.

With the anticipated increase in the number of aged persons in our local population, there will be an increased workload for the family doctor caring for the elderly in the community. Diseases thought to be attributed to ageing may be non-degenerative and hence treatable. This paper highlights the role of the family physician in the care of the elderly as the doctor's recognition of these diseases and consequent early intervention may result in an improved outcome for the patient. Optimal care can be achieved with the family doctor's systematic planning of the individual's care, networking with hospitals and other health professionals and providing support for carers.

Risks of asthma associated with occupations in a community-based case-control study.

The aim of this study was to identify occupational risk groups which might usefully be targeted for occupational asthma surveillance and control, using a community-based case-control approach. Data on previous and current occupations held by subjects were analyzed for 787 adult patients with bronchial asthma and 1591 nonasthmatic patient controls, aged 20-54 years, belonging to the three major races (Chinese, Malays, and Indians) in five outpatient primary care polyclinics. Odds ratios (OR) and 95% confidence intervals (95% CI) of association were adjusted for sex, age, race, smoking, and clinical atopy. No associated risks of asthma were found for clerical or sales workers in general. Significantly reduced risks of association with asthma were found for professional, technical, administrative, and managerial occupations (OR, 0.62; 95% CI, 0.47-0.82). The associated risks of asthma were generally elevated for service workers (OR, 1.35; 95% CI, 1.04-1.74) and manufacturing production and related workers (OR, 1.49; 95% CI, 1.23-1.81). Among them, increased risks were observed for cleaners, particularly municipal cleaners and sweepers (OR, 1.91; 95% CI, 1.22-2.99), textile workers (OR, 5.83; 95% CI, 1.93-17.57), garment markers (OR, 1.61; 95% CI, 1.01-2.58), electrical and electronic production workers (OR, 1.36; 95% CI, 1.06-1.75), printers (OR, 2.24; 95% CI, 1.17-4.31), and construction/renovation workers (OR, 2.24; 95% CI, 1.30-3.85). The odds ratio of association of asthma with exposures in service and production-related occupations overall, relative to the "nonexposed" reference group of nonmanual professional/technical, administrative/managerial, clerical, and sales occupations, was estimated to be 1.72 (95% CI, 1.36-2.19); the estimated population attributable risk was 0.33 (95% CI, 0.22-0.44).

Proteinuria and enzymuria in non-insulin-dependent diabetics.

Urine albumin, alpha 1- and beta 2-microglobulins, retinol-binding protein (RBP) and N-acetyl-beta-D-glucosaminidase (NAG) were measured in early morning urine samples from 99 non-insulin-dependent diabetic (NIDDM) patients receiving ambulatory care at a primary health care polyclinic. Elevated NAG levels were found in 90% of diabetics regardless of the duration of their disease. Almost half (43.4%) of the subjects had microalbuminuria. Over a third of the subjects without albuminuria had elevated alpha 1-microglobulin levels in their urine. The proportion of subjects with elevated alpha 1 levels increased significantly with the presence of albumin, poor glycaemic control and increased duration of disease. These findings suggest that proximal tubular as well glomerular dysfunction coexist in the NIDDM patients studied.

Knowledge and concerns of newly diagnosed NIDDM patients in Singapore.

This paper describes the findings of a questionnaire survey of the knowledge and concern of 152 newly diagnosed NIDDM patients presenting at the Government Polyclinic (primary health care centre). This study is part of a project on outpatient diabetic care in Singapore. It was found that 23.7% of the subjects had no education and 51.3% had only primary school education. More than eighty percent of the subjects understood the importance of diet control and weight control in their condition. More than half of the subjects, 61% of males and 52.7% of females were aware that diabetes could not be cured and that once diabetes is controlled, that medication cannot be stopped and that one must still take the medication even if one feels well. Less than 30% knew about the interpretation of blood and urine sugar findings. The two major concerns amongst the subjects were complications and the need for long-term medication. These findings will be incorporated into the next phase of the project where a health education programme for NIDDM patients will be developed and evaluated.

Using role-play to teach consultation skills--the Singapore experience.

Role-play by students has been adopted as a teaching method for learning consultational skills during a primary health care posting for fourth year medical students in the National University of Singapore. This article describes the construction of the framework used, and reports on its evaluation by both the students and their teachers. The overall response to the session by the students was positive. Suggestions were then solicited to make refinements to enhance its efficacy as a teaching tool.

The computer in group practice--a British experience.

This paper describes the author's work experience using a computer in consultation in a large computerised academic practice in Manchester, U.K. Prescribing, preventive health screening and recall, the use of disease registers and billing are common medical applications with proven usefulness. System implementation however is not without problems; the capital cost to the practice, decisions regarding hard and software, the conversion of written to computerised records, access and confidentiality and staff training are issues to be resolved. Computer use may also extend consultation and staff time. It is hoped that this experience will help doctors intending to computerise to focus on applications and implementation issue.