Relationship between circulating vascular endothelial growth factor and its soluble receptors in adults with dengue virus infection: a case-control study

BACKGROUND

We performed a case-control study to assess the relationship between vascular endothelial growth factor (VEGF) and its soluble receptors (sVEGFR-1 and 2) in adult patients with dengue fever (DF) and dengue hemorrhagic fever (DHF).

METHODS

We recruited 60 adult patients (34 DF and 26 DHF) with serologically-confirmed dengue infections, 10 patients with non-hemorrhagic infections, and 31 community-based healthy volunteers. The levels of VEGF, sVEGFR-1, and sVEGFR-2 were measured and the differences in these markers were compared using one-way analysis of variance (ANOVA), which was adjusted for multiple comparisons.

RESULTS

We observed lower VEGF levels in DF and DHF compared to study controls (p<0.01). sVEGFR-1 was higher in DHF than DF, whilst sVEGFR-2 was lower in DF and DHF compared to study controls (all p<0.01). In DHF, lower VEGF levels were observed in older patients. The use of a single marker, sVEGFR-1>350 pg/ml, was predictive of DHF.

CONCLUSION

The changes in VEGF and its soluble receptors highlight the importance of vascular permeability cytokines in the pathogenesis of DHF.

Different patterns of oxidized lipid products in plasma and urine of dengue fever, stroke, and Parkinson's disease patients: cautions in the use of biomarkers of oxidative stress

Many products of lipid oxidation have been associated with human diseases. These include F2-isoprostanes (F2-IsoPs), hydroxyeicosatetraenoic acid products (HETEs), and cholesterol oxidation products (COPs). Here we present measurements of F2-IsoPs, HETEs, COPs, and arachidonate in single plasma samples of patients with acute (dengue fever and ischemic stroke) and chronic (Parkinson's) diseases, and in age-matched study controls. Urine samples were collected for F2-IsoPs analysis. Our analysis demonstrated elevated F2-IsoPs levels in ischemic stroke, HETEs in Parkinson's disease, dengue fever, and ischemic stroke, and COPs in Parkinson's disease and dengue fever patients, as compared with those in age-matched study controls. Strong but complex correlations were observed between levels of certain oxidized lipid products and age. The relations between various oxidized lipids and dengue fever, stroke, and Parkinson's disease are discussed in relation to the selection and application of biomarkers of oxidative lipid damage, in particular the need for corrections for age and lipid levels.

Harnessing the IT factor in medical education

Escalating healthcare costs in Singapore have produced a significant movement of patients into ambulatory care, and the consequent dearth of clinical teaching materials. This deficiency has likewise prompted the creation of ambulatory teaching clinics and the use of standardised patients and simulators. In the last few decades, educators have utilised digital technology, for instance, digitally recorded heart and breath sounds, and digitised video vignettes, in medical education. We describe several pedagogical initiatives that we have undertaken at our university school of medicine.

In-house medical education: redefining tele-education

BACKGROUND

Hip and tech-savvy medical students and junior doctors are likely to find lecture-based professionalism and ethics modules boring. Medical-based television dramas and films, on the other hand, are exciting and topical, and often feature real-life situations, albeit presented with artistic license. Current "hot" television series, such as House, ER, and Grey's Anatomy, feature scenarios which are thought-provoking, not only for the fascinating cases featured, but also for the ethical dilemmas and professionalism issues which present themselves.

SUMMARY

We discuss the educational merits of the genre of the medical drama and propose to develop an "In-House" Medical Education Initiative, in which an episode of House is shown, and participants encouraged, at the end of the screening, to discuss the following: ethics, professionalism (communications skills, confidentiality, sensitivity, and empathy), history taking and clinical examination, diagnostic steps and mis-steps, and finally learning points (or take-home messages).

CONCLUSION

Television programs, purported to "rot the mind," can actually be put to good use in the teaching of "soft skills" in medicine.

Overcoming preconceptions and perceived barriers to medical communication using a 'dual role-play' training course

BACKGROUND

Communication is a core component of clinical competence. We introduced a dual role-play (DRP) course, in which participants role-played both the doctor-candidate and the standardized patient. The aim of the study was to assess the usefulness of a DRP communication course for physicians and to identify factors that inhibit effective medical communication.

METHODS

We conducted four medical communication skills courses from 2004 to 2006. A questionnaire was administered before and after completion of each course. We assessed respondents' confidence levels before and after the course and sought to identify perceived barriers to effective communication among medical trainees in Singapore. Finally, we asked if they found participation in the course and its DRP nature to be useful.

RESULTS

Twenty-six participants, 20 men, 6 women, of mean age 30.2 years (standard deviation (SD) 2.01) completed the survey. The pre-course confidence levels (rated on a scale of 1-10) of 6.23 (SD 1.18) rose significantly to 7.58 (SD 0.95) on completion of the course (P = 0.001, Wilcoxon signed rank test). All respondents felt that they had benefited from participation in the medical communication skills course. 24 (92.3%) respondents deemed it useful to have role-played both the doctor and standardized patient in the exercise. We identified respondents with language difficulties to have benefited the most from the course (P = 0.031, odds ratio 2.906 (95%CI 0.292-5.519), linear regression analysis).

CONCLUSION

DRP is an effective way to train doctors in medical communication.

Botulinum toxin: description of injection techniques and examination of controversies surrounding toxin diffusion

The benefits derived from botulinum toxin (BTX) injections may be negated by unintentional weakness of adjacent uninjected muscles. Such weakness may be the result of inaccurate targeting, or diffusion of BTX to surrounding muscles. Several techniques, using electromyographic, endoscopic or imaging guidance are purported to increase the accuracy of targeting. Diffusion of BTX is thought to be influenced by factors such as dose, concentration, injectate volume, number of injections, site and rate of injection, needle gauge, muscle size, muscular fascia, distance of needle tip from the neuromuscular junction, and protein content of the BTX formulation. This article describes techniques that aim to increase the accuracy of BTX injections and examines the controversies surrounding diffusion of BTX following injection.

Botulinum toxin, Quo Vadis?

Botulinum toxin (BTX), derived from the exotoxin of Clostridium botulinum, cleaves Soluble N-ethylmaleimide-sensitive factor-Attachment protein REceptor (SNARE) proteins, causing chemodenervation of cholinergic neurons. BTX also inhibits exocytosis of vesicles containing norepinephrine, glutamate, substance P and calcitonin gene-related peptide (CGRP) and inhibits expression of the vanilloid receptor. Clinical applications of BTX, which include the treatment of overactive skeletal and smooth muscles, hypersecretory and painful disorders, have increased exponentially since it was first used clinically to treat strabismus more than two decades ago. In this editorial, we discuss reports of new therapeutic indications of BTX, and propose new areas for research.

Segmental dystonia following electrocution in childhood

Electrical injuries to the extremities may result in a range of neurologic manifestations, which include movement disorders such as parkinsonism, segmental myoclonus, choreoathetosis, tremors and dystonia. A 66-year-old man developed segmental dystonia of the right upper extremity at the age of nine, three years after he accidentally held a live 240-V electrical wire in his right hand. MRI brain and cervical cord were normal. We discuss this unusual cause of secondary dystonia and review the literature.

Can botulinum toxin put the restless legs syndrome to rest?

The restless legs syndrome (RLS), affecting between 3% and 15% of the population, is characterised by an urge to move the legs during wakefulness, associated with a range of unpleasant sensory symptoms, especially when sitting or lying down at night. The symptoms can even be painful, and lead to sleep disturbances and depression. RLS is treated with dopaminergic agents, anticonvulsants, opioids, clonidine and benzodiazepines. In a small percentage of cases, RLS is refractory to treatment, requiring combination therapy. Botulinum toxin (BTX), derived from the exotoxin of Clostridium botulinum, cleaves soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) proteins, causing chemodenervation of cholinergic neurons. BTX has been demonstrated to ameliorate pain syndromes, possibly by reducing peripheral and central sensitization to pain. We postulate that BTX can be injected subcutaneously to the lower limbs to effect amelioration of the symptoms of RLS.

Attitudes of medical students to placebo therapy

BACKGROUND

Studies have described opposing perceptions of placebo use, with laypersons for and health-care workers against it. Opinions of medical students have not previously been elicited. This study was based on online electronic survey on beliefs, knowledge and attitudes about placebo therapy, that is, use of placebo in clinical practice, rather than in randomized controlled clinical trials.

METHODS

The participants were preclinical (years 1, 2) and clinical (years 3-5) medical students. Descriptive analyses and chi2 tests were used to compare the opinions of preclinical and clinical students with statistical significance set at P < 0.05.

RESULTS

Four hundred and two (35.6%) out of 1153 students responded, of which 181 were preclinical and 221 were clinical students. Two hundred and eighty-five (70.9%) students felt that placebo therapy was acceptable and 134 (33.3%) believed that it was beneficial in organic disease. Fifty-two (12.9%) students felt that it was ethical to prescribe placebo for organic disease with known definitive treatment, 259 (64.4%) for organic disease with no known treatment and 328 (81.6%) for psychogenic disease. More preclinical than clinical students approved of placebo therapy (odds ratio 2.140 (95% confidence interval 1.161-3.944), P = 0.015) and opined that it was ethical to prescribe placebo therapy to organic diseases for which there was appropriate treatment (odds ratio 1.800 (95% confidence interval 0.992-3.266), P = 0.053). A greater number of clinical when compared with preclinical students said that there is evidence that placebo therapy has a beneficial effect on organic disease (odds ratio 2.299 (95% confidence interval 1.468-4.405), P < 0.001).

CONCLUSION

Our medical students felt that placebo therapy is acceptable in certain situations. We identified their erroneous acceptance of placebo therapy in organic diseases, for which there is established treatment, as an area to be addressed in our undergraduate curriculum.

Take a bao if you are not superstitious

INTRODUCTION

Singaporeans are superstitious, and medical staff are no exception to the rule. We conducted a survey to determine the prevalence of superstitious beliefs and practices amongst doctors, nurses and medical students in Singapore.

METHODS

Internet and face-to-face surveys of 68 respondents, all of whom completed the survey after being threatened with curses and hexes.

RESULTS

Sixty-eight doctors, nurses and medical students responded to our survey. Only 11 admitted to being superstitious, yet 31 believed in the ill-fortune associated with eating bao or meat dumplings, 6 in the nefarious powers of black (5) or red (1) outfits on call, and 14 believed that bathing (6 insisting on the powers of the seven-flower bath) prior to the onset of a call portended good fortune, in terms of busy-ness of a call. Twenty-four believed in "black clouds", i.e. people who attracted bad luck whilst on call, and 32 refused to mouth the words "having a good call" until the day after the event. We discovered 2 hitherto undescribed and undiscovered superstitions, namely the benefits of eating bread and the need to avoid beef, for the good and ill fortune associated with their ingestion.

DISCUSSION

Superstitious practices are alive and well in modern-day Singapore, the practice not necessarily being restricted to the poorly-educated or foolish.

Is there a place for placebo in management of psychogenic movement disorders?

INTRODUCTION

The management of psychogenic movement disorders is fraught with difficulties. Empathy and a non-judgmental manner are essential in dealing with patients, and a neurobiological explanation of the symptoms may help to foster trust, acceptance, understanding and recovery.

CLINICAL PICTURE

We report a 17-year-old Chinese girl with psychogenic blepharospasm. Her parents refused psychotherapy and pharmacotherapy.

TREATMENT AND OUTCOME

Placebo therapy (with parental consent) was prescribed with favourable results.

CONCLUSION

We examine the ethical considerations for and against placebo therapy, and explore the role of placebo therapy in the management of psychogenic movement disorders.