Simultaneous cardio-cerebral infarction: a meta-analysis

BACKGROUND/INTRODUCTION

Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse.

AIM

We aimed to summarize the reported cardio-cerebral infarction cases in the literature.

DESIGN

Meta-analysis.

METHODS

Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors.

RESULTS

A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported.

DISCUSSION/CONCLUSION

The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.

Abstract TP177: Lipid Paradox In Acute Ischemic Stroke: Study Of Lipid Parameters On Outcomes After Intravenous Thrombolysis

Background: Contradicting evidence exists regarding the role of lipids in intravenous (IV) thrombolysis with tissue plasminogen activator (tPA), with some studies suggesting low lipid levels are paradoxically associated with poorer post-thrombolysis outcomes.

Methods: Restricted cubic spline regression, multivariable-adjusted logistic regression and risk score models evaluated associations of five lipid parameters with poor functional outcome (90-day modified Rankin Scale >2), symptomatic intracranial hemorrhage (SICH), and mortality among 1004 acute ischemic stroke (AIS) patients who received IV tPA in a comprehensive stroke center.

Results: There was a U-shaped relationship of low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) with all three outcomes using spline regression. Quartile (Q) 2 and Q4 of non-HDL-C were associated with increased odds of SICH (OR 4.2, 95% CI 1.2-15.0, p=0.026 and OR 5.1, 95% CI 1.4-18.2, p=0.011) compared to Q3. Similar quartile associations were found for total cholesterol (TC), and for LDL-C/HDL-C ratio with poor functional outcome. Q1 and Q2 of HDL-C were associated with increased odds of poor functional outcome (OR 1.6, 95% CI 1.0-2.5, p=0.043 and OR 1.6, 95% CI 1.0-2.4, p=0.042) compared to Q4. Only Q3 of LDL-C/HDL-C ratio was associated with increased odds of large-artery atherosclerotic stroke (OR 1.9, 95% CI 1.0-3.7, p=0.039) compared to Q1.

Conclusion: In AIS patients who received IV tPA, a U-shaped relationship was found between non-HDL-C and SICH. Low LDL-C was associated with increased odds of mortality, while HDL-C may be protective against poor functional outcome.

Abstract TP198: FIB-4 Index And Acute Ischemic Stroke Outcomes After Intravenous Thrombolysis

Introduction: It could be theorised that liver fibrosis and acute ischemic stroke (AIS) are related by inflammatory changes, but few studied this link, let alone in patients receiving intravenous thrombolysis (IVT). The Fibrosis (FIB)-4 index is an established rapid score to detect liver fibrosis. We aimed to understand the role of FIB-4 in predicting AIS subtype, severity and outcomes after IVT.

Methods: AIS patients receiving IVT without severe liver derangement from 2006 to 2018 at a stroke centre were studied. Stroke subtype was defined using Trial of Org 10172 in Acute Stroke Treatment. Moderate and severe stroke was defined as National Institutes of Health Stroke Scale (NIHSS) ≥10. FIB-4 index was stratified into no advanced fibrosis (FIB-4 <1.45) and advanced fibrosis (FIB-4 >3.25). The primary outcome - functional outcome at 90-days using the modified Rankin Scale (mRS) - was analysed by ordinal shift analysis. Multivariable adjusted logistic regression evaluated associations of FIB-4 with stroke severity, functional independence (90-day mRS 0-2 vs 3-6), 90-day mortality, and symptomatic intracranial hemorrhage (SICH).

Results: Among 900 patients, higher median FIB-4 was seen in cardioembolic stroke (CES) than non-CES (1.93 [IQR: 1.39-2.81] vs 1.27 [IQR: 0.92-1.90], p<0.001). On multivariate analysis, higher FIB-4 predicted moderate and severe stroke (OR: 1.33, 95% CI: 1.08-1.68, p=0.012). On ordinal shift analysis, advanced fibrosis was associated with an unfavourable shift in 90-day mRS compared to no advanced fibrosis (OR: 1.75, 95% CI: 1.06-2.89, p=0.028). Advanced fibrosis was also associated with increased mortality (OR: 3.07, 95% CI: 1.47-6.48, p=0.003) and SICH (OR: 3.65, 95% CI: 1.21-11.17, p=0.022), but not functional independence (OR: 0.80, 95% CI: 0.40-1.55, p=0.512).

Conclusion: Liver fibrosis was associated with higher rates of CES, more severe AIS, and poorer outcomes after IVT. This is a novel marker that could prognosticate IVT use in AIS.

Abstract TP208: Prevalence Of Adverse Cerebrovascular Events In Hypertrophic Cardiomyopathy Patients With And Without Atrial Fibrillation: A Systematic Review And Meta-analysis

Introduction: Hypertrophic cardiomyopathy (HCM) predisposes to adverse cerebrovascular events (ACEs) including ischaemic stroke, transient ischaemic attack (TIA), thromboembolic event (TEE) and peripheral embolism (PE). Concomitant atrial fibrillation (AF), which is more prevalent in the HCM population, confers even higher risk. Our aims are to report the prevalence of ACEs in HCM patients and to determine the additional clinical risks of AF on the prognosis of this population.

Methods: A systematic literature search was performed on PubMed, Scopus, Embase/ Ovid and Cochrane library from inception to 20 th March 2021. No limitations on language or date of publication were applied. The primary outcome of this review was to examine and compare the prevalence of ischaemic stroke in the HCM population with or without AF. Secondary outcomes were to identify their risk of non-stroke clinical outcomes such as TIA, non-specified TEE and PE. Non-specified TEE in our paper only referred to thromboembolic events whereby their types were not specified in the included studies. Meta-analysis was performed using StataSE 16 software, and heterogeneity was assessed using I 2 test.

Results: A total of 713 studies were identified, and 35 articles with 42,570 patients were included. The pooled prevalence of stroke/ TIA was 7.45% (95% confidence interval [CI] 5.80 - 9.52, p = 0.000) across 24 studies in the overall HCM population of 37,643 patients. AF contributed to a significantly higher risk of non-specified TEE (Risk ratio [RR] 4.49, 95% CI 1.88 - 10.73, p = 0.0007, I 2 = 87.0) and total stroke/ TIA (RR 3.26, 95% CI 1.75 - 6.08, p = 0.0002, I 2 = 76.0) in our study population. Within the apical HCM (ApHCM) population, the prevalence of stroke/ TIA was 9.30% (95% CI 6.64 - 12.87, p = 0.316).

Conclusion: Our study concludes that concomitant AF diagnosis increases the risk of developing thromboembolic events and the stroke-related mortality rate. Although the prevalence of stroke/ TIA in the ApHCM subtype was slightly higher than the overall HCM population, further studies investigating the clinical outcomes of HCM subtypes are warranted.

Abstract P108: Impact of the Covid-19 Pandemic on Hyperacute Stroke Treatment: Experience From a Comprehensive Stroke Centre in Singapore

Background: The Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and affecting healthcare systems across the world. Singapore has escalated its alert level to Disease Outbreak Response System Condition (DORSCON) Orange, signifying severe disease with community spread.

Objectives: We aimed to study the overall volume of AIS cases and the delivery of hyperacute stroke services during DORSCON Orange.

Methods: This was a single-centre, observational cohort study performed at a comprehensive stroke centre responsible for AIS cases in the western region of Singapore, as well as providing care for COVID-19 patients. All AIS patients reviewed as an acute stroke activation in the Emergency Department (ED) from November 2019 to April 2020 were included. System processes timings, treatment and clinical outcome variables were collected.

Results: We studied 350 AIS activation patients admitted through the ED, 206 (58.9%) pre- and 144 during DORSCON Orange. Across the study period, number of stroke activations showed significant decline (p =0.004, 95% CI 6.513 - -2.287), as the number of COVID-19 cases increased exponentially, whilst proportion of activations receiving acute recanalization therapy remained stable ( p = 0.519, 95% CI -1.605 - 2.702). Amongst AIS patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 hours (-4 versus -4, p = 0.685) were largely similar between the pre- and during DORSCON orange periods.

Conclusions: The number of stroke activations decreased while the proportion receiving acute recanalization therapy remained stable in the current COVID-19 pandemic in Singapore.

Abstract P89: Covid-19 and Ischemic Stroke: A Systematic Review and Meta-Summary of the Literature

Background: Acute ischemic stroke (AIS) is a life-threatening complication of coronavirus disease 2019 (COVID-19) infection. Increasing reports suggest an association between COVID-19 and AIS, although the underlying mechanism remains uncertain.

Objectives: We performed a systematic review to characterize the clinical characteristics, neuroimaging findings, and outcomes of AIS in COVID-19 patients.

Methods: A literature search was performed in PubMed and Embase using a suitable keyword search strategy from 1st December 2019 to 29th May 2020. All studies reporting AIS occurrence in COVID-19 patients were included.

Results: A total of 39 studies comprising 135 patients were studied. The pooled incidence of AIS in COVID-19 patients from observational studies was 1.2% (54/4466) with a mean age of 63.4 ± 13.1 years. The mean duration of AIS from COVID-19 symptoms onset was 10 ± 8 days, and the mean NIHSS score was 19 ± 8. Laboratory investigations revealed an elevated mean D-dimer (9.2 ± 14.8 mg/L) and fibrinogen (5.8 ± 2.0 g/L). Antiphospholipid antibodies were detected in a significant number of cases. The majority of AIS neuroimaging patterns observed was large vessel thrombosis, embolism or stenosis (62.1%, 64/103), followed by multiple vascular territory (26.2%, 27/103). A high mortality rate was reported (38.0%, 49/129).

Conclusion: We report the pooled incidence of AIS in COVID-19 patients to be 1.2%, with a high mortality rate. Elevated D-dimer, fibrinogen and the presence of antiphospholipid antibodies appear to be prominent in COVID-19 patients with concomitant AIS, but further mechanistic studies are required to elucidate their role in pathogenesis.

Abstract P528: Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy a Meta-Analysis

Introduction and hypothesis: In patients with acute ischemic stroke with large vessel occlusion (AIS-LVO), the role of intra-arterial adjunctive medications (IAM) like urokinase, tPA or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We hypothesize that AIS-LVO patients treated with both MT + IAM (rescue or concurrent) achieve better safety and efficacy outcomes than patients treated with MT alone and aim to determine the efficacy and safety of concomitant or rescue IAM for AIS-LVO patients undergoing MT.

Methods: We searched Medline, Embase and Cochrane Stroke Group Trials Register databases from inception until 13th March 2020. We analysed all studies with patients diagnosed with AIS-LVO in the anterior or posterior circulation, that provided data for the two treatment arms: 1)MT+IAM and 2)MT-only, and also reported on at least one of the following outcomes: reperfusion, 90-days modified Rankin Scale (mRS), symptomatic intracranial hemorrhage (sICH) and 90-days mortality. Data were collated in accordance with the PRISMA guidelines.

Results: Sixteen non-randomized observational studies with a total of 4581 patients were analysed. MT-only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT+IAM. As compared to patients treated with MT alone, patients treated with combination therapy (MT +IAM) had a higher likelihood of achieving good functional outcome (risk ratio=1.13, 95% CI 1.03-1.24) and a lower risk of 90-day mortality (risk ratio=0.82, 95% CI 0.72-0.94). There was no significant difference in successful reperfusion (risk ratio=1.02, 95% CI 0.99-1.06) and sICH between the two groups (risk ratio = 1.13, 95% CI 0.87-1.46) (Figure 1).

Conclusions: In AIS-LVO, use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to confirm the safety and efficacy of IAM as adjunctive treatment of MT.

Navitoclax enhances the effectiveness of EGFR-targeted antibody-drug conjugates in PDX models of EGFR-expressing triple-negative breast cancer

BACKGROUND

Targeted therapies for triple-negative breast cancer (TNBC) are limited; however, the epidermal growth factor receptor (EGFR) represents a potential target, as the majority of TNBC express EGFR. The purpose of these studies was to evaluate the effectiveness of two EGFR-targeted antibody-drug conjugates (ADC: ABT-414; ABBV-321) in combination with navitoclax, an antagonist of the anti-apoptotic BCL-2 and BCL-XL proteins, in order to assess the translational relevance of these combinations for TNBC.

METHODS

The pre-clinical efficacy of combined treatments was evaluated in multiple patient-derived xenograft (PDX) models of TNBC. Microscopy-based dynamic BH3 profiling (DBP) was used to assess mitochondrial apoptotic signaling induced by navitoclax and/or ADC treatments, and the expression of EGFR and BCL-2/XL was analyzed in 46 triple-negative patient tumors.

RESULTS

Treatment with navitoclax plus ABT-414 caused a significant reduction in tumor growth in five of seven PDXs and significant tumor regression in the highest EGFR-expressing PDX. Navitoclax plus ABBV-321, an EGFR-targeted ADC that displays more effective wild-type EGFR-targeting, elicited more significant tumor growth inhibition and regressions in the two highest EGFR-expressing models evaluated. The level of mitochondrial apoptotic signaling induced by single or combined drug treatments, as measured by DBP, correlated with the treatment responses observed in vivo. Lastly, the majority of triple-negative patient tumors were found to express EGFR and co-express BCL-XL and/or BCL-2.

CONCLUSIONS

The dramatic tumor regressions achieved using combined agents in pre-clinical TNBC models underscore the abilities of BCL-2/XL antagonists to enhance the effectiveness of EGFR-targeted ADCs and highlight the clinical potential for usage of such targeted ADCs to alleviate toxicities associated with combinations of BCL-2/XL inhibitors and systemic chemotherapies.

[Reduction of FXIII during myelosuppression in acute leukemia after chemotherapy and adverse relation with bleeding events]

目的

探讨急性白血病患者化疗后骨髓抑制期外周血凝血因子XIII（FXIII）浓度与出血事件的关系。

方法

纳入2017年8月至2018年3月期间55例PLT<50×10⁹/L的化疗后骨髓抑制期急性白血病患者（非急性早幼粒细胞性急性髓系白血病35例，急性淋巴细胞白血病20例），以35例非血液疾病患者作为对照组。用ELISA方法检测外周血FXIII浓度，分析急性白血病患者化疗后骨髓抑制期外周血FXIII水平与出血事件的关系。

结果

急性白血病患者化疗后骨髓抑制期FXIII水平明显低于对照组（P<0.001），FXIII水平与出血评分呈负相关（Spearman相关系数为-0.761）。当FXIII浓度的临界值为103.9 µg/L时，诊断化疗后骨髓抑制期急性白血病患者出血的敏感性为0.939，特异性为0.909。

结论

化疗后骨髓抑制期急性白血病患者外周血FXIII水平减低，且与出血事件及严重程度呈负相关，是急性白血病化疗后骨髓抑制期患者出血的独立影响因素之一。

Abstract P3-11-06: Pre-clinical assessment of combined ABT-263/Navitoclax and ABT-414 or ABBV-321 treatment for EGFR-expressing TNBC

Despite a notable incidence of EGFR1 copy number alterations and/or enrichment of EGFR protein in a significant fraction of TNBCs, clinical application of classical EGFR-targeted therapeutics has been discouraging. Tumor specific EGFR-targeted antibodies (ABT-806) and their antibody-drug conjugates (ADC:414;321), which eliminate side effects associated with systemic anti-EGFR treatments, represent promising alternative therapeutic approaches. 414, comprised of 806 conjugated to the powerful cytotoxic MMAF, has demonstrated notable effectiveness within EGFR1-amplified/mutated tumors. However, since TNBCs are often enriched for EGFR expression in the absence of EGFR1 amplification or mutation, we explored whether neutralization of BCL-2/XL via ABT-263/Navitoclax would enhance the effectiveness of 414. Here, we evaluated 414+263 in a panel of seven EGFR-expressing patient-derived xenograft (PDX) models of TNBC. Tumor-bearing mice were randomized into one of two groups, either 414+263 or placebos. Tumor volumes were calculated via caliper-based measurements pre- and post-treatment. 14 days post-treatment, tumor growth inhibition was observed in five out of seven combination-treated tumor models; however, consistent tumor regressions were only observed in one of these models (HCI-010). Compared to the other PDX models, HCI-010 tumors were distinguished by EGFR1 low polysomy and the highest EGFR expression levels. To further explore combined treatment within HCI-010, we evaluated single-agents. To determine EGFR relevance, we also included a non-tumor targeted ADC (095-MMAF) as a single agent or in combination with 263. Tumor growth inhibition & regressions were observed in either 263 or 414+263 treated tumors. These responses were most significant under combined treatment conditions (avg. regression=40%). Tumor growth was unaffected by 414 or 095-MMAF single agents. Tumors treated with 095-MMAF+263 were comparable to single agent 263. Based upon these results, we considered an alternative EGFR-targeted ADC (321). 321, comprised of an affinity-matured version of 806 conjugated to the powerful cytotoxic PBD, exhibits enhanced EGFR affinities and has demonstrated notable effectiveness within EGFR-overexpressing tumors. To evaluate 321 combined treatment within HCI-010, tumor-bearing mice were randomized into six groups: placebos; 263; 321; 263+321; 095-PBD; 263+095-PBD. Tumor growth inhibition & tumor regressions were maintained under 263 and, unlike 414, also observed under 321 treatments. 321 resulted in dramatic tumor regressions (avg. regression=66%). Notably, 263 enhanced the effectiveness of 321 as evidenced by even more dramatic and near complete tumor regressions (avg. regression=88%). We extended these studies to include HCI-025, an additional PDX characterized by EGFR1 low polysomy and EGFR expression levels comparable to HCI-010. To evaluate 321 combined treatment within HCI-025; we performed a similar six-group study. HCI-025 tumors were also sensitive to single agent 321 (avg. regression=36%). Similar to HCI-010 and as evidenced by dramatic tumor regressions, 263 also enhanced the effectiveness of 321 within HCI-025 (avg. regression=68%). 095-PBD and 263+095-PBD also resulted in HCI-010 and HCI-025 tumor growth inhibition & regressions; however supportive of EGFR-mediated effects, 321 responses were greater than 095-PBD and 263+321 responses were greater than 263+095-PBD. These results underscore the significant potential of BCL-2/XL-inhibitors to enhance the effectiveness of cytotoxic agents delivered via ADCs. Notably, this strategy avoids the toxicities associated with systemic chemotherapy and BCL-2/XL-inhibitors. These results also highlight the translational relevance of 321+263, within the context of EGFR-expressing TNBC.

Citation Format: Jason J Zoeller, Aleksandr Vagodny, Veerle W. Daniels, Krishan Taneja, Benjamin Y. Tan, Yoko S. DeRose, Maihi Fujita, Alana L. Welm, Anthony Letai, Joel D. Leverson, Vincent Blot, Roderick T. Bronson, Deborah A. Dillon, Joan S. Brugge. Pre-clinical assessment of combined ABT-263/Navitoclax and ABT-414 or ABBV-321 treatment for EGFR-expressing TNBC [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-11-06.

Abstract WP80: Thrombus Imaging Characteristics and Association With Functional Outcomes in Patients Undergoing Endovascular Treatment

Background: Intracranial thrombus characteristics on computed tomography angiography (CTA) in patients undergoing endovascular therapy (ET) for anterior circulation large vessel occlusion (LVO) acute ischemic stroke (AIS) has been shown to be useful in prognosticating functional outcomes. We establish if thrombus characteristics on non-contrast computed tomography (CT) scans and CTA were associated with clinical outcomes.

Methods: We included 257 patients with anterior circulation LVO AIS from our Hyper-Acute Stroke Thrombolysis and Endovascular (HASTEN) registry treated at our tertiary academic institution from 2014-2018. We evaluated associations of patient’s characteristics and thrombus imaging characteristics with patients’ functional outcomes, scored with the modified Rankin Scale (MRS) at 3 months. Imaging characteristics were assessed on CT and CTA. Patient characteristics included age, presence of co-morbidities, initial NIHSS and ASPECTS. Thrombus characteristics included presence of hyperdense middle cerebral artery (MCA) sign, CT dense MCA length, CTA location and length of thrombus, CTA clot burden score (CBS) and recanalization status (mTICI). A good functional outcome was defined as patients who achieved an MRS of 0-2 at 3 months.

Results: Patient characteristics associated with good functional outcomes were younger age, absence of diabetes mellitus, lower NIHSS, higher ASPECTS and successful recanalization measured by a mTICI 2b/3 (Table 1). Thrombus characteristics associated with good functional outcomes were a shorter CT dense MCA length and a higher CTA CBS (Table 1). Of note, presence of a hyperdense MCA sign on CT and CTA thrombus length were not significantly associated with good functional outcomes.

Conclusions: In patients with anterior circulation LVO AIS, a shorter CT dense MCA length and a higher CTA CBS were associated with good functional outcomes, and may aid in improving patient selection.

Abstract WP13: Left Ventricular Systolic Dysfunction is Associated With Poor Functional Outcomes and Mortality After Endovascular Thrombectomy for Acute Ischemic Stroke

Background: Endovascular thrombectomy (ET) has transformed acute ischaemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD as measured by LVEF, and clinical outcomes in patients with anterior cerebral circulation LVO who undergo ET.

Methods: This retrospective study examined patients from our AIS endovascular thrombectomy registry from 2013-2018. We included all consecutive patients who had anterior circulation LVO (ICA, M1, M2) who underwent ET, and had transthoracic two-dimensional echocardiography. LVSD was measured by assessment of the LVEF using Simpson’s biplane method of discs according to American Society of Echocardiography guidelines. LVSD was defined as a reduced LVEF of <50%. Primary outcome was defined as good functional outcome using a modified Rankin Scale (mRS) of 0-2 at 3-months.

Results: Of 254 AIS patients with anterior circulation LVO, we included 229 patients with complete echocardiography assessment. On multivariate analyses, older age, diabetes mellitus, lower ASPECTS, unsuccessful recanalization, smaller LV outflow tract diameter and LVSD were significantly associated with poor functional outcomes (Table 1). On ordinal (shift) analyses, LVSD was associated with an unfavourable shift in the mRS outcomes (OR 3.09, 95% CI 1.68 - 5.69, p < 0.001) after adjusting for age and ischemic heart disease (Figure).

Conclusion: Anterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to tailor peri-procedural management strategies.

Abstract 25: Left Atrial Volume Index is Associated With Atrial Fibrillation and Recurrent Stroke in Embolic Stroke of Undetermined Source (ESUS)

In ESUS, the relationship between atrial cardiopathy, occult AF and embolic stroke risk remains unclear. Studies suggest that left atrial volume index (LAVi) may be a better estimate of atrial cardiopathy than LA diameter. We explored LAVi as a marker of occult AF detection and ischemic stroke recurrence.

Methods: From 2015-2017, consecutive ESUS patients diagnosed based on consensus criteria were studied. LAVi was measured using the Biplane Area-Length Method on TTE by trained cardiologists. Clinical outcomes measured were occult AF detection and ischemic stroke recurrence in a time-to-event analysis. Kaplan-Meier curves were constructed to compare outcomes in those with high versus low LAVi at optimized cut-off values.

Results: 199 consecutive ESUS patients were followed up for 2.2±1.0 years. 9 patients were excluded due to technically inadequate views. Increased LAVi was associated with AF detection (36.63mL/m 2 ± 12.2 vs 26.93mL/m 2 ± 9.6) and stroke recurrence (32.13mL/m 2 ± 9.3 vs 27.23mL/m 2 ± 10.1). On multivariate regression adjusting for age, sex, hypertension and diabetes mellitus, LAVI was independently associated with AF detection (OR 1.08, CI 95% 1.03-1.14; p=0.003) and stroke recurrence (OR 1.05, CI 95% 1.01-1.10; p=0.026). Kaplan-Meier curves showed significant differences in occult AF (log-rank 8.67, p=0.003) and stroke recurrence (log-rank 5.31, p=0.021) between high (>27.7ml/m 2 ) and low LAVi (≤27.7ml/m 2 ) groups.

Conclusion: Increased LAVi in ESUS patients was associated with AF detection and stroke recurrence, suggesting that this may be a useful echocardiographic marker to identify high-risk patients who may potentially benefit from anticoagulation.

Abstract TP211: Long-Term Trends in Ischemic Stroke Risk Factors and Outcomes in a Multiethnic Population

Introduction: Stroke medicine has evolved over time, with changing demographics and improving outcomes. We aimed to evaluate trends in incidence, risk factors, treatment and case fatality of acute ischemic stroke (AIS) in a multiethnic population.

Methods: Data was obtained from the Singapore Stroke Registry. 60,325 AIS cases that presented to Singapore’s public hospitals from 2005-16 were studied. Trends were analyzed with Poisson regression, logistic regression and Cox regression.

Results: The AIS age-standardized incidence rate has decreased by 11.6% (126.5 to 111.8 per 100,000 person-years from 2005-07 to 2014-16, p < 0.001). This was observed in all gender and ethnic groups except in those younger than 65, which saw a 2.5% increase (51.0 to 52.4 per 100,000 person-years, p = 0.017). In terms of risk factors, hypertension, hyperlipidemia, and atrial fibrillation have increased in prevalence, while history of stroke, ischemic heart disease, diabetes, and smoking have decreased (Figure A). Treatment-wise, thrombolysis utilization rates have increased significantly from 0.8% in 2005-2007 to 6.7% in 2014-2016 (p < 0.001). While atrial fibrillation (AF) has become more prevalent (15.8% to 25.2%, p < 0.001), anticoagulant prescription has not increased by the same magnitude (13.2% to 14.4%, p = 0.014). Case fatality has reduced by 25.6% (8.2% to 6.1%, p < 0.001).

Conclusion: In a multi-ethnic population, whilst we found that AIS age-standardized incidence rate has been declining, we demonstrate a temporal trend of changing risk factors. Further research is needed to investigate the causes and implications of these trends, so as to better strategize prevention efforts.

Neutralization of BCL-2/XL Enhances the Cytotoxicity of T-DM1 In Vivo

One of the most recent advances in the treatment of HER2+ breast cancer is the development of the antibody-drug conjugate, T-DM1. T-DM1 has proven clinical benefits for patients with advanced and/or metastatic breast cancer who have progressed on prior HER2-targeted therapies. However, T-DM1 resistance ultimately occurs and represents a major obstacle in the effective treatment of this disease. Because anti-apoptotic BCL-2 family proteins can affect the threshold for induction of apoptosis and thus limit the effectiveness of the chemotherapeutic payload, we examined whether inhibition of BCL-2/XL would enhance the efficacy of T-DM1 in five HER2-expressing patient-derived breast cancer xenograft models. Inhibition of BCL-2/XL via navitoclax/ABT-263 significantly enhanced the cytotoxicity of T-DM1 in two of three models derived from advanced and treatment-exposed metastatic breast tumors. No additive effects of combined treatment were observed in the third metastatic tumor model, which was highly sensitive to T-DM1, as well as a primary treatment-exposed tumor, which was refractory to T-DM1. A fifth model, derived from a treatment naïve primary breast tumor, was sensitive to T-DM1 but markedly benefited from combination treatment. Notably, both PDXs that were highly responsive to the combination therapy expressed low HER2 protein levels and lacked ERBB2 amplification, suggesting that BCL-2/XL inhibition can enhance sensitivity of tumors with low HER2 expression. Toxicities associated with combined treatments were significantly ameliorated with intermittent ABT-263 dosing. Taken together, these studies provide evidence that T-DM1 cytotoxicity could be significantly enhanced via BCL-2/XL blockade and support clinical investigation of this combination beyond ERBB2-amplified and/or HER2-overexpressed tumors.

Psychosomatic symptoms during South East Asian haze crisis are related to changes in cerebral hemodynamics

OBJECTIVES

Forest fires in South Asia lead to widespread haze, where many healthy individuals develop psychosomatic symptoms. We investigated the effects of haze exposure on cerebral hemodynamics and new symptoms. We hypothesised that vasoactive substances present in the haze, would lead to vasodilation of cerebral vasculature, thereby altering cerebral hemodynamics, which in turn may account for new psychosomatic symptoms.

METHODS

Seventy-four healthy volunteers were recruited, and serial transcranial Doppler (TCD) ultrasonography was performed to record blood flow parameters of bilateral middle cerebral arteries (MCA). The first TCD was performed in an air-conditioned environment. It was repeated outdoors after the participants spent 30-minutes in the haze environment. The prevailing level of pollutant standards index (PSI) was recorded. Appropriate statistical analyses were performed to compare cerebral hemodynamics at baseline and after haze exposure in all participants. Subgroup analyses were then employed to compare the findings between symptomatic and asymptomatic participants.

RESULTS

Study participants' median age was 30 years (IQR 26-34), and new psychosomatic symptoms were reported by 35 (47.3%). There was a modest but significant decrease in pulsatility index (PI) and resistivity index (RI) in the left MCA after haze exposure (PI: p = 0.026; RI: p = 0.021). When compared to baseline parameters, haze exposure resulted in significantly lower mean PI (p = 0.001) and RI (p = 0.001) in symptomatic patients, but this difference was not present in asymptomatic patients (PI: p = 0.919; RI: p = 0.970).

CONCLUSION

Haze causes significant alterations in cerebral hemodynamics in susceptible individuals, probably responsible for various psychosomatic symptoms. The prognostic implications and health effects of haze require evaluation in a larger study.

Multi-Domains Lifestyle Interventions Reduces Depressive Symptoms among Frail and Pre-Frail Older Persons: Randomized Controlled Trial

BACKGROUND

We investigated the effect of multi-domain lifestyle (physical, nutritional, cognitive) interventions among frail and pre-frail community-living older persons on reducing depressive symptoms.

METHOD

Participants aged 65 and above were randomly allocated to 24 weeks duration interventions with nutritional supplementation (N=49), physical training (N=48), cognitive training (N=50), combination intervention (N=49) and usual care control (N=50). Depressive symptoms were assessed by the Geriatric Depression Scale (GDS-15) at baseline (0M), 3 month (3M), 6 month (6M) and 12 month (12M).

RESULTS

Mean GDS scores in the control group increased from 0.52 (0M) and 0.54 (3M) to 0.74 (6M), and 0.83 (12M). Compared to the control group, interventions showed significant differences (∆=change) at 6M for cognitive versus control (∆=-0.39, p=0.021, group*time interaction p=0.14); physical versus control (∆ =-0.37, p=0.026, group*time interaction p=0.13), and at 12M for nutrition versus control (∆ =-0.46, p=0.016, group*time interaction p=0.15). The effect for combination versus control was significant at 6M (∆ =-0.43, p=0.020) and 12M (∆ =-0.51, p=0.005, group*time interaction p=0.026). Estimated 12-month cumulative incidence of depressive symptoms (GDS≥2) relative to control were OR=0.38, p=0.037 (nutrition); OR=0.71, p=0.40 (cognitive); OR=0.39, p=0.042 (physical training) and OR=0.38, p=0.037 (combination). Changes in gait speed and energy level were significantly associated with changes in GDS scores over time.

CONCLUSION

Multi-domain interventions that reverse frailty among community-living older persons also reduce depressive symptomatology. Public health education and programmatic measures combining nutritional, physical and cognitive interventions for at-risk frail older people may likely benefit psychological wellbeing.

Phyllodes tumours of the breast: a consensus review

Phyllodes tumours constitute an uncommon but complex group of mammary fibroepithelial lesions. Accurate and reproducible grading of these tumours has long been challenging, owing to the need to assess multiple stratified histological parameters, which may be weighted differently by individual pathologists. Distinction of benign phyllodes tumours from cellular fibroadenomas is fraught with difficulty, due to overlapping microscopic features. Similarly, separation of the malignant phyllodes tumour from spindle cell metaplastic carcinoma and primary breast sarcoma can be problematic. Phyllodes tumours are treated by surgical excision. However, there is no consensus on the definition of an appropriate surgical margin to ensure completeness of excision and reduction of recurrence risk. Interpretive subjectivity, overlapping histological diagnostic criteria, suboptimal correlation between histological classification and clinical behaviour and the lack of robust molecular predictors of outcome make further investigation of the pathogenesis of these fascinating tumours a matter of active research. This review consolidates the current understanding of their pathobiology and clinical behaviour, and includes proposals for a rational approach to the classification and management of phyllodes tumours.

Phyllodes tumours of the breast: a consensus review

Phyllodes tumours constitute an uncommon but complex group of mammary fibroepithelial lesions. Accurate and reproducible grading of these tumours has long been challenging, owing to the need to assess multiple stratified histological parameters, which may be weighted differently by individual pathologists. Distinction of benign phyllodes tumours from cellular fibroadenomas is fraught with difficulty, due to overlapping microscopic features. Similarly, separation of the malignant phyllodes tumour from spindle cell metaplastic carcinoma and primary breast sarcoma can be problematic. Phyllodes tumours are treated by surgical excision. However, there is no consensus on the definition of an appropriate surgical margin to ensure completeness of excision and reduction of recurrence risk. Interpretive subjectivity, overlapping histological diagnostic criteria, suboptimal correlation between histological classification and clinical behaviour and the lack of robust molecular predictors of outcome make further investigation of the pathogenesis of these fascinating tumours a matter of active research. This review consolidates the current understanding of their pathobiology and clinical behaviour, and includes proposals for a rational approach to the classification and management of phyllodes tumours.

Stress fracture of the ulna associated with bisphosphonate therapy and use of walking aid

We report a case of a stress fracture of the ulna secondary to long-term bisphosphonate therapy and walking cane. Physicians need to have a high index of suspicion of stress fractures occurring in patients complaining of chronic upper limb pain if they are on bisphosphonate therapy and are using walking aids. Stress fractures of the upper extremities are rare and are usually associated with athletes; however, a few recent case reports have shown an association between stress fractures of the upper extremities and the use of walking aids. The association between increased incidence of upper extremity stress fractures and the use of both bisphosphonates and walking aids in patients has not been well studied, with only one previously reported case. Here, we report a case of a complete stress fracture of the ulna in a 77-year-old female, premorbidly ambulant with walking cane, on long-term bisphosphonates without any pre-existing medical conditions which could result in secondary causes of bone loss. Investigations did not reveal any causes of pathological fracture. This fracture is attributed to the use of long-term bisphosphonate therapy in conjunction with the use of a walking cane. This case highlights the importance of entertaining the possibility of such fractures occurring in any patient who is on bisphosphonate therapy presenting with stress fractures of the upper extremity.

Novel electrogram device with web-based service centre for ambulatory ECG monitoring

INTRODUCTION

Arrhythmias are often intermittent, and a normal electrocardiogram (ECG) may not be diagnostic. The purpose of this study was to evaluate the usefulness of HeartWave500 (HW), a novel web-based ambulatory ECG monitoring device.

METHODS

A total of 120 patients from the National Heart Centre, Singapore were prospectively randomised in a three to one ratio to either HW or a standard transtelephonic (TT) event recorder. HW records five leads and transmits to an internet server, while TT transmits audio data to a central station. Monitoring was conducted for two weeks. The diagnostic yield was calculated in two ways: the percentage of patients successfully diagnosed as a function of time, and the absolute number of new diagnoses per patient per week.

RESULTS

33 patients (14 male, 19 female; mean age 49.6 + or - 11.1 years) were randomised to TT. 87 patients (32 male, 55 female; mean age 43.7 + or - 12.2 years) were randomised to HW. At the end of two weeks, the percentage of patients diagnosed with any arrhythmia was similar for both groups (66.7 percent for TT versus 67.8 percent for HW). There was a trend toward significance for the number of diagnoses per patient per week for Week 2 between TT and HW (0.58 + or - 0.75 versus 0.34 + or - 0.55, p is 0.06). Transmitted ECGs were read earlier for HW (18 minutes versus 1107 minutes, Mann-Whitney non-parametric test, p is less than 0.05). Transmitted recordings that were unreadable were also significantly lower for HW (8.0 percent versus 17.6 percent, chi-square test, p is less than 0.05).

CONCLUSION

HW and TT have similar diagnostic yields. There is a trend toward a shorter monitoring time for HW. The ability of HW to record and transmit via the web, the earlier review of data and low unreadable data make HW an attractive alternative to TT.

Health Promotion Board-Ministry of Health clinical practice guidelines: functional screening for older adults in the community

The Health Promotion Board (HPB) and the Ministry of Health (MOH) publish clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HPB-MOH clinical practice guidelines on Functional Screening for Older Adults in the Community, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Health Promotion Board website (http://www.hpb.gov.sg/uploadedFiles/HPB_Online/Publications/CPGFunctionalscreening.pdf). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Myocardial infarction in Singapore: a nationwide 10-year study of multiethnic differences in incidence and mortality

INTRODUCTION AND METHODS

Cardiovascular diseases have progressively increased in importance as a major contributor of morbidity and mortality in Asia. However, many countries in Asia do not have nationwide systematically-collected and standardised data on myocardial infarction (MI). To accurately document the extent of atherosclerotic coronary heart disease in Singapore, a nationwide myocardial infarct registry was established in the mid-1986. Possible myocardial infarct events were identified through daily national lists of cardiac enzymes, hospital discharge codes, mortuary records and the national death registry. Data obtained from clinical history, cardiac enzymes and 12-lead electrocardiogram Minnesota codes were entered into an algorithm based on the WHO MONICA study. Cases identified as "definite" MI were included in the decade's review for this study.

RESULTS

From 1988 to 1997, 13,048 myocardial infarct events were diagnosed with 3367 deaths. There was a 39.1% decline in mortality, with an average decline of 6.5% per year [95% confidence intervals (CI), -3.9% to -9.1%]. However, the decline in incidence was only 20.8% with an average decline of 2.4% per year (95% CI, -6.6% to -1.2%). The highest incidence and mortality rates for both genders were seen in the Indians, followed by the Malays and the Chinese.

CONCLUSION

Over 10 years, from 1988 to 1997, we documented a significant fall in mortality from MI in Singapore. There was a smaller decline in the incidence of infarction. Singapore implemented a National Healthy Lifestyle Programme in 1992 as a 10-year effort. The disparity in the incidence and mortality may suggest that a more dramatic and immediate impact has taken place in mortality through therapeutic programmes; primary preventive programmes would be more difficult to evaluate and have a more gradual impact. Only with continual accurate data collection through the whole country, over a much longer period, can the relative value of preventive and therapeutic programmes in coronary heart disease be assessed.

A countrywide approach to the control of non-communicable diseases--the Singapore experience

INTRODUCTION

Many developed and developing countries are grappling with recent epidemics of non-communicable diseases and how to effectively control them. Singapore as a small, compact and highly urbanized country has similarly experienced a rapid increase in its chronic disease load and has adopted a national approach to control them.

METHODS

This paper traces the strategies taken in the 80s and the 90s to control non-communicable diseases and evaluates the effectiveness of the two approaches.

RESULTS

In the 80s, the control programme was largely a Ministry of Health responsibility using a persuasive approach to reach out to the target groups. This produced some results through the lowering of hypertension and cholesterol. For the 90s, the approach was one of leadership by government working with relevant agencies to reach out to all relevant sectors in the population. This National Healthy Lifestyle Programme was given top political support. The integrated and comprehensive approach used showed some improvements in health and gave the direction where efforts should be channelled.

CONCLUSION

The countrywide approach taken in Singapore for the control of non-communicable diseases illustrates a model where a national framework was adopted, harnessing health promotion and disease prevention and involving personal responsibility as a key success factor. This rides on a well-developed continuum of healthcare which aims to become an integrated and seamless one.

Risk factors and incident coronary heart disease in Chinese, Malay and Asian Indian males: the Singapore Cardiovascular Cohort Study

OBJECTIVE

This prospective study in Singapore investigated the relationships of established coronary risk factors with incident coronary heart disease (CHD) for Chinese, Malay, and Asian Indian males.

SUBJECTS

A cohort (consisting of 2879 males without diagnosed CHD) derived from three previous cross-sectional surveys.

METHODS

Individual baseline data were linked to registry databases to obtain the first event of CHD. Hazard ratios (HR) or relative risks for risk factors were calculated using Cox's proportional hazards model with adjustment for age and ethnic group and adjustment for age, ethnic group and all other risk factors (overall adjusted).

RESULTS

There were 24,986 person-years of follow-up. The overall adjusted HR with 95% CI are presented here. Asian Indians were at greatest risk of CHD, compared to Chinese (3.0; 2.0-4.8) and Malays (3.4; 1.9-3.3). Individuals with hypertension (2.4; 1.6-2.7) or diabetes (1.7; 1.1-2.7) showed a higher risk of CHD. High low density lipoprotein cholesterol (LDL-C) (1.5; 1.0-2.1), high fasting triglyceride (1.5; 0.9-2.6) and low high density lipoprotein cholesterol (HDL-C) (1.3; 0.9-2.0) showed a lesser but still increased risk. Alcohol intake was protective with non-drinkers having an increased risk of CHD (1.8; 1.0-3.3). Obesity (body mass index > or =30) showed an increased risk (1.8; 0.6-5.4). An increased risk of CHD was found in cigarette smokers of > or =20 pack years (1.5; 0.9-2.5) but not with lesser amounts.

CONCLUSIONS

The increased susceptibility of Asian Indian males to CHD has been confirmed in a longitudinal study. All of the examined established risk factors for CHD were found to play important but varying roles in the ethnic groups in Singapore.

Relationships between indices of obesity and its co-morbidities in multi-ethnic Singapore

OBJECTIVE

To investigate the effect of body mass index (BMI) and body fat distribution as measured by waist-to-hip ratio (WHR) on the cardiovascular risk factor profile of the three major ethnic groups in Singapore (Chinese, Malay and Indian people) and to determine if WHO recommended cut-off values for BMI and WHR are appropriate for the different sub-populations in Singapore.

DESIGN

Cross-sectional population study.

SUBJECTS

A total of 4723 adult subjects (64% Chinese individuals, 21% Malay individuals and 15% Indian individuals) were selected through a multi-staged sampling technique to take part in the National Health Survey in 1998.

MEASUREMENTS

Data on socio-economic status (education level, occupation, housing type) and lifestyle habits (smoking and physical activity), body weight, body height, waist and hip circumferences and blood pressure measured using standardised protocols. Fasting venous blood samples were obtained for determination of serum total cholesterol (TC), high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides (TG). Venous blood samples were taken for 2 h oral glucose tolerance test (2 h glu).

RESULTS

Absolute and relative risks for at least one cardiovascular risk factor (elevated TC, elevated TC/HDL ratio, elevated TG, hypertension and diabetes mellitus) were determined for various categories of BMI and WHR. At low categories of BMI (BMI between 22 and 24 kg/m(2)) and WHR (WHR between 0.80 and 0.85 for women, and between 0.90 and 0.95 for men), the absolute risks are high, ranging from 41 to 81%. At these same categories the relative risks are significantly higher compared to the reference category, ranging from odds ratio of 1.97 to 4.38. These categories of BMI and WHR are all below the cut-off values of BMI and WHR recommended by WHO.

CONCLUSIONS

The results show that, at relatively low BMI and WHR, Singaporean adults experience elevated levels of risks (absolute and relative) for cardiovascular risk factors. These findings, in addition to earlier reported high percentage body fat among Singaporeans at low levels of BMI, confirm the need to revise the WHO cut-off values for the various indices of obesity and fat distribution, viz BMI and WHR, in Singapore.

Diabetes mellitus abolishes ethnic differences in cardiovascular risk factors: lessons from a multi-ethnic population

AIMS

To compare cardiovascular risk factors in diabetic subjects of different ethnic groups, and between new and known diabetic subjects, in the Singapore National Health Survey '92.

METHODS

Disproportionate stratified sampling followed by systematic sampling were used in 3568 (total) respondents of whom 2743 were non-diabetics, 179 newly diagnosed diabetics and 150 known diabetics. Amongst the diabetics, there were 185 Chinese, 66 Malays and 78 Asian Indians. Diagnosis of diabetes mellitus (DM) was based on the 2 h glucose alone, after a 75 g oral glucose tolerance test. Blood pressure (BP), lipid profile, glucose, insulin and anthropometric indices were obtained from all subjects.

RESULTS

Subjects with diabetes (new and known) exhibited significantly higher triglyceride (TG), lower high density lipoprotein cholesterol (HDL-C) and low density lipoprotein (LDL)/apolipoprotein B (apo B) ratio (LDL size) compared with normoglycaemic subjects. They were more obese (generalised and central) and had higher systolic and diastolic BP. There was no difference in lipid risk factors between the two groups with diabetes although those with new diabetes were more obese whilst those with known diabetes had higher fasting glucose. Amongst subjects with diabetes, there were no significant differences between ethnic groups in TG, HDL-C, LDL/apo B ratio, or waist to hip ratio (WHR). Female Malays with diabetes had higher total cholesterol and were more obese whilst male Asian Indians with diabetes had higher fasting insulin.

CONCLUSION

Asian Indians had lower HDL-C and LDL/apo B ratio than Chinese or Malays amongst normoglycaemic subjects. However, these differences between ethnic groups were not seen in subjects with DM.

Levels of cardiovascular disease risk factors in Singapore following a national intervention programme

OBJECTIVE

To evaluate the impact of the National Healthy Lifestyle Programme, a noncommunicable disease intervention programme for major cardiovascular disease risk factors in Singapore, implemented in 1992.

METHODS

The evaluation was carried out in 1998 by the Singapore National Health Survey (NHS). The reference population was 2.2 million multiracial Singapore residents, 18-69 years of age. A population-based survey sample (n = 4723) was selected by disproportionate stratified and systematic sampling. Anthropometric and blood pressure measurements were carried out on all subjects and blood samples were taken for biochemical analysis.

FINDINGS

The 1998 results suggest that the National Healthy Lifestyle Programme significantly decreased regular smoking and increased regular exercise over 1992 levels and stabilized the prevalence of obesity and diabetes mellitus. However, the prevalence of high total blood cholesterol and hypertension increased. Ethnic differences in the prevalence of diabetes mellitus, hypertension, and smoking; and in lipid profile and exercise levels were also observed.

CONCLUSION

The intervention had mixed results after six years. Successful strategies have been continued and strengthened.

Screening for diabetes mellitus--a two-step approach in individuals with impaired fasting glucose improves detection of those at risk of complications

AIMS

To compare the new American Diabetes Association (ADA) fasting plasma glucose (FPG) criteria to the 1985 World Health Organization (WHO) 2-h post glucose (2hPG) criteria when used for screening of those with no prior history of diabetes mellitus.

METHODS

The study included 3,407 subjects without a history of diabetes in whom both FPG and 2hPG were available from the 1992 Singapore National Health Survey. The agreement (kappa) between FPG and 2hPG for the diagnosis of DM was assessed. The optimal cut-off of FPG for the detection of individuals with 2hPG > or = 11.1 mmol/l was determined by receiver-operating characteristics analysis.

RESULTS

The prevalence of diabetes diagnosed by FPG alone was 7.3% compared to 8.4% diagnosed by 2hPG. The prevalence of impaired fasting glucose was 8.0%. FPG and 2hPG showed moderate agreement (kappa = 0.646, 95% confidence interval 0.584-0.708). Age, ethnic group and obesity did not affect the degree of agreement. Of those with 2hPG > or = 11.1 mmol/l, 40.8% had FPG in the non-diabetic range while 24.8% of those with FG > or = 7.0 mmol/l had 2hPG in the non-diabetic range. The optimal FPG for the detection of 2hPG > or =11.1 mmol/l was 6.1 mmol/l. Oral glucose tolerance tests (OGTT) in those with 6.0 mmol/ < FPG < 7.0 mmol/l resulted in the diagnosis of diabetes in 90.7% of individuals at risk of microvascular complications.

CONCLUSIONS

FPG provides a simple screening test for diabetes, which shows moderate agreement with the 2hPG. A two-step strategy of OGTT in those with impaired fasting glucose improves the detection of at-risk individuals. However, diabetes should not be diagnosed on a single test. The test should be repeated on another day if an individual tests positive for diabetes.

Homeostasis model assessment in a population with mixed ethnicity: the 1992 Singapore National Health Survey

We studied insulin resistance and beta-cell function with reference to ethnic group, glucose tolerance and other coronary artery disease risk factors in a cross section of the Singapore population which comprises Chinese, Malays and Asian Indians. 3568 individuals aged 18-69 were examined. Blood pressure, anthropometric data, blood lipids, glucose and insulin were assayed in the fasting state. Glucose and serum insulin were measured 2 h after an oral glucose challenge. Insulin resistance and beta-cell function were calculated using homeostasis model assessment. Asian Indians had higher insulin resistance than Chinese or Malays. Impaired glucose tolerance (IGT) and diabetes mellitus (DM) were associated with greater insulin resistance and impaired beta-cell function compared to normal glucose tolerance (NGT). Insulin resistance was positively correlated with blood pressure in women and total cholesterol, LDL cholesterol and triglyceride in both men and women. It was negatively correlated with HDL cholesterol and LDL/apolipoprotein B ratio. beta-cell function showed no significant correlations with the cardiovascular risk factors studied. It appears that both impaired beta-cell function and insulin resistance are important for the development of hyperglycemia whereas insulin resistance alone seems more important in the development of coronary artery disease as it correlates with several known coronary artery disease risk factors.

Cardiovascular risk profile in individuals with borderline glycemia: the effect of the 1997 American Diabetes Association diagnostic criteria and the 1998 World Health Organization Provisional Report

OBJECTIVE

In 1997, the American Diabetes Association (ADA) recommended a new diagnostic category, impaired fasting glucose (IFG), to describe individuals with borderline glucose tolerance. On the other hand, the World Health Organization (WHO) suggested retaining the category of impaired glucose tolerance (IGT). We studied the prevalence of IFG and IGT in a multiethnic society and compared the cardiovascular risk profiles of subjects with IFG, IGT, or both IFG and IGT.

RESEARCH DESIGN AND METHODS

A total of 3,568 subjects were examined from the 1992 National Health Survey of Singapore, which involved a combination of disproportionately stratified sampling and systematic sampling. Anthropometric, blood pressure, insulin, lipid profile, and uric acid measurements were taken, and a standard 75-g oral glucose tolerance test was performed after a 10-h overnight fast.

RESULTS

The prevalence rates of IFG only, IGT only, and both IFT and IGT were 3.45, 10.2, and 3.4%, respectively. The degree of agreement (kappa) between the two diagnostic criteria (the ADA IFG and the WHO IGT) was only 0.25. A fasting glucose level of 5.5 mmol/l was the optimal cutoff for predicting a 2-h postload glucose level of > or =7.8 mmol/l. The following cardiovascular risk factors were higher in subjects with both IFG and IGT compared with those with either IFG or IGT alone: systolic blood pressure (131 +/- 20 vs. 125 +/- 21 and 125 +/- 19 mmHg, respectively; P < 0.05 and P < 0.001, respectively); diastolic blood pressure (77 +/- 12 vs. 73 +/- 12 and 74 +/- 12 mmHg, respectively; P < 0.05); BMI (26.2 +/- 4.2 vs. 24.4 +/- 4.0 and 24.6 +/- 4.4 kg/m2, respectively; P < 0.01 and P < 0.001, respectively); waist circumference (84.1 +/- 10.3 vs. 79.3 +/- 10.7 and 79.3 +/- 10.6 cm, respectively; P < 0.001); waist-to-hip ratio (0.84 +/- 0.08 vs. 0.82 +/- 0.09 and 0.81 +/- 0.08, respectively; P < 0.05 and P < 0.001, respectively); fasting insulin (12.1 +/- 9.7 vs. 9.2 +/- 5.3 and 9.9 +/- 7.7 mU/l; P < 0.01); insulin resistance (by homeostasis model assessment [HOMA]) (3.41 +/- 2.77 vs. 2.58 +/- 1.50 and 2.43 +/- 1.83, respectively; P < 0.01 and P < 0.001, respectively); total cholesterol (5.81 +/- 1.1 vs. 5.51 +/- 1.1 and 5.53 +/- 1.1 mmol/l, respectively; P < 0.05) and apolipoprotein(B) [apo(B)] (1.5 +/- 0.38 vs. 1.40 +/- 0.34 and 1.39 +/- 0.35 mmol/l, respectively; P < 0.01). The pattern of difference remained significant only for fasting insulin, insulin resistance (HOMA), and apo(B) (borderline) after adjustment for age, sex, and ethnic differences.

CONCLUSIONS

Obvious discordance was evident in the classification of glycemic status when applying the criteria proposed by the ADA (IFG) or WHO (IGT) in a multiethnic society like Singapore. However, subjects with either IFG or IGT had similar cardiovascular risk profiles. Therefore, both criteria identified individuals at high risk for cardiovascular disease. Individuals with both IFG and IGT had a greater incidence of the cardiovascular dysmetabolic syndrome.

Incidence of ischaemic heart disease and stroke in Chinese, Malays and Indians in Singapore: Singapore Cardiovascular Cohort Study

INTRODUCTION

This is the first prospective cohort study in Singapore to describe the incidence of ischaemic heart disease (IHD) and stroke among Chinese, Malays and Asian Indians.

MATERIALS AND METHODS

The Singapore Cardiovascular Cohort Study is a longitudinal follow-up study on a general population cohort of 5920 persons drawn from 3 previous cross-sectional surveys. Morbidity and mortality from IHD and stroke were ascertained by record linkage using a unique identification number with the death registry, Singapore Myocardial Infarct Registry and in-patient discharge databases.

RESULTS

There were 193 first IHD events and 97 first strokes during 52,806 person-years of observation. The overall incidence of IHD was 3.8/1000 person-years and that of stroke was 1.8/1000 person-years. In both males and females, Indians had the highest IHD incidence, followed by Malays and then Chinese. For males after adjusting for age, Indians were 2.78 times (95% CI 1.86, 4.17; P < 0.0001) and 2.28 times (95% CI 1.34, 3.88; P = 0.002) more likely to get IHD than Chinese and Malays respectively. For females after adjusting for age, Indians were 1.97 times (95% CI 1.07, 3.63; P = 0.03) and 1.37 times (95% CI 0.67, 2.80; P = 0.39) more likely to get IHD than Chinese and Malays respectively. For stroke, male Chinese and Indians had higher incidence than Malays (though not statistically significant). However, in females, Malays had the highest incidence of stroke, being 2.57 times (95% CI 1.31, 5.05; P = 0.008) more likely to get stroke than Chinese after adjustment for age.

CONCLUSIONS

This prospective study of both mortality and morbidity has confirmed the higher risk of IHD in Indians. It has also found that Malay females have a higher incidence of stroke, which deserves further study because of its potential public health importance.

Isolated low HDL cholesterol: an insulin-resistant state only in the presence of fasting hypertriglyceridemia

Individuals with isolated low HDL cholesterol are at increased risk of coronary artery disease. It has been reported previously that this is an insulin-resistant state. We analyzed data from the 1992 Singapore National Health Survey with the objective of defining the clinical and metabolic parameters associated with isolated low HDL cholesterol. A total of 3,568 individuals were selected by stratified random sampling. Subjects with low HDL cholesterol (<0.9 mmol/l) and "ideal" total cholesterol (<5.2 mmol/l) were identified. Data on anthropometry, blood pressure (BP), insulin resistance, glucose tolerance, sex, smoking habit, and ethnic group were examined. We found that this group was heterogeneous. Those with fasting triglyceride (TG) >1.7 mmol/l (low HDL/high TG) displayed features of the insulin resistance syndrome characterized by obesity, higher diastolic BP, greater insulin resistance, and a greater tendency to have diabetes or impaired glucose tolerance (IGT). If fasting TG was <1.7 mmol/l (isolated low HDL cholesterol), individuals were similar to the general population in terms of insulin resistance and obesity. Both groups were more commonly men and Asian Indian. The ethnic difference in prevalence could not be explained by differences in diet, exercise, alcohol ingestion, or smoking. Our data support the view that Asian Indians are genetically predisposed to isolated low HDL cholesterol as well as the insulin resistance syndrome. The higher prevalence of isolated low HDL cholesterol, the young age at which individuals exhibit this phenotype (mean age 32.5 years), along with the greater propensity for Asian Indians to develop insulin resistance and IGT contribute to the threefold increased incidence of myocardial infarction in those <65 years of age in this ethnic group.

Prevalence of diabetes and ethnic differences in cardiovascular risk factors. The 1992 Singapore National Health Survey

OBJECTIVE

The purpose of the 1992 Singapore National Health Survey was to determine the current distribution of major noncommunicable diseases and their risk factors, including the prevalence of diabetes and dyslipidemia, in Singapore.

RESEARCH DESIGN AND METHODS

A combination of disproportionate stratified sampling and systematic sampling were used to select the sample for the survey. The final number of respondents was 3,568, giving a response rate of 72.6%. All subjects fasted for 10 h and were given a 75-g glucose load, except those known to have diabetes. Blood was taken before and 2 h after the glucose load. Diagnosis of diabetes was based on 2-h glucose alone.

RESULTS

The age-standardized prevalence of diabetes in Singapore residents aged 18-69 years was 8.4%, with more than half (58.5%) previously undiagnosed. Prevalence of diabetes was high across all three ethnic groups. The prevalence of impaired glucose tolerance was 16.1%, that of hypertension was 6.5%, and 19.0% were regular smokers. The total cholesterol (mean +/- SD) of nondiabetic Singaporeans was 5.18 +/- 1.02 mmol/l; 47.9% had cholesterol > 5.2 mmol/l, while 15.4% had levels > 6.3 mmol/l. Mean LDL cholesterol was 3.31 +/- 0.89 mmol/l; HDL cholesterol was 1.30 +/- 0.32 mmol/l, and triglyceride was 1.23 +/- 0.82 mmol/l.

CONCLUSIONS

Prevalence of diabetes was high across all three ethnic groups. Ethnic differences in prevalence of diabetes, insulin resistance, central obesity, hypertension, smoking, and lipid profile could explain the differential coronary heart disease rates in the three major ethnic groups in Singapore.

Serum cholesterol and dietary fat of two populations of southern Chinese

Children in Hong Kong (HK) are the second generation of Chinese migrants from Guangdong Province and are leading a more affluent lifestyle than those in Jiangmen (JM). The association between affluence and coronary risk was investigated by comparing the serum cholesterol and dietary fat intake of children in HK and JM. Fasting serum cholesterol was examined in 94 HK children and 99 JM children, all aged seven, using the same enzymatic method by the same observer. Duplicate meals were collected in two subsamples of 20 children, one each from HK and JM and analysed for their total fat intake and fatty acid profile, again by the same observer using gravimetric methodology and gas chromatography. The mean (SD) cholesterol of HK children was 4.59 (0.83) mmol/l, significantly higher than that of JM, 4.16 (0.61) mmol/l. The daily fat intake by the HK children was 48 g, 37% higher than that of JM at 35 g. PS ratio was 0.6in HK and 0.8 in JM. Cl8-2/C14-0, the cholesterol-lowering ratio, was mostly below 10 in HK, whereas that of JM was between 10 and 40 Therefore, in order to lower the total serum cholesterol of Hong Kong children, dietary intervention to lessen total fat, in particular milk and animal fat, while moderately increasing fat consumption from vegetable sources would seem to be appropriate.

The effect of dentin bonding agents on the microleakage of porcelain veneers

OBJECTIVES

This in vitro study was conducted to investigate the effect of dentin bonding agents on the microleakage of porcelain veneers cemented on dentin margins.

METHODS

Forty human premolars were prepared on both the buccal and palatal surfaces. Each half was randomly assigned to eight groups. The veneer preparation of one group was cut entirely within enamel, to serve as controls. The remaining groups had cervical margins extending 1 mm beyond the cemento-enamel junction. Six dentin bonding agents were tested. The specimens were subjected to thermocycling and evaluated for marginal leakage using a silver nitrate stain technique. After sectioning, the extent of microleakage was measured at four interfaces: (1) incisal porcelain-composite; (2) incisal tooth-composite; (3) cervical porcelain-composite; and (4) cervical tooth-composite.

RESULTS

Statistical analysis showed that the cervical tooth-composite interface had a significantly higher leakage value (p < 0.05) than the other three interfaces when the cervical margins were in dentin.

SIGNIFICANCE

The dentin bonding agents tested did not significantly reduce the marginal leakage of the porcelain veneers cemented on dentin margins.

Ovarian cancer in Oriental women from Singapore: disease pattern and survival

A retrospective analysis of 88 ovarian tumours diagnosed over five years (1980-1984) in multi-racial Singaporean Oriental women revealed 70 (79%) epithelial tumours (ET), 17 (8%) sex cordstromal (SCS), six (7%) germ cell (GCT) and five (6%) secondary (metastatic) (SEC) cancers. The racial proportions and histological types found in the study were very similar to those of all Singaporean women in the population. Of 70 ET, 33 (47%) were stage I, five (7%) stage II, 30 (43%) stage III and two (3%) stage IV. In 97% surgical resection of primary tumour with/without removal of the uterus and opposite ovary was performed, followed by adjuvant chemotherapy in 76% and complete follow-up in 98%. The 5-year actuarial survivals in ET were in stage I 84% (low malignant potential 100% and frank carcinomas 70%), stage II 60%, stage III 29% and 0% in stage IV, whereas of the others none with SCS but four with GCT and all five with SEC died of disease. Though the incidence of ovarian cancer is much lower in Oriental than Caucasian women the proportion of different histological types, stage at presentation and survival from ovarian cancer in Oriental women does not differ from that in Caucasians.

A profile of patients with temporomandibular disorders in Singapore--a descriptive study

This is a descriptive study to establish the profile of 120 consecutive patients seeking relief from symptoms and dysfunction of the masticatory system at the Dental Clinic, Singapore General Hospital from February 1988-September 1988. The mean age of the patients was 29.4 years and females outnumber males by 2:1. The patients complained of TMJ clicking (66%), TMJ pain (55%), painful chewing (47%), headaches (42%), painful opening (37%), jaw locking (33%), and jaw muscle pain (23%). The possible etiological factors were recorded: macrotrauma (27%), stressful episodes (24%), unilateral mastication (53%), clenching (28%), grinding (26%) and excessive chewing habits (10%). Unilateral chewing was significantly associated with pain on opening (p less than 0.05) and joint pain (p less than 0.05). A statistical relationship was found between night grinding and laterotrusive wear of teeth (p less than 0.001). There was evidence that tension headache reported by TMD sufferers was related to temporalis muscle/tendon dysfunction (p less than 0.001).

Wilson's disease revisited in the tropics

The clinical features and investigations of 17 patients were analysed. Thirteen of them were Chinese and the rest Indians. Their ages at presentation ranged from 8 to 63 years (mean 18.35 years). Thirteen patients (76%) were symptomatic; 8 with predominantly hepatic manifestations and 5 with neurological features. Four were asymptomatic siblings. At diagnosis, however, 10(59%) had features of liver involvement singly, 3 (18%) had neurological involvement alone and 4 (27%) had mixed presentations. Family histories were available in 15 patients; 26.9% of siblings had Wilson's Disease. Serum ceruloplasmin was low in 82% of the patients. 24-hour urinary copper was measured in 16 patients and was raised in all of them. About half the patients (41%) had evidence of concomittant renal tubular dysfunction with hypouricaemia and aminoaciduria. Three patients (18%) had joint involvement at presentation. All 17 patients were treated with Penicillamine. Complications due to therapy included pemphigus in one and toxic epidermal necrolysis and later a lupus like syndrome in another. The features of clinical improvement included fading of K-F rings, improvement of neurological signs and the normalisation of serum transaminases. One patient developed primary hepatocellular carcinoma 5 years after presentation. Delay in diagnosis was encountered in half of the patients reviewed. Being a treatable condition, Wilson's Disease, although rare, should always be thought of in patients with haemolysis, liver diseases or extrapyramidal disorders.

Insulin secretory capacity in Singapore diabetic subjects

The determination of serum C-peptide has been found to be a sensitive indicator of endogenous insulin secretion, and serves to define diabetic patients who require insulin therapy i.e., insulin-dependent (Type I, IDDM) and those non-insulin dependent (Type II, NIDDM). The aim of our study is to establish the types of diabetes mellitus with C-peptide measurement in a group of diabetic subjects on different modes of therapy. Eighty-eight diabetic patients (60 males, 28 females) were studied. Thirty-four were on insulin (age 40 +/- 2 years; means +/- SEM), 35 on oral agents (54 +/- 1 years), and 19 on diet alone (46 +/- 3 years). Twenty healthy subjects (10 males, 10 females) serve as normal controls (37 +/- 3 years). Blood samples for serum C-peptide and blood glucose estimations were obtained after an overnight fast and one hour after a 75 grams oral glucose load. Fasting C-peptide levels obtained for the various groups were: 0.62 +/- 0.07 (nmol/L, means +/- SEM) (normal), 0.16 +/- 0.02 (insulin), 0.79 +/- 0.06 (oral), 2.15 +/- 0.15 (diet). The C-peptide values after oral glucose were 1.80 +/- 0.20 (normal), 0.23 +/- 0.05 (insulin), 1.72 +/- 0.02 (oral), 2.15 +/- 0.15 (diet). Both the fasting and post-glucose C-peptide concentrations were significantly lower (p less than 0.001) in the insulin group compared to the normals, whereas values for the diet and oral groups were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

Pyogenic hepatic abscess and diabetes mellitus--a probable association

Four patients with pyogenic hepatic abscesses are reported. There were three females and one male with an age range of 36-75 years. In all the cases, diabetes mellitus was associated. Confirmation of the abscesses was obtained by liver scanning or ultrasonography, or both. In one patient, the clinical course was complicated by sympathetic pericardial effusion with right heart failure. Two patients had percutaneous transhepatic drainage of the abscesses under fluoroscopy. All four patients eventually required laparotomy and open drainage of the abscesses. Diabetic control was achieved with insulin therapy. The common causative organism in all instances was the Klebsiella species. Three patients recovered. The remaining one developed hypotension post-operatively and died of brain-stem infarction and the hepato-renal syndrome.