Question banks: credit? Or debit? A qualitative exploration of their use among medical students

BACKGROUND

Online question banks are the most widely used education resource amongst medical students. Despite this there is an absence of literature outlining how and why they are used by students. Drawing on Deci and Ryan's self-determination theory, our study aimed to explore why and how early-stage medical students use question banks in their learning and revision strategies.

METHODS

The study was conducted at Newcastle University Medical School (United Kingdom and Malaysia). Purposive, convenience and snowball sampling of year two students were employed. Ten interviews were conducted. Thematic analysis was undertaken iteratively, enabling exploration of nascent themes. Data collection ceased when no new perspectives were identified.

RESULTS

Students' motivation to use question banks was predominantly driven by extrinsic motivators, with high-stakes exams and fear of failure being central. Their convenience and perceived efficiency promoted autonomy and thus motivation. Rapid feedback cycles and design features consistent with gamification were deterrents to intrinsic motivation. Potentially detrimental patterns of question bank use were evident: cueing, avoidance and memorising. Scepticism regarding veracity of question bank content was absent.

CONCLUSIONS

We call on educators to provide students with guidance about potential pitfalls associated with question banks and to reflect on potential inequity of access to these resources.

Dietary Interventions in Atopic Dermatitis: A Comprehensive Scoping Review and Analysis

BACKGROUND

This scoping review aims to critically assess gaps in the current literature on atopic dermatitis (AD) by evaluating the overall effectiveness of dietary interventions. Through a comprehensive analysis that follows the Preferred Reporting Item for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines, we conducted a thorough search on the Web of Science database in May 2023 using specific search strategies to identify all relevant studies on the research topic.

SUMMARY

A total of 104 full-text articles were included for review. Our synthesis identified seven notable categories of dietary interventions for AD, showcasing the diversity of interventions utilized. This includes vitamin supplementation, probiotic and prebiotic supplementation, dietary fat, biological compounds, foods from natural sources, major nutrients, and diet-related approaches. Further analyses stratified by targeted populations revealed a predominant focus on pediatrics, particularly in probiotic supplementation, and on adults, with an emphasis on vitamin D and E supplementation.

KEY MESSAGES

Despite most dietary interventions demonstrating overall effectiveness in improving AD severity and its subjective symptoms, several significant gaps were identified. There was a scarcity of studies on adults and whole-diet interventions, a prevalence of short-term interventions, heterogeneity in study outcomes, designs, and population, occasional disparity between statistical significance and clinical relevance, and a lack of a comprehensive multidisciplinary approach. Nonetheless, these findings offer valuable insights for future AD research, guiding additional evidence-driven dietary interventions and informing healthcare professionals, researchers, and individuals, advancing both understanding and management of AD.

Sleep and allergic diseases among young Chinese adults from the Singapore/Malaysia Cross-Sectional Genetic Epidemiology Study (SMCGES) cohort

BACKGROUND AND OBJECTIVE

Sleep disruption has been shown to affect immune function and thus influence allergic disease manifestation. The specific effects of sleep on allergic diseases, however, are less well-established; hence, in a unique population of young Chinese adults, we investigated the association between sleep and allergic disease.

METHODS

Young Chinese adults recruited from Singapore in the Singapore/Malaysia Cross-Sectional Genetic Epidemiology Study (SMCGES) were analyzed. We used the International Study of Asthma and Allergies in Childhood (ISAAC) protocol and a skin prick test to determine atopic dermatitis (AD), allergic rhinitis (AR), and asthma status. Information regarding total sleep time (TST) and sleep quality (SQ) was also obtained.

RESULTS

Of 1558 participants with a mean age of 25.0 years (SD = 7.6), 61.4% were female, and the mean total sleep time (TST) was 6.8 h (SD = 1.1). The proportions of AD, AR, and asthma were 24.5% (393/1542), 36.4% (987/1551), and 14.7% (227/1547), respectively. 59.8% (235/393) of AD cases suffered from AD-related sleep disturbances, 37.1% (209/564) of AR cases suffered from AR-related sleep disturbances, and 25.1% (57/227) of asthma cases suffered from asthma-related sleep disturbances. Only asthma cases showed a significantly lower mean TST than those without asthma (p = 0.015). Longer TST was significantly associated with lower odds of AR (OR = 0.905, 95% CI = 0.820-0.999) and asthma (OR = 0.852, 95% CI = 0.746-0.972). Linear regression analyses showed that lower TST was significantly associated with asthma (β =  - 0.18, SE = 0.076, p-value = 0.017), and AR when adjusted for AR-related sleep disturbances (β =  - 0.157, SE = 0.065, p-value = 0.016). Only sleep disturbances due to AR were significantly associated with a poorer SQ (OR = 1.962, 95% CI = 1.245-3.089).

CONCLUSIONS

We found that sleep quality, but not sleep duration was significantly poorer among AD cases, although the exact direction of influence could not be determined. In consideration of the literature coupled with our findings, we posit that TST influences allergic rhinitis rather than vice versa. Finally, the association between TST and asthma is likely mediated by asthma-related sleep disturbances, since mean TST was significantly lower among those with nighttime asthma symptoms. Future studies could consider using objective sleep measurements coupled with differential expression analysis to investigate the pathophysiology of sleep and allergic diseases.

Dietary Protein Intake and Associated Risks for Atopic Dermatitis, Intrinsic Eczema, and Allergic Sensitization among Young Chinese Adults in Singapore/Malaysia: Key Findings from a Cross-sectional Study

Through an investigator-administered questionnaire that follows the standard protocol of the International Study of Allergy and Asthma in Childhood, data on symptomatic histories of eczema and dietary habits were collected from 11,494 young Chinese adults in Singapore/Malaysia. Allergic sensitization status was assessed through a skin prick test reactivity to common house dust mites. Using three dietary indices (dietary protein score, animal protein score, and plant protein score), the associations between atopic dermatitis, intrinsic eczema, allergic sensitization, and intake of various proteins were estimated. On average, most subjects frequently eat meat, vegetables, and rice in their diets. Through a multivariable logistic regression adjusted for age, sex, body mass index, and parental eczema, subjects with high dietary protein score (adjusted OR = 1.397; 95% confidence interval = 1.133-1.724; P < 0.003) and high animal protein score (adjusted OR = 1.353; 95% confidence interval = 1.106-1.682; P < 0.003) were associated with increased risk of atopic dermatitis. Interestingly, synergy factor analysis revealed that a higher intake of plant proteins than animal proteins in diets significantly reduced overall associated risks of atopic dermatitis and allergic sensitization but not those of intrinsic eczema. Most importantly, these associations are independent of dietary fat intake. Taken together, frequent adherence to diets rich in plant proteins reduced associated risks of atopic dermatitis in Singapore/Malaysia Chinese adults.

A dietary pattern of frequent plant-based foods intake reduced the associated risks for atopic dermatitis exacerbation: Insights from the Singapore/Malaysia cross-sectional genetics epidemiology cohort

BACKGROUND

The prevalence of atopic dermatitis (AD) has been increasing in recent years, especially in Asia. There is growing evidence to suggest the importance of dietary patterns in the development and management of AD. Here, we seek to understand how certain dietary patterns in a Singapore/Malaysia population are associated with various risks of AD development and exacerbation.

METHODS

A standardized questionnaire following the International Study of Asthma and Allergies in Childhood (ISAAC) guidelines was investigator-administered to a clinically and epidemiology well-defined allergic cohort of 13,561 young Chinese adults aged 19-22. Information on their sociodemographic, lifestyle, dietary habits, and personal and family medical atopic histories were obtained. Allergic sensitization was assessed by a skin prick test to mite allergens. Spearman's rank-order correlation was used to assess the correlation between the intake frequencies of 16 food types. Dietary patterns were identified using principal component analysis. Four corresponding dietary scores were derived to examine the association of identified dietary patterns with allergic sensitization and AD exacerbations through a multivariable logistic regression that controlled for age, gender, parental eczema, BMI, and lifestyle factors.

RESULTS

The correlation is the strongest between the intake of butter and margarine (R = 0.65). We identified four dietary patterns, "high-calorie foods", "plant-based foods", "meat and rice", and "probiotics, milk and eggs", and these accounted for 47.4% of the variance in the dietary habits among the subjects. Among these patterns, moderate-to-high intake of "plant-based foods" conferred a negative association for chronic (Adjusted odds ratio (AOR): 0.706; 95% confidence interval (CI): 0.589-0.847; p < 0.001) and moderate-to-severe AD (AOR: 0.756; 95% CI: 0.638-0.897; p < 0.01). "Meat and rice" and "probiotics, milk and eggs" were not significantly associated with AD exacerbation. While frequent adherence to "high-calorie foods" increased the associated risks for ever AD and moderate-to-severe AD, having a higher adherence to "plant-based foods" diminished the overall associated risks.

CONCLUSIONS

Frequent adherence to "plant-based foods" was associated with reduced risks for AD exacerbation in young Chinese adults from Singapore/Malaysia. This provides the initial evidence to support the association between dietary factors and AD. Further research is needed to better understand the pathomechanisms underlying diet and AD exacerbations.

Burgers, Fast Foods, and Increased Associated Risk for Atopic Dermatitis: A Cross-Sectional Study of Dietary Habits among Young Chinese Adults in Singapore/Malaysia

BACKGROUND

We see increasing evidence that dietary and nutrients factors play a pivotal role in allergic diseases and recent global findings suggest that dietary habits influence the pathogenesis of atopic dermatitis (AD). Frequent consumption of fast food diets is associated with AD development. Despite the rising prevalence of AD in Asia, efforts in investigating the role of dietary habits and AD in adults are still lacking.

METHODS

We evaluated the association between the dietary intake of 16 food types and AD manifestations using our Singapore/Malaysia Cross-sectional Genetics Epidemiology Study (SMCGES) population. Dietary habits profiles of 11,494 young Chinese adults (1,550 AD cases/2,978 non-atopic controls/6,386 atopic controls) were assessed by an investigator-administered questionnaire. AD cases were further evaluated for their chronicity (550 chronic) and severity (628 moderate-to-severe). Additionally, we derived a novel food index, Quality of Diet based on Glycaemic Index Score (QDGIS), to examine the association between dietary intake of glycaemic index (GI) and various AD phenotypes.

RESULTS

The majority of AD subjects are distributed in the good (37.1%) and moderate (36.2%) QDGIS classes. From the multivariable analyses for age and gender, a moderate QDGIS class was significantly associated with a lower odds of AD (adjusted odds ratio (AOR): 0.844; 95% confidence interval (CI): 0.719-0.991; p < 0.05) and moderate-to-severe AD (AOR: 0.839; 95% CI: 0.714-0.985; p < 0.05). A good QDGIS class was only significantly associated with a lower odds of chronic AD (AOR: 0.769; 95% CI: 0.606-0.976; p < 0.05). Among high GI foods, frequent consumption of burgers/fast food was strongly associated with an increased risk of chronic and moderate-to-severe AD. Among low GI foods, increased intake frequencies of fruits, vegetables, and pulses decreased the odds of AD. Finally, we identified significant associations between frequent seafood, margarine, butter, and pasta consumption with an increased odds of AD despite them having little GI values.

CONCLUSION

While genetic components are well-established in their risks associated with increased AD prevalence, there is still a lack of a focus epidemiology study associating dietary influence with AD. Based on the first allergic epidemiology study conducted here in Singapore and Malaysia, it laid the groundwork to guide potential dietary interventions from changing personal dietary habits.

A Dietary Pattern for High Estimated Total Fat Amount Is Associated with Enhanced Allergy Sensitization and Atopic Diseases among Singapore/Malaysia Young Chinese Adults

INTRODUCTION

Frequent dietary patterns for fast food diets are suggested to be a risk factor for atopic disease development. Excessive dietary fats in fast foods are postulated to promote low-grade chronic inflammation. However, no studies in Asia have yet to characterize the dietary pattern for high-fat foods with atopic diseases. Thus, this study aims to assess the association between dietary fats with the prevalence of atopic diseases in an allergic cohort.

METHODS

Through an investigator-administered questionnaire that follows the International Study of Asthma and Allergies in Childhood (ISAAC) protocol, we evaluated the eating habits, lifestyle behaviours, sociodemographics, and atopic symptoms, and history among 11,494 young Chinese adults in Singapore and Malaysia. A skin prick test (SPT) for common house dust mites was also conducted to determine the atopic (allergic) status. We identified 1,550 atopic dermatitis (AD), 1,301 allergic asthma (AS), and 3,757 allergic rhinitis (AR) atopic cases. We derived a novel dietary index, Diet Quality based on Total Fat Amount (DQTFA), to examine the association between eating patterns for estimated total fat amount with various atopic outcomes.

RESULTS

There was a preponderance of subjects having positive SPT reaction (69.0%) with the prevalence of AR being the highest (32.7%), then AD (13.5%), and AS (11.3%). Additionally, there is a significantly higher proportion of subjects with an atopy background and atopic diseases consume diets with a high estimated mean fat amount. The adherence to a dietary pattern of the higher estimated total fat amount was shown to be strongly associated with all atopic diseases and exhibited dose-dependent responses in the univariate analysis. These associations remained significant even with the adjustments for age, gender, body mass index, use of alcohol, sedentary lifestyles, and physical activity. A dietary pattern for high-fat amount is more strongly associated with AS (adjusted odds ratio [AOR]: 1.524; 95% confidence interval [CI]: 1.216-1.725; p < 0.001) and AR (AOR: 1.294; 95% CI: 1.107-1.512; p < 0.001) compared to AD (AOR: 1.278; 95% CI: 1.049-1.559; p < 0.05). Finally, it was shown that having either one of the atopic comorbidities was strongly associated with a dietary pattern of high-fat amounts (AOR: 1.360; 95% CI: 1.161-1.594; p < 0.001).

CONCLUSION

Our findings altogether provide initial evidence that the dietary pattern of a diet high in fat amount is associated with an increased risk of atopy and atopic diseases in young Chinese adults in Singapore and Malaysia. Balancing the consumption of dietary fats and changing personal dietary habits by choosing foods of the lower fat amount may reduce the associated odds of atopic diseases.

An updated prevalence of asthma, its phenotypes, and the identification of the potential asthma risk factors among young Chinese adults recruited in Singapore

Background

Asthma is a chronic inflammatory disease of the airway characterized by respiratory symptoms: wheezing, shortness of breath, coughing, and chest tightness. Globally, asthma affects over 300 million individuals and carries high morbidity and mortality burden. Previous studies have estimated the prevalence of asthma; however, prevalence estimates have been changing over time. Here, in a population of young Chinese adults from Singapore, we aimed to obtain an updated prevalence of asthma and its phenotypes, and identify potential associated risk factors.

Methods

The Singapore/Malaysia Cross-Sectional Genetics Epidemiology Study (SMCGES) is an ongoing study which uses established ISAAC guidelines to collect epidemiological data and information pertaining to allergic diseases such as asthma. Responses from young Chinese adults recruited in the National University of Singapore were analyzed.

Results

Lifetime asthma prevalence rate was estimated at 19.1% (2049/10,736), while current asthma prevalence rate was estimated at 6.3% (679/10,736). For ever asthma, the most important risk factor was a parental history of asthma. Increased consumption of pulses (aOR: 0.822, 95% CI: 0.706-0.958) was associated with a lowered odds of ever asthma, but cereals (aOR: 1.256, 95% CI: 1.006-1.580), pasta (aOR: 1.265, 95% CI: 1.027-1.553), butter (aOR: 1.350, 95% CI: 1.113-1.632), and margarine (aOR: 1.343, 95% CI: 1.081-1.660) were associated with a higher risk of ever asthma. Increased television/computer usage was associated with a decreased risk of ever asthma (aOR: 0.448, 95% CI: 0.367-0.545). Conversely, genetic factors had a lower strength of effect on current asthma (parental history of asthma - OR: 1.465, 95% CI: 1.135-1.888) as compared to ever asthma. Only increased potato consumption was significantly associated with an increased risk of current asthma (most or all days per week vs never or only occasionally - aOR: 1.577, 95% CI: 1.145-2.180). Physical activity (aOR: 0.693, 95% CI: 0.542-0.885) was associated with a lower odds of asthma, while second-hand smoke exposure was associated with an increased risk for current asthma (aOR: 1.435, 95% CI: 1.001-2.047).

Conclusion

Overall, the prevalence of lifetime asthma and current asthma among young Chinese adults was 19.1% and 6.3%, higher than that of previous studies. Our results suggested a stronger association between genetic factors and ever asthma as compared to current asthma. Parental asthma was the most important intrinsic epidemiological factor for asthma manifestation, while various foods, physical activity levels, and television or computer usage were also significantly associated with asthma. Future studies should consider risk factors in conjunction with other accompanying variables given the potential interactions between them, to discern the effects of environment and lifestyle on asthma more distinctly.

Allergic rhinitis in Chinese young adults from the Singapore/Malaysia cross-sectional genetics epidemiology study (SMCGES) cohort: Prevalence, patterns, and epidemiology of allergic rhinitis

Background

Allergic rhinitis (AR) is characterized by the occurrence of at least 2 symptoms of nasal itching, nasal blockage, rhinorrhea, and sneezing, when not afflicted with a cold or flu, with defined atopic sensitization demonstrated by skin prick test or specific IgE responses. Besides the detriment to standard of living and economic burden of AR, both multicentre and single-cohort studies have observed an increase in AR prevalence in Asia over time.

Methods

In total, 12 872 individuals, with mean age 22.1 years (SD = 4.8), were recruited from universities in Singapore and Malaysia. Each participant provided epidemiological data based on an investigator-administered questionnaire adapted from the validated International Study of Allergies and Asthma in Childhood (ISAAC) protocol, and atopy status was determined using a skin prick test (SPT) performed by qualified staff. AR was diagnosed according to Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines and a positive SPT result.

Results

Sensitization (determined by SPT) to either Blomia tropicalis or Dermatophagoides pteronyssinus was prevalent in 66.5% of the cohort. Current rhinitis (manifesting ≥2 rhinitis symptoms, within the past 12 months) was observed in 48.9% of our population, while AR, which included atopy status, was estimated at 39.4%. Sneezing and rhinorrhea were the most common symptoms among AR cases. AR prevalence decreased with increasing age (OR: 0.979; 95% CI: 0.969-0.989), while male gender (OR: 2.053; 95% CI: 1.839-2.294), and a parental history of allergic diseases (OR: 2.750; 95% CI: 2.284-3.316) were significant risk factors for AR. Upon adjustment for age, gender, and parental history, housing type (OR: 0.632; 95% CI: 0.543-0.736) and income level (>$6000 vs <$2000; OR: 2.461; 95% CI: 2.058-2.947) remained as significant risk factors for AR, while ever having kept a pet (OR: 1.167; 95% CI: 1.025-1.328) emerged as a risk factor. Conflicting results were obtained for indicators of sedentary lifestyle: frequent physical activity (OR: 1.394; 95% CI: 1.150-1.694) and increased duration spent using the TV/computer (OR: 1.224; 95% CI: 1.006-1.489) both increased the risk of AR. Lastly, we used the Quality of Diet based on Glycaemic Index Score (QDGIS) to assess the Glycaemic Index (GI) level of overall diet. We identified lower GI level of overall diet as a protective factor against AR manifestation (OR: 0.682; 95% CI: 0.577-0.807).

Conclusion

While the previously established non-modifiable risk factors for AR were present in our study population, the identification of modifiable risk factors, such as TV/computer usage, and dietary habits, opens a new area for research, both in the areas of gene-environment interaction, and management of AR.

Visual outcomes after Phacoemulsification with Intraocular Implantation surgeries among patients with and without Diabetes Mellitus

INTRODUCTION

The aim of this study was to compare the visual outcomes of phacoemulsification with intraocular lens implantation (IOL) surgery in patients with and without diabetes mellitus (DM) in Malaysia over a 12-year period and to identify factors that may contribute to poor visual outcome.

MATERIALS AND METHODS

Data was retrieved from the webbased Malaysian Cataract Surgery Registry (CSR). Perioperative data for cataract surgery performed from 2007- 2018 were analysed. Inclusion criteria were age ≥40 years, phacoemulsification and IOL and senile cataract. Combined surgeries, surgeries performed by trainees and ocular comorbidities were excluded. Post-operative Best-Corrected Visual Acuity (BCVA) were compared. Factors affecting poor visual outcomes among those with DM were analysed using multivariate logistic regression to produce adjusted odds ratio (OR) for variables of interest.

RESULTS

Total number of cases between 2007-2018 was 442,858, of whom 179,210 qualified for our analysis. DM group consisted of 72,087 cases (40.2%). There were 94.5% cases in DM group and 95.0Ź from non-DM group who achieved BCVA ≥6/12 (p<0.001). Among patients with DM, advanced age (70-79 years old, OR: 2.54, 95% Confidence Interva, 95%CI: 1.91, 3.40; 80-89 years old, OR: 5.50, 95%CI: 4.02, 7.51), ≥90 years, OR: 9.77, 95%CI: 4.18, 22.81), poor preoperative presenting visual acuity [<6/18-6/60] (OR: 2.40, 95%CI: 1.84, 3.14) and <6/60-3/60 (OR: 3.00, 95%CI: 2.24, 4.02), <3/60 (OR 3.63, 95%CI: 2.77, 4.74)], presence of intraoperative complication (OR 2.24, 95%CI: 1.86, 2.71) and presence of postoperative complication (OR 5.21, 95%CI: 2.97, 9.16) were significant factors for poor visual outcome.

CONCLUSIONS

Visual outcomes following phacoemulsification with IOL implantation surgery among cases with DM were poorer compared to cases without DM. Risk factors for poor visual outcomes among cases with DM were identified.

Effects of soy isoflavones on the concentration of hyaluronic acid in the vagina of type 1 diabetic rats

OBJECTIVE

To assess the effects of isoflavones and 17β-estradiol on the vaginal epithelium extracellular matrix and hyaluronic acid (HA) in the diabetic rat model.

METHODS

Sixty adult, virgin, female rats underwent ovariectomy, then randomization into six groups of ten animals each: GI, sham ovariectomized control animals; GII, sham ovariectomized control diabetic animals; GIII, control ovariectomized rats receiving propylene glycol vehicle; GIV, control ovariectomized diabetic animals receiving propylene glycol vehicle; GV, diabetic ovariectomized animals treated with soy isoflavones (150 mg/kg by gavage); GVI, ovariectomized diabetic rats treated with estrogen (17β-estradiol, 10 mg/kg, subcutaneously). Treatment took place over 30 consecutive days. After euthanasia, a portion of the vagina was immersed in liquid nitrogen for RT-qPCR and Western blotting. Another portion was processed for paraffin embedding. Sections were stained with hematoxylin & eosin for histomorphometry and Picro Sirius Red for collagen quantification.

RESULTS

Vaginal epithelium histomorphometry in GIII (15.3 ± 1.1 µm) and GIV (14.5 ± 1.8 µm) was thinner than in GV (41.3 ± 1.5 µm) and GVI (74.3 ± 1.6 µm). There was an increase in collagen content in GV (84.1 ± 1.2 µm) and GVI (88.2 ± 1.7 µm). HA quantification was higher in GV (0.38 ± 1.1 μg/mg) and GVI (0.49 ± 1.4 μg/mg) when compared with GIII (0.12 ± 1.1 μg/mg) and GIV (0.10 ± 1.2 μg/mg), p < 0.05.

CONCLUSIONS

Soy isoflavones increase hyaluronic acid concentration in the vagina of diabetic ovariectomized rats. Such findings might help to attenuate the effects of vulvovaginal atrophy in women.

Long-term proliferation and characterization of human spermatogonial stem cells obtained from obstructive and non-obstructive azoospermia under exogenous feeder-free culture conditions

OBJECTIVES

The aim of the present study was to improve efficiency of isolation and to optimize proliferative potential of human spermatogonial stem cells (SSCs) obtained from obstructive azoospermic (OA) and non-obstructive azoospermic (NOA) patients, and further, to characterize these cells for potential use in infertility treatment or study of reproductive biology.

MATERIALS AND METHODS

We have applied a cell-sorting method, using collagen and magnetic activated cell separation to overcome obstacles, developing a collection system, and simple long-term proliferation system, that yields large numbers of high-purity SSCs from obstructive OA and NOA patients.

RESULTS

SSCs derived from OA and NOA patients proliferated and maintained their characteristics for more than 12 passages (>6 months) in vitro. Moreover, the population of cells positive for the SSC-specific markers GFRalpha-1 and integrin alpha6, increased to more than 80% at passage 8.

CONCLUSION

These finding may support the idea that in vitro propagation of SSCs could be a useful tool for infertility treatment and study of reproductive biology.

Impact of tinnitus as measured by the Tinnitus Handicap Inventory among tinnitus sufferers in Singapore

INTRODUCTION

The effects of tinnitus on quality of life (QOL) have never been extensively studied in Singapore. We describe the characteristics of tinnitus and its impact on QOL as measured by the Tinnitus Handicap Inventory (THI) in a series of ear, nose and throat clinic patients.

METHODS

A total of 327 patients who attended a tinnitus counselling clinic completed the THI questionnaire, a self-report measure with 25 items grouped into functional, emotional and catastrophic subscales.

RESULTS

The mean age of the 134 female and 193 male patients was 48.9 years. 36.7 percent of these patients had bilateral tinnitus and 64.6 percent had symptoms for less than one year. 270 patients had hearing loss, 74 percent of whom presented with bilateral high frequency hearing loss. Most patients (84.1 percent) perceived only one type of sound. The total THI score distribution was: 107 (33 percent) patients had THI less than 16, 100 (31 percent) had THI 18 to 36, 59 (18 percent) had THI 38 to 56, and 61 (19 percent) had THI more than 58. There were no differences in the overall THI and subscale scores between the patients' gender, those with or without hearing loss, and those with unilateral or bilateral tinnitus. However, significantly higher total THI and all subscale scores were found among patients who were hearing more than one type of tinnitus sound. The areas of concern that were commonly reported by the patients in this series were a lack of control over tinnitus, frustration and stress.

CONCLUSION

Tinnitus patients who hear multiple sounds tend to have a higher THI and subscale scores. The management of tinnitus should address common areas of concern, and may include counselling. The THI is a potential screening tool to determine if patients require counselling. A series of THI assessments can be used to chart the progress of treatment.

Foreign-body granuloma occurring in the mandible subsequent to orthognathic surgery: a case report

We report the first case of foreign-body granuloma occurring in the mandible of a patient with a history of orthognathic surgery. A 20-year-old male patient had a hard swelling and pain in the left mandibular angle and the parotid area. Plain radiographs showed a radiolucent lesion extending from the buccal area under the left sigmoid notch of the mandible to the mandibular angle. Computed tomographs showed an expanded osteolytic mass in the same area, with destruction of most of the bone on the buccal side. A microscopic examination revealed filamentous foreign material associated with chronic inflammatory cell infiltration and an aggregation of multinucleated giant cells. Foreign-body granuloma in the mandible, although rare, should be included in the differential diagnosis in cases of postoperative masses.

Critical incident stress management

Recent studies have indicated implementation of the CISM Program has impacted and reduced the cost of workers' compensation claims for stress related conditions and the number of lost work days (Ott, 1997; Western Management Consultants, 1996). Occupational health professionals need to be ready to develop and implement a comprehensive critical incident stress management process in anticipation of a major event. The ability to organize, lead, or administer critical incident stress debriefings for affected employees is a key role for the occupational health professional. Familiarity with these concepts and the ability to identify a critical incident enhances value to the business by mitigating the stress and impact to the workplace. Critical Incident Stress Management Systems have the potential for decreasing stress and restoring employees to normal life function--a win/win situation for both the employees and the organization.

Clinical significance of neck node metastasis in squamous cell carcinoma of the maxillary antrum

PURPOSE

To further clarify the clinical significance of neck node metastasis in squamous cell carcinoma of the maxillary sinus (maxillary SCC).

MATERIALS AND METHODS

The medical charts of the 116 patients with maxillary SCC were retrospectively reviewed. Twelve patients (10.3%) presented initially with neck node metastases, and 14 (13.5%) of 104 node-negative patients subsequently developed regional recurrence during the follow-up period. The high-risk factors for neck node metastasis, patterns of regional failure, and survival for node-positive patients were analyzed with the patient cohort that had largely been treated with radiation alone.

RESULTS

Of the various factors, the tumor extension to the nasopharynx or oral cavity was the statistically significant determinants predictive of neck node metastasis at the initial diagnosis. During the follow-up period, regional failure was far less common than local failure (19.0% v 68.1%), and the majority of regional failures were accompanied by local recurrences. The oral cavity extension and control status of local disease were the high-risk factors for subsequent development of regional recurrence in node-negative patients. The overall 5-year survival rate for node-positive patients (16.7%) showed a poorer outcome compared with that for node-negative patients (31.3%), but it was similar to that of T4N0 patients (26.6%). Although patients who subsequently developed neck node recurrence during follow-up represented a dismal prognosis, uncontrolled local diseases in these patients still remained a major problem, resulting in a poor prognosis.

CONCLUSIONS

Despite an unfavorable prognosis of patients with neck node metastasis, an aggressive trial to achieve maximum local control of the primary tumor was considered to be more important than elective neck treatments.

Diagnostic imaging of pigmented villonodular synovitis of the temporomandibular joint associated with condylar expansion

Pigmented villonodular synovitis (PVNS) is a rare lesion of the temporomandibular joint. We report a case which was initially misdiagnosed as a parotid tumor. CT revealed a well-defined mass demonstrating higher attenuation than the adjacent soft tissue with marked expansion of the mandibular condyle. MRI clearly delineated the extent of the lesion which had very low signal intensity on both T1W and T2W sequences due to the effect of hemosiderin. The usefulness of these imaging procedures in diagnosis of PVNS is discussed.

Phorboxazole synthetic studies. 1. Construction of a C(3-19) subtarget exploiting an extension of the Petasis-Ferrier rearrangement

[formula: see text] In this, the first of two letters, we outline our overall strategy for the total synthesis of phorboxazoles A (1) and B (2), rare oxazole-containing macrolides possessing extraordinary antimitotic activity, and describe the assembly of a C(3-19) subtarget (-)-5 for the total synthesis of phorboxazole A. The synthesis of (-)-5 was achieved in 15 linear steps (12% overall yield), exploiting a modification of the Petasis-Ferrier rearrangement to construct the C(11-15) cis-tetrahydropyran. Dimethylaluminum chloride (Me2AlCl) proved to be the Lewis acid of choice for the Petasis-Ferrier rearrangement.

Sensory and motor dysfunction assessed by anorectal manometry in uterine cervical carcinoma patients with radiation-induced late rectal complication

PURPOSE

To investigate the effects of radiation on anorectal function in patients with carcinoma of the uterine cervix.

METHODS AND MATERIALS

Anorectal manometry was carried out on 24 patients (complication group) with late radiation proctitis. All of the manometric data from these patients were compared with those from 24 age-matched female volunteers (control group), in whom radiation treatment had not yet been performed.

RESULTS

Regardless of the severity of proctitis symptoms, 25% of patients demonstrated all their manometric data within the normal range, but 75% of patients exhibited one or more abnormal manometric parameters for sensory or motor functions. Six patients (25%) had an isolated sensory dysfunction, eight patients (33.3%) had an isolated motor dysfunction, and four patients (16.7%) had combined disturbances of both sensory and motor functions. The maximum tolerable volume, the minimal threshold volume, and the urgent volume in the complication group were significantly reduced compared with those in the control group. The mean squeeze pressure in the complication group was significantly reduced, whereas the mean resting pressure and anal sphincter length were unchanged.

CONCLUSIONS

Physiologic changes of the anorectum in patients with late radiation proctitis seem to be caused by a variety of sensory and/or motor dysfunctions in which many different mechanisms are working together. The reduced rectal reservoir capacity and impaired sensory functions were crucial factors for functional disorder in such patients. In addition, radiation damage to the external anal sphincter muscle was considered to be an important cause of motor dysfunction.

Rapid response: care of burn victims

1. The occupational health nurse must understand the prehospital principles for treatment of burn victims. This understanding promotes appropriate burn management which can impact mortality and morbidity. 2. The most important concept in emergency management of burn victims is scene safety, the nurse's safety, and ultimately, the victim's safety. 3. All burn victims need to be managed as trauma victims with a primary and secondary survey to rapidly determine life threatening problems and whether other injuries are present. 4. Familiarity with the structures and functions of the skin is imperative to understand the pathophysiology and consequences of burn injuries.

Assessment of the trauma victim in an occupational setting

1. It is important for the occupational health nurse to be aware of and understand the mechanism of injury and forces involved in a trauma event. This understanding provides insight into the potential injuries that may be present even if the victim appears unhurt. 2. The primary survey is designed to rapidly determine life threatening problems and provide immediate interventions. 3. The secondary survey is a more detailed, head to toe assessment of the victim to determine if other injuries are present. This part of the examination helps determine more subtle findings.

Clinical observations on nail changes in psoriasis

410 cases of psoriasis [282 males (68%) and 127 females (31%)] were interviewed and examined to study the nail changes. The prevalence of nail changes was 78.0% (males = females). Common changes were pitting (67.5%) and onycholysis (67.2%). Dystrophy of varying degrees occurred in 35.0%, subungual hyperkeratosis in 24.7%, discoloration in 18.4%, loss of nails in 2.8% and pustulation in 1.3%. Pitting and onycholysis was the most common combination (45.6%). Nail changes were significantly more common in patients who have moderate to severe psoriasis as compared with patients with mild psoriasis; in patients who have psoriasis for greater than 5 years as compared with patients who have psoriasis for less than 5 years; and in patients older than age 50 as compared with those aged less than 50. A definite correlation was found between the prevalence of nail changes and the presence of scalp and periungual psoriasis, and the presence of joint involvement.

An 11-kDa form of human immunodeficiency virus protease expressed in Escherichia coli is sufficient for enzymatic activity

In order to define the protease domain of human immunodeficiency virus 1, various regions of the pol open reading frame were cloned and expressed in Escherichia coli. Antiserum directed against the conserved retroviral protease active site was used to identify pol precursor and processed species containing the presumed protease domain. The smallest product that accumulates is about 11 kDa as measured by NaDodSO4/PAGE. This size agrees with that predicted from the presence in this region of two Phe-Pro sequences, which is one of the cleavage sites recognized by HIV protease. DNA encoding only the predicted 11-kDa protein was cloned, bypassing the need for autoprocessing, and the protein was expressed to a high level in E. coli. This form is active as demonstrated by its ability to specifically cleave protease-deficient pol protein in vivo in E. coli. Extracts of E. coli containing the 11-kDa protease also process human immunodeficiency virus gag substrates in vitro. These results demonstrate that the 11-kDa protease is sufficient for enzymatic activity and are consistent with a major role for this form in virus maturation.

Evaluation of transport pathways for Na+ across frog skin epithelium by means of presteady-state flux ratio

A method is described that makes it possible to separate the sodium fluxes through the isolated frog skin into sets characteristic of the cellular and the paracellular pathway, respectively. If there are two significant pathways for the ion, and if they differ with respect to flux ratio as well as mean passage time, the flux ratios for the individual pathways can be obtained from a set of inward and outward tracer fluxes, covering the time from the addition of the tracers until the achievement of constant fluxes in both directions.

Ionic selectivity of the paracellular shunt path across rabbit corneal endothelium

We have measured the dilution and biionic potentials across the isolated rabbit corneal endothelium in order to learn about the ionic selectivity of its intercellular junctions. Single-salt dilution potentials have been measured as a function of [NaCl] or [NaHCO3] gradients across the tissue. Biionic potentials were similarly measured by replacing Na+ with K+ on either side of the tissue. The potentials thus measured were fit to the constant field equation and to an approximation of it to obtain the ionic permeabilities for K+, HCO-3 and Cl- relative to Na+. The permeability sequence obtained was PK greater than PNa greater than PHCO3 approximately equal to PCl. Potentials were also measured after imposing an osmotic gradient across the preparation using sucrose. The results obtained with all these methods are consistent and suggest that this tissue is slightly more permeant to cations than anions, but that the selectivity of the intercellular junction is relatively low. From these experiments, a 30 mM gradient of salt across the endothelial layer would be needed in order to explain the observed spontaneous potential difference (about 1 mV, aqueous negative) across that layer if the potential was due to the selectivity of the intercellular junctions. Such a value for the gradient is much larger than theoretical estimates of it; therefore, we favor electrogenic transport of HCO-3 as a better explanation for the origin of the spontaneous potential difference.

Analysis of presteady-state Na+ fluxes across the rabbit corneal endothelium

Instead of the conventional steady-state fluxes, the presteady-state fluxes of 22Na across the rabbit corneal endothelium were measured. In contrast to reports that there is no net Na+ movement across the corneal endothelium, we find a net transport of Na+ across this tissue. The direction of net Na+ flux is from the stromal to the aqueous side and the magnitude is 2.3 +/- 0.4 mueq/cm2 X hr (n = 11, SEM). Net Na+ transport is inhibited in the presence of ouabain (10(-4) M). Acetazolamide (10(-4) M) has only a slight inhibitory effect on the rate of Na+ transport but decreases the transendothelial potential difference by about 30%. The passive component of the Na+ transport has been estimated by analyzing the presteady-state influx and efflux curves and found to occur 10% via cellular and 90% via paracellular routes. The analysis for the separation of the pathways has been based on a recently proposed theory which holds that the flux ratio, regardless of its driving forces, is independent of time.

Electrical properties of rabbit corneal endothelium as determined from impedance measurements

Alternating- and direct-current electrical characteristics of rabbit corneal endothelium were studied under varying experimental conditions. The measurements were performed by sending a 10-microA current (AC or DC) across the tissue layer. Maximal values of transendothelial potential difference and resistance were 1.3 +/- 0.1 mV and 73 +/- 6 omega . cm2, respectively. The short-circuit current was estimated from the potential and resistance values. Impedance loci were obtained for the frequency range 0.5-100 kHz. A capacitive reactance (C = 0.63 +/- 0.02 microF/cm2) was observed in the 100 Hz-100 kHz range. To relate the impedance data to the electrical parameters of the cell membranes, the voltage-divider ratio was determined by sending square pulse across the tissue and measuring voltage responses across the apical and basal membranes with an intracellular microelectrode. The intracellular potential difference was on the average -61 +/- 1 mV, and the voltage-divider ratio was found to be between 0.33 and 4. Impedance data were fit by a computer to an equivalent circuit representing a "lumped" model, and the agreement between the model and the data was satisfactory. The results are discussed in terms of both the morphological characteristics and properties of the fluid transport mechanism across the preparation.

Na+ transport across the rabbit corneal endothelium

It has been reported so far that the Na+ transport across the corneal endothelium is symmetrical and therefore, that there is no net transport. We now report that there is a net Na+ transport across the rabbit corneal endothelium. Instead of measuring the conventional steady-state fluxes, pre-steady state fluxes were measured as a function of time (readings were taken at two minute intervals). This technique is based on a theory, proposed very recently, that the flux ratio (efflux/influx) is independent of time. Both the efflux and influx reached their steady state values about fifteen minutes after the addition of the isotope to one side of the chamber. The net sodium flux was obtained from the difference between the steady state efflux and influx values. The direction of the net Na+ flux was from the stromal to the aqueous side, with a magnitude of 2.3 +/- 0.4 microEq/h.cm2 (n = 11, S.E.M.). The net Na+ transport was inhibited by the presence of ouabain (10(-4)M).

Adenosine stimulation of fluid transport across rabbit corneal endothelium

The rate of fluid transport across rabbit corneal endothelium has been measured with an automatic volumetric method. The present resolution of the procedure is 1-3 nanoliters, and intervals of measurement can be made as small as seconds. In the presence of glucose, oxidized glutathione (GSSG), and adenosine, the maximal rates were 6.2+/-1.0 microliter/hr cm2, and 8.2+/-0.8 microliter/hr cm2 if a large portion of the stroma was dissected away. In the presence of glucose and GSSG only, the rates were lower, namely 3.7+/-0.5 microliter/hr cm2. The rates consistently increased or decreased when adenosine was added or deleted, respectively, during given experiments. The stimulation of fluid transport by adenosine was in the order of 40-50%. The results raise the possibility that this transport mechanism might be subject to metabolic control.

Standing-gradient osmotic flow. Examination of its validity using an analytical method

The solutions to the non-linear differential equations governing solute-solvent coupling in the intercellular spaces of epithelial layers have been obtained by using an analytical method, rather than the usual numerical ones. When the present series solution includes second-order correction terms, the concentration and velocity profiles obtained by the analytical method agree very well with those coming from numerical solutions. This method has further allowed us to examine the standing-gradient hypothesis when applied to the backwards fluid transport system of the corneal endothelium. With the information presently available for the relevant parameters (osmotic permeability, rate of transport, radius and length of the spaces, and location of the pumping sites), near-isotonicity of the transported fluid would not be explained by the standing-gradient model.

Role of cations, anions and carbonic anhydrase in fluid transport across rabbit corneal endothelium

1. A small electrical potential difference (541 +/- 48 muV, aqueous side negative) across rabbit corneal endothelium has been recently found. Its dependence on ambient [Na(+)], [K(+)], [H(+)] and metabolic and specific inhibitors was examined.2. Changes in concentration of the ions above either were known or were presently shown to affect the rate of fluid transport across this preparation (normal value: 5.2 +/- 0.4 mul./hr.cm(2)). Ionic concentration changes were also found here to influence potential difference in the same way as fluid transport. In the cases tested, the effects on both fluid transport and potential difference were reversible.3. Fluid transport and potential difference were both decreased or abolished in absence of Na(+), K(+) and HCO(3) (-), and when [H(+)] was decreased. Fluid transport and potential difference were saturable functions of [HCO(3) (-)] and half-saturation occurred in both cases at about 13 mM-HCO(3) (-). The potential difference was also a saturable function of [Na(+)] (half-saturation around 15 mM). There was a pH optimum for potential difference in the range 7.4-7.6. Lower pH values decreases the potential difference and the fluid transport, and a small (-100 muV) reversed potential was observed in the range of 5.3-5.5.4. Total replacement of Cl(-) by HCO(3) (-) or SO(4) (2-) produced no impairment on either fluid transport or potential difference.5. Carbonic anhydrase inhibitors (ethoxyzolamide 10(-5) or 10(-4)M and benzolamide 10(-3)M) produced a 40-60% decrease in the rate of fluid pumping. In contrast, ethoxyzolamide 10(-4)M or acetazolamide 10(-3)M did not produce any change in the potential difference. NaCN and Na iodoacetate (both 2 mM) eliminated the potential difference in 1-1.5 hr while in controls it lasted for 5-6 hr.6. Ouabain (10(-5)M) abolished the potential difference in less than 10 sec when added to the aqueous side, which suggests the existence of an electrogenic pump. This extremely fast time transient can be accounted for by the accessibility and simple geometry of the present monocellular layer. Ouabain abolished also the reversed potential difference observed at low pH.7. The data are interpreted in terms of a scheme similar to that advanced for other epithelia and in which (a) H(+) would be pumped into the intercellular spaces, while Na(+) and CO(2) would enter into the cells, and (b) Na(+) would be subsequently pumped into the aqueous humour, producing as a result the fluid movement observed. The actual origin of the potential difference is further discussed in terms of two contrasting possibilities: (i) one or more electrogenic pumps, and (ii) a neutral pump which would create a diffusion potential across ;leaky' intercellular junctions.

Thermogravimetric analysis of dentin

Four peaks were observed in the differential primary weight loss with temperatures up to 1,000 C. The first and second peaks correspond to the loss of water and the volatilization of protein. The third peak results from the carbonate. The fourth peak, which occurs at 700 to 800 C, probably is related to the transformation of hydroxyapatite to β-tricalcium phosphate. A zero order of reaction was assumed, and the activation energies in vacuum were determined to be 10.2 and 12.5 kcal/mol for loss of water and protein, respectively.

An investigation of the bound water in tendon by dielectric measurement

The dielectric constant of natural tendon in the frequency range of 200 Hz to 100 kHz has been determined as a function of temperature (300-450 degrees K) for water concentrations ranging from about 6 to 16% by weight. The results compare well with the approach taken by Haggis and his coworkers. Based on the assumption that at low concentration of water the probability of water-water bonding is small and hence may be disregarded, a structure for water in the collagen matrix is proposed in which the water is either bonded in one of four possible states to the polar groups of the polypeptide chains, or is unbound. In determining the distribution of the water among these states an approach similar to that of Haggis and his co-workers, in conjunction with the order-disorder theory of Bragg and Williams, is used. The number of water molecules per unit volume is then determined experimentally by relating it to weight loss as a function of temperature, as determined by thermogravimetric analysis. The dispersion which is normally found in dipolar substances has not been found for tendon. A maximum in the value of the dielectric constant is observed to occur between 25 and 80 degrees C, the temperature depending upon the heating rate.