[show abstract][hide abstract] ABSTRACT: Systemic lupus erythematosus (SLE), a chronic illness with an unpredictable and variable course, profoundly affects the quality of life (QOL). General health questionnaires are used to assess QOL in SLE, but a disease-specific instrument could offer enhanced responsiveness and content validity. We detail the steps we took to develop and validate a new SLE-specific QOL instrument, SLEQOL.
Rheumatology professionals nominated items that they felt were important determinants of QOL of SLE patients. One hundred SLE patients were asked to assess the importance and frequency of occurrence of these items and to suggest those that had not been listed. Item reduction was performed using Rasch model and factor analyses to create a new questionnaire in English. This final questionnaire was administered to a cohort of 275 patients to study its psychometric properties.
Fifty-one items covering a wide range of QOL concerns were identified. The patients' responses led to the elimination of 11. The new questionnaire of 40 items was found to have Cronbach's alpha of 0.95 and to consist of eight domains covering physical, mental and social QOL issues. It has good test-retest reliability, poor to fair cross-sectional correlation with the SF-36, with poor correlation with lupus activity or damage indices. The SLEQOL was more responsive to change than the SF-36.
We have developed a new 40-item SLEQOL in English and showed that it is valid for use in SLE patients in Singapore. It offers better content validity and responsiveness to change than the SF-36.
[show abstract][hide abstract] ABSTRACT: The importance of assessing health-related quality of life (HRQL) of patients with allergic rhinitis (AR) has been well established, but the specific roles of rhinitis-specific or general health instruments have not been delineated.
We analysed the psychometric properties of a disease-specific instrument, the Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ) and the general health instrument, the Medical Outcome Short-Form 36 (SF-36) as they are employed in combination in patients with persistent AR in clinical practice.
We analysed the data collected from a prospective study of 43 newly diagnosed patients with persistent AR and 44 controls. We interviewed the patients four times, at baseline, weeks 4, 8 and 10.
The RQLQ and SF-36 have good discriminative property, internal consistency, and test-retest reliability. The RQLQ is superior to the SF-36 as an evaluative instrument because more of its domains respond to change, the magnitude of change was greater, and the response was faster. The SF-36 is more susceptible to floor and ceiling effects. Both instruments are unsuitable for mildly symptomatic patients based on Rasch model analysis. Each questionnaire assesses a distinct and significant portion of the total HRQL of persistent AR.
The SF-36 and RQLQ are good for discriminating rhinitis patients from controls, but the former is poor for detecting changes in QOL. Both are inappropriate for mildly symptomatic patients. Each instrument measures non-overlapping halves of the measurable HRQL. For an assessment of the HRQL in persistent AR that is complete and responsive both instruments should be employed together.
[show abstract][hide abstract] ABSTRACT: It is unclear whether patients use alternative medicine because of psychological distress associated with their disease or philosophical congruence with this form of treatment. Therefore, we have studied why patients with systemic lupus erythematosus (SLE) employ alternative medicine. We interviewed 192 consecutive Chinese SLE outpatients in a tertiary-care rheumatology centre. We recorded their demographic data, usage of traditional Chinese medication, the predominant form of alternative medicine in this group, and the Rheumatology Attitudes Index score. We distinguished two types of alternative medicine users: those who use it with intent to treat SLE (disease-specific users; 73 users, 38.0%) and those who use it for cultural and other reasons (general-health users; 55 users, 28.6%). Users regarded their disease as mild compared to nonusers. Disease-specific users were distinguished from nonusers by having Chinese as a first language (odds ratio, 2.14-8.83), greater learned helplessness (odds ratio, 1.02-1.29), and an earlier age of diagnosis (odds ratio, 0.92-0.98 for older age). In conclusion, the majority of our lupus patients have used alternative medicine. The motivations of general-health and disease-specific users are different. The patients' first language and perceived helplessness influenced the disease-specific users, while general-health users were subject to neither of these.
[show abstract][hide abstract] ABSTRACT: Patients with systemic lupus erythematosus (SLE) frequently have gastrointestinal (GI) symptoms. These are usually self-limiting and related to treatment side-effects or concurrent illness. However, abdominal pain may be due to bowel ischaemia which can lead to infarction and perforation. The likelihood of these serious events is increased in individuals with pain severe enough to require assessment in hospital or a SLEDAI score > 5. This paper describes a group of patients with active SLE and GI symptoms severe enough to require admission to hospital using a retrospective review of 52 SLE patients admitted to hospital with acute abdominal symptoms. The results showed that abdominal pain (87%), vomiting (82%) and diarrhoea (67%) had been present for a mean of 4.4 +/- 6.5 days and SLEDAI score was > or = 4 in 83% of patients. CT scanning showed evidence of serositis and bowel involvement in 63% of patients who underwent this investigation. Intravenous (iv) fluids were used in 87%, parenteral steroids in 90% and iv cyclophosphamide in 31%. Most (n = 51) were discharged well. Recurrence of GI symptoms occurred in 12 patients. The conclusions are that active SLE may manifest as an acute gastrointestinal syndrome. Early diagnosis, bowel rest, supportive medical therapy and treatment with corticosteroids and/or immunosupressives can result in a good outcome.
[show abstract][hide abstract] ABSTRACT: The aim of the study was to investigate and compare the usefulness and accuracy of various cardiac markers [troponin I, creatine kinase MB (CKMB) mass, creatine kinase (CK), CKMB activity] to aid early diagnosis of myocardial infarction. We also examined the ability of the various cardiac markers to prognosticate future adverse cardiac events.
Patients admitted within 8 hours of maximal chest pain suggestive of acute coronary syndrome with non-diagnostic electrocardiograms were recruited. Blood samples were obtained on admission to the wards and repeated 4 hours later. These results were later correlated to the final hospital discharge diagnosis.
The 37 patients in the study were a high-risk population with over 50% presenting with a Thrombolysis in Myocardial Infarction (TIMI) risk score of greater or equal to 3. Myoglobin was the most sensitive marker (100% sensitivity) in early prediction of patients who were subsequently diagnosed to have a myocardial infarction. Patients with an elevated troponin I level but normal CK and myoglobin levels had a significantly higher risk of developing a major adverse clinical event (MACE) within 3 months of the initial presentation.
Myoglobin is the most sensitive marker when compared to CK, CKMB and troponin I for diagnosing patients presenting early with chest pain and a non-diagnostic electrocardiogram and who subsequently develop either a ST-elevation myocardial infarction or non-ST elevation myocardial infarction. Patients with an elevated troponin I level but normal CK and myoglobin levels are at higher risk of an adverse clinical event.
Annals of the Academy of Medicine, Singapore 12/2002; 31(6):772-6. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Hyperhomocysteinaemia is an emerging risk factor for coronary artery disease (CAD) and most studies done to date are in Caucasian populations. We aimed to determine whether hyperhomocysteinaemia is a risk factor for acute myocardial infarction (AMI) in a Southeast Asian population comprising different ethnic groups and relate it to the traditional risk factors and plasma vitamin B12 and folate levels.
This was a case-control study comprising 168 AMI patients and 141 controls with a median age of 55 years (range, 27 to 77 years), living in Singapore. Homocysteine was measured by fluorescence polarisation immunoassay and vitamin B12 and folate were measured by electrochemiluminescence immunoassay. Logistic regression analysis was use to test the association of homocysteine, vitamin B12 and folate with the occurrence of AMI. The study was approved by the Tan Tock Seng Ethics Committee.
We found that the odds of having AMI was higher for subjects with hypertension, smoking habit, lower plasma folate and vitamin B12 levels and non-Chinese ethnic group. On the other hand, plasma homocysteine level was not significantly associated with AMI. The baseline levels of plasma total homocysteine in both AMI patients and controls were higher than other studies (median values between 12 and 14 umol/L).
In our population, plasma total homocysteine levels were not associated with AMI but low plasma levels of folate and vitamin B12 were independently associated.
Annals of the Academy of Medicine, Singapore 10/2002; 31(5):636-40. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine norms for assessing Health-related Quality of Life (HRQOL) in Singapore using the Short Form 36 Health Survey (SF-36).
Mean SF-36 scores were calculated for 24 population subgroups (categorised by age, gender, ethnicity and questionnaire language) and for subjects with self-reported co-morbid conditions using data from a community-based survey in Singapore.
The English and Chinese SF-36 was completed by 4122 and 1381 subjects, respectively, 58% (n = 3188) of whom had self-reported co-morbid conditions. SF-36 scores varied in subgroups differing in age, gender and ethnicity. In general, subjects with self-reported co-morbid conditions had lower SF-36 scores than those without these conditions, the magnitude of which exceeded 20 points in several instances. A method for calculation of SF-36 scores adjusted for age, gender, ethnicity and questionnaire language is described.
We present norms for English and Chinese SF-36 versions in Singapore and describe potential uses for these data in assessing HRQOL in Singapore.
Annals of the Academy of Medicine, Singapore 06/2002; 31(3):366-74. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Despite the prognostic importance of learned helplessness (LH) in rheumatic diseases, there are no validated measures of LH in Chinese or other Asian languages. We therefore assessed the validity of a Chinese translation of the Rheumatology Attitudes Index (CRAI; a widely used measure of LH) and its Helplessness (CHS) and Internality (CIS) subscales in patients with SLE. Chinese-speaking SLE patients (n = 69) completed identical, self-administered questionnaires containing the CRAI and assessing demographic/socio-economic variables twice within 2 weeks. SLE activity, damage and quality of life were assessed using the BILAG, SLICC/ACR Damage Index and SF-36 respectively. Scale psychometric properties were assessed through Cronbach's alpha, intra-class correlations, quantifying test-retest differences, factor analysis and known-groups construct validity. Internal consistency and reliability were acceptable, with Cronbach's alpha for the CHS, CIS and CRAI being 0.70, 0.69 and 0.74, respectively. Mean differences in test-retest scores spanned 1.6-2.4% of possible scale ranges and intra class correlations ranged from 0.72 to 0.88. Factor analysis identified two major factors corresponding to the CHS and CIS subscales of the CRAI. Eight of 10 a priori hypotheses relating the CRAI and CHS to demographic, disease and quality of life variables were confirmed, supporting the construct validity of these scales. The CRAI and its helplessness subscale are valid and reliable measures of learned helplessness in Chinese-speaking SLE patients.
[show abstract][hide abstract] ABSTRACT: We sought to test our clinical impression that using a low dose methylprednisolone pulse (MEP; < or = 1500 mg over 3 days) in treating flares of systemic lupus erythematosus (SLE) was effective and associated with fewer serious infections. We retrospectively studied SLE patients who received MEP between 1989 and 2000. A 'low dose' group of 26 patients who had received 1-1.5 g and a 'high dose' group of 29 patients who received 3-5 g of MEP were identified. SLEDAI scores and prednisolone doses were recorded at the time of MEP pulses and 6 months later. All serious infections (requiring admission and i.v. antibiotics) occurring during this 6 month period and their outcomes were recorded. Both groups had similar demographic data, initial SLEDAI scores, i.v. cyclophosphamide use, and SLE organ involvement. Despite high- and low-dose MEP being efficacious in controlling disease activity (lowering of SLEDAI scores and subsequent prednisolone dose) there were only nine episodes of serious infection in seven patients in the low-dose group compared with 20 episodes in 17 patients from the high-dose group (P = 0.04). In both groups a majority of infections (75 and 77% in the high- and low-dose groups) occurred in the first month after MEP. Those with a low serum albumin (< 20 g/l) had an increased risk of mortality (OR 44, 90% CI 6.19-312.98) and a trend towards greater numbers of infections. Low-dose MEP was effective in controlling SLE flares and associated with fewer serious infections than traditional high-dose MEP.
[show abstract][hide abstract] ABSTRACT: When standing height (StndHt) cannot be assessed, arm span (AS) or sitting height (SitHt) has been used as surrogate variables for prediction of StndHt in adult caucasians and blacks. We examined (1) the relationship between StndHt, AS and SitHt among adult Chinese, Malays and Indians; and (2) whether anthropometry could explain the ethnic differences in lung volumes (as StndHt-adjusted lung volumes are known to differ significantly: Chinese > Malays > Indians). We recruited 1250 consecutive outpatients aged 20-90 years. Prediction equations of StndHt (with AS, SitHt, weight, age as predictors) for each subgroup of race and sex were formulated with multiple linear regressions. Equations with both AS and SitHt as predictors had the best goodness of fit (SEE = 2.37-2.85 cm, adjusted R2 = 0.67-0.87), as compared to equations with either AS (SEE = 3.00-3.91 cm, adjusted R2 = 0.58-0.80) or SitHt alone (SEE = 3.48-4.00 cm, adjusted R2 = 0.45-0.76). GLM general factorial analyses found that age- and weight-adjusted SitHt-to-StndHt ratios differed significantly among Chinese (0.539), Malays (0.529) and Indians (0.518). This paralleled the ethnic differences in lung volumes. The equations with both AS and SitHt as predictors provide the most accurate estimate of StndHt. Ethnic differences in upper body segment length may explain in part the lung volume differences.
Respiratory Medicine 04/2001; 95(4):297-304. · 2.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: Scaling assumptions and validity of the English (UK) and Chinese (HK) short form 36 health survey (SF-36) were assessed in a community-based survey of 5,503 Chinese, Malays and Indians in Singapore using the international quality of life assessment project approach of item and scale level validation. Missing data for SF-36 items and scales occurred in less than 1.0% of subjects. Item level validation of both versions generally supported assumptions underlying Likert scoring and hypothesised item-order clustering. Item level factor analysis supported the eight-scale structure of the SF-36. In scale level validation, SF-36 scale scores showed wide variability and acceptable internal-consistency reliability (Cronbach's alpha > 0.70 for six English and seven Chinese scales), conformed to hypothesised patterns and generally varied according to hypotheses in subjects known to differ in quality of life. Scale level factor analysis of both versions yielded very similar patterns of factor correlation, comparable to that found in Japan, but differing from that seen in Western populations. Taken together, these results support the validity of the English (UK) and Chinese (HK) SF-36 versions in the multi-ethnic Asian socio-cultural context of Singapore.
Quality of Life Research 02/2001; 10(2):175-88. · 2.41 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Singapore Tuberculosis Control Unit.
1) To identify any demographic, social, disease or treatment-related characteristics which may be predictive of patients defaulting from treatment; 2) to assess the effectiveness of home visits as a means of defaulter recall; 3) to ascertain outcome in these patients.
A retrospective, case-controlled study of TB treatment defaulters, defined as patients who missed their scheduled appointments and required a home visit to recall for treatment. Controls were randomly selected, non-defaulting patients who started treatment on the same dates as the defaulters.
Forty-four patients required home visits in 1996. Compared to controls, defaulters were more likely to be non-Chinese, and to live on their own or with friends. There was no significant association of defaulting with age, sex, marital or employment status, disease characteristics, or treatment-related factors. Seventy per cent defaulted during the continuation phase of treatment. Home visits did not result in contact with the patient (or any other person) 41% of the time. Although 48% of the defaulters remained lost to follow-up at the time of the survey, all but one of the sputum-positive patients had bacteriologically converted by the time of default.
Non-Chinese ethnicity and lack of family support were found to be factors strongly predictive of default. Age, sex, marital and employment status, treatment-related factors and disease characteristics were not significant in distinguishing those at risk for defaulting.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 07/2000; 4(6):496-503. · 2.61 Impact Factor
[show abstract][hide abstract] ABSTRACT: To prospectively identify factors influencing quality of life (QOL) over 6 months in patients with systemic lupus erythematosus (SLE).
Ninety ethnically diverse patients with SLE completed questionnaires administered 6 months apart assessing QOL (using the Medical Outcomes Study Short Form-36) and demographic, socioeconomic, psychosocial, and behavioral factors. Disease activity, damage, and treatment were recorded at both evaluations. Multiple linear regression (adjusting for baseline health status) was used to identify factors influencing mental and physical health.
Improved physical health after 6 months was associated with reductions in learned helplessness (p = 0.034), improved mental health (p<0.001), longer disease duration (p = 0.009), and better physical health at baseline (p = 0.027). Improved mental health after 6 months was associated with better family support (p = 0.002), improvements in physical health (p<0.001), disease activity, and prednisolone dose (interaction term p = 0.019), less disease related damage (p<0.001), non-use of cytotoxic drugs (p = 0.02), and older age at diagnosis (p = 0.007).
Potentially modifiable psychosocial, disease, and therapy related factors influence QOL in patients with SLE.
The Journal of Rheumatology 06/2000; 27(6):1414-20. · 3.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: To study the accuracy of medical record scoring of the SLICC/ACR Damage Index (DI) for SLE.
Medical record DI (MDI) scoring of 60 SLE patients by one physician was compared with prospective direct DI (DDI) scoring a median of 2 y earlier. Agreement between DDI and MDI total and organ system scores was compared using Cohen's kappa, the degree of misclassification by MDI and the significance of differences between DDI and MDI scores.
The mean duration of SLE at DDI scoring was 5.2 y. The median/mean (SD) DDI and MDI total scores were 0/0.78 (1.38) and 0/0. 85 (1.44). Damage was present on DDI and MDI scoring in 36.7% (22/60) and 38.3% (23/60) of patients. Qualitative MDI and DDI total scores (damage present/absent) showed good agreement (kappa=0.61, 95% CI=0.40-0.82, 18.3% misclassification). Quantitative MDI and DDI total scores (degree of damage) showed moderate agreement (kappa=0. 47, 95% CI=0.28-0.66, 36.7% misclassification). 9 of 12 MDI organ system scores misclassified <10% of subjects. There was no statistically significant difference between DDI and MDI total or organ system scores.
MDI total scoring is a good qualitative and moderate quantitative reflection of SLE related damage. MDI organ system scores are more accurate than MDI total scores.
[show abstract][hide abstract] ABSTRACT: Though sufferers of perennial allergic rhinitis do not die from their ailment, they endure years of chronic nose disease that Interferes with many important aspects of their lives. A rhinitis-specific instrument to gauge the quality of life of patients with this disease was published in 1991. Here, we validated the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) for use in English-speaking patients with perennial allergic rhinitis. We established that the RQLQ distinguishes between patients and control, demonstrates internal consistency and is sensitive to change. This study suggests that the RQLQ can be used to assess the quality of life of patients with perennial allergic rhinitis in Singapore.
Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand 10/1999; 17(3):163-7. · 0.79 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine the frequency and character of temporomandibular disorders (TMD) in Oriental patients with rheumatoid arthritis (RA) and to investigate the relationship between TMD and RA in a tertiary referral center.
Symptoms and signs related to TMD were investigated in 80 patients (67 female, 13 male) who fulfilled the American College of Rheumatology 1987 revised criteria for RA. Diagnoses of TMD including muscle, disk displacement, or temporomandibular joint (TMJ) disorders were made based on clinical assessment. TMJ disorder was then correlated with the clinical, laboratory, and radiological features of RA.
The mean age of the study population was 49.7 years and the mean duration of RA was 86.9 months. Eleven patients (13.8%) had active RA at the time of TMD assessment. About 76% of the study population had seropositive disease and 62% had peripheral joint erosions. Osteoarthrosis of the TMJ was the most common TMD in this Oriental population. Joint sounds on opening (35%), joint sounds on moving sideways or forward (27.5%), and pain in jaw joints (23.7%) were common TMD symptoms. Deviated mouth opening (45%) and coarse crepitus (15-21.3%) were most prevalent on examination.
Patients with RA who had prolonged disease duration of RA and active peripheral joints tended to have osteoarthrosis of the TMJ. Presence of rheumatoid factor or peripheral joint erosions was not associated with TMJ osteoarthrosis.
The Journal of Rheumatology 10/1999; 26(9):1918-22. · 3.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: To assess the internal consistency, reliability, and construct validity of the Rheumatology Attitudes Index (RAI) and its subscales in a cohort of Asian patients with systemic lupus erythematosus (SLE).
English speaking ethnic Chinese, Malay, or Indian patients with SLE (n = 120) seen at a rheumatology unit completed a questionnaire containing the RAI twice within a 2 week period. Lupus activity was assessed using the British Isles Lupus Activity Group (BILAG) score, disease related damage using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index, and quality of life using the Medical Outcome Survey Short Form 36 Health Survey (SF-36). Factor analysis and Cronbach's alpha were used to study the psychometric properties of the RAI. The magnitude of test-retest differences was assessed using the method of Bland and Altman. Relationships between the RAI, its helplessness (HS) and internality (IS) subscales, and BILAG, SLICC/ACR damage index and SF-36 scores were studied using Spearman's rank correlation.
Factor analysis (n = 105) identified 2 factors corresponding to the HS and IS subscales of the RAI. All scales showed acceptable internal consistency, with Cronbach's alpha of 0.64 for the HS, 0.77 for the IS, and 0.74 for the RAI. Mean (SD) test-retest differences were 0.85 (3.96) points for the HS (n = 86), 0.81 (4.44) points for the IS (n = 85), and 1.46 (7.88) points for the RAI (n = 74). Six of 10 hypotheses relating the RAI and HS to demographic, disease, and quality of life variables were confirmed, supporting the construct validity of these scales.
The RAI and its helplessness subscale are valid and reliable measures of learned helplessness in a multiethnic cohort of Asian patients with SLE in Singapore.
The Journal of Rheumatology 08/1999; 26(7):1512-7. · 3.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: To validate the Medical Outcomes Study Family and Marital Functioning Measures (FMM and MFM) in a multi-ethnic, urban Asian population in Singapore.
English speaking Chinese, Malay or Indian SLE patients (n=120) completed a self-administered questionnaire containing the FFM and MFM at baseline, after 2 weeks and after 6 months. Lupus activity, disease-related damage and quality of life were assessed using the British Isles Lupus Assessment Group (BILAG), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index and SF-36 Health Survey respectively. Scale psychometric properties were assessed through factor analysis, Cronbach's alpha, quantifying test-retest differences and known-groups construct validity.
Factor analysis of scores obtained at baseline and after 6 months identified 3 factors corresponding to the FFM (1 factor) and the MFM (2 factors). Both scales showed acceptable internal consistency, with Cronbach's alpha of 0.95 for the FFM and 0.70 for the MFM. Mean (s.d.) test-retest differences were -0.31 (3.82) points for the FFM and -0.70 (4.26) points for the MFM. Eleven out of 13 a priori hypotheses relating both the FFM and MFM to demographic, disease and quality of life variables were confirmed, supporting the construct validity of these scales.
The FFM and MFM are valid and reliable measures of family and marital functioning in a multi-ethnic cohort of Asian SLE patients in Singapore.