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Brunei Darussalam Elsewhere Brunei Int Med J. 2011; 7 (4): 240-243
This section of the journal serves to highlight the works and researches done by local
doctors or doctors either in Brunei Darussalam or in collaborations with other centers
that have been published in regional or international journals. This also includes works
published as part of collaboration with centers outside of Brunei Darussalam. These
works include review articles, original articles and case reports published between 16th
June to 15th August 2011. (Some publications have been published or indexed at a later
date than publication).
TEC-family kinases in health and
disease: Loss-of-function of BTK and
ITK and the gain-of-function fusions
ITK-SYK and BTK-SYK.
Hussain A, Yu L, Faryal R, Mohammad DK, Mo-
hamed AJ, Edvard Smith CI.
FEBS J. 2011 Apr 23. doi: 10.1111/j.1742-
4658.2011.08134.x.
The TEC-family constitutes an ancient and the sec-
ond largest family of cytoplasmic tyrosine kinases.
In 1993 loss-of-function mutations in the BTK gene
were reported as the cause of X-linked agammag-
lobulinemia (XLA). Out of all the existing 90 tyro-
sine kinases in humans, BTK is the kinase where
most mutations have been identified. These experi-
ments of nature collectively provide a form of mu-
tation scanning with direct implications for those
several hundred endogenous signaling proteins
carrying domains also found in BTK. In 2009 an
inactivating mutation in the ITK gene was shown to
cause susceptibility to lethal Epstein-Barr virus in-
fection (EBV). Both kinases represent interesting
targets for inhibition; in the case of BTK as an im-
munosuppressant, while there is evidence that inhi-
bition of ITK could influence the infectivity of HIV
and also have anti-inflammatory activity. Since
2006 several patients carrying a fusion protein,
originating from a translocation joining genes en-
coding the kinases ITK and SYK, were found to
develop T-cell lymphoma. We review these disease
processes and also describe the role of the N-
terminal PH-TH domain doublet of BTK and ITK in
the downstream intracellular signaling of such fu-
sion proteins.
Correspondence: Benjamin MA. Department of Obstetrics
and Gynecology, RIPAS Hospital, Bandar Seri Begawan,
Brunei. mridulaben@yahoo.com.
A r t i c l e i s a v ai l a bl e f r ee f r o m h t tp : / /
www.jmedicalcasereports.com/content/4/1/136 (Journal
website).
Basilar artery stenosis.
Bickle IC, Warren DJ, Genever A. Abdominal Imag-
ing. Case 8492. 10.1594/EURORAD/CASE.8492
This 35-year-old lady attended A & E complaining
of headache and brief loss of consciousne ss. After
an unremarkable clinical assessment she was dis-
charged home. Three hou rs later she returned with
similar symptoms and whilst awaiting review her
GSC dropped to 7/15. Intubation was required.
Prompt CT imaging of the head was performed.
Correspondence: Ian Bickle, Department of Radiology,
and Department of Medicine, RIPAS Hospital, Brunei Da-
russalam. Article available from EURORAD website at
http://www.eurorad.org/case.php?id=8492
Exophytic gastric adenocarcinoma.
Bickle I, Chong VH, Alludin BPM.Abdominal Imag-
ing. Case 9300. 10.1594/EURORAD/CASE.9300
This 79-year-old lady presented with a four week
history of upper abdominal pain, anorexia, vomiting
and mild weight loss. She denied any previous his-
tory of abdominal problems or melena. Her only
relevant past medical history was of hypertension
and dyslipidemia. Examination revealed a non-
tender epigastric mass.
Correspondence: Ian Bickle, Department of Radiology,
and Department of Medicine, RIPAS Hospital, Brunei Da-
russalam. Article available from EURORAD website at
http://www.eurorad.org/case.php?id=9300
Analysis of APC allelic imbalance/
loss of heterozygosity and APC
protein expression in cutaneous
squamous cell carcinomas.
Gray SE, Kay EW, Leader M, Mabruk M.
Brunei Int Med J. 2011; 7 (4): 241
Cancer Genomics Proteomics. 2011 May-Jun;8
(3):149-55.
BACKGROUND: The adenomatous polyposis coli
(APC) gene is a tumor suppressor gene which is
mutated in the hereditary disease, familial adeno-
matous polyposis (FAP). Somatic mutations of the
APC gene have also been identified in the majority
of sporadic colorectal carcinomas, and mutation of
the APC gene appears to be an early step in the
initiation of colon cancer. Loss of heterozygosity
(LOH) of APC has been described in a variety of
other cancer types, including renal cell carcinoma,
gastric cancer, non-small cell lung cancer, endo-
metrial cancer and oral squamous cell carcinomas
(SCC). Aim: To determine the role played by APC
gene in the genesis of cutaneous SCC. MATERIALS
AND METHODS: Allelic imbalance/loss of het-
erozygosity (AI/LOH) was examined in twenty-two
histologically confirmed cutaneous squamous cell
carcinomas (SCC) using microsatellite markers,
proximal to the APC gene. Immunohistochemical
analysis of APC protein expression was also exam-
ined in the cutaneous SCC. RESULTS: AI/LOH was
detected in 60% of the SCC samples using D5S346
marker (proximal to the APC gene). Ninty-five per-
cent of the SCC samples showed positive reduced
APC expression, however the localization of the APC
protein was abnormal. CONCLUSION: The abnor-
mal expression of APC suggests that APC gene may
play a role in cutaneous SCC development.
Correspondence: Professor M Mabruk, PAPRSB Institute
of Health Sciences, University of Brunei Darussalam Jalan
Tungku Link, Gadong BE1410 Bandar Seri Begawan,
Brunei Darussalam. Email to mabruk@ubd.edu.bn/
mmabruk03@yahoo.co.uk.
Comparison of RIPASA and Alvarado
scores for the diagnosis of acute
appendicitis
Chong CF, Thien A, Mackie AJA, Tin AS, Tripathi S,
Ahmad MA, Tan LT, Ang SH, Telisinghe PU.
Singapore Med J 2011:52(5):340-5.
Introduction: The accuracy of the Alvarado score
in diagnosing acute appendicitis in an Asian popula-
tion has been disappointingly low. We prospectively
compared the RIPASA score with the Alvarado
score for the diagnosis of acute appendicitis. Meth-
ods: 200 consecutive patients who presented to
the Accident and Emergency Department with right
iliac fossa pain were recruited in the study. Both
the RIPASA and Alvarado scores were derived, but
decisions for appendicectomy were based on clinical
judgement. Receiver operating curve (ROC), sen si-
tivity, specificity, positive predictive value (PPV)
and negative predictive value (NPV) for both scor-
ing systems were calculated. Results: Only 192
out of the 200 patients who satisfied the inclusion
and exclusion criteria were included in the analysis.
At the optimal cut-off threshold score of 7.5 derived
from the ROC, the sensitivity, specificity, PPV, NPV
and diagnostic accuracy of the RIPASA score were
98.0 percent, 81.3 percent, 85.3 percent, 97.4 per-
cent and 91.8 percent, respectively. At the cut-off
threshold score of 7.0 for the Alvarado score, the
sensitivity, specificity, PPV, NPV and diagnostic
accuracy were 68.3 percent, 87.9 percent, 86.3
percent, 71.4 percent and 86.5 percent, respec-
tively. The RIPASA score correctly classified 98 per-
cent of all patients confirmed with histological acute
appendicitis to the high-probability group (RIPASA
score greater than 7.5) compared with 68.3 per-
cent with the Alvarado score (Alvarado score
greater than 7.0; p-value less than 0.0001). Con-
clusion: The RIPASA score at a cut-off threshold
total score of 7.5 is a better diagnostic scoring sys-
tem than the Alvarado score for the diagnosis of
acute appendicitis in our local setting.
Correspondence: Chong CF. Department of General Sur-
gery, Raja Isteri Pengiran Anak Saleha Hospital, Bandar
Seri Begawan, BA 1710, Brunei Darussal am.
Email: chong_chee_fui@hotmail.com. Article available free
from http://smj.sma.org.sg/5205/5205a2.pdf (Journal
website)
Melioidosis of the extremities in
Brunei Darussalam
Pande KC, Hj Abdul Kadir KA. Singapore Med J
2011:52(5):346-50.
Introduction: Melioidosis caused by Burkholderia
pseudomallei is an infectious disease endemic to
Southeast Asia and northern Australia. It has a
broad spectrum of clinical manifestations and high
mortality, and can mimic other infectious diseases.
The aim of this study was to review cases of melioi-
dosis of the extremities in Brunei Darussalam.
Methods: Culture-positive cases for Burkholderia
pseudomallei in Raja Isteri Pengiran Anak Saleha
Hospital were identified from records in the Microbi-
ology Department. The case notes were reviewed
to identify patients who were treated for problems
affecting the extremities. 14 (13 males and one
female) out of 48 patients were identified. Results:
The median age of the patients was 45 (range 14–
55) years. Septicaemia was the most common pre-
senting feature in 11 patients. Multisystem involve-
ment was noted in eight patients, diabetes mellitus
in nine patients and other risk factors in two pa-
tients. Blood culture was positive in ten patients
and pus culture in 11 patients. The presentations
noted were cellulitis of the limbs, abscess, osteo-
myelitis (three patients each) and septic arthritis
(five patients). Orthopaedic intervention (joint
washout/incision and drainage/curettage) was re-
quired in 11 patients. The median hospital stay was
27.5 (range 13–63) days; two patients required
admission to intensive care. No mortality was re-
ported. Conclusion: Melioidosis of the extremities
is not uncommon in Brunei Darussalam. It is asso-
ciated with significant morbidity, and a large num-
ber of patients require surgical intervention. Thus,
a high index of suspicion is required for early diag-
nosis and institution of appropriate antibiotic ther-
apy.
Correspondence: Pande KC. Department of Orthropae-
dics, Raja Isteri Pengiran Anak Saleha Hospital, Bandar
Seri Begawan, BA 1710, Brunei Darussal am.
E mail: ketanpande@yahoo.com.
Article available free from http://
smj.sma.org.sg/5205/5205a3.pdf (Journal website)
Physician home visit by palliative
medical fellow.
Ang SK, Legrand SB, Walsh D, Davis MP, Lagman
RL. Am J Hosp Palliat Care. 2011 Jun 10. [Epub
ahead of print]
BACKGROUND: Physician home visits (HVs) are an
important model of care for the terminally ill. Hos-
pice and palliative medicine (HPM) fellows make a
minimum of 25 HVs. OBJECTIVE: To describe HPM
fellow hospice HVs in an academic palliative medi-
cine practice. METHODS: Retrospective chart re-
view of HVs conducted by 1 HPM fellow. RESULTS:
Twenty-five HVs were made to 21 hospice patients.
Nineteen had advanced cancer. Indications for vis-
its were symptom management (22) and education
(21). On average 2.8 symptoms (± SD 1) were
addressed on each visit, usually pain. Medications
were reviewed at every visit. CONCLUSIONS: HVs
are an important part for patient care and fellow
education, which provided an opportunity for medi-
cation revision and sympto m education.
Correspondence: Ang SK. Department of I nternal Medi-
cine, RIPAS Hospital, Bandar Seri Begawan, Brunei. E mail:
Sikim2000@gmail.com
Performance and cross-cultural
comparison of the short-form
version of the CPQ11-14 in
New Zealand, Brunei and Brazil.
Foster Page LA, Thomson WM, Mohamed AR, Trae-
bert J. Health Qual Life Outcomes. 2011 Jun 7;9
(1):40. [Epub ahead of print]
BACKGROUND: The Child Perception Question-
naire (CPQ11- 14) is a self-report instrument devel-
oped to measure oral-health-related quality of life
(OHRQoL) in 11-14-year-olds. Earlier reports con-
firm that the 16-item short-form version performs
adequately, but there is a need to determine the
measure's validity and properties in larger and
more diverse samples and settings. Aim: The ob-
jective of this study was to examine the perform-
ance of the 16-item short-form impact version of
the CPQ11-14 in different communitie s and cultures
with diverse caries experience. METHOD: Cross-
sectional epidemiological surveys of child oral
health were conducted in two regions of New Zea-
land, one region in Brunei, and one in Brazil. Chil-
dren were examined for dental caries (following
WHO guidelines), and OHRQoL was measured using
the 16-item short-form item-impact version of the
CPQ11-14, along with two global questions on
OHRQoL. Children in the 20% with the greatest
caries experience (DMF score) were categorised as
the highest caries quintile. Construct validity was
evaluated by comparing the mean scale scores
across the categories of caries experience; correla-
tional construct validity was assessed by comparing
mean scores and children's global ratings of oral
health and well-being. RESULTS: There were sub-
stantial variations in caries experience among the
different communities (from 1.8 in Otago to 4.9 in
Northland) and in mean CPQ11-14 scores (from
11.5 in Northland to 16.8 in Brunei). In all samples,
those in the most severe caries experience quintile
had higher mean CPQ11-14 scores than those who
were caries-free (P<0.05). There were also greater
CPQ scores in those with worse self-rated oral
health, with the Otago sample presenting the most
marked gradient across the response categories for
self-rated oral health, from 'Excellent' to 'Fair/
Poor' (9.6 to 19.7 respectively). CONCLUSION:
The findings suggest that the 16-item short-form
item impact version of the CPQ11-14 performs well
across diverse cultures and levels of caries experi-
ence. Reasons for the differences in mean CPQ
scores among the communities are unclear and
may reflect subtle socio-cultural differences in sub-
jective oral health among these populations, but
elucidating these requires further exploration of the
face and content validity of the measure in different
populations. Key Words: Adolescents, caries experi-
ence, quality of life, validity, short-form CPQ11-14.
Brunei Int Med J. 2011; 7 (4): 242
Brunei Int Med J. 2011; 7 (4): 243
Complete Dislocation of the Lens of
the Eye - Always review the com-
plete study.
Bickle I. Philipp J Otolaryngol Head Neck Surg
2011; 26(1):49-50. ICID: 945452
This 37 year-old male patient underwent high reso-
lution CT imaging of the face including the parana-
sal sinuses following trauma.
Correspondence: Ian Bickle, Department of Radiology,
and Department of Medicine, RIPAS Hospital, Brunei Da-
russalam. Article available from http://pso-hns.org/
psojournals/pjohns/2011a/07-from-the-viewbox.pdf
Alveolar rhabdomyosarcoma
Bickle IC. Paediatric Radiology. Case 9384.
10.1594/EURORAD/CASE.9384
This 8-year-old girl presented to paediatric outpa-
tient clinic after her mother noticed a mass within
the central abdomen. There were no further symp-
toms. Clinical examination confirmed the presence
of a painless firm mass extending from the pelvis to
above the umblicus. Alpha fetoprotein and HCG
were normal.
Correspondence: Ian Bickle, Department of Radiology,
and Department of Medicine, RIPAS Hospital, Brunei Da-
russalam. Article available from EURORAD website at
http://www.eurorad.org/case.php?id=9384
BOOK CHAPTERS
Operative Oral and Maxillofacial
Surgery. Ed. Langdon J, Patel M, Ord
R and Brennan P. Arnold Fodder
publishing. 2010.
PART ELEVEN: FACIAL AESTHETIC SURGERY
11.1 Nonsurgical techniques: botox, fillers.
N Ravindranathan
11.2 Hair transplantation
N Ravindranathan and E Antonio Mangubat
11.6 Rhinoplasty and septoplasty: Closed and open
techniques and the Oriental nose.
Luc Cesteleyn, N Ravindranathan and Corazon
Collantes Jose