bluuebunny/crossref_metadata_2025 huggingface dataset:
A Case of Multisystemic Langerhans Cell Histiocytosis in an Adult
Authors: Chng Chiaw Ling
Published: July 2015

Langerhans cell histiocytosis is a rare disease in adults with a myriad of clinical presentations. A case of multisystemic Langerhans cell histiocytosis with involvement of bone, skin, lungs, and the hypothalamic-pituitary-axis is reported. The possibility of a disseminated disease should be considered in the diagnosis of Langerhans cell histiocytosis, and these patients should undergo a careful evaluation and follow up with early institution of treatment.
A Clinical Quality Improvement Project to Reduce the Rate of Electronic Prescription Errors in Primary Care Practice
Authors: Low Sher Guan
Published: July 2015

Prescription errors are not uncommon in clinical practice. At the Bukit Merah Polyclinic, the rates of prescription errors for the month of May and June 2009 were 0.40% to 0.45% respectively. The error rates for other clinics at Singhealth Polyclinics ranged from 0.35% to 0.97% over the same period of time. The objective of the project was to reduce electronic prescription error rates at the Bukit Merah Polyclinic. Initial data showed that most of the errors occurred because of wrong patient identification, as well as errors in dosing and frequency which were perpetuated by repeating mistakes made previously when all the medications were repeated en-bloc in our Electronic Prescription Manager (Rx Manager). Using Quality Improvement tools, the team identified possible causes, and implemented interventions. Our interventions, abbreviated “IR” as an easy-to-remember mnemonic, were targeted at the main sources of errors. This involved “I”dentifying the patient correctly and “R”e-typing and amending the erroneous prescriptions on our Rx Manager, “R”e-printing and “R”e-sending them to the pharmacy, before dispensing could occur. Post-intervention results were analysed to evaluate the effectiveness of the measures taken. The results showed a significant and sustainable drop in our prescription error rates (0.45% in June 2009 before the commencement of the interventions, compared to 0.15% in December 2009, upon completion of the project). By targeting patient identification and correcting mistakes made in the Rx Manager, we managed to reduce electronic prescription error rates.
Herbal/Health Supplements Intake by Polyclinic Patients on Warfarin
Authors: Goh Bandy Qiuling , Tan Swee Keng , Tay Siew Cheng Sarah , Goh Chin Chin , Lo Pauline Fei Ling , Tang Woh Peng , Khoo Shu Yuen Rachel
Published: July 2015

Aims:

It is well documented that many herbal/health supplements (collectively referred as supplements) interact with warfarin. This research aimed to study the prevalence and intake of supplements by SingHealth Polyclinics patients on warfarin, and their knowledge of and perception towards potential supplements-warfarin interactions.

Methods:

One hundred SingHealth Polyclinics patients who were on warfarin were recruited from 4 polyclinics. Each patient was interviewed in person and completed a 6-part survey. The results of the survey were statistically analysed.

Results:

In this 3-month study, a significant 42% of the patients took supplements concurrently with warfarin. Traditional Chinese Medicines, glucosamine and omega-3 fatty acids were the 3 most common supplements consumed. Eighty-nine per cent of the patients were unable to verbalise the supplements that could interact with warfarin. Out of the 42 patients who were on supplements, 74% (31 out of 42) felt that it was important to inform their healthcare professionals with regards to their supplements use. However, 45% (14 out of 31) of them did not inform their healthcare professionals. The correlation between the importance attached by patients to inform healthcare professionals about their supplements intake and their actual decision to inform their healthcare professionals was significant (p=0.0122). Doctors, pharmacists and family members were their top 3 sources of information when they needed advice before their intake of supplements.

Conclusion:

Patients' concurrent intake of supplements without informing their healthcare professionals poses potential risk to their health. Healthcare professionals can play a significant role in advancing medication safety by educating these patients on the possibility of supplements-warfarin interactions and the risk of interference with anticoagulation therapy. This study also highlighted supplements on which further research could be done to determine their potential for interactions with warfarin.
A Randomised Controlled Trial Evaluating the Efficacy of a Nurse Controlled Analgesia (NCA) Protocol in Post Anaesthesia Care Unit (PACU)
Authors: Tan Michelle , Tan Boon Suan , Wee Choo Neo , Yang Jumei , Gao Fei , Ho Kok-Yuen , Ong Sharon
Published: July 2015

Introduction:

The purpose of this trial was to determine the efficacy of a Nurse Controlled Analgesia (NCA) protocol in reducing the time taken to achieve a satisfactory postoperative pain score. The safety aspects of the NCA protocol were also evaluated.

Method:

120 patients undergoing major surgery were randomised into 2 groups – NCA group and the doctor administered analgesia group (DRA). Nurses in the Post Anaesthestic Care Area (PACU) administered analgesia based on a protocol whereas analgesia was titrated at the discretion of the doctor in the DRA group. Effective pain control was measured by the time taken to obtain first dose of analgesia and the time taken to achieve either a pain score of less than 4/10 or if the patient refused further analgesia.

Results:

Patients received their first dose of morphine faster in the NCA group compared to DRA group, 6.7 minutes versus 9.5 minutes respectively (p= 0.037). Time taken to achieve a pain score of less than 4 was shorter in the doctor group although this was not significant. Complication rates were not different in both groups.

Conclusion:

Nurse administered analgesia based on a protocol can provide pain relief for patients in the postoperative period as effectively and safely as doctor administered analgesia.
Ideal Blood Glucose Control for Type 2 Diabetes Management: A New Clinical Equipoise
Authors: How Choon How
Published: July 2015

Diabetes mellitus is a common chronic condition and an old friend to family physicians practising in the community. The long-standing practice had aimed to lower glucose levels in type 2 diabetes to prevent long-term complications. The recent evidence from some publications since June 2008 had suggested the possible harm to our patients when we adopt intensive treatment strategies with tight treatment control targets (below HbA1c of 6%) and many meta-analyses have been published. This review highlights the evidence from recent studies that shook the previous dogma and the new clinical equipoise.
A Review of Health Literacy: Problem, Tools and Interventions
Authors: How Choon How
Published: July 2015

Health literacy is an important concept that is increasingly being recognised internationally worldwide as a fundamental skill required in maintaining health and accessing the local healthcare system. Not recognising low health literacy can be serious and costly as Singapore's population ages and chronic disease becomes more prevalent. As there are few local studies available, this clinical review highlights the current known prevalence and problem of health literacy in other countries; the assessment tools available; and some useful lessons we can draw from published interventions. This review may be useful in promoting awareness of health literacy, generating interest in this area among clinicians and inspiring more local work into this emerging field.
Perceptions of High-Fidelity Simulation Teaching by Non-Specialist Doctors in an Emergency Department in Singapore
Authors: Thng Shin Ying , Tiah Ling , Tan Elaine Ching Ching
Published: July 2015

Simulation training was introduced in 2008 as part of the core education program for non-specialist doctors posted to our department. It aims to help them improve clinical knowledge and skills, as well as to facilitate teamwork and communication. A survey was conducted to elicit their views on this training technique. All the participants felt that it was most effective in improving knowledge base in resuscitation work while 97 % felt that the session allowed them to train their critical decision making skills. Only 57% felt that the session helped them to improve their patient and doctor communication skills. Simulation training has been generally well received and deemed beneficial by the participants in our study.
Factors Influencing Decisions to Withdraw or Continue Life Support and Attitudes towards Treatment of the Critically Ill: A Survey of Registered Nurses in Intensive Care Units
Authors: Tai Clara Chia Chia , Li Li Ng Deborah
Published: July 2015

Introduction:

To examine the major determinants influencing the decision to withdraw or continue life support and the attitudes of registered nurses towards the treatments for the critically ill patients in intensive care units (ICUs).

Methods:

A self-administered questionnaire was distributed to a convenience sample of registered nurses working in 4 ICUs of a large teaching hospital in Singapore. The questionnaire consisted of 3 sections. The first section gathered details about the respondent's demographics; the second section required respondents to rate the importance of 18 different factors influencing the decision to withdraw or continue life support (1 = least important, 5 = most important) while the third section elicited responses about management strategy to 2 clinical scenarios from a possible pool of 6 different scenarios.

Results:

Eighty-three nurses responded (response rate: 70%). Patient advance directives (μ =3.63), likelihood of surviving current episode (μ = 3.52) and premorbid cognitive function (μ = 3.49) were the most important consideration factors for the withdrawal of life support. Across various clinical scenarios, the majority (82.6%) reported that “continue with current management” was most likely to be in the patients' best interests. Level of agreement between what the respondents believed to be in the patient's best interest and their responses on what they would do if they encountered a similar case was good (Kappa=0.78).

Conclusion:

Respondents regarded “Patient advanced directives” to be the most important factor in influencing decisions to withdraw or continue life support. In general, nurses were uncomfortable with complete withdrawal of life support. One way to minimise the impact of clinician's social, ethical, moral and religious values on medical decision making is to encourage more Singaporeans to make an Advance Medical Directive.
Hospital Preparedness for Radiation Emergencies and Medical Management of Multiple Combined Radiation Injury Victims
Authors: Lim Hoon Chin Steven , Ng Keng Sin , Tan Hock Heng , Leong Kok Wah Gabriel
Published: July 2015

Radiological accidents and disasters can have a huge and lasting impact on public health. Hospitals should be prepared to respond to potential radiation emergencies as determined by risk assessments based on local and regional radioactive hazards, threats and vulnerabilities. Approach to hospital management of multiple combined radiation injury victims require attention to casualty triage, decontamination and prevention of secondary contamination, healthcare personnel radiation safety, trauma care system, medical staff knowledge of radiation related injuries and availability of pharmaco-therapeutic options. Considering surge science, preparedness strategies are described according to the key components of the “3 S” system.
Vasopressin and Terlipressin in the Treatment of Vasodilatory Septic Shock: A Systematic Review
Authors: Soong Jie Lin , Lim Wai Hing
Published: July 2015

Background:

Vasodilatory septic shock unresponsive to fluid resuscitation requires the addition of vasopressors. Catecholamines remain the first line vasopressor therapy, but treatment failure is a potential problem. Vasopressin and its analogue, terlipressin, have been used for this indication.

Objective:

This systematic review aims to evaluate the effects of vasopressin and terlipressin on mortality and morbidity outcomes in patients with vasodilatory shock. Secondary outcomes include the effects of vasopressin and terlipressin on haemodynamic stability and organ function.

Method:

A computerised search of MEDLINE from January 1966 till June 2010 and screening of references of relevant articles were conducted. Only prospective, randomised controlled trials comparing vasopressin or terlipressin versus standard vasopressors or placebo were included.

Results:

Seven studies using vasopressin, three using terlipressin and one using both were identified. Four vasopressin trials assessing mortality and morbidity outcomes showed a trend towards benefit for mortality in adults but possibly adverse outcomes in a small paediatric study. No data was available on the long-term mortality and morbidity outcomes of terlipressin. Vasopressin and terlipressin were similar to standard vasopressors in maintaining haemodynamic parameters, while allowing a beneficial catecholamine-sparing effect. These agents also had a neutral to positive effect on organ function.

Conclusion:

Vasopressin and terlipressin was comparable to conventional agents in the maintenance of haemodynamic stability and organ function in vasodilatory shock. Since morbidity and mortality data do not differentiate vasopressin and terlipressin from catecholamines, their role remains unclear. More large studies evaluating the long-term outcomes in this group of patients are required.
Screening for Coronary Artery Disease Using CT Coronary Angiography, Coronary Artery Calcium Scoring and Myocardial Perfusion Imaging: A Review of Current Evidence of Potential Benefits and Risks
Authors: Wong Siong Sung , Keng Felix Yung Jih
Published: July 2015

Screening for coronary artery disease (CAD), using CT coronary angiography, coronary artery calcium scoring and myocardial perfusion imaging, seems an attractive idea. However, there is considerable uncertainty whether the overall potential benefits outweigh the risks. In a situation where the prevalence of disease is very low, the positive predictive value of any test will tend to be low, and false positive results frequent, requiring a large number of individuals to undergo further testing to confirm disease in a small number of patients. Even when disease is detected, the benefits of revascularisation are uncertain in asymptomatic populations. There is considerable uncertainty about the risks from radiation as a result of imaging tests such as CT scans. Based on available data, the actual risks of malignancy for most individuals appear to be small and of limited concern in a symptomatic patient with a moderate likelihood of disease. However, in a low risk population as in the context of coronary artery screening, the likelihood of benefit is likely to be much smaller due to the lower likelihood of disease, and may well be balanced by the possibility of harm. Screening for CAD using CT coronary angiography, coronary artery calcium scoring and myocardial perfusion imaging should be undertaken only after all these limitations have been properly discussed with the patient, and the patient's global risk of CAD has been estimated using conventional risk scoring. Testing should not be undertaken without careful consideration of whether the test result might change the patient's risk category and plan of management.
Review on Non-Invasive Risk Stratification of Sudden Cardiac Death
Authors: Fam Jiang Ming , Ching Chi Keong
Published: July 2015

Sudden cardiac death (SCD) is one of the most significant and challenging problems facing modern medicine today given its unpredictable nature. The evaluation of the patient at risk for sudden cardiac death still remains a complex task. The use of ICDs (implantable cardioverter defibrillators) remains the mainstay of primary prevention of sudden cardiac death. However, much remains to be determined on how best to identify patients at high risk of sudden cardiac death who would most benefit from ICD implantations. This paper will review the current issues in the risk assessment of sudden cardiac death and non-invasive markers of sudden death.
Neutrophil Gelatinase Associated Lipocalin: An Emerging Biomarker for Acute Kidney Injury in Cardiovascular Disease
Authors: Yeo C , Khurana R
Published: July 2015

Acute kidney injury (AKI) commonly occurs in hospitalised patients resulting in short and long-term morbidity and mortality. A subset of patients especially those with cardiovascular diseases appear particularly vulnerable. The diagnosis of AKI currently depends on changes in serum creatinine and is usually made at least 24 to 48 hours after the initial renal insult. This hinders formulation of possible early therapeutic strategies which could otherwise reduce the clinical sequelae of AKI. Neutrophil gelatinase-associated lipocalin (NGAL) is released in both serum and urine, and has shown great promise in identifying AKI as early as two to four hours after renal injury. NGAL has been demonstrated to be both specific and sensitive in a variety of renal conditions associated with AKI, compared to serum creatinine. This article discusses the emerging role of NGAL in the diagnostic and prognostic evaluation of AKI secondary to cardiovascular diseases and interventions including its benefits and pitfalls. NGAL has been shown to be useful in the diagnosis of AKI particularly for contrast induced nephropathy (CIN) after percutaneous coronary intervention (PCI) and renal dysfunction complicating acute and chronic heart failure. Larger prospective outcome studies with therapeutic interventions are warranted to further validate the role of NGAL in the diagnosis of AKI and in cardiorenal syndrome.
Clinical Use of Natriuretic Peptides
Authors: Yap Clementine YF , Phua Soon Kieng , Aw Tar Choon
Published: July 2015

Either B-type natriuretic peptide (BNP) or NT-proBNP may be used as a diagnostic, screening, prognostic and therapeutic tool for CHF. The Food and Drug Administration (FDA) cleared the cut-off point for BNP at 100 pg/mL, and that of NT-proBNP at 125 pg/mL for patients <75 years and 450 pg/mL for those >75. A steadily rising titre even below the cut-off value should be raised as a concern as heart failure is progressive if left untreated and may result in cardiac death. Both biomarkers are also featured in lab investigations for patients with acute coronary syndrome (ACS).
Mastoid Obliteration and Reconstruction: A Review of Techniques and Results
Authors: Chan Ching Yee , Chan Yew Meng
Published: July 2015

The aim of cholesteatoma surgery is to obtain a safe, dry and self-cleaning ear. Several methods have been tried and tested to achieve this goal with varying degrees of success. This article reviews some of the more common methods for mastoid reconstruction and obliteration and their results. Current trends appear to favour a combination of mastoid obliteration and reconstructive techniques, with biologic materials such as muscle flaps and bone chips preferred over non-biologic materials such as hydroxyapatite crystals and ceramic. However, there is large variation among the type of biologic flap used, which can vary between fascia, muscle and periosteum. After an extensive review, there is no ideal method for mastoid obliteration and reconstruction, as most methods appear to have a certain degree of success. The basic principles of a low facial ridge, large meatoplasty and an oval mastoid cavity should be adhered to, and the surgeon should choose a method that he or she is comfortable with.
The Hearing Screening Programme for Infants in KK Women's and Children's Hospital — Its Development and Role in Reducing the Burden of Hearing Impairment in Singapore
Authors: Daniel Lourdes Mary , Lim Sok Bee
Published: July 2015

This paper describes a successful hearing screening programme for infants in KK Women's and Children's Hospital (KKH). Between April 2002 and January 2010, 100,237 (99.8% of all eligible babies) were screened, surpassing the international benchmark of 95%; 0.5% were referred for audiological investigations, significantly below the international benchmark of 4%. The median age of diagnosis in 280 infants diagnosed with Hearing Impairment (HI) [4.8months (1–24)] was lower than in HI children in special schools in Singapore [20.8 months (0–86)]. Hearing aids were fitted for 84 infants at a median age of 7.6 months (2–45) which was higher than the international benchmark of six months, but much lower than in special school children [42.2months (1–120)]. Twenty infants received a cochlear implant at a median age of 20 months (8–38). 69.3% of infants with risk factors for HI were rescreened at three to six months of life. This identified a further 88 infants with HI. Nine were fitted with hearing aids. The incidence of HI in KKH was 3.7 per 1000 infants. The KKH programmes identified 69% of infants with HI born in the restructured hospitals in Singapore, providing the opportunity for early intervention and increased likelihood of a hearing and talking child with HI.
Acupuncture in Dentistry: Its Possible Role and Application
Authors: Wong Li Beng
Published: July 2015

This article reviews the possible role and application of acupuncture in dentistry. The use of acupuncture in Traditional Chinese Medicine (TCM) has a long history and for the past forty years, many studies have been conducted to understand the scientific basis behind its therapeutic effects in Western medicine. The possible application of acupuncture in the dental field like managing post-operative pain, orofacial pain, xerostomia, Bell's palsy and dental anxiety will be discussed in detail. The inherent challenges in conducting clinical trials in acupuncture using the evidence-based medicine model will also be covered. It is envisioned that acupuncture may play a promising role in complementing conventional treatment in certain dental conditions and more studies with improved methodology should be carried out to verify its application.
Keratoconus with Corneal ‘Pips’
Authors: Anuar Ainur Rahman , Mehta Jodhbir S
Published: July 2015

Keratoconus is a common ectatic corneal disorder. There are several causes of corneal opacity in keratoconic patients. This case illustrates two different causes, in the same patient, in either eye, and diagnostic imaging characteristics on Fourier-domain optical coherence tomography (FD-OCT) that aided surgical management.
A Retrospective Study of Temporomandibular Joint Internal Derangement Treated with Arthrocentesis and Arthroscopy
Authors: Tan Danny Ben Poon , Krishnaswamy Gita
Published: July 2015

Introduction:

Internal Derangement of the Temporomandibular Joint is an intra-articular condition in which there is a disruption in the normal relationship of the articular disc to the articular eminence and the condyle when the joint is at rest or in function. Patients may complain of pain and/or limitation of mouth opening. Treatment of internal derangement of temporomandibular joint includes arthrocentesis and arthroscopy. The aims of this retrospective study are to examine the efficacy of arthrocentesis and arthroscopy in the treatment of internal derangement of temporomandibular joint, specifically in relation to joint movement and pain.

Methods:

Twenty consecutive patients with internal derangement of temporomandibular joint seen in National Dental Centre of Singapore, from 2010 to 2011, were included in this study. Nine patients underwent arthrocentesis and 11 had arthroscopic lysis and lavage. The pre and postoperative pain score, in Visual Analogue Scale (0 to 10) and maximal inter-incisal opening were recorded to evaluate the effectiveness of both treatment modalities. The patients were reviewed one week and one month post-operation. The data obtained were statistically analysed.

Results:

Significant increase in postoperative mouth opening and reduction in pain were found in both groups of patients. In the arthrocentesis group, the mean increase in maximal inter-incisal opening was 13 ± 5mm and reduction of pain in VAS was 4.56 ± 1.74. For the arthroscopy group, the mean increase in maximal inter-incisal opening was 6.6mm ± 4.8mm and the reduction of pain was 2.5 ± 2.2. Duration of symptoms prior to treatment appeared to have influenced the treatment outcome of both treatments.

Conclusion:

Arthrocentesis and arthroscopy are effective in the treatment of internal derangement of temporomandibular joint. Factors that may influence treatment outcomes need to be investigated to provide more information on the predictability of arthrocentesis and arthroscopy.
Radiological Findings of a 57-Year-Old Male with Follicular Lymphoma of the Mandible
Authors: Teh Luan Yook , Saigo Leonardo
Published: July 2015

A 57-year-old male with follicular lymphoma of mandible presented with clinical and radiographic features suggestive of osteomyelitis. He was treated for his ‘infection’ over three years. Several biopsies taken from early 2007 to 2009 reported negative for malignancy. Radiographic findings over the same period showed diffuse radiolucent area at the right body/angle mandible that slowly extended anteriorly and posteriorly to his mid-ramus. The lesion had ill-defined borders. Following biopsy and histological examination, the lesion was diagnosed as follicular lymphoma. This case report highlights that malignancies like follicular lymphoma in the mandible can mimic osteomyelitis in the mandible both clinically and radiographically.
Pathological Outcome in Men with Prostate Cancer Suitable for Active Surveillance after Radical Prostatectomy
Authors: Tan Grace , Ho Henry , Huang Hong g , Cheng Christopher Wai Sam , Lau Weber Kam On
Published: July 2015

Background:

Active surveillance (AS) as a treatment option for low risk prostate cancer is gaining recognition. We evaluate the validity of the AS protocol in our patient population, by defining the risk of undergrading and understaging in their pathology. We also aim to determine more accurate inclusion criteria, in order to improve the prediction of early low risk prostate cancer.

Materials and Methods:

Data was taken from our institutional prostate cancer registry for all men who underwent radical prostatectomy (RP) between Jan 2000 and June 2009. We determined if any of the patients would have met the University of Toronto's (UoT) AS inclusion criteria and examined their post-operative pathology. The primary end-point was pathological upgrading and upstaging. The individual inclusion factors i.e. preoperative PSA, were tested for statistical significance and better cutoffs. Univariate, multivariate and ROC curves were used in the statistical analysis.

Results:

216 RPs were performed between January 2000 and June 2009. We identified 79 men who fulfilled the UoT AS criteria. 35% of patients had a Gleason score upgrade from biopsy to surgery, and 21.5% of patients had an upstage to T3 disease. Overall, 34 (43%) patients had an unfavourable change in the grade and/or stage of their prostate cancer.

Conclusions:

There is a significant risk of undergrading and understaging with the current criteria used for AS. There is a need to identify more discriminative AS criteria before it can be offered as an option to patients with clinically early prostate cancer.
Minimally Invasive Surgical and Medical Management of Urinary Calculi
Authors: Sundaram Palaniappan , Tan Yeh Hong
Published: July 2015

Management of urinary calculi has changed from open pyelolithotomy and ureterolithotomy to predominantly non-invasive procedures such as extracorporeal shockwave lithotripsy (ESWL) as well as endourological such as ureterorenoscopy (URS) and percutaneous nephrolithotripsy (PCNL). Technology has advanced rapidly allowing stone disease to be treated with minimally invasive techniques that have lower morbidity than the open operations of the past. Newer semi-rigid ureteroscopes of size 7 to 9 F allow visualisation of the ureter without traumatic dilatation. There is the flexible ureteroscope developed with smaller fibre optics, the addition of the working channel that allows the use of laser fibres for stone fragmentation and a greater deflection of the tip that enables all parts of the pelvicalyceal system to be inspected for stones. New generation lithotripters for ESWL deliver shockwave to a smaller focal zone so as to minimise damage to surrounding soft tissue but as a result, there are higher failure rates. PCNL, though more invasive than ESWL and URS, is the procedure of choice for large renal stones. It is highly efficient in such situations as newer equipment to disintegrate stone and newer techniques for percutaneous access has been developed. In addition to all these minimally invasive surgical techniques, there is medical therapy available to allow the expulsion of distal ureteric stones as well as alkalinising agents to dissolve uric acid stones. Metabolic evaluation is necessary for patients with recurrent stones. Dietary adjustments may help prevent recurrent stone formation in selected patients depending on the results. With all these techniques currently available, management of urinary calculi has to be tailored according to the size, location of stone as well as patient preference.
The Singapore General Hospital Peritoneal Dialysis Programme from 2000–2008
Authors: Choo Jason Chon Jun , Ong Shin Yeu , Krishnasamy Thanaletchumi , Foo Marjorie Wai Yin
Published: July 2015

Introduction:

There is lack of data regarding outcomes of peritoneal dialysis (PD) in Singapore. The aim of this study is to retrospectively evaluate the patient characteristics, technique survival, and patient survival in a single centre.

Methods:

The retrospective review included 1,015 adults (47.3% female, 72.6% Chinese, mean age 58±12.4 years, mean follow-up 39.7±27.7 months) initiated on PD at the Singapore General Hospital from January 2000 to December 2008. Baseline characteristics, including cause of end-stage renal disease (ESRD), comorbid conditions, and endpoints (ie. death, transfer to HD or transplantation, renal recovery or until last follow-up on 31 December 2010) were collected. Demographic variables and patient and technique survival rates were analysed.

Results:

The main causes of ESRD were diabetes mellitus (DM) (58.0%), glomerulonephritis (GN) (23.3%) and hypertension (15.4%). The 1, 2, 5 and 10-year patient survival rates were 88.7%, 77.7%, 39.8% and 15.4%, respectively. Causes of death were related to infection (43.1%) and cardiac (37.8%). Patient survival rates were significantly better in PD patients with ESRD due to GN, compared with DM (5-year survival rates of 70.2% versus 22.3%, P <0.001). Patients aged 65 years and older had lower survival rates compared with those aged less than 65 years ( P <0.001). The 1, 2, 5 and 10-year technique survival rates were 92.9%, 85.0%, 64.8% and 32.9%, respectively. Peritonitis was the main cause of technique failure (63.5%), and caused 13.8% of deaths. Technique survival rates were better in patients with ESRD due to GN, compared with DM (5-year survival rates of 70.9% versus 62.0%, P <0.05).

Conclusion:

In our single-centre retrospective review, technique survival was comparable to other East Asian centres. The poorer patient survival observed in this study may be due to older age and higher comorbidity.
Emphysematous Cystitis Complicated by Urinary Bladder Perforation: A Case Report
Authors: Qin Yan , Tulsidas Haresh , Jaufeerally Fazlur , Tan Raymond Kim Leong
Published: July 2015

Emphysematous cystitis is a rare serious complication of urinary tract infection characterised by gas formation in the wall or lumen of the urinary bladder due to bacterial fermentation. We report a case of an 86-year-old female with emphysematous cystitis complicated by anterior bladder wall perforation. Her urine grew Escherichia coli and imaging showed gas collection inside the urinary bladder and outside the ruptured anterior bladder wall. She was treated with antibiotics and bladder irrigation and responded well without surgery. Early diagnosis and treatment improve the outcome, hence the importance of a high index of suspicion.
Dermatitis Secondary to Hypersensitivity to Icodextrin is a Rare Complication of Icodextrin Therapy in Peritoneal Dialysis
Authors: Tan Ru Yu , Oei Elizabeth , Foo Marjorie WY
Published: July 2015

Case report on dermatitis secondary to hypersensitivity to icodextrin, which is a rare complication of icodextrin therapy in peritoneal dialysis.
Preliminary Report on Efficacy of Acupuncture versus meToclopramide for Management of Post-Operative Gastroparesis (EAT POSTOP Trial)
Authors: Ho Vui Kian , Ong Sharon , Cui Shuli , Hwang Nian Chih
Published: July 2015

Introduction:

Gastroparesis is common in intensive care patients and may increase the incidence of malnutrition and nosocomial pneumonia, leading to poorer patient outcomes. Current pharmacotherapy has shown only modest efficacy. Acupuncture without pharmacotherapy has been shown to improve gastroparesis in animal studies and in recent clinical trials. However, no trials studying the efficacy of acupuncture as an adjunctive therapy for surgical intensive care patients have been done. This study aims to evaluate the effectiveness of adding electro-acupuncture therapy to pharmacotherapy in the management of gastroparesis in these patients.

Methods:

For this prospective block randomised controlled trial, we aim to recruit 200 adult surgical intensive care patients who require gastric enteral nutrition, and mechanical-assisted ventilation, and who have gastroparesis (gastric residual volumes more than 120 mL twice four hours apart). Patients will receive either metoclopramide 20 mg intravenously thrice daily (Group M) or electro-acupuncture comprising four sessions of 30-minute electro-acupuncture at specific sites over 48 hours in addition to intravenous metoclopramide 20 mg thrice daily (Group A). Gastroparesis resolution is defined as 24-hour cumulative gastric residual volumes less than 200 mL. Patients are followed-up for 48 hours from the commencement of therapy.

Results:

Three patients have been recruited in a four-month period thus far. Two are in Group A and one in Group M. All have met the study definition of gastroparesis resolution. The incidence of gastroparesis in this period among longer stayers in the unit (n = 92) is 8.7%.

Conclusions:

The trial is on-going. Reasons for the low incidence of gastroparesis are discussed. The study of the use of acupuncture in the treatment of intensive care patients with gastroparesis is worthwhile due to its excellent side-effect profile and if successful, will be a tool to improve nutritional support.
Evidence for Low Residue Diet in the Management of Gastrointestinal Related Conditions
Authors: Ong Chengsi , Ong Christina , Han Wee Meng
Published: July 2015

The low residue diet is commonly recommended for pre-colonoscopy bowel preparation as well as in the management of some gastrointestinal conditions including inflammatory bowel disease. There is no objective measurement for residue, resulting in poor standardisation of a low residue diet. This review examines the efficacy of a low residue diet in the management of gastrointestinal conditions. A literature search was conducted in Medline and the Cochrane Library, and eight randomised controlled trials with human subjects met the inclusion criteria. Six studied the low residue diet for pre-colonoscopy bowel preparation, the other two were conducted in Crohn's disease and post-gynaecological surgery, respectively. The low residue diet was comparable to the clear liquid diet for bowel preparation without increased side-effects. Post-gynaecological surgery, early feeding using low residue diet decreased nausea without increasing gastrointestinal symptoms when compared to the traditional feeding method. There was limited evidence on the advantage of a low residue diet over a normal diet in the management of acute, non-stenosing Crohn's disease. More rigorous studies are required to evaluate the efficacy of the low residue diet for the management of gastrointestinal conditions. In addition, substituting a low residue diet with a low fibre diet would be a more measurable and objective method to standardise guidelines both for research and therapy.
Anaesthesia for Living Related Liver Transplantation
Authors: Teo Li-Ming
Published: July 2015

With the greater success of liver transplantation, livers from deceased donors are insufficient to meet the need for livers required for transplantation. In various parts of Asia, living related liver transplantation is the treatment for patients with end-stage liver disease. An overview of anaesthesia for both the donor and the recipient is described. Controversies involving epidural anaesthesia, blood loss prevention and blood conservation techniques in the donor are discussed. Various aspects in the anaesthetic management of the recipient are also looked at.
Case Report of an Internal Hernia through a Unilateral Congenital Defect of the Broad Ligament and Literature Review
Authors: Lim Sue Zann , Tan Veronique Kiak Mien , Teo Melissa Ching Ching
Published: July 2015

We report a case of small bowel obstruction resulting from the herniation of small bowel through a unilateral defect in the broad ligament of a woman who had no prior abdominal surgery and was nulliparous. In the absence of previous uterine surgery, delivery trauma and pelvic pathology, congenital abnormality should be considered the cause of the defect in the broad ligament.
Journey of KK Children's Hospital — Collective Memories
Authors: Chay Oh Moh , Ng Kee Chong , Helena Mahesan , Pang Nguk Lan , Ho Lai Yun , Phua Kong Boo , Tan Kok Hian
Published: July 2015

This paper presents the collective memories of many individuals who were closely associated with the growth and development of the Children's Hospital. It is based on the perspective of the authors' personal recollections and by no means the whole of this exciting story. The focus is on the development of paediatric medicine in KK Women's and Children's Hospital (KKH). Neonatology will be discussed in a separate paper.
Nosocomial Infections (Late Onset Sepsis) in the Neonatal Intensive Care Unit (NICU)
Authors: Joseph Carolin Jeyanthi , Lian Wee Bin , Yeo Cheo Lian
Published: July 2015

Objective:

Neonates admitted to the Neonatal Intensive Care Unit (NICU) are at high-risk of developing nosocomial infection. Ongoing infectious disease surveillance is essential to minimise the occurrence of nosocomial infection. To determine the incidence of nosocomial infection, distribution of pathogens, associated risk factors and outcomes, we evaluated a cohort of 263 neonates who were admitted to NICU from May 2005 to May 2007.

Methods:

The Singapore General Hospital neonatal database was tapped into to obtain information on all nosocomial infections that occurred during the review period. The inpatient case notes of these infants were reviewed, detailed data on epidemiology of infection, results of blood and cerebral spinal fluid culture were collected; associated risk factors and outcomes were evaluated.

Results:

Out of 255 neonates who were analysed, 20 infants (7.8%) developed nosocomial infection. The vast majority of infections (85%) were caused by Gram-positive organisms with coaugulase-negative Staphylococci accounting for 55% infection. Birth weight and gestational age were inversely related to rate of infection (13% of very low birth weight infants [VLBW] versus 4.1% of non-VLBW infants). Among VLBW infants, prolonged mechanical ventilation, central line insertion and chest tube insertion were associated with an increased rate of late-onset sepsis (LOS). Neonates with LOS had a significantly prolonged hospital stay (mean length of stay 84 days versus 54 days). The mortality rate for nosocomial sepsis was 5%.

Conclusion:

This study documents the high prevalence of nosocomial infection in neonates admitted to NICU, particularly VLBW infants. Identification of VLBW infants who are at high-risk for LOS and early detection of LOS remain the keys to successful management of this condition.
Paediatrics Rheumatology Clinic Population in Singapore: The KKH Experience
Authors: Tan Justin Hung Tiong , Fun Hoh Sook , Arkachaisri Thaschawee
Published: July 2015

Introduction:

The subspecialty of paediatric rheumatology (PR) is the newest discipline established at KK Women's and Children's Hospital, in 2009. The service provides tertiary care for children with rheumatic diseases in Singapore. Referral population to this subspecialty has not been described in this region.

Methods:

Using the Registry for Childhood Onset Rheumatic Diseases (RECORD), a dedicated web-based data entering system, case descriptions and diagnoses were captured. Standardised descriptions of diagnoses were used.

Results:

Data from January 1, 2009 to March 31, 2012 included 1158 referrals which were analysed. Almost half (42.2%) were diagnosed as non-rheumatic conditions. Systemic vasculitides (28.4%) with Henoch-schonlein purpura (HSP) and Kawasaki disease (KD) were the most common rheumatic diseases. Enthesitis related juvenile idiopathic arthritis (JIA) was common but JIA associated uveitis was rare, so as to antinuclear antibody (ANA) positivity (25.4%). The remaining 36.4% of patients with rheumatic disease had a variety of other conditions. Primary angiitis of the central nervous system (CNS) and recurrent aphthous stomatitis were seen more commonly in local patient than in patients from the west. Of the patients with non-rheumatic disease, 66.3% had orthopaedic/mechanical related conditions, 7.4% had a fever of unknown causes and 4.9% had infections. Mechanical joint pain (67.6%) and hypermobility syndrome (18.5%) were the most frequent referrals.

Conclusion:

Our report described, for the first time, a large single centre cohort of a PR clinic population. Local frequencies or burden of paediatric rheumatic diseases and unique findings were delineated. Targeted education and awareness to both healthcare professionals and members of the public were made possible. However, continuous prospective longitudinal data collection is on-going in order to confirm our initial observation.
Anorexia Nervosa Presenting with Spontaneous Pneumomediastinum
Authors: Wong Sharon Mun Yee , Barathi Rajendra , Kumudhini Rajasegaran
Published: July 2015

Spontaneous pneumomediastinum (SP) is uncommon in children and adolescents. It can be associated with anorexia nervosa (AN), particularly in cases having a preceding history of vomiting. We highlight the case of a 15-year-old girl with SP as the presenting symptom of AN. She lost 10 kilograms (kg) over six months but denied vomiting. She complained of neck swelling and dysphagia. Physical examination revealed subcutaneous crepitations over the neck. X-rays confirmed subcutaneous emphysema and also revealed pneumomediastinum. The patient was managed with oxygen therapy as well as slow re-feeding. A subsequent chest X-ray showed complete resolution in 16 days.
High Sensitivity Troponins — Translating Research into Practice
Authors: Aw Tar Choon
Published: July 2015

Troponin is vital in the evaluation of acute coronary syndrome. Decision limits, based on the 99th percentile upper reference limit derived from a sufficiently large normal reference population, must be determined for each specific troponin method. The new troponins exhibit high-sensitivity performance – assay precision at less than 10% coefficient of variation (at the 99th percentile upper reference limit) and ability to detect measurable values in healthy subjects. The troponin literature has reached a tipping point necessitating guidance on its use from specialist societies.
Disease Characteristics of the Singapore Systemic Sclerosis Cohort
Authors: Ling Andrea Low Hsiu , Gee Teng Gim , Giap Law Weng , Cheng Ng Swee , Santosa Amelia , Chan Grace , Lim Anita , Ee Png May , Qing Teo Huan , Ting Lee Ping , Thumboo Julian
Published: July 2015

Introduction:

Systemic sclerosis (SSc) has one of the worst prognoses among autoimmune diseases. Multi-ethnic Western cohorts have shown ethnic differences in disease characteristics. Due to a paucity of data in Asia, we aimed to describe the disease characteristics and autoantibody profile of Asian SSc patients.

Methods:

The Singapore SSc database consists of prevalent and incident cases from four institutions. Data were recorded annually according to a standardised protocol. Cumulative disease characteristics were analysed using descriptive statistics.

Results:

From 2008 to 2012, 200 patients (85.5% females; Chinese 78%, Malays 10.5%, Indians 6%) diagnosed at a mean age of 46 years, fulfilled the American College of Rheumatology (ACR) (88.0%) or the Very Early Diagnosis of SSc (VEDOSS) (12%) criteria. SSc subtypes include limited cutaneous SSc (LcSSc) (32%) or diffuse cutaneous SSc (DcSSc) (37.6%), SSc-overlap syndromes (27.4%) and sine scleroderma (3%). Predominant disease manifestations were Raynaud's phenomenon (n=161, 80.5%), gastrointestinal (GI) (n=125, 62.5%), joint pain (n=116, 58%) and interstitial lung disease (ILD) (n=99, 51.8%). Pulmonary arterial hypertension (PAH) by echocardiography was present in 23.2% (39/168) of patients (mean systolic pulmonary arterial pressure 55.0+19.7mmHg). Renal crisis was rare (n=4, 2%). Anti-nuclear antibodies (ANA) tested positive in 78.7% (155/197), with anti-Scl-70 (69/197, 35.0%), anti-ribonucleoprotein (RNP) (56/192, 29.2%) and anti-Ro60 (40/193, 20.7%) most frequently detected. Anti-centromere antibodies were infrequent (23/190, 12.1%). Treatment included corticosteroids (80.7%), for peripheral vasculopathy (61.4%), GI (68%), PAH (11.2%) and immunosuppression (62.9%).

Conclusion:

Compared to Caucasian patients, our predominantly Chinese Asian SSc patients were diagnosed at an earlier age, with more severe PAH, less frequent Raynaud's phenomenon, an autoantibody profile characterised by anti-Scl70, anti-RNP and anti-Ro60, infrequently anti-centromere and more patients had DcSSc.
Educating Future Learners of Rheumatology
Authors: Yoong Jon , Lui Nai Lee
Published: July 2015

With changing learner characteristics and learning environments, the teaching of rheumatology has been required to evolve. The importance of competency with managing rheumatologic disorders and education theories on which rheumatology curriculums are based on are discussed. Past, present and possible future rheumatology curriculums are reviewed. The way in which the key components of a successful programme are applied is illustrated with a discussion of the Singapore General Hospital (SGH) Department of Rheumatology and Immunology (RHI) curriculum.
Key Advances in Spondyloarthritis and the Role of the Spondyloarthritis Clinic in the Singapore General Hospital
Authors: Lui Nai Lee
Published: July 2015

For the past 20 years, the world has witnessed remarkable advances in the field of spondyloarthritis (SpA) from better understanding of the genetics and pathophysiology of SpA, utilisation of magnetic resonance imaging (MRI) for early diagnosis, to the discovery of advanced therapeutics for patients with non-steroidal anti-inflammatory drugs (NSAID)-refractory SpA. This is a vast improvement from the past where treatment was limited to NSAIDs and was frequently unsatisfactory for both physician and patient, and where diagnosis was made based on clinical evaluation and structural changes on plain radiographs. These advances have inevitably revolutionised the management of SpA in Singapore and patients can now look forward to an earlier diagnosis of their condition and better treatment. This review summarises the key advances in the field of SpA and describes the aims of the SpA clinic in the Singapore General Hospital (SGH).