bluuebunny/crossref_metadata_2025 huggingface dataset:
Therapeutic Hypothermia for Hypoxic Ischaemic Encephalopathy in Singapore General Hospital: Two Patient Case Series and Review of Literature
Authors: Arunachalam Sridhar , Poon Woei Bing
Published: July 2015

Neonatal encephalopathy affects 2–5/1000 live births and hypoxic ischaemic encephalopathy (HIE) is the major cause1. Therapeutic hypothermia reduces brain injury and improves the neurodevelopmental outcome.

We are sharing our local experience in therapeutic hypothermia in the form of a case series of two patients. Our incidence of moderate to severe HIE is 0.6/1000 live births. Both patients were cooled for 72 hours.

The challenges faced were mainly in the time taken for achieving the target temperature and the time needed for re-warming, which varied from one to six hours and 4–24 hours, respectively. Complications like hyponatremia, hypokalemia, sinus bradycardia and thrombocytopenia were noted. Amplitude integrated electroencephalogram (aEEG) remained abnormal post cooling for both babies. Clinical markers, aEEG and MRI head findings combine to prognosticate well for the neurodevelopmental outcomes.

We need to be familiar with the protocol for timely implementation of cooling, whichever the cooling method. Concentrating these high-risk cases in selected tertiary centres capable of instituting cooling as well as long-term follow-up will ensure better outcomes.
A Perspective on Osteoarthritis Research in Singapore
Authors: Leung Ying Ying , Pua Yong Hao , Thumboo Julian
Published: July 2015

Knee osteoarthritis (OA) is common and is one of the five leading causes of disability in Singapore; it entails significant cost to society. Singapore is one of the faster ageing populations in Asia and obesity is on the rise. The public health consequences of OA, particularly knee OA are therefore expected to rise dramatically. There is thus an urgent need for advancement in research in this area. An accurate estimate of the prevalence of knee OA would improve the understanding of its impact in different sectors of society, and facilitate public health decision-making and resource allocation to address this upcoming challenge in public health. Currently there is no proven drug that slows down the osteoarthritis process and management of knee OA is symptomatic. Identification of genetic, environmental, inflammatory and biomechanical risk factors will help us to understand the pathogenesis and find factors for its prevention. There is a need for early diagnosis of knee OA and identifying subjects who are more likely to benefit from drug treatment. Effort is needed in the discovery of drugs that have disease modifying effect to treat this disabling disease. Understanding the biomechanical factors underlying knee OA may also lead to the discovery of new recommendation and treatment strategies.
Nail-Patella Syndrome: A Case Report
Authors: Law Annie Hui Nee , Chew Li Ching
Published: July 2015

Nail-patella syndrome (NPS), also known as hereditary onycho-osteodystrophy (HOOD) is a rare inherited autosomal dominant disease with involvement of the LMX1 gene. We report a case of NPS with atypical involvement of the lip, palate, and lung and discuss the possible genetic associations between NPS, recurrent pneumothoraces, and cleft lip/palate.
The Ethics of Neonatal Resuscitation
Authors: Ong Shin Yeu
Published: July 2015

Decisions about initiating resuscitation are often based on the best-interest principle, which considers the chance of survival, pain of attempted resuscitation, and subsequent benefits or burdens that continued living with potential disability may bring. For neonates at 23–25 weeks gestation, this decision is difficult given the uncertain prognosis. It is thus reasonable to defer to parental wishes given that the family has to bear the burden of taking care of the child. Adequate and early antenatal counselling is important to enable parents to make an informed decision. Further studies of local long-term outcomes are needed to identify better markers for outcomes to help guide resuscitation decisions.
A Peri-Operative Audit of the Paediatric Cochlear Implantation Programme at the Singapore General Hospital
Authors: Phoon HYP , Kan AD , Yam PC Ip
Published: July 2015

Introduction:

Paediatric cochlear implantation has become an established procedure for treating irreversible hearing loss. The aim of this survey was to review the peri-operative anaesthetic management of this programme since its inception.

Methods:

We conducted a retrospective clinical audit of 184 paediatric (age <12) cochlear implantation cases by reviewing clinical records. The surgery was performed by the same surgeon at the Singapore General Hospital (SGH) from 1997 to 2010.

Results:

A total of 184 procedures (including five bilateral cases) were performed on 173 patients. The average age (mean [standard deviation, range]) at the time of surgery was 3.7 (±2.6, 0.7–11) years. The mean duration of the unilateral and bilateral implantation procedures were 3.2 (±1.0, 1.2–6.5) hours and 4.7 (±0.8, 4–6) hours respectively. Inhalational anaesthesia (66.3%) was the most popular choice for induction. 15 (8.1%) patients required additional analgesia in the post-anaesthetic care unit. In the ward, 14 patients (7.6%) required stronger analgesia in addition to paracetamol. Peak paracetamol requirement (22.9 [±16.6] mg/kg) was on the first postoperative day. Nausea and vomiting was reported in 19 (10.3%) procedures. The correlation between increasing age and post-operative nausea and vomiting was statistically significant (p<0.05) as was the association between age and analgesic requirements. The average duration of hospital stay was 3.2 (±1.0, 1–6) days. Mean age at time of surgery as well as duration of unilateral implantation procedures decreased over time. A trend towards same day admission (SDA) was also noted.

Conclusion:

Cochlear implantation in paediatric patients is a relatively safe procedure involving few complications.
Functional Outcomes after Inpatient Rehabilitation in a Prospective Stroke Cohort
Authors: Ng Yee Sien , Astrid Suantio , De Silva Deidre Anne , Tan May Leng Dawn , Tan Yeow Leng , Chew Effie
Published: July 2015

Aim:

Rehabilitation is proven to improve function following a stroke. The functional outcomes of stroke patients and benefits from rehabilitation are highly variable. We aim to describe functional outcomes and gains following inpatient rehabilitation post-stroke and identify factors associated with improved outcomes.

Methods:

In this five-years prospective study, data for 1332 consecutive stroke patients admitted to the Singapore General Hospital inpatient rehabilitation unit were charted into a custom-designed rehabilitation database. The primary outcome measure was the Functional Independence Measure (AFIM) and discharge (DFIM). The functional gain was defined as the DFIM-AFIM.

Results:

The mean age was 64.1±12.5 years, 58.9% were male patients and 78.9% consisted of ischaemic (versus haemorrhagic) strokes. The average rehabilitation length of stay (RLOS) was 18.7±13.9 days and the majority (87.7%) were discharged home. The most common risk factor was hypertension (78.4%) and urinary tract infection (21.2%) was the commonest post-stroke complication. The mean AFIM and DFIM scores were 67.9±23.0 and 83.2±23.5 respectively with a mean functional gain of 15.4±12.3 FIM points. Younger, male, and haemorrhagic stroke patients had better functional outcomes. Multiple regression analysis results revealed that higher DFIM score was associated with higher admission motor and cognitive FIM scores, younger age, male gender, employment at admission, single patients, presence of a caregiver, haemorrhagic stroke, right-sided motor impairments, absence of urinary tract infection or depression, acupunction treatment, and a longer RLOS. The regression model on functional gain was associated with similar independent predictors on DFIM scores except that a higher AFIM was associated with lower functional gains.

Conclusion:

In this large cohort study, stroke patients make significant functional gains and should be offered rehabilitation to improve outcomes. A comprehensive set of multiple interacting demographic, clinical, cultural, and social factors significanctly impact on stroke functional outcomes after inpatient rehabilitation. The identification of these factors allows optimising rehabilitation for individual patients, and is important for discharge and resource planning.
Advocating for the Best Interests of Critically Ill Newborn Infants
Authors: Ho Lai Yun , Tan Tong Khee , Goh Pheck Suan June
Published: July 2015

This bioethics article deals with the conflict and difficulty in quality of life judgements.

The importance and roles of the various stakeholders in determining the management of critically ill infants are described. This is an in-depth insider perspective of one of the most difficult medical decision making processes when dealing with infants with poor prognoses.

The complex treatment options often fraught with ethical dilemmas and conflict are discussed from the viewpoints of patient, family, and physician.

The role of the ethics committee and legislation in the decision making process is discussed.
A Comparison of Clinical Outcomes of Two Methods of Femoral Hamstring Graft Pin Fixation in Anterior Cruciate Ligament Reconstruction
Authors: Puah Ken Lee , Wong Khai Phang , Yeo William , Tan Andrew Hwee Chye
Published: July 2015

The outcome of anterior cruciate ligament (ACL) reconstruction with hamstring grafts depends on early rehabilitation and secure graft fixation. Various devices available for graft fixation at the femoral tunnel have different biomechanical properties as demonstrated on cadaveric studies. The aim of this study was to compare clinical outcomes in patients using either of two methods of transfemoral pin fixation for hamstring grafts in ACL reconstruction. Twenty-eight patients undergoing primary ACL reconstruction with hamstring autograft with either transfemoral expansion fixation (Rigidfix) or cortical-cancellous suspension (Transfix) by a single surgeon were analysed including subjective knee scores and objective measurements including range of motion and arthrometer-measured anterior translation. Transfix was used in 14 (50.0%) patients and Rigidfix was used in 14 (50.0%) patients. There was no significant difference in pre-injury Tegner activity scores, pre-operative Tegner activity scores, Lysholm scores and age or in Tegner post-operative activity scores, Lysholm scores, range of motion, Lachman and pivot scores absolute anterior translation and anterior translation compared to the non-operated knee at two years. There was a significant improvement in Tegner (2.6 ± 2.4, p<0.00) and Lysholm (25.3 ± 21.2, p<0.00) scores at two years with no significant difference between the two groups. One patient had a broken Transfix cross-pin 13 months after surgery which presented as a subcutaneous swelling which was removed. Although the biomechanical properties of Rigidfix and Transfix differ as demonstrated in cadaveric studies, both devices had similar favourable clinical outcomes in our series.
Management of Periprosthetic Fracture in Unicompartmental Knee Arthroplasty Patients: A Case Series
Authors: Woo Yew Lok , Chin Pak Lin , Lo Ngai Nung , Chia Shi-Lu , Tay Darren Keng Jin , Yeo Seng Jin
Published: July 2015

Unicompartmental knee arthroplasty (UKA) has been one of the treatment modality specifically for unicompartmental osteoarthritis of the knee. The advantages of UKA are faster recovery period, shorter length of hospital stay, reduced morbidity, and good functional outcome. However, one of the complications in UKA is periprosthetic fracture where most papers suggested a surgical intervention such as revision to total knee replacement. In our six years of experience with UKA surgery from 2005 to 2010, we encountered six periprosthetic fractures out of 966 knees that were operated on among 901 patients. Five patients were treated conservatively by casting and were advised not to bear weight on the affected side. One patient was revised to total knee replacement immediately. Each patient underwent a series of scoring system such as Knee Society Clinical Rating and Oxford Questionnaire to evaluate the outcome of treatment. The results were variable with only one patient showing reasonable improvement by conservative management alone. Another three patients did not show significant functional improvements despite the fractures healing. One patient developed non-union and had to undergo internal fixation to correct the deformity. The patient who underwent a revision to total knee replacement showed significant improvement. We conclude that surgical intervention produced better outcome. Revision to total knee replacement was the preferred treatment.
A Pilot Study to Evaluate the Role of Therapeutic Drug Monitoring of Pegfilgrastim in Lymphoma Patients Receiving Chemotherapy
Authors: See Michelle , Shih Vivianne Lee Chuen , Ho Han Kiat , Tang Tiffany Pooi Ling , Farid Mohamad , Quek Richard Hong Hui , Tao Miriam , Lim Soon Thye , Chan Alexandre
Published: July 2015

Background:

Despite primary prophylaxis of febrile neutropenia (FN) with pegfilgrastim, studies have demonstrated a significant number of breakthrough FN events among Asian lymphoma patients receiving chemotherapy. This study was designed to investigate the association of pegfilgrastim concentrations during the lowest point of absolute neutrophil count (ANC nadir) after chemotherapy administration and the occurrence of breakthrough FN, to evaluate whether Therapeutic drug monitoring of pegfilgrastim can guide management of FN.

Methods:

This was a single-centre, prospective cohort study of Asian lymphoma patients who received prophylactic pegfilgrastim after completion of their chemotherapy. Pegfilgrastim serum concentrations were measured from blood samples taken during ANC nadir and at development of breakthrough FN using an enzyme-linked immunosorbent assay. Descriptive statistics, t-tests and correlation curves were used in the statistical analyses.

Results:

Nineteen patients were recruited from May to August 2012 and received 21 cycles of pegfilgrastim. Three (15.8%) developed breakthrough FN. The median pegfilgrastim concentration among patients who developed breakthrough FN was 0.257 (0.231–0.631) ng/ml, compared to 0.299 (0.001–0.829) ng/ml in patients who did not (p=0.740). Baseline ANC levels were significantly lower in patients with breakthrough FN (3.59 × 109/L, range 2.71–3.87) versus those who did not (5.36 × 109/L, range 2.80–16.48; p=0.014).

Conclusion:

There was no difference in pegfilgrastim levels during ANC nadir between patients who developed breakthrough FN and those who did not, but the study was underpowered. Therapeutic drug monitoring of pegfilgrastim cannot be recommended at this time.
An Approach to the Patient with Non-Surgical Bleeding and a Normal Coagulation Screen
Authors: Tha Mya Hae , Ng Heng Joo
Published: July 2015

In the context of non-surgical bleeding, an initial coagulation screen is useful as a guide to further management. It usually consists of platelet count, prothrombin time, activated partial thromboplastin time, thrombin time and fibrinogen level. When the results are normal, underlying coagulation disorders which evade the scope of the initial coagulation screen are suspected. With the knowledge of the principles of the tests used for the initial coagulation screen and the awareness of the rare coagulation disorders which will not affect the initial results, a systematic approach can be applied in the management of such patients. This review aims to highlight the importance of pitfalls in the interpretation of the initial coagulation screening results and provides a brief summary on the coagulation disorders without a deranged initial coagulation screen.
Pregnancy Outcomes in HIV-Positive Women in Singapore
Authors: Chin Hsuan , Chern Bernard Su Min
Published: July 2015

Singapore had her first HIV patient tested sero-positive in 1985. Ever since then, the number of new patients being diagnosed has been on the uprising trend. Based on the current evidences in the literature, we look at how our local practice should be positioned. The objective is to study the general profile of all HIV-positive women in Singapore and to compare the difference in vertical transmission rate between women with very low viral count i.e. < 50 copies/ml who underwent caesarean section and normal vaginal deliveries. Also with proper intrapartum and postpartum advice and care, we look at the outcome of unbooked pregnancies. A ten-year retrospective review of HIV-positive women who delivered in KK Women's & Children's Hospital (Singapore) was conducted. All case notes were reviewed and data was collected and analysed using Microsoft Excel. A total of 75 deliveries by 67 women were identified. Four neonates were tested HIV-positive, amounting to a vertical transmission rate of 5.3%. Of the 12 women who were found to have viral counts of less than 50 copies/ml before their deliveries, four underwent normal vaginal deliveries while eight underwent caesarean sections. All babies were tested HIV-negative. Among the five unbooked pregnancies and two pregnancies that were booked at term, one neonate was found to be positive (14.3%). There is no difference in perinatal transmission in women with very low viral count irrespective of the mode of delivery. For those women with unbooked pregnancies, proper intrapartum care, neonatal anti-retroviral therapy together with avoidance of breastfeeding reduces vertical transmission rate and improves neonatal outcome.
Retrospective Analysis of Vascularised Free Fibula Grafts in Oromandibular Reconstruction and Dental Rehabilitation following Resection of Ameloblastoma
Authors: Lim William Tian Wei , Teh Luan Yook , Yong Loong Tee , Tan Hiang Khoon , Peck Raymond Hong Lian
Published: July 2015

Objective:

The objective of the study was to review 1) patient demographics, 2) hard tissue defect, 3) surgical information and outcomes, 4) early and late complications and 5) dental rehabilitation.

Study Design:

A retrospective review was carried out on 44 cases of mandibular ameloblastoma that were treated by resection and mandibular reconstruction using fibula grafts from October 1994 to October 2011 in local institutions.

Results:

The patients were predominantly Chinese (67.4%) with ages ranging from 11 to 57 years. Defect and surgical data were reviewed and there was only one failure of graft (2.3%). Early complications were observed in 10 patients (23.3%) while late complications were observed in six patients (14%). Dental rehabilitations were in the form of removable dentures (41.9%) and implant supported prostheses (4.7%).

Conclusion:

The fibula flap has been shown to be a reliable flap with low morbidity and also suitable for future dental rehabilitation.
Pulmonary Function Test: Spirometry
Authors: Sewa Duu Wen , Ong Thun How
Published: July 2015

Spirometry is a useful tool in assessing the physiological lung function of a patient, and can be helpful in differentiating the etiology of the patient's symptoms. Indications for the test and the actual procedure are as described. Validity of a spirometry depends on patient co-operation and criteria for acceptability and repeatability must be met for useful interpretation of the results. Commonly measured parameters are described and a simple logarithm for interpretation of a spirometry result is given. Physicians must be mindful when interpreting the result in the context of extreme of ages, size or differing ethnicity as reference values for these groups of individuals are often extrapolated and not validated.
The Minimally Invasive Treatments for Benign Prostrate Hyperplasia
Authors: Lim Yong Wei , Tay Kae Jack , Ho Henry Sun Sien
Published: July 2015

The prevalence of benign prostatic hyperplasia (BPH) increases with age, affecting more than 50% of men above the age of 50 to varying degrees. As it enlarges, it compresses onto the urethra causing bladder outlet obstruction. This can cause a spectrum of problems ranging from irritative and obstructive lower urinary tract symptoms (LUTS) to retention of urine with obstructive uropathy. Transurethral resection of prostate (TURP) is the standard for surgical intervention, however with the advent of an ageing population, there is an increasing number of patients who have ischaemic heart disease who require long-term anticoagulation and have multiple co-morbidities that put them at an increased risk of general anaesthesia. This review aims to critically appraise the effectiveness and evidence for use of these minimally invasive techniques.

Both PubMed and Ovid were used to search for randomised control trials (RCT) comparing the various minimally invasive techniques against TURP. In cases where there were no RCTs, the results of the respective trial were compiled. This was later compiled in a summary table.

An effective minimally invasive treatment modality will play a complimentary role to TURP which remains the standard of surgical treatment for BPH. Technologies progressing towards rapid re-creation of prostatic channel, minimal blood loss and non-urethral instrumentation will bridge the divide between pharmacotherapy and surgery.
Potential Applications of Spectral-Domain Optical Coherence Tomography (SD-OCT) in the Study of Alzheimer's Disease
Authors: Ong Yi-Lin , Ong Yi-Ting , Ikram Mohammad Kamran , Chen Christopher Li Hsian , Wong Tien Yin
Published: July 2015

Alzheimer's Disease (AD) is the most common subtype of dementia. As the prevalence of dementia is projected to increase, the burden of the disease on society is expected to become increasingly significant. The link between eye pathology and neurodegenerative diseases has been established in multiple studies. In particular, optic nerve parameters associated with neuronal loss in AD include retinal ganglion cells (RGC). Retinal ganglion cells are similar to neurons in the cerebral cortex, and have been correlated to neurodegeneration in AD. Ocular imaging techniques such as optical coherence tomography (OCT) have provided a rapid and non-invasive method for quantifying optic nerve parameters in vivo. Spectral domain (SD)-OCT has shown good potential in the study of the optic nerve in AD as it enables more comprehensive assessment of RGCs. Earlier generation OCT techniques only assess the retinal nerve fibre layer, which consists of RGC axons. Spectral domain-OCT offers ultra-high scan speed and image resolution, enabling improved sampling of retinal layers. Retinal layers such as the ganglion cell-inner plexiform layer (GC-IPL), which contain the dendrites and nuclei of RGCs, can be assessed with SD-OCT. This article presents a review of literature associating eye pathology with AD, and explores the potential of SD-OCT in future AD studies. Spectral domain-OCT has the potential to draw more links between optic nerve pathology and neurodegeneration.
Radiation Injury Presenting to the Emergency Department: A Case Report
Authors: Tan Kenneth Boon Kiat , Lee Jean Mui Hua , Ng Yih Ying , Ponampalam R
Published: July 2015

Radiation injuries are closer to home than expected as radioactive sources are common in daily life. Our case study illustrates a case of radiation burns to the hand which presented about two weeks later to the emergency department after accidental exposure to an industrial radiation source. A 45-year old Chinese man presented 17 days later after being exposed accidentally to iridium-192 source at 43 curies. He subsequently suffered burns that required multiple operations to treat. The diagnosis of patients who present early after exposure with no clinical signs will likely pose a challenge for the emergency medicine clinician as radiation burns take time to manifest and may present days to weeks after radiation exposure.
Prevalence of Burnout among Nurses in a Community Hospital in Singapore: A Cross-Sectional Study
Authors: Tay Wei Yi , Earnest Arul , Tan Shu Yun , Ng Matthew Joo Ming
Published: July 2015

Introduction:

Burnout among nurses is a significant problem in healthcare establishments and has negative implications on clinical outcomes. International studies have shown the prevalence of burnout ranged from 30% to 80%. However, this is unknown amongst nurses in a community hospital in Singapore. Our objectives are to determine the prevalence of burnout among nurses at a community hospital in Singapore as well as explore the factors associated with burnout.

Methods:

The nurses, from a community hospital with palliative, rehabilitation, chronic sick and nursing home services, self-administered the Professional Quality of Life Scale to determine the level of burnout. An anonymous survey was included to collect demographics and variables that were postulated to be associated with burnout.

Results:

With a response rate of 51.4%, the prevalence of burnout was found to be 33.3%. Nurses working in the rehabilitation wards had higher odds of burnout (p=0.026). Multivariate analysis indicated increased number of years working as a nurse (p = 0.006) and whether work interferes “sometimes” & “often” with family commitments (p = 0.006 & 0.028 respectively) to be significantly associated with burnout.

Conclusion:

The prevalence of burnout was found to be comparable to that of a tertiary hospital and this deserves further attention. In conclusion, this research reveals the extent of nursing burnout in intermediate and long term care sector as well as identifies factors associated with burnout.
The Effect of a Brief Low-Intensity Therapeutic Lifestyle Counselling Intervention on Weight Loss among Overweight Patients in Primary Care: A Pilot Randomised Controlled Trial
Authors: Ng Lee Beng , Yang Yong , Koh Gerald Choon-Huat
Published: July 2015

Introduction:

To preliminarily assess the effectiveness of a simple low intensity therapeutic lifestyle counselling intervention on weight reduction in overweight patients in primary care.

Methods:

We piloted a six-month randomised controlled trial on 200 primary care clinic patients aged between 21 to 75 years with body mass index (BMI) >23 kg/m2 who were randomised into two groups. The intervention group received a structured intervention consisting of a 15-minute education session on calorie content of common local food items, healthy food choices, exercise frequency, intensity, type, and time duration, and weight reduction goal setting; the control group received usual care. The primary outcome measure was change in body mass index (BMI) from recruitment to 6 months.

Results:

Five hundred and seventeen out of the 1,304 patients assessed were eligible for the study. Of these, 317 declined to participate (61.3%). Among the 200 who participated, 88 were assigned to usual care and 112 were assigned to intervention. Only 62 participants completed the six-month follow-up (24 in control and 38 in intervention group). The mean BMI decline was greater in the intervention than control group [0.71 (SD=1.17) and 0.08 (SD=0.90) kg/m2 respectively, p=0.021], and remained statistically significant after adjusting for age, gender and baseline BMI (p=0.041).

Conclusion:

Our pilot study found that a simple six-month low-intensity therapeutic lifestyle counselling intervention resulted in statistically significant but small reductions in BMI in overweight patients in primary care. These results should be interpreted with caution due to high participation refusal and lost-to-follow-up rates, and lack of objective process measures.
Barriers and Motivators of Influenza Vaccination Uptake among Primary Healthcare Workers in Singapore
Authors: Hwang Siew Wai , Lim Hwee Boon
Published: July 2015

Introduction:

Healthcare workers, especially primary healthcare workers, are at risk of contracting influenza from patients at their workplace. The uptake of influenza immunisation among healthcare workers has been inadequate in spite of this risk and the recommendation to receive annual influenza vaccination. This study aims to assess the barriers as well as the motivators of influenza immunisation among staff from an organisation of primary healthcare polyclinics in Singapore.

Methods:

Focus group interviews were conducted on healthcare workers from different occupation categories within the organisation and results were analysed.

Results:

Factors identified as barriers to influenza immunisation were: misconceptions regarding influenza immunisation, fear of experiencing pain or reaction from the vaccination, influence from other staff, uncertainty over the efficacy of influenza vaccination and perceived immunity against influenza virus. Motivators to immunisation were: the influence of other staff, direction from senior management, incentives for vaccination, accessibility and convenience in receiving the immunisation, reduction in risk of transmitting influenza to others and awareness and knowledge of influenza vaccination.

Conclusion:

Interventions to promote influenza immunisation based on these identified factors may help increase the immunisation uptake among healthcare workers.
Asthma Does Not Always Have a Reversible Airflow Obstruction: A Case Study and a Family Physician Perspective
Authors: Vasanwala Farhad Fakhrudin , Low Lian Leng
Published: July 2015

Asthma has traditionally been seen as a treatment-responsive and reversible inflammatory process, while COPD has been characterised by fixed airway narrowing and alveolar destruction not responsive to treatment. However, in the past two decades there has been increasing evidence on the airway non-reversibility of asthma especially among the elderly patients. This condition has been referred to as overlap syndrome, as they have overlapping features of asthma and COPD. Our case study illustrates the fact that daily high inhaled corticosteroids are the mainstay of treatment, and co-management of such patients with our respiratory colleagues is crucial in stabilising this disease.
Neck Pain in Changi General Hospital: An Observational Study
Authors: Praveen Jayamoorthy Jacob , Lim Ting Jun , O'Brien Aileen
Published: July 2015

Introduction:

The aim of this study is to describe the profile of neck pain patients in the local population and to investigate the efficacy of physiotherapy management of neck pain.

Methods:

A retrospective study was done with neck pain patients who have attended the Musculoskeletal Physiotherapy Clinic at Changi General Hospital from August 2010 to September 2011. The following data was collected from each patient: age, gender, occupation, mechanism of injury, chronicity, posture type, symptom location, physiotherapy management, number of treatment sessions, pain and functional scores pre- and post-therapy. The patients were also categorised according to International Classification of Functioning, Disability and Health (ICF) categories and observed for clinical profiles.

Results:

Ninety-one records were screened. The majority of patients (79%) were aged between 35–65 years. The condition was slightly more prevalent in males (55%) than females (45%). Seventy per cent of the patients had non-traumatic and 30% traumatic onset. The majority (69%) had chronic neck pain; 25% had sub-acute and 6% acute neck pain. The majority of patients had slouched sitting posture (84%). Almost half of the neck patients (48.9%) had unilateral neck pain; 20.2% had central neck pain, 16% had neck pain with shoulder pain, 12.8% had neck pain with radiating pain and 2.1% had neck pain with headache. The categorisation showed 51.1% reported neck pain with movement co-ordination, 30.9% with mobility deficit, 12.8% with radiating pain and 5.2% with headache. The multi-modal method showed significant improvement on the pain scale (p >0.001) within an average of 4.3 physiotherapy sessions.

Conclusion:

Neck pain is common in Singapore, affecting the middle-aged population. Many of these cases presented chronic neck pain, with no trauma involved at symptom onset. A slouched sitting posture was observed most commonly amongst patients with neck pain. Our study indicates that the classification system is valid for clinical use. Patients with headache registered a higher pain intensity than those in other categories. The multi-modal approach is effective in the treatment of neck pain.
Prospective Review of Safety Incidents Reported in the iMRI OT (Intraoperative Magnetic Resonance Imaging Operating Theatre)
Authors: Tan Jerry Keng Tiong , Tan Tong Khee , Goh June Pheck Suan , Ghadiali Natascha Fherzinah
Published: July 2015

Introduction:

The purpose of this study was to determine the types of incidents that occurred in the iMRI OT over a nineteen-month period in our institution. We aim to prevent any future avoidable incidents from happening in this potentially hazardous environment.

Methods:

This is a single centre prospective non-anonymous observational study conducted from February 2009 to September 2010 on surgeries performed in the iMRI OT. Safety incidents specific to the iMRI OT such as violation of safety protocols and equipment failures were reported as well as any other safety incidents resulting in potential or actual adverse safety outcomes. The outcomes of the incidents were included and the data analysed at the end of the study period.

Results:

Of 271 cases that were operated in the iMRI OT, 43 incidents were reported by the staff involved in the care of the patient. Of the 43 incidents, 14 incidents (32.6%) were classified as staff/personnel error and were preventable. Incidents resulted in either delayed surgery or cancellation of the surgery. There were no major adverse incidents that led to patient harm.

Conclusion:

Many of the incidents were preventable and measures have been instituted to prevent the recurrence of such incidents. Staff training, safety protocols and stringent maintenance of equipment are paramount to safe and efficient use of the iMRI operating theatre.
Certification of Death in Singapore
Authors: Ong Serene Ai Kiang , Lai Siang Hui
Published: July 2015

Proper certification of death has legal, social, and epidemiological significance. There is unfortunately little in the existing medical literature relevant to such an important issue in Singapore. With the implementation of the Coroners Act 2010, there has been recent surge in interest in this matter, highlighting a need for additional instruction on the accurate completion of death certificates. This review explains how a death certificate should be filled out, with particular focus on the difference between the terms cause, mechanism, mode, and manner of death. The article is aimed at doctors in Singapore, and highlights legal and practical issues.
A Pilot Study of 2-Octyl Cyanoacrylate (Dermabond™) versus Conventional Suture Skin Closures for Caesarean Sections
Authors: Tan Shu Qi , Malhotra Rahul , Allen John Carson , Tan Thiam Chye
Published: July 2015

Introduction:

2-octyl cyanoacrylate (Dermabond™, Ethicon, USA) has been available as an alternative skin closure since 1997. There are no reports on keloid formation with 2-octyl cyanoacrylate (2OC) closure for Caesarean section. Our study aims to assess keloid formation after Caesarean sections, as well as the safety and efficacy of 2OC for skin closure in Caesarean sections.

Methods:

A pilot study of 97 cases of Caesarean section performed by a single surgeon was done — 50 2OC closure versus 47 suture closure. Keloid formation, average operating time, wound infection, wound dehiscence and adverse peri-wound conditions were compared. Proportions across the two series were compared using chi-square/fisher exact test. Average operating time was compared using unpaired t-test.

Results:

Keloid formation was not statistically significant (2OC 24.0% versus S 14.9%, p=0.382). Mean operating time was similar (2OC 34.1±7.2 minutes versus S 32.7±7.2 minutes, p=0.33). Wound infection rate was similar (2OC 2.0% versus S 2.1%, p=0.939). More women experienced adverse peri-wound conditions with suture closure (2OC 2.0% versus S 6.4%, p=0.303). No woman experienced wound dehiscence.

Conclusion:

2-octyl cyanoacrylate has similar efficacy to suture skin closure in terms of keloid formation, operating time, wound infection and adverse peri-wound conditions. It can be a safe alternative for Caesarean section skin closure.
Review of the Clinical Evidence and Controversies in Therapeutic Hypothermia for Survivors of Sudden Cardiac Death
Authors: Lim Eric Tien Siang , Wong Aaron Sung Lung , Ahmad Nur Shahidah binte , Tan Kenneth Boon Kiat , Ong Marcus Eng Hock , Tan Jack Wei Chieh
Published: July 2015

Sudden cardiac arrest constitutes a major public health burden in both developed and developing countries. In those successfully resuscitated from cardiac arrest, subsequent mortality is still high (∼75%) and is due to a combination of ischaemia and reperfusion injury. The purpose of this review is to describe the experimental and clinical evidence supporting therapeutic hypothermia in survivors of sudden cardiac arrest. We also discuss controversies and unresolved issues in therapeutic hypothermia, including the optimum target temperature for therapeutic hypothermia, and the role of pre-hospital induction of hypothermia. We conclude with a perspective on therapeutic hypothermia as it applies to the Singapore context.
Revisiting Oto-Acoustic Emissions
Authors: Soh Leonard Jie Min , Chan Yew Meng
Published: July 2015

Oto-acoustic emissions (OAEs) are an audiometric diagnostic test that allows quick objective measure of hair cell function in the inner ear. It is a reflection of hearing function at the interface of conductive and sensorineural components in the human ear. Unfortunately, it is not commonly used due to the unique expertise and niche equipment required to successfully carry it out. This article is to further shed light about the use of such tests to junior doctors so that such resources can be better utilised. It also reviews the current and possible future applications of OAEs at the frontiers in otology today.
Time Heals All Wounds: Obstacles in Glaucoma Surgery from an Asian Perspective
Authors: Toh Zhi Hong , Lee Chrisanda Si Ying , Chew Annabel Chee Yen , Perera Shamira
Published: July 2015

Glaucoma is the leading cause of irreversible blindness worldwide and is a particular burden on the Asian population. Glaucoma surgeries such as trabeculectomy and glaucoma drainage implants are routinely performed to lower intraocular pressure (IOP) to prevent disease progression. However, scarring of the filtering bleb limits their long-term success and Asian eyes are more at risk. Although this is so, many existing studies have been done on Caucasian patients, but few have focused solely on Asian patients. Intraoperative anti-metabolites such as Mitomycin-C (MMC) and 5-Fluorouracil (5-FU) are the current mainstay of adjunctive treatments to reduce scarring, and in this review, we evaluate the evolution, benefits and side effects of these agents. Recently, newer methods of wound modulation including anti-vascular endothelial growth factor (VEGF) agents and collagen implants are also being investigated as part of a multi-pronged approach to tackle this problem. Some opportunities exist to limit scarring post-operatively, but it is an ongoing battle.
Combined Use of the Glidescope and Flexible Fibrescope as a Rescue Technique in a Difficult Airway
Authors: Liew Geoffrey Haw Chieh , Wong Theodore Gar Ling , Lu Anqi , Kothandan Harikrishnan
Published: July 2015

Indirect laryngoscopy, in the form of flexible fibrescopy remains the gold standard in the management of predicted difficult intubation. In the last decade, indirect laryngoscopy in the form of videolaryngoscopy has quickly gained popularity as a tool in the anaesthetists' armamentarium in difficult airway management. We describe a case of successful intubation in a difficult airway with the combination of both videolaryngoscopy and flexible fibrescopy when attempts with other commonly used techniques failed.
CD19-redirected chimeric antigen receptor-modified T cells: a promising immunotherapy for children and adults with B-cell acute lymphoblastic leukemia (ALL)
Authors: Tasian Sarah K. , Gardner Rebecca A.
Published: July 2015

Relapsed and chemotherapy-refractory B-cell acute lymphoblastic leukemia (B-ALL) remain significant causes of cancer-associated morbidity and mortality for children and adults. Development of new molecularly targeted treatment strategies for patients with high-risk B-ALL is thus a major preclinical and clinical priority. Adoptive cellular therapy with patient-derived human T cells genetically engineered to express CD19 redirected chimeric antigen receptors (CD19 CAR T cells) is one immunotherapeutic modality that has recently demonstrated remarkable efficacy in re-inducing remission in patients with multiply relapsed B-ALL. Investigative teams at several major cancer centers are currently conducting phase I clinical trials in children and/or adults with relapsed/refractory B-ALL to assess the safety and to identify the maximally tolerated dose of each group’s CD19 CAR T-cell product. All groups have reported major clinical toxicities associated with CD19 CAR T-cell treatment, including cytokine release syndrome (CRS) and macrophage activation syndrome, neurologic dysfunction and aplasia of normal B lymphocytes, while CD19 CAR T cells persist in vivo. Toxicities have generally been transient or manageable with supportive care measures. Some patients with life-threatening CD19 CAR T-cell induced sequelae have received anti-cytokine receptor antibody treatment to diminish CRS symptoms and/or corticosteroids to terminate CAR T-cell proliferation. Remarkably, 67–90% of children and adults with B-ALL treated with CD19 CAR T cells in these trials have achieved morphologic leukemia remission with many patients also in molecular remission. The duration of CD19 CAR T cell persistence in vivo has varied appreciably among treated patients and likely reflects differences in the CD19 CAR constructs utilized at each institution. CD19-positive and CD19-negative B-ALL relapses after CD19 CAR T-cell treatment have occurred in some patients. Phase II trials to assess the efficacy of CD19 CAR T-cell immunotherapy in larger cohorts of patients with relapsed/refractory B-ALL are ongoing or planned.
Anti-dementia medications: current prescriptions in clinical practice and new agents in progress
Authors: Stella Florindo , Radanovic Márcia , Canineu Paulo Renato , de Paula Vanessa J. R. , Forlenza Orestes V.
Published: July 2015

Almost three decades after the publication of the first clinical studies with tacrine, the pharmacological treatment of Alzheimer’s disease (AD) remains a challenge. Randomized clinical trials have yielded evidence of significant – although modest and transient – benefit from cholinergic replacement therapy for people diagnosed with AD, and disease modification with antidementia compounds is still an urgent, unmet need. The natural history of AD is very long, and its pharmacological treatment must acknowledge different needs according to the stage of the disease process. Cognitive and functional deterioration evolves gradually since the onset of clinical symptoms, which may be preceded by several years or perhaps decades of silent, presymptomatic neurodegeneration. Therefore, the pharmacological treatment of AD must ideally comprise both a symptomatic effect to preserve or improve cognition and a disease-modifying effect to tackle the progression of the pathological process. Primary prevention is the ultimate goal, should these strategies be delivered to patients with preclinical AD. In this article, we briefly address the pharmaceutical compounds that are currently used for the symptomatic treatment of AD and discuss the ongoing strategies designed to modify its natural course.
Active surveillance for low-risk prostate cancer
Authors: Hadjipavlou Marios , Promponas John , Madaan Sanjeev
Published: July 2015

Overtreatment of prostate cancer has become evident as studies comparing radical prostatectomy vs watchful waiting have shown that radical treatment benefits only a proportion of patients. Active surveillance was introduced as a management option for prostate cancer at low-risk of progression with the aim to closely observe for disease progression or change of tumour characteristics and offer active treatment if and when necessary. Active surveillance has been reserved for patients with Gleason 6 localised disease and low PSA; however, selection criteria may be widened as intermediate-term outcomes demonstrate excellent safety, efficacy and patient acceptance.
Incidence and Prevalence of Musculoskeletal Injury in Ballet
Authors: Smith Preston J. , Gerrie Brayden J. , Varner Kevin E. , McCulloch Patrick C. , Lintner David M. , Harris Joshua D.
Published: July 2015

Background

Most published studies on injuries in the ballet dancer focus on the lower extremity. The rigors of this activity require special training and care. By understanding prevalence and injury pattern to the musculoskeletal system, targeted prevention and treatment for this population can be developed.

Purpose

To determine the incidence and prevalence of musculoskeletal injuries in ballet.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review registered with PROSPERO was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Level 1 through 4 evidence studies reporting incidence of musculoskeletal injuries in male and female ballet dancers were included, with the numbers and types of injuries extracted from each. Injury rates were recorded and calculated based on professional status, sex, and nature of injury. Incidence was defined as number of injuries sustained over a specific time. Prevalence was defined as proportion of subjects with an injury at a given point in time.

Results

The studies analyzed reported injury incidence or prevalence in more than 1365 amateur and 900 professional dancers. The mean age was 16.2 years among amateur and 27.0 years among professional dancers. The incidence of injury among amateur dancers was 0.99 and 1.09 injuries per 1000 dance hours in males and females, respectively; 75% of injuries were overuse, with similar rates among males and females. In professional dancers, the incidence of injury was 1.06 and 1.46 injuries per 1000 dance hours in males and females, respectively, and 64% of female injuries were overuse, compared with 50% in males ( P < .001). Only 3 studies provided prevalence data, including 62% prevalence of lumbosacral pain, 58% painful snapping hip, and 29% patellofemoral pain. Lower extremity injuries comprised 66% to 91% of all injuries, with the foot and ankle accounting for 14% to 57%.

Conclusion

The overall incidence of injury among amateur and professional ballet dancers is 0.97 and 1.24 injuries per 1000 dance hours, respectively. The majority are overuse in both amateur and professional dancers, with amateur ballet dancers showing a higher proportion of overuse injuries than professionals ( P < .001). Male professional dancers show a higher proportion of traumatic injuries, accounting for half of their injuries ( P < .001).
The polyphosphate–factor XII pathway drives coagulation in prostate cancer-associated thrombosis
Authors: Nickel Katrin F. , Ronquist Göran , Langer Florian , Labberton Linda , Fuchs Tobias A. , Bokemeyer Carsten , Sauter Guido , Graefen Markus , Mackman Nigel , Stavrou Evi X. , Ronquist Gunnar , Renné Thomas
Published: July 2015

Key Points

Polyphosphate-activated coagulation factor XII drives prostate cancer-associated venous thrombosis. Targeting the polyphosphate/factor XII pathway reduces procoagulant activity in prostate cancer patient plasma and may permit safe anticoagulation.
Pegylated, full-length, recombinant factor VIII for prophylactic and on-demand treatment of severe hemophilia A
Authors: Konkle Barbara A. , Stasyshyn Oleksandra , Chowdary Pratima , Bevan David H. , Mant Tim , Shima Midori , Engl Werner , Dyck-Jones Jacqueline , Fuerlinger Monika , Patrone Lisa , Ewenstein Bruce , Abbuehl Brigitt
Published: July 2015

Key Points

BAX 855, a pegylated full-length rFVIII with extended half-life, was highly effective in the prevention and treatment of bleeding events. No subjects receiving BAX 855 developed FVIII inhibitory antibodies nor experienced unexpected adverse events.