Clinical evaluation of the use of laryngeal tube versus laryngeal mask airway for out-of-hospital cardiac arrest by paramedics in Singapore

INTRODUCTION@#It remains unclear which advanced airway device has better placement success and fewer adverse events in out-of-hospital cardiac arrests (OHCAs). This study aimed to evaluate the efficacy of the VBM laryngeal tube (LT) against the laryngeal mask airway (LMA) in OHCAs managed by emergency ambulances in Singapore.@*METHODS@#This was a real-world, prospective, cluster-randomised crossover study. All OHCA patients above 13 years of age who were suitable for resuscitation were randomised to receive either LT or LMA. The primary outcome was placement success. Per-protocol analysis was performed, and the association between outcomes and airway device group was compared using multivariate binomial logistic regression analysis.@*RESULTS@#Of 965 patients with OHCAs from March 2016 to January 2018, 905 met the inclusion criteria, of whom 502 (55.5%) were randomised to receive LT while 403 (44.5%) were randomised to receive LMA. Only 174 patients in the LT group actually received the device owing to noncompliance. Placement success rate for LT was lower than for LMA (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.90). Complications were more likely when using LT (OR 2.82,0 95% CI 1.64-4.86). Adjusted OR for prehospital return of spontaneous circulation (ROSC) was similar in both groups. A modified intention-to-treat analysis showed similar outcomes to the per-protocol analysis between the groups.@*CONCLUSION@#LT was associated with poorer placement success and higher complication rates than LMA. The likelihood of prehospital ROSC was similar between the two groups. Familiarity bias and a low compliance rate to LT were the main limitations of this study.

Age and diabetes mellitus associated with worse outcomes after percutaneous coronary intervention in a multi-ethnic Asian dialysis patient population

INTRODUCTION@#There is limited literature on clinical outcomes following percutaneous coronary intervention (PCI) in Asian dialysis patients. We evaluated the angiographic characteristics and clinical outcomes of dialysis patients treated with PCI in an Asian society.@*METHODS@#A retrospective analysis was performed of 274 dialysis patients who underwent PCI in a tertiary care institution from January 2007 to December 2012. Data on clinical and angiographic characteristics was collected. The primary endpoint was major adverse cardiac events (MACE), defined as a composite of cardiac death, acute myocardial infarction (AMI) and stroke at two years.@*RESULTS@#274 patients (65.0% male, median age 62.0 years) with 336 lesions (81.8% Type B2) were treated. 431 stents (35.0% drug-eluting stents) with a mean diameter of 2.96 mm and mean length of 21.30 mm were implanted. The MACE rate was 55.8% (n = 153) at two years, from death (36.5%) and AMI (35.0%). In multivariable analysis, age and diabetes mellitus were significant predictors of both mortality (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05-1.12, p < 0.001; OR 2.65, 95% CI 1.46-4.82, p = 0.001, respectively) and MACE (OR 1.06, 95% CI 1.03-1.08, p < 0.001; OR 1.84, 95% CI 1.07-3.15, p = 0.027, respectively). Left ventricular ejection fraction (LVEF) (OR 0.97, 95% CI 0.95-0.99, p = 0.006) was a significant predictor of mortality but not MACE.@*CONCLUSION@#Asian dialysis patients who underwent PCI had a two-year MACE rate of 55.8% due to death and AMI. Age, LVEF and diabetes mellitus were significant predictors of mortality at two years.

Determining Whether High Nodal Burden in Early Breast Cancer Patients Can Be Predicted Preoperatively to Avoid Sentinel Lymph Node Biopsy / 한국유방암학회지

PURPOSE: The Z0011 trial showed that axillary lymph node dissection (ALND) can be safely avoided in breast cancer patients with low nodal burden (LNB). ALND can be performed in patients with high nodal burden (HNB). We aimed to determine whether HNB in early breast cancer patients can be predicted preoperatively to avoid sentinel lymph node biopsy (SLNB). METHODS: Early invasive breast cancer patients (cT1-2cN0) were retrospectively reviewed. We excluded patients with neoadjuvant chemotherapy and incomplete data. The patients were divided into the following groups based on surgical histology: no positive (N0), LNB, and HNB, defined as 0, 1–2, and ≥ 3 metastatic lymph nodes (LNs), respectively. Of the patients with metastatic nodal disease, only those with ALND were included in the analysis. Clinical, radiological, and histological parameters were evaluated using logistic regression analysis as predictors of HNB versus LNB and N0 combined. RESULTS: Of the 1,298 included patients, 832 (64.1%), 286 (22.0%), and 180 (13.9%) had N0, LNB, and HNB, respectively. Univariate logistic regression analysis revealed that sonographic features of breast tumor size (p < 0.0001), number of abnormal LNs (p < 0.0001), cortical thickness (p = 0.0002), effacement of the fatty hilum (p < 0.0001), and needle biopsy being performed (p < 0.0001) were indicators of HNB. Breast tumor grade (p = 0.0001) and human epidermal growth factor receptor 2 status (p = 0.0262) were also statistically significant. Among these significant features, multivariable stepwise logistic regression showed that the number of abnormal LNs is the sole independent predictor of HNB (p < 0.0001, area under the curve = 0.774). The positive predictive value of HNB in patients with ≥ 4 abnormal LNs was 92.9%. CONCLUSION: The detection of ≥ 4 abnormal LNs on ultrasound can help to identify HNB patients who require upfront ALND and thus avoid SLNB.

Does Low Birth Weight Vary Geospatially in Singapore?

<p><b>INTRODUCTION</b>Low birth weight (LBW, <2500 g) is an important risk factor for perinatal mortality and morbidity. We performed the first geospatial study of LBW in Singapore, with focus on the public sector and analysis of the national planning areas.</p><p><b>MATERIALS AND METHODS</b>A dataset of 24,615 singleton deliveries from 2012 to 2014 was obtained from the largest maternity hospital in Singapore. Maternal residences were identified with 28 planning areas according to postal code. Multiple logistic regression was used to examine associations between LBW rates and planning areas. Moran's I statistic was used to test for geospatial clustering of LBW rates among planning areas.</p><p><b>RESULTS</b>The LBW rate across planning areas ranged from 5.3 to 11.5 per 100 live births (median, 8.4). High LBW rates were associated with: 1) a lower individual socioeconomic status, 2) non-compliance to antenatal visits, and 3) biological factors such as maternal hypertension, low body mass index and Indian race. Moran's statistic indicated no geospatial clustering of LBW rates among the 28 planning areas ( = 0.12). LBW rates were moderately correlated with the Socioeconomic Disadvantage Index (r = 0.58) but uncorrelated with distance travelled to hospital (r = -0.08).</p><p><b>CONCLUSION</b>There was no evidence of clustering of LBW rates among planning areas in Singapore that would indicate inequitable distribution of health resources among planning areas. The 2 areas showing the highest rates of LBW infants were Outram and Bukit Merah. We recommend targeted health interventions and outreach programmes to encourage antenatal visits in these areas.</p>

Patterns and predictors of treatment outcome for antenatal major depression

<p><b>INTRODUCTION</b>Antenatal major depression is a relatively common and potentially debilitating illness, but knowledge of its treatment outcomes and strategies is still lacking. This study aimed to explore the clinical profiles and treatment outcomes of patients with antenatal major depression, to look for patterns and associations that could guide subsequent research and clinical applications.</p><p><b>METHODS</b>From May 2006 to November 2010, 118 consecutive patients with antenatal major depression were naturalistically assessed over eight months of individualised therapy, and their characteristics were assessed as potential predictors of treatment outcome.</p><p><b>RESULTS</b>All participants accepted supportive counselling and case management, although only 51 (43.2%) participants accepted low-dose antidepressant therapy. Overall, 95 (80.5%) of them were successfully discharged, while 12 (10.2%) required extended treatment into the postnatal period. An equation for prognosticating the need for extended treatment was obtained using multiple logistic regression analysis, which incorporated three predictors: previous depression (odds ratio [OR] 12.4, 95% confidence interval [CI] 1.40-110; p = 0.024); maternal age < 26 years or > 35 years (OR 6.88, 95% CI 1.67-28.4; p = 0.008); and no use of antidepressant (OR 6.94, 95% CI 0.79-60.9; p = 0.080). Among participants with previous depression and at either extreme of maternal age, the number needed to treat with antidepressants to avert extended treatment was three.</p><p><b>CONCLUSION</b>The majority of women with antenatal major depression recovered after receiving short-term treatment. Those with previous depression and who were of relative extreme maternal age were most likely to benefit from antidepressant treatment to expedite recovery.</p>

Anti-BP180 NC16A IgG Titres as an Indicator of Disease Activity and Outcome in Asian Patients with Bullous Pemphigoid

<p><b>INTRODUCTION</b>Anti-BP180 IgG titres were observed to parallel disease activity in case series of bullous pemphigoid (BP). This study aimed to examine whether anti-BP180 titres are an indicator of disease severity, clinical course and outcome in Asian patients with BP.</p><p><b>MATERIALS AND METHODS</b>This was a prospective observational study conducted between March 2005 and March 2008 in the Immunodermatology Clinic at the National Skin Centre, Singapore. Disease activity and anti-BP180 IgG titres were measured 4-weekly for 12 weeks and during disease flares and clinical remission. Associations between anti-BP180 titres and disease activity, disease flare, clinical remission and cumulative prednisolone dose were examined.</p><p><b>RESULTS</b>Thirty-four patients with newly diagnosed BP were recruited. Median follow-up duration was 3 years. Notable correlations between disease activity and anti-BP180 titres were at baseline (r = 0.51, P = 0.002), and disease flare (r = 0.85, P <0.001). Lower titres at Week 12 were associated with greater likelihood of clinical remission (P = 0.036). Post hoc, patients with anti-BP180 titres above 87.5 U/mL at time of diagnosis who reached remission within 2 years of diagnosis received significantly higher cumulative doses (mg/kg) of prednisolone (median, 72.8; range, 56.5 to 127.1) than those with titres <87.5 U/mL (median, 44.6; range, 32.5 to 80.8); P = 0.025).</p><p><b>CONCLUSION</b>Anti-BP180 titres may be a useful indicator of disease activity at time of diagnosis and at disease flare. Lower titres at Week 12 may predict greater likelihood of clinical remission. Titres above 87.5 U/mL at time of diagnosis may suggest the need for higher cumulative doses of prednisolone to achieve remission within 2 years.</p>

A prospective study of risk factors for first trimester miscarriage in Asian women with threatened miscarriage

<p><b>INTRODUCTION</b>The present study aimed to assess the demographic, socioeconomic, medical and lifestyle factors associated with the progression of a threatened miscarriage to a complete miscarriage in the first trimester.</p><p><b>METHODS</b>A prospective cohort study was conducted on 157 women who presented with vaginal bleeding in the fifth to tenth week of gestation. Cox regression analysis was used to determine the risk factors for progression to a complete miscarriage within 16 weeks of gestation.</p><p><b>RESULTS</b>Of the 139 women included for data analysis, 36 (25.9%) had a miscarriage, mostly within two weeks of presentation. The results of our study showed that women aged ≥ 34 years were more likely to miscarry (hazard ratio [HR] = 1.95). Compared to women whose partner was 20-30 years of age, women whose partner was ≥ 41 years of age also had a higher likelihood of experiencing a miscarriage (HR = 8.33). However, the presence of nausea (HR = 0.33) and a high stress score (i.e. ≥ 17) on the Perceived Stress Scale (HR = 0.49) were associated with a reduced likelihood of miscarriage.</p><p><b>CONCLUSION</b>Older pregnant women experiencing a threatened miscarriage should be counselled about their higher risk of miscarriage, especially if they have an older partner.</p>