Determinants of emergency department utilisation by older adults in Singapore: A systematic review

INTRODUCTION@#Adults aged ≥60 years contribute to disproportionately higher visits to the emergency departments (ED). We performed a systematic review to examine the reasons why older persons visit the ED in Singapore.@*METHODS@#We searched Medline, Embase and Scopus from January 2000 to December 2021 for studies reporting on ED utilisation by older adults in Singapore, and included studies that investigated determinants of ED utilisation. Statistically significant determinants and their effect sizes were extracted. Determinants of ED utilisation were organised using Andersen and Newman's model. Quality of studies was evaluated using Newcastle Ottawa Scale and Critical Appraisal Skills Programme.@*RESULTS@#The search yielded 138 articles, of which 7 were used for analysis. Among the significant individual determinants were predisposing (staying in public rental housing, religiosity, loneliness, poorer coping), enabling (caregiver distress from behavioural and psychological symptoms of dementia) and health factors (multimorbidity in patients with dementia, frailty, primary care visit in last 6 months, better treatment adherence). The 7 included studies are of moderate quality and none of them employed conceptual frameworks to organise determinants of ED utilisation.@*CONCLUSION@#The major determinants of ED utilisation by older adults in Singapore were largely individual factors. Evaluation of societal determinants of ED utilisation was lacking in the included studies. There is a need for a more holistic examination of determinants of ED utilisation locally based on conceptual models of health seeking behaviours.

A randomised controlled trial investigating the analgesic efficacy of transversus abdominis plane block for adult laparoscopic appendicectomy

<p><b>INTRODUCTION</b>We conducted a single-centre, prospective randomised clinical trial to investigate the analgesic efficacy of transversus abdominis plane (TAP) block in adult patients undergoing laparoscopic appendicectomy.</p><p><b>METHODS</b>Patients undergoing urgent laparoscopic appendicectomy under general anaesthesia alone (control group) and general anaesthesia supplemented by TAP block (TAP intervention group) were compared. All patients received a multimodal analgesia regime, which included postoperative morphine via a patient-controlled analgesia device. The primary endpoints were morphine consumption at 12 hours and 24 hours postoperatively. Secondary endpoints included pain scores, incidence of nausea and vomiting, and time to hospital discharge. A total of 58 patients were recruited, with 29 patients in each group.</p><p><b>RESULTS</b>Mean postoperative morphine consumption at 12 hours (control group: 11.45 ± 7.64 mg, TAP intervention group: 9.79 ± 8.09 mg; p = 0.4264) and 24 hours (control group: 13.38 ± 8.72 mg, TAP intervention group: 11.31 ± 8.66 mg; p = 0.3686) for the control and TAP intervention groups were not statistically different. Secondary outcomes were also not different between the two groups. Length of stay in the post-anaesthesia care unit was significantly shorter for the TAP intervention group, with a trend toward faster hospital discharge being observed.</p><p><b>CONCLUSION</b>TAP block, a regional anaesthetic procedure performed immediately prior to skin incision for laparoscopic appendicectomy, did not significantly improve postoperative analgesia outcomes.</p>

Medication discrepancies and associated risk factors identified among elderly patients discharged from a tertiary hospital in Singapore

<p><b>INTRODUCTION</b>Medication discrepancies and poor documentation of medication changes (e.g. lack of justification for medication change) in physician discharge summaries can lead to preventable medication errors and adverse outcomes. This study aimed to identify and characterise discrepancies between preadmission and discharge medication lists, to identify associated risk factors, and in cases of intentional medication discrepancies, to determine the adequacy of the physician discharge summaries in documenting reasons for the changes.</p><p><b>METHODS</b>A retrospective clinical record review of 150 consecutive elderly patients was done to estimate the number of medication discrepancies between preadmission and discharge medication lists. The two lists were compared for discrepancies (addition, omission or duplication of medications, and/or a change in dosage, frequency or formulation of medication). The patients' clinical records and physician discharge summaries were reviewed to determine whether the discrepancies found were intentional or unintentional. Physician discharge summaries were reviewed to determine if the physicians endorsed and documented reasons for all intentional medication changes.</p><p><b>RESULTS</b>A total of 279 medication discrepancies were identified, of which 42 were unintentional medication discrepancies (35 were related to omission/addition of a medication and seven were related to a change in medication dosage/frequency) and 237 were documented intentional discrepancies. Omission of the baseline medication was the most common unintentional discrepancy. No reasons were provided in the physician discharge summaries for 54 (22.8%) of the intentional discrepancies.</p><p><b>CONCLUSION</b>Unintentional medication discrepancies are a common occurrence at hospital discharge. Physician discharge summaries often do not have adequate information on the reasons for medication changes.</p>

Risk factors for typhoid fever in children in squatter settlements of Karachi: a nested case-control study

Typhoid fever remains a major public health problem in developing countries such as Pakistan. A great majority of cases occur in children living in poor sanitary conditions in squatter settlements in large cities. We conducted a case-control study to identify risk factor for typhoid fever in children under the age of 16 years residing in squatter settlements of Karachi. We enrolled 88 typhoid fever patients, diagnosed by positive blood culture or Typhidot[R] test, between June 1999 and December 2001. Simultaneously, we enrolled 165 age-matched neighborhood controls. Multivariate analysis done through conditional binary logistic regression analysis technique showed that increasing number of persons in the household [odds ratio [OR] = 1.9; 95% confidence interval [CI] 1.2-3.1], non-availability of soap near hand washing facility [OR = 2.6; 95% CI 1.1-6.3], non-use of medicated soap [OR = 11.2; 95% CI 1.3-97.6] and lack of awareness about contact with a known case of typhoid fever [OR = 3.7; 95% CI 1.6-8.4] were independent risk factors of the disease. Health education with emphasis on hand washing may help decrease the burden of typhoid fever in developing countries