Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department

INTRODUCTION@#Although ketamine is one of the commonest medications used in procedural sedation of children, to our knowledge, there is currently no published report on predictors of respiratory adverse events during ketamine sedation in Asian children. We aimed to determine the incidence of and factors associated with respiratory adverse events in children undergoing procedural sedation with intramuscular (IM) ketamine in a paediatric emergency department (ED) in Singapore.@*METHODS@#A retrospective analysis was conducted of all children who underwent procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 October 2017. Demographics and epidemiological data, including any adverse events and interventions, were extracted electronically from the prospective paediatric sedation database. The site of procedure was determined through reviewing medical records. Descriptive statistics were used for incidence and baseline characteristics. Univariate and multivariate logistic regression analyses were performed to determine significant predictors.@*RESULTS@#Among 5,476 children, 102 (1.9%) developed respiratory adverse events. None required intubation or cardiopulmonary resuscitation. Only one required bag-valve-mask ventilation. The incidence rate was higher in children aged less than three years, at 3.6% compared to 1.0% in older children (odds ratio [OR] 3.524, 95% confidence interval [CI] 2.354-5.276; p < 0.001). Higher initial ketamine dose (adjusted OR 2.061, 95% CI 1.371-3.100; p = 0.001) and the type of procedure (adjusted OR 0.190 (95% CI 0.038-0.953; p = 0.044) were significant independent predictors.@*CONCLUSION@#The overall incidence of respiratory adverse events was 1.9%. Age, initial dose of IM ketamine and type of procedure were significant predictors.

Graduates’ and Employers’ Perceptions on Competencies Obtained from An Undergraduate Dental Curriculum Persepsi Graduan dan Majikan terhadap Kompetensi yang Diperolehi dari Kurikulum Program Pergigian Prasiswazah / Jurnal Sains Kesihatan Malaysia

@#The effectiveness of a dental curriculum as reflected by the competencies of the graduates is paramount in ensuring its relevance in the rapidly evolving field of dentistry. This work aimed to assess the competencies of dental graduates of the Faculty of Dentistry, Universiti Kebangsaan Malaysia (UKM) as perceived by the graduates and their employers on the basis of the core competencies listed in the undergraduate dental curriculum. A self-administered questionnaire consisting of 43 questions based on eight competency domains were sent to all UKM dental graduates of years 2012 to 2015 and to senior dental officers who represented their employers. The eight domains assessed were as follows: 1) gathering information at chair-side, 2) diagnosis, 3) treatment planning, 4) treatment and prevention, 5) communitybased, 6) management and administrative, 7) communication and 8) personal management and professional development. a total of 132 graduates (75%) and 18 employers (55%) responded. Only domain E on community-based skills was collectively rated ‘satisfactory’ while the rest of the seven domains had an ‘excellent’ rating by all respondents. With regard to individual skill, basic life support was rated very low for both groups (38.6% graduates and 23.5% employers). A strong association was found between the scores given by the graduates and their employers (p= 0.00). Generally, no difference was found between the scores of graduates from different years. The findings allow an evaluation of the curriculum in a myriad of angles. Although the graduates reported a good level of competency in most domains, the employers were reserved on the community-based skills. Poor competency in the key skill of basic life support in medical emergencies was highlighted and must be addressed in the curriculum or during training at the workplace.

Radiographic features of COVID-19 based on an initial cohort of 96 patients in Singapore

INTRODUCTION@#Chest radiographs (CXRs) are widely used for the screening and management of COVID-19. This article describes the radiographic features of COVID-19 based on an initial national cohort of patients.@*METHODS@#This is a retrospective review of swab-positive patients with COVID-19 who were admitted to four different hospitals in Singapore between 22 January and 9 March 2020. Initial and follow-up CXRs were reviewed by three experienced radiologists to identify the predominant pattern and distribution of lung parenchymal abnormalities.@*RESULTS@#In total, 347 CXRs of 96 patients were reviewed. Initial CXRs were abnormal in 41 (42.7%) out of 96 patients. The mean time from onset of symptoms to CXR abnormality was 5.3 ± 4.7 days. The predominant pattern of lung abnormality was ground-glass opacity on initial CXRs (51.2%) and consolidation on follow-up CXRs (51.0%). Multifocal bilateral abnormalities in mixed central and peripheral distribution were observed in 63.4% and 59.2% of abnormal initial and follow-up CXRs, respectively. The lower zones were involved in 90.2% of initial CXRs and 93.9% of follow-up CXRs.@*CONCLUSION@#In a cohort of swab-positive patients, including those identified from contact tracing, we found a lower incidence of CXR abnormalities than was previously reported. The most common pattern was ground-glass opacity or consolidation, but mixed central and peripheral involvement was more common than peripheral involvement alone.

The Singapore Paediatric Triage Scale Validation Study

<p><b>INTRODUCTION</b>This study aimed to determine the usefulness and validity of the triaging scale used in our emergency department (ED) by analysing its association with surrogate clinical outcome measures of severity consisting of hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalisation.</p><p><b>METHODS</b>A retrospective observational study was conducted of the performance markers of the Singapore Paediatric Triage Scale (SPTS) to identify children who needed immediate and greater care. All children triaged and attended to at the paediatric ED at KK Women's and Children's Hospital, Singapore, from 1 January 2014 to 31 December 2014 were included. Data was retrieved from the Online Paediatric Emergency Care system, which is used for patients' care from initial triaging to final disposition.</p><p><b>RESULTS</b>Among 172,933 ED attendances, acuity levels 1, 2 plus, 2 and 3 were seen in 2.3%, 26.4%, 13.5% and 57.8% of patients, respectively. For admissions, triage acuity level 1 had a strong positive predictive value (79.5%), while triage acuity level 3 had a strong negative predictive value (93.7%). Fewer patients with triage acuity level 3 (6.3%) were admitted as compared to those with triage acuity level 1 (79.5%) (p < 0.001). There was a correlation between triage level and length of ED stay.</p><p><b>CONCLUSION</b>The SPTS is a valid tool for use in the paediatric emergency setting. This was supported by strong performance in important patient outcomes, such as admission to hospital, ICU admissions and length of ED stay.</p>

Predictors of emesis in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department

<p><b>INTRODUCTION</b>Emesis is one of the most common adverse events associated with ketamine sedation. However, its predictors have not been clearly studied among Asian children. This study aimed to determine the incidence and predictors of emesis in children undergoing intramuscular (IM) ketamine sedation in an emergency department (ED) in Singapore and to identify high-risk groups, so that antiemetics may be administered prophylactically.</p><p><b>METHODS</b>In a prospective observational study, all children requiring procedural sedation with IM ketamine in the paediatric ED between 1 April 2013 and 31 January 2015 were included. All cases of emesis following ketamine sedation were prospectively documented. Univariate and multivariate logistic regression analyses were performed to identify the predictors of emesis.</p><p><b>RESULTS</b>2,502 sedations were performed using IM ketamine in the ED during the study period. Overall incidence of emesis associated with IM ketamine sedation was 8.4%. Children aged ≥ 8 years were significantly associated with increased risk of emesis (odds ratio 4.636, 95% confidence interval 3.271-6.570; p < 0.001), with an emesis rate of 19.6%. Other variables such as initial dose (3 mg/kg vs. 4 mg/kg), total dosage (including top-ups), type and site of procedure, gender and ethnicity were not significant predictors. The number needed to treat for antiemetics in children aged ≥ 8 years was five.</p><p><b>CONCLUSION</b>Age is a significant predictor of emesis. We recommend conducting a randomised controlled trial to compare the effects of prophylactic oral ondansetron in patients stratified into the age groups of ≥ 8 years and < 8 years.</p>

Short-term effect of titanium abutmentversus zirconia abutment on peri-implant tissues in anterior teeth / 中国组织工程研究

BACKGROUND: With the increasing aesthetic pursuit of patients, an aesthetic abutment with certain strength has aroused people's attentions either in the anterior or posterior tooth repair. OBJECTIVE: To evaluate the effects of titanium abutment and zirconia abutment on peri-implant tissue in anterior teeth.METHODS: A total of 40 anterior teeth from 34 patients were selected and received single crown restoration with Ankylos implants. Among them, titanium abutments were used in 20 teeth, and zirconia abutments in the other 20 teeth. All the patients were re-visited at 12 months after crown restoration. Peri-implant marginal bone resorption length (MBL), periodontal probing depth (PD), modified plaque index (mPLI), modified sulcus bleeding index (mSBI), and papilla index (PP) were detected; patient satisfaction investigation was carried out; and aesthetic assessment was done based on the pink esthetic score (PES).RESULTS AND CONCLUSION: There were no differences between two groups in MBL, PD, mPLI, mSBI, PP. Patients in both groups were satisfied with the treatment outcomes with insignificant difference (P > 0.05). The PES value in the zirconia abutment group was significantly higher than that in the titanium abutment group (P < 0.05). Overall, titanium and zirconia abutments show the similar effects on the peri-implant tissues and both can achieve good clinical outcomes. However, zirconia abutments have certain advantages in the aesthetic restoration for anterior teeth, and further investigation on long-term effects is warranted.

Short-term effect of titanium abutmentversus zirconia abutment on peri-implant tissues in anterior teeth / 中国组织工程研究

BACKGROUND: With the increasing aesthetic pursuit of patients, an aesthetic abutment with certain strength has aroused people's attentions either in the anterior or posterior tooth repair. OBJECTIVE: To evaluate the effects of titanium abutment and zirconia abutment on peri-implant tissue in anterior teeth.METHODS: A total of 40 anterior teeth from 34 patients were selected and received single crown restoration with Ankylos implants. Among them, titanium abutments were used in 20 teeth, and zirconia abutments in the other 20 teeth. All the patients were re-visited at 12 months after crown restoration. Peri-implant marginal bone resorption length (MBL), periodontal probing depth (PD), modified plaque index (mPLI), modified sulcus bleeding index (mSBI), and papilla index (PP) were detected; patient satisfaction investigation was carried out; and aesthetic assessment was done based on the pink esthetic score (PES).RESULTS AND CONCLUSION: There were no differences between two groups in MBL, PD, mPLI, mSBI, PP. Patients in both groups were satisfied with the treatment outcomes with insignificant difference (P > 0.05). The PES value in the zirconia abutment group was significantly higher than that in the titanium abutment group (P < 0.05). Overall, titanium and zirconia abutments show the similar effects on the peri-implant tissues and both can achieve good clinical outcomes. However, zirconia abutments have certain advantages in the aesthetic restoration for anterior teeth, and further investigation on long-term effects is warranted.

Role of farnesoid X receptor in establishment of ontogeny of phase-I drug metabolizing enzyme genes in mouse liver

The expression of phase-I drug metabolizing enzymes in liver changes dramatically during postnatal liver maturation. Farnesoid X receptor (FXR) is critical for bile acid and lipid homeostasis in liver. However, the role of FXR in regulating ontogeny of phase-I drug metabolizing genes is not clear. Hence, we applied RNA-sequencing to quantify the developmental expression of phase-I genes in both-null and control (C57BL/6) mouse livers during development. Liver samples of male C57BL/6 and-null mice at 6 different ages from prenatal to adult were used. The-null showed an overall effect to diminish the "day-1 surge" of phase-I gene expression, including cytochrome P450s at neonatal ages. Among the 185 phase-I genes from 12 different families, 136 were expressed, and differential expression during development occurred in genes from all 12 phase-I families, including hydrolysis: carboxylesterase (), paraoxonase (), and epoxide hydrolase (); reduction: aldoketo reductase (), quinone oxidoreductase (), and dihydropyrimidine dehydrogenase (); and oxidation: alcohol dehydrogenase (), aldehyde dehydrogenase (), flavin monooxygenases (), molybdenum hydroxylase (and), cytochrome P450 (P450), and cytochrome P450 oxidoreductase (). The data also suggested new phase-I genes potentially targeted by FXR. These results revealed an important role of FXR in regulation of ontogeny of phase-I genes.

Epigenetic regulation of drug metabolism and transport

The drug metabolism is a biochemical process on modification of pharmaceutical substances through specialized enzymatic systems. Changes in the expression of drug-metabolizing enzyme genes can affect drug metabolism. Recently, epigenetic regulation of drug-metabolizing enzyme genes has emerged as an important mechanism. Epigenetic regulation refers to heritable factors of genomic modifications that do not involve changes in DNA sequence. Examples of such modifications include DNA methylation, histone modifications, and non-coding RNAs. This review examines the widespread effect of epigenetic regulations on genes involved in drug metabolism, and also suggests a network perspective of epigenetic regulation. The epigenetic mechanisms have important clinical implications and may provide insights into effective drug development and improve safety of drug therapy.

Incidence of discontinuation of angiotensin-converting enzyme inhibitors due to cough, in a primary healthcare centre in Singapore

<p><b>INTRODUCTION</b>The incidence of cough induced by angiotensin-converting enzyme (ACE) inhibitors has been reported to be 5%-20%, with less than half of affected patients requiring discontinuation due to persistent cough. However, the incidence in the local Asian population has not been studied. This study aimed to objectively evaluate the incidence of discontinuation of ACE inhibitors due to cough, in a primary healthcare centre in Singapore.</p><p><b>METHODS</b>We retrospectively reviewed the medical records, both electronic and written, of patients who attended Tampines Polyclinic to identify those who were newly prescribed ACE inhibitors. The written medical records were analysed to identify patients who discontinued the use of ACE inhibitors and to find out the reasons for discontinuation.</p><p><b>RESULTS</b>A total of 424 patients were identified during the study period. Out of the 424 patients, 129 (30.4%) discontinued the use of ACE inhibitors due to cough. Overall, 90 (21.2%) patients who were initially started on ACE inhibitors were eventually switched to angiotensin receptor blockers (ARBs).</p><p><b>CONCLUSION</b>In our cohort, the incidence of discontinuation of ACE inhibitors due to cough is higher than most other studies. The relationship between ethnicity and tolerance of medications should not be underestimated. As there is a high incidence of discontinuation of ACE inhibitors due to cough in the local population, ARBs may be a reasonable substitute as a first-line medication, if clinically indicated.</p>

Extracorporeal life support for cardiac arrest in a paediatric emergency department

The initiation of extracorporeal membrane oxygenation (ECMO) in the emergency department (ED) is a rare event. Herein, we report a case of acute fulminant myocarditis in a nine-year-old girl who was successfully resuscitated by early initiation of ECMO support in the paediatric ED of KK Women's and Children's Hospital, Singapore. The patient had rapidly progressed into a witnessed pulseless ventricular tachycardia on presentation, and ECMO was started in the ED following the failure of standard resuscitation measures to establish spontaneous circulation. ECMO was continued for nine days. The patient recovered well with normal neurocognitive function. The initiation of ECMO in the ED is potentially life-saving in the resuscitation of children with witnessed in-hospital cardiac arrest due to a reversible cause.

Effect of location of out-of-hospital cardiac arrest on survival outcomes

<p><b>INTRODUCTION</b>This study aims to study how the effect of the location of patient collapses from cardiac arrest, in the residential and non-residential areas within Singapore, relates to certain survival outcomes.</p><p><b>MATERIALS AND METHODS</b>A retrospective cohort study of data were done from the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Out-of- hospital cardiac arrest (OHCA) data from October 2001 to October 2004 (CARE) were used. All patients with OHCA as confirmed by the absence of a pulse, unresponsiveness and apnoea were included. All events had occurred in Singapore. Analysis was performed and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI).</p><p><b>RESULTS</b>A total of 2375 cases were used for this analysis. Outcomes for OHCA in residential areas were poorer than in non-residential areas-1638 (68.9%) patients collapsed in residential areas, and 14 (0.9%) survived to discharge. This was significantly less than the 2.7% of patients who survived after collapsing in a non-residential area (OR 0.31 [0.16 - 0.62]). Multivariate logistic regression analysis showed that location alone had no independent effect on survival (adjusted OR 1.13 [0.32 - 4.05]); instead, underlying factors such as bystander CPR (OR 3.67 [1.13 - 11.97]) and initial shockable rhythms (OR 6.78 [1.95 - 23.53]) gave rise to better outcomes.</p><p><b>CONCLUSION</b>Efforts to improve survival from OHCA in residential areas should include increasing CPR by family members, and reducing ambulance response times.</p>

Recognition and treatment of out-of-hospital cardiac arrests by non-emergency ambulance services in Singapore

<p><b>INTRODUCTION</b>Prompt recognition of cardiac arrest and initiation of cardiopulmonary resuscitation (CPR) and defibrillation is necessary for good outcomes from out-of-hospital cardiac arrest (OHCA). This study aims to describe the recognition and treatment of OHCA in patients conveyed by non-emergency ambulance services (EAS) in Singapore.</p><p><b>MATERIALS AND METHODS</b>This is a multi-centre, retrospective chart review, of cases presenting to public emergency departments (EDs), conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. The study was from October 2002 to August 2009. The following variables were examined: ability to recognise cardiac arrest, whether CPR was carried out by the ambulance crew and whether an automated external defibrillator (AED) was applied.</p><p><b>RESULTS</b>Eighty-six patients were conveyed by non-EAS and found to be in cardiac arrest upon ED arrival. Mean age was 63 years (SD 21.8), 70.9% were males. A total of 53.5% of arrests occurred in the ambulance while 70.9% were found to be asystolic upon ED arrival. Seven patients had a known terminal illness. Survival to discharge was 3.5%. Cardiac arrest went unrecognised by the ambulance crew in 38 patients (44.2%). CPR was performed in 35 patients (40.7%) of the 86 patients and AED was applied in only 10 patients (11.6%).</p><p><b>CONCLUSION</b>We found inadequate recognition and delayed initiation of treatment for OHCA. Possible reasons include a lack of training in patient monitoring and detection of cardiac arrest, lack of CPR training, lack of confidence in performing CPR, lack of AEDs on ambulances and lack of training in their use.</p>

Empathy – The Essentials in Counselling People with HIV

The landscape of HIV has changed from an incurable disease to be more like a chronic disease as the result of advances in medications; the lifespan of People Living with HIV (PLHIV) has also lengthened, HIV defining diseases are delayed, and many of the complications of HIV prevented with adherence to medications. The stigma and discrimination of HIV remain however. PLHIV need to cope with emotional issues of guilt, shame, and self-blame; social issues of rejection, termination of employment, fear and bad social experiences. The paradigm shift from negative regard of PLHIV to that of empathy, which is a deliberate and conscious attitude to relate to PLHIV as fellow travellers in life, to be able to feel with them rather than against them, has therapeutic effects. Empathy has its processes of active listening, responding with appropriately chosen words to describe feelings of the patients, and reflecting the desire to understand more about the patient’s emotions and social turmoil. The benefit of empathy in counseling are the ability to connect with the patient, to build trust from the patient being counseled, and a more objective perspective of being able to see the patient from his/her perspective rather than from the therapist’s perspective. More importantly empathy is a positive response to emotional and social issues experienced by the patient compared to platitudes like “You will be alright; or “don’t worry”, which negate and minimise the opportunity to have a catharsis.

Early diagnosis and treatment of compartment syndrome caused by landslides:a report of 20 cases / 中国骨伤

<p><b>OBJECTIVE</b>To summarize early diagnosis and treatment methods of 20 patients with compartment syndrome caused by landslides during coal mine accidents in order to improve the level of diagnosis and treatment of compartment syndrome and reduce disability.</p><p><b>METHODS</b>From September 2006 to April 2010,20 patients with compartment syndrome were treated with the methods of early decompression, systemic support. All the patients were male with an average age of 42 years (ranged, 23 to 54). All the patients with high tension limb swelling, pain, referred pain passive positive; 5 extremities feeling diminish or disappear and the distal blood vessel beat were normal or weakened or disappeared; myoglobinuria, hyperkalemia, serum urea nitrogen and creatinine increased in 5 cases and oliguria in occurred 1 case. The function of affected limbs was observed according to disability ratings.</p><p><b>RESULTS</b>Three cases complicated with infection of affected limb and 6 cases occurred with renal function insufficiency. Total recovery was in 16 cases, basically recovery in 3, amputation in 1 case. All patients were followed up for 6-15 months with an average of 12 months. The ability to work according to national standard identification--Employee work-related injuries and occupational disability rating classification (GB/T16180-2006) to assess, grade 5 was in 1 case, grade 8 in 2 cases, grade 10 in 1 case, no grade in 16 cases.</p><p><b>CONCLUSION</b>Arteriopalmus of dorsalis pedis weaken and vanished can not be regard as an evidence in early diagnosis of compartment syndrome. Early diagnosis and decompression, systemic support and treatment is the key in reducing disability.</p>