Local anaesthetic toxicity during an awake tracheal intubation course.

We report a case of local anaesthetic toxicity in an anaesthetic trainee participating as a subject for an awake tracheal intubation training course. The trainee experienced symptoms of toxicity despite the dose of lidocaine administered being less than the maximum safe dose recommended for airway topicalisation. We argue this highlights the variability in absorption of local anaesthetic and the importance of safety during awake tracheal intubation training courses. It is essential to use the minimum safe dose of local anaesthetic required during topicalisation for awake tracheal intubation. We have now made it our course policy that participants cannot undergo awake tracheal intubation less than 2 weeks before a period of coryzal illness. We recommend that operators remain vigilant for signs of local anaesthetic toxicity when undertaking this procedure and adhere to newly published Difficult Airway Society awake tracheal intubation guidelines.

Oncogenic osteomalacia -- hypophosphataemic spectrum from "benignancy" to "malignancy".

Though case reports and case series about oncogenic osteomalacia due to benign mesenchymal tumours and much more rarely, secondary to malignant ones exist in the literature, there has not been any series reported from a single department spanning the gamut of causes from benign to malignant. We present 3 patients who were seen at the department of endocrinology of our hospital between 2010 and 2012 with hypophosphataemia and severe skeletal complications. All of them were found to have oncogenic osteomalacia otherwise known as tumour induced osteomalacia (TIO) - a paraneoplastic syndrome characterised by renal phosphate wasting and severe hypophosphataemia. The implicating tumours in our patients ranged from a subcutaneous mesenchymal tumour in the heel to a mixed connective tissue variant within the nasal cavity to metastatic prostate cancer. All our patients had protracted periods before the diagnosis was made, during which time the burden of their metabolic and skeletal pathology had increased. A timely recognition of the clinical features and biochemical findings of this rare but potentially debilitating disease is critical. Physicians should be cognizant of the presence of the disease and its localising and treatment strategies.

Management of blebitis in the United Kingdom: a survey.

AIM: To investigate the current management trend in blebitis among glaucoma consultants registered with the Royal College of Ophthalmologists (London). METHOD: An anonymous survey consisting of 13 questions to ascertain blebitis management was posted to the glaucoma consultants. A χ(2) test was used to analyse the correlation patterns among respondents' answers to the questionnaire. RESULTS: Out of 112 questionnaires, 68 (61%) were returned. Fifty-five per cent of the consultants admit blebitis patients into hospital for treatment. Seventy-four per cent obtain a conjunctival swab, and 28% instil iodine on the conjunctiva as part of their treatment regime. Thirty-four per cent use topical fluroquinolone monotherapy, 28% cefuroxime and gentamicin, 18% fluroquinolone with cefuroxime, and 9% ceftazidime and vancomycin. Fluroquinolones are the only oral antibiotics used by those who routinely prescribe oral treatment (69%). One-fifth of respondents use intravitreal antibiotic in treating blebitis patients. Eighty-two per cent surveyed include topical corticosteroids as part of their treatment regime. Ninety-one per cent use a topical cycloplegic. Twenty-three per cent of the respondents treat blebitis as endophthalmitis, even without or with only mild anterior chamber (AC) activity. Thirty-eight per cent would do so if there was moderate AC activity, and 34% if there was severe AC activity including a hypopyon. CONCLUSION: A wide variation exists in the management of blebitis among glaucoma consultants. A standard treatment regime does not exist at the moment. Further research is needed to ascertain effective strategies to manage this condition.

Health Promotion Board-Ministry of Health clinical practice guidelines: functional screening for older adults in the community.

The Health Promotion Board (HPB) and the Ministry of Health (MOH) publish clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HPB-MOH clinical practice guidelines on Functional Screening for Older Adults in the Community, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Health Promotion Board website (http://www.hpb.gov.sg/uploadedFiles/HPB_Online/Publications/CPGFunctionalscreening.pdf). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Transulnar artery approach for percutaneous coronary intervention: an alternative route in a patient with challenging transfemoral access and hypoplastic radial artery.

Transradial coronary angiography and intervention has become a popular technique due to reduced local and bleeding complications, easier post-procedural care and patient preference. In certain patients, transradial access may not be possible due to various anatomical reasons. Usually, the transfemoral route is used for these patients. In a minority of patients, such as those with significant peripheral arterial disease or obesity, the transfemoral approach is challenging and is associated with an increased risk of local complications or bleeding. Transulnar arterial access, however, has recently been shown to be feasible and safe for both coronary angiography and intervention. The procedural success, advantages and complication rates for this procedure appear similar to those for the transradial approach. We describe a case of transulnar artery percutaneous coronary intervention in an obese patient with a hypoplastic radial artery.

Percutaneous transcatheter aortic valve replacement: first transapical implant in Asia.

Percutaneous transcatheter implantation of the aortic valve has been demonstrated as an alternative to open heart surgery in high-risk patients with symptomatic severe aortic stenosis (AS) who are not suitable for open surgery. The majority of these new devices are delivered via the transfemoral approach. However, due to the current size of delivery sheaths, the small and tortuous iliofemoral anatomy makes this approach challenging. The transapical approach provides a viable option for this patient subgroup. The first-in-Asia transcatheter aortic valve implantation via the transapical route is described. A 79-year-old Chinese woman with symptomatic severe AS and peripheral arterial disease, who was at high surgical risk, was successfully treated, and had good functional and haemodynamic results at the three-month follow-up.

Percutaneous transcatheter aortic valve replacement: first transfemoral implant in Asia.

Surgical aortic valve replacement (AVR) is the standard of care for patients with symptomatic severe aortic stenosis (AS), providing relief of symptoms and prolonging survival. However, many patients are either denied or not offered surgery due to high surgical risk or non-operability for open AVR. The technology of percutaneous aortic valve implantation emerged in 2002, and has since evolved rapidly with satisfactory results. Currently, almost all the procedures are performed predominantly in Europe and North America. The first-in-Asia percutaneous transcatheter aortic valve implantation via the transfemoral route is described. A 77-year-old man with symptomatic severe AS and at high surgical risk was successfully treated, with sustained clinical improvement and satisfactory haemodynamic results at 30-day follow-up.

The use of control charts in monitoring postcataract surgery endophthalmitis.

AIM: To apply the control chart method to retrospectively analyse the variation in postcataract surgery endophthalmitis. METHODS: The endophthalmitis data between 01/07/97 and 30/06/07 (10 years) at the Royal Gwent Hospital were analysed using the control chart method. Certain criteria related to the control chart were employed to detect unusual variations and early outbreaks of endophthalmitis. RESULTS: A total of 21 032 cases of cataract were performed in that period, with a mean annual incidence of 0.16%. The control chart could provide a reliable method to detect an early outbreak of endophthalmitis before it was suspected and acted on. The chart provided visual information of the altering trends of endophthalmitis cases and allows unusual variations to be detected early. CONCLUSION: The control chart is potentially a sensitive method to detect anomaly in the cases of postcataract surgery endophthalmitis. Its control limits are dynamic and factor in recent performance to detect any unusual variation.

Navigability trumps all: stenting of acute middle cerebral artery occlusions with a new self-expandable stent.

Acute stroke intervention is rapidly evolving. New technologies are improving device deliverability and rates of recanalization. We describe 2 cases of acute middle cerebral artery occlusions wherein Wingspan stents could not be delivered to the occlusive site because of excessive vascular tortuosity. Merci thrombectomy was also unsuccessful. Revascularization was only achieved with deployment of the highly navigable Enterprise stent, resulting in thrombolysis in myocardial infarction 2/3 flow. Thus, all devices should be considered in the armamentarium of stroke therapy.

The efficacy of corticosteroid therapy in inflammatory bowel disease: analysis of a 5-year UK inception cohort.

BACKGROUND: Corticosteroids remain the mainstay of first-line therapy in active inflammatory bowel disease. AIMS: To determine the clinical outcome after the first corticosteroid-therapy and to identify factors which predict response/failure. METHODS: 216 (136 ulcerative colitis and 80 Crohn's disease) patients were identified in this 5-year inception cohort. The outcomes of early (30 days) and late (1 year) responses were used. Multivariate analyses were performed to identify factors associated with outcome. RESULTS: 86 (63%) and 60 (75%) ulcerative colitis and Crohn's disease required corticosteroid therapy, respectively. In ulcerative colitis, at 30 days, 69 (51%), 42 (31%) and 25 (18%) patients demonstrated complete response, partial response and no response, respectively. For Crohn's disease, these outcomes were observed in 32 (40%), 28 (35%) and 20 (25%). After 1 year, 75 (55%), 23 (17%) and 29 (21%) patients with ulcerative colitis demonstrated prolonged response, corticosteroid-dependence or required surgery, respectively. For Crohn's disease, these outcomes were observed in 30 (38%), 19 (24%) and 27 (35%) patients. Extensive ulcerative colitis was a predictor of surgery (P = 0.001, OR: 15.2). In Crohn's disease, inflammatory disease behaviour was negatively associated with surgery (P = 0.02, OR: 0.13). CONCLUSION: Although corticosteroids are effective, dependence/resistance remains common. Patients with extensive ulcerative colitis and fistulizing/stricturing Crohn's are most at risk of failing corticosteroid therapy.

Electrocardiographical case. An elderly lady with chest pain. Diagnosis: isolated posterior myocardial infarct (MI).

A 72-year-old woman with diabetes mellitus, hypertension and dyslipidaemia presented with severe chest pain of four hours duration. Her electrocardiogram (ECG) showed tall R waves in leads V1-2, and ST segment depression in leads V1- 4, consistent with an isolated posterior myocardial infarction (MI). Emergency coronary angiogram showed an occluded left circumflex coronary artery, and primary angioplasty and stenting was performed. The ECG criteria for isolated posterior MI and pitfalls in using the conventional 12-lead ECG are discussed.

Major pulmonary embolism treated with a rheolytic thrombectomy catheter.

The current treatment of massive pulmonary embolism (PE) has been either thrombolysis or surgical embolectomy. Recently, percutaneous rheolytic thrombectomy has emerged as an alternative treatment in patients with contraindications to thrombolysis. We describe a 45-year-old woman who developed major PE post-operatively, who was treated successfully with the AngioJet system. The principles of percutaneous rheolytic thrombectomy, its effectiveness and potential complications are discussed.

Kikuchi's disease: a Singapore case series.

INTRODUCTION: Kikuchi's disease is a benign form of cervical lymphadenopathy that commonly affects young adults. We report a case series from our hospital. METHODS: The clinical features of 23 cases of Kikuchi's disease diagnosed at Changi General Hospital over a seven year period are presented. The cases were identified from pathology records using the search term histiocytic necrotising lymphadenitis. RESULTS: Most of our patients (78 percent) were young women who presented with cervical lymphadenopathy. The median age was 31 years. In the 18 cases who completed follow-up at the hospital, there was spontaneous resolution of symptoms within a six-month period. One patient demonstrated seropositivity for systemic lupus erythematosus (SLE) and was initially started on steroids. However, the treatment was discontinued shortly afterwards since she did not meet the diagnostic criteria for SLE. Excision biopsy of the affected lymph node was the diagnostic method of choice. CONCLUSION: Kikuchi's disease is not uncommon in the Singaporean population. Establishing an early diagnosis is crucial since the clinical presentation can mimic tuberculous lymphadenitis or malignant lymphoma. The diagnostic method of choice is excision biopsy.

Localised outbreak of Falciparum malaria in Singapore.

Malaria is primarily an imported disease in Singapore. Local outbreaks are uncommon. We describe a localised outbreak of three patients with Falciparum malaria, which we believe to be locally acquired. There was one fatality due to severe disease and late presentation. Malaria should be considered as a cause of febrile illness as the likelihood of cure depends on early detection and treatment.

The ethnic characteristics and prevalence of diabetes mellitus, hypertension and hyperlipidaemia in patients who underwent coronary artery bypass grafting in Hospital Universiti Kebangsaan Malaysia.

A retrospective study was done on 302 patients who had undergone coronary artery bypass grafting (CABG) in Hospital Universiti Kebangsaan Malaysia--46.0% were Chinese, 40.1% were Malays and 11.6% were Indians. Overall and irrespective of race and sex, the prevalence of diabetes mellitus, hypertension and hyperlipidaemia was 45.7%, 78.8% and 89.1% respectively indicating that hyperlipidaemia was the most prevalent risk factor amongst this cohort. The Indians had the highest prevalence of the three risk factors. The Chinese and the Malays most frequently presented with the combination of hypertension and hyperlipidaemia.

Validation and comparison of three brief depression scales in an elderly Chinese population.

The study aimed to establish the diagnostic accuracy of the Geriatric Depression Scale (GDS), the Even Briefer Assessment Scale for Depression (EBAS DEP), and the single question test for depression in our elderly Chinese population, and to determine if any one instrument was to be preferred. Ninety-eight community-living, socially active and non-depressed elderly and 75 patients diagnosed with depression were administered the three depression scales. Receiver operating characteristics (ROC) were employed to determine the optimal cut-off scores for the GDS and EBAS DEP, and the diagnostic performance of all three instruments were then compared. ROC analysis indicated an optimal cut-off score of 4 and above for the 15-item GDS, with a sensitivity of 84.0% and a specificity of 85.7%, while the EBAS DEP had 77.3% sensitivity and 89.8% specificity at the optimal cut-off score of 3 and above. The sensitivity and specificity of the single question were 64.0% and 94.9%, respectively. The non-parametric test of the areas-under-the-curve showed no significant difference between the diagnostic performances of the GDS and the EBAS DEP; visually, however, the ROC plot of the GDS was superior. The GDS, the EBAS DEP, and the single question were all valid screening tools for depression in the elderly Chinese population. For busy physicians, there is rationale to first use the single-question test, supplemented where necessary with either the GDS or the EBAS DEP, as an efficient diagnostic strategy for identifying depression amongst older Chinese patients.