The association between mode of transport and out-of-hospital cardiac arrest outcomes in Singapore.

OBJECTIVE: We aimed to examine the survival outcomes of out-of-hospital cardiac arrest (OHCA) patients, stratified by the transportation modes to the Emergency Department (ED). METHODS: This was a retrospective analysis of Singapore's Pan-Asian Resuscitation Outcomes Study registry from Apr 2010-Dec 2017. The primary outcome was survival to discharge or 30 days post-arrest. Secondary outcomes were the return of spontaneous circulation (ROSC) rate and neurological outcomes. A subgroup analysis was performed for OHCA cases who collapsed enroute. RESULTS: A total of 15,376 cases were analysed. 15,129 (98.4%) were conveyed by Emergency Medical Services (EMS), 111 (0.72%) by private ambulance, 106 (0.69%) by own transport and 30 (0.2%) by public transport. 80% of patients brought by public transport arrested enroute, compared to 48.1% by own transport, 25.2% by private ambulance and 2.5% in the EMS group. 33/120 (27.5%) of paediatric OHCA cases were brought in by non-EMS transport to paediatric hospitals. The EMS group had the lowest survival rate at 4.5%, compared to 13.3% for public transport, 11.3% for own transport and 14.4% for private ambulance. ROSC rate was statistically significant but not for neurological outcomes. For the subgroup analysis, there was no statistical difference for primary and secondary outcomes across the groups. CONCLUSION: In Singapore, most OHCA patients are conveyed by EMS to the hospital, but some OHCA patients still arrive via alternative transport without prehospital interventions like bystander CPR. More can be done to educate the public to recognise an impending cardiac arrest and to activate EMS early for such cases.

Improvement of Mortality Prognostication in Patients With Epidermal Necrolysis: The Role of Novel Inflammatory Markers and Proposed Revision of SCORTEN (Re-SCORTEN).

IMPORTANCE: Epidermal necrolysis is a severe cutaneous adverse reaction in which severe systemic inflammation results in extensive epithelial keratinocyte necrosis. The most commonly used prognostic score in epidermal necrolysis, the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN), was recently found to overestimate mortality in contemporary cohorts. Identification of independent prognostic markers may help to stratify risk more accurately. OBJECTIVE: This study evaluates the association between novel inflammatory markers and in-hospital mortality in patients with epidermal necrolysis to study the incremental prognostic value of these markers in combination with SCORTEN. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted over a 17-year period from 2003 to 2019. Patients were enrolled from Singapore General Hospital, the national referral center for epidermal necrolysis. A total of 196 patients with epidermal necrolysis were recruited, 4 (2%) of whom were excluded owing to incomplete data. MAIN OUTCOMES AND MEASURES: The main outcome assessed was the in-hospital mortality rate. Discrimination and calibration of risk scores were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plot, respectively. Evaluation of the incremental prognostic value of these markers was done by comparing the AUC between the old and new risk score, and the use of net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS: Among 192 total patients (median [IQR] age 56 [42-70] years; 114 [59.4%] women), there were 43 (22.4%) who did not survive to discharge. Of the novel inflammatory markers, only red cell distribution width to hemoglobin ratio was significant in predicting in-hospital mortality (odds ratio [OR] 3.55; 95% CI, 1.76-7.16; P < .001) after adjusting for SCORTEN. The RDW/Hb as applied in 4 risk groups showed similar discrimination to SCORTEN (AUC [95% CI]: RDW/Hb in 4 groups, 0.76 [0.69-0.84], vs SCORTEN, 0.78 [0.70-0.85], P = .89). When RDW/Hb was added to SCORTEN, the composite score Re-SCORTEN showed significantly better discrimination than SCORTEN alone (AUC [95% CI]: Re-SCORTEN, 0.83 [0.77-0.89], vs SCORTEN, 0.78 [0.70-0.85], P = .02). The overall NRI was 0.94 (95% CI, 0.68-1.20), P < .001. The IDI was 0.06 (95% CI 0.03-0.08), P < .001. Re-SCORTEN showed good calibration based on the calibration plot. CONCLUSIONS AND RELEVANCE: In this cohort of patients, RDW/Hb, an inexpensive and readily available marker, showed similar predictive accuracy with SCORTEN. Furthermore, when used in combination with SCORTEN, it also helped augment prognostic ability.

Evaluating the preoperative breast cancer characteristics affecting the accuracy of axillary ultrasound staging.

We evaluate the preoperative breast cancer (BC) characteristics that affect the diagnostic accuracy of axillary ultrasound (US) and determine the reliability of US in the different subgroups of BC patients. Axillary US assessments in women with invasive BC diagnosed between 2009 and 2016 in a single institution were retrospectively reviewed. The diagnostic accuracy of axillary US was obtained using surgical nodal histology as the gold standard. Preoperative breast tumor sonographic and histological factors affecting axillary US diagnostic accuracy were examined. Of the 605 newly diagnosed invasive BC cases reviewed, 251 (41.5%) had nodal metastases. Axillary US sensitivity was 75.7%, specificity 92.9%, positive predictive value 88.4%, negative predictive value 84.4%, and false-negative rate 24.3%. Lower US sensitivity was seen with invasive lobular cancer (ILC) (P = .043), grade I/II, (P = .021), unifocal (P = .039), and smaller tumors (P < .001). US specificity was lower in grade III (P < .001), estrogen receptor (ER)-negative (P < .001), progesterone receptor (PR)-negative (P = .004), HER2-positive (P = .015), triple-negative (P = .001), and larger breast tumors (P < .001). US has moderate sensitivity and good specificity in detecting metastatic axillary lymph nodes. Based on preoperative cancer characteristics, US was less sensitive for nodal metastases from ILC, unifocal, lower grade, and smaller breast tumors. It was also less specific in grade III, ER-negative, PR-negative, HER2-positive, triple-negative, and larger breast tumors. Caution is suggested in interpreting the US axillary findings of patients with these preoperative tumor features.

Embryo transfer day does not affect the initial maternal serum ß-hCG levels: A retrospective cohort study.

The aim of this study is to compare the serum ß-hCG values post transfer of a cleavage stage embryo versus a blastocyst stage embryo at equal time intervals post oocyte retrieval (OR) in clinically pregnant patients, and to ascertain a ß-hCG value to predict pregnancy outcomes. This is a retrospective cohort study of 560 women with clinical pregnancy who underwent an embryo transfer performed at either the cleavage stage or the blastocyst stage of embryo development between January 2003 and June 2014 at the Center for Assisted Reproduction (CARE), Singapore General Hospital. The serum ß-hCG level was measured on day 17 post OR. The ß-hCG values were not significantly different in the cleavage stage versus the blastocyst stage embryos (mean±SD: 387±486IU/L D3 vs. 352±268IU/L D5, p=0.96, median value 297 in both groups). Our study suggests that the initial maternal serum ß-hCG values were not affected by the day of transfer of the embryos since assessing the ß-hCG at equivalent points after transfer should not lead to a significant difference assuming the progress and development of the embryos occurred as expected.

Infectious complications in bullous pemphigoid: an analysis of risk factors.

BACKGROUND: Infections are common in bullous pemphigoid and contribute to significant mortality. OBJECTIVES: We sought to define the spectrum of infectious complications and to identify associated risk factors in a bullous pemphigoid cohort. DESIGN: A retrospective cohort study conducted at an academic medical center. RESULTS: In all, 97 patients were included. Infectious complications occurred in 54 patients (56%) and the median duration from diagnosis to first episode of infection was 3 months. Bacteremia occurred in 14 patients (26%) and 26 of 30 deaths (87%) were attributable to infections. On univariate analysis, significant risk factors include low Karnofsky score (<60) (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.5-8.3; P < .01), high Charlson comorbidity index score (≥6) (OR 2.4, 95% CI 1.1-5.5; P = .04), and dementia (OR 4.9, 95% CI 1.5-15.8; P = .01). On multivariate analysis, low Karnofsky score and dementia remained significant with an OR of 3.3 (95% CI 1.1-10.0; P = .03) and OR of 4.2 (95% CI 1.2-14.7; P = .03), respectively. LIMITATIONS: Limitations include potential selection bias as a result of study design and primary outcome measures focused on significant infections requiring hospitalizations. Minor infections were not included. CONCLUSIONS: Identified risk factors for infectious complications include functional impairment and the presence of dementia, which may allow for better risk stratification and individualized treatment of bullous pemphigoid.

Creation and validation of the Singapore birth nomograms for birth weight, length and head circumference based on a 12-year birth cohort.

INTRODUCTION: Both gestation and birth weight have significant impact on mortality and morbidity in newborn infants. Nomograms at birth allow classification of infants into small for gestational age (SGA) and large for gestational age (LGA) categories, for risk stratification and more intensive monitoring. To date, the growth charts for preterm newborn infants in Singapore are based on the Fenton growth charts, which are constructed based on combining data from various Western growth cohorts. Hence, we aim to create Singapore nomograms for birth weight, length and head circumference at birth, which would reflect the norms and challenges faced by local infants. MATERIALS AND METHODS: Growth parameters of all babies born or admitted to our unit from 2001 to 2012 were retrieved. Following exclusion of outliers, nomograms for 3 percentiles of 10th, 50th, and 90th were generated for the gestational age (GA) ranges of 25 to 42 weeks using quantile regression (QR) combined with the use of restricted cubic splines. Various polynomial models (second to third degrees) were investigated for suitability of fit. The optimum QR model was found to be a third degree polynomial with a single knotted cubic spline in the mid-point of the GA range, at 33.5 weeks. Check for goodness of fit was done by visual inspection first. Next, check was performed to ensure the correct proportion: 10% of all cases fall above the upper 90th percentile and 10% fall below the lower 10th percentile. Furthermore, an alternative formula-based method of nomogram construction, using mean, standard deviation (SD) and assumption of normality at each gestational age, was used for counterchecking. RESULTS: A total of 13,403 newborns were included in the analysis. The new infant-foetal growth charts with respect to birth weight, heel-crown length and occipitofrontal circumference from 25 to 42 weeks gestations with the 10th, 50th and 90th were presented. CONCLUSION: Nomograms for birth weight, length and head circumference at birth had significant impact on neonatal practice and validation of the Singapore birth nomograms against Fenton growth charts showed better sensitivity and comparable specificity, positive and negative predictive values.

Continuous infiltration of local anaesthetic following total knee arthroplasty.

PURPOSE: To determine whether continuous infiltration of local anaesthetic can reduce the pain score and morphine use over 48 hours after total knee arthroplasty (TKA). METHODS: 11 men and 43 women aged 50 to 82 years who underwent unilateral TKA for osteoarthritis were recruited. They were randomised into 3 groups. In group 1, 17 patients who acted as controls received patient-controlled analgesia (PCA) with intravenous morphine for 48 hours. In group 2, 16 patients received continuous infiltration of bupivacaine to the subcutaneous tissue and intra-articular space for 48 hours, in addition to PCA. In group 3, 21 patients received an intra-articular injection of local anaesthetic, followed by continuous infiltration of bupivacaine to the subcutaneous tissue and intraarticular space for 48 hours, in addition to PCA. For each patient, a visual analogue score (VAS) for pain was recorded postoperatively at 2, 4, 6, 12, 24, 36, and 48 hours. The total amount of morphine used was recorded at 24 and 48 hours. RESULTS: Over 48 hours, the VAS for pain and morphine use was significantly higher in controls than patients in groups 2 and 3. CONCLUSION: Continuous infiltration of local anaesthetic into the intra-articular space and subcutaneous tissues, in addition to PCA with intravenous morphine, provides significantly more pain relief and reduces morphine use.

Obstructive sleep apnoea in Singapore: polysomnography data from a tertiary sleep disorders unit.

INTRODUCTION: Comprehensive sleep architecture and respiratory event data in local patients with suspected obstructive sleep apnoea (OSA) from overnight polysomnography (PSG), the gold standard for the evaluation of sleep-related breathing disorders, are not widely available. We present 1 year retrospective PSG data with the objective of describing PSG characteristics of patients evaluated for OSA in Singapore. MATERIALS AND METHODS: PSG data of patients evaluated for OSA in 1 year (January through December 2005) in the Sleep Laboratory of a public tertiary hospital were retrospectively reviewed. RESULTS: Five hundred and eighty-four diagnostic PSG studies were performed in patients with symptoms suggestive of sleep-disordered breathing, including snoring, excessive daytime sleepiness, unrefreshing sleep, or recurrent unexplained awakenings. There were 449 male patients (76.9%) and 135 female patients (23.1%), with a mean age of 47.5 years (SD 12.7). Men were on average younger than women, 46.1 years versus 52.0 years (P <0.0005). The mean body mass index (BMI) was 27.9 (SD 6.7), with no significant difference between genders. An association was shown between apnoea-hypopnoea index (AHI) and BMI (Pearson correlation index r = 0.362). Men had overall significantly higher AHI (16.5 vs 9), shorter mean sleep onset latency (11 vs 16.5 minutes), more light sleep (65.5% vs 58.9%), less deep sleep (17.7% vs 23%), and more respiratory event related arousals per hour of sleep (11.6 vs 5.1) (P <0.0005). Severity was classified: AHI <5 ("Normal Overall AHI") (28.3%), AHI 5-15 ("Mild") (22.3%), AHI >15-30 ("Moderate") (18.3%), AHI >30 ("Severe") (31.2%). There was no significant age difference among the 4 groups. More severe OSA patients were significantly heavier, and had more light sleep, less deep sleep, less REM sleep, more respiratory event related arousals and lower levels of oxygen desaturation. CONCLUSION: OSA is predominant in middle-aged, overweight Singapore males and much less common in females who tend to be older. A majority of patients have moderate to severe OSA, which significantly disturbs normal sleep architecture. The relatively lower BMI compared to Caucasian OSA populations may be related to local craniofacial characteristics and/or higher percentage of body fat for BMI which has been described in Singaporeans.

The lower subscapular nerve conduction studies and utilisation in brachial plexopathy evaluation.

OBJECTIVE: To define the optimal nerve conduction study (NCS) method of lower subscapular nerve and evaluate its clinical utility. METHODS: Thirty healthy adults (8 males) with a mean age of 45.2+/-16.5 (range, 21-75) years were recruited in this study. A total of sixty nerves were studied using the Dantec Counterpoint EMG machine (Dantec, Skovlunde, Denmark). 6 patients with clinical and electrodiagnostic evidence of brachial plexopathy were also evaluated. RESULTS: The mean+/-2 standard deviation values of the distal latencies, base-to-peak amplitudes and inter-side amplitude ratio were 2.38+/-0.52 (range, 1.80-2.90) ms, 13.10+/-5.10 (range, 8.70-21.10) mV and 0.93+/-0.12 (range, 0.67-1.00), respectively. There was a significant correlation between the subject age and the base-to-peak amplitudes. All 6 patients with brachial plexopathy had reduced base-to-peak amplitudes as well as inter-side amplitude ratio of less than 0.67 (the normal limits for control). CONCLUSION: The lower subscapular NCS were satisfactorily recordable and well tolerated. It was useful in evaluation of patients with brachial plexopathy.

Sensorineural hearing loss after radiotherapy and chemoradiotherapy: a single, blinded, randomized study.

PURPOSE: The synergistic ototoxicity of radiation and cisplatin (CDDP) has not been adequately studied. This study investigated whether the use of concurrent and postradiotherapy CDDP in patients with nasopharyngeal carcinoma (NPC) resulted in a difference in postradiotherapy sensorineural hearing when compared with the use of radiotherapy alone. PATIENTS AND METHODS: Newly diagnosed patients were randomly assigned to the radiotherapy or chemoradiotherapy groups. Bone conduction hearing thresholds were performed before treatment and at 1 week, 6 months, 1 year, and 2 years after completion of radiotherapy. Statistical analysis was performed using the Mann-Whitney U test. RESULTS: Hearing thresholds averaged over 0.5, 1, and 2 kHz were found to be poorer in the chemoradiotherapy group (58 patients) compared with the radiotherapy group (57 patients) at 1 year (P = .001) and 2 years (P = .03) after radiotherapy. Hearing thresholds at 4 kHz were significantly worse for patients in the chemoradiotherapy arm at all of the postradiotherapy time points studied and were more severely affected than the thresholds at lower speech frequencies. In the radiotherapy group, deterioration of median hearing thresholds, which occurred in the immediate post-treatment period, improved within the first year but deteriorated again at 2 years. In the chemoradiotherapy group, median hearing threshold deterioration, which started immediately after radiotherapy, stabilized by 1 year. CONCLUSION: Patients with NPC who received radiotherapy and concurrent/adjuvant chemotherapy using CDDP experienced greater sensorineural hearing loss compared with patients treated with radiotherapy alone, especially to high-frequency sounds in the speech range. Normal inner ear tissue tolerance, which was once defined only for radiotherapy patients alone, should be redefined in chemoradiotherapy patients.

Clinical characteristics and outcome of severe melioidosis requiring intensive care.

STUDY OBJECTIVE: To describe the clinical characteristics and outcome of patients with severe melioidosis requiring intensive care. DESIGN: Retrospective chart review. SETTING: Two ICUs from a tertiary-care teaching hospital. PATIENTS: Twenty-seven adult ICU patients with microbiologically documented melioidosis. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The median age was 59 years with a male preponderance (26:1). Twenty patients (74%) had medical comorbidities, with diabetes mellitus being the most common (59.3%). Almost all patients (96.3%) were bacteremic. Twenty patients (74.1%) presented with pneumonia. Twenty patients (74.1%) were in septic shock, and 16 patients (59.3%) had ARDS. Twelve patients (44.4%) required hemodialysis. The patients had a median of three organ dysfunctions, and the median APACHE (acute physiology and chronic health evaluation) II score was 27. The overall mortality was 48.1%. Mortality among patients with septic shock was 60%. The median ICU length of stay for survivors and nonsurvivors was 11 days and 2 days, respectively. Multivariate analysis revealed that the number of organ dysfunctions is an independent predictor of mortality (odds ratio, 8.2; 95% confidence interval, 1.3 to 51.4). CONCLUSIONS: The outcome of severe melioidosis requiring intensive care is poor, with death being predicted by the number of organ dysfunctions.

An anthropometric analysis of indices of severity in the unilateral cleft lip.

The aim of this study was to analyze the relationships among three key anthropometric parameters in the unilateral cleft lip to determine the correlations, if any, among these indices of severity. Using a standardized anthropometric documentation protocol, preoperative measurements of 125 unilateral cleft lips (103 complete and 22 incomplete) were performed under general anesthesia by a single surgeon at the time of primary lip repair at the age of 3 months. The following key measurements were analyzed statistically: (1) the philtral height difference (PHD) between the cleft and noncleft sides, (2) the nasal floor width difference (NFWD) between the cleft and noncleft sides, and (3) the cleft width (CW). The mean values of all three indices were greater in the complete group versus the incomplete group. These differences were statistically significant. Linear relationships were obtained between NFWD and GAP, between PHD and GAP, and between PHD and NFWD in the complete group. In contrast, the relationships between PHD and GAP, and between PHD and NFWD were nonlinear in the incomplete group. These findings suggest that there was a strong correlation between the transverse and vertical tissue deficiencies in the complete cleft lip. In incomplete clefts, however, this correlation did not exist. In other words, the incomplete cleft lip can be associated with a severely short philtrum even in the presence of a relatively mild transverse tissue deficit. Therefore, it is not necessarily easier to repair an incomplete cleft lip in terms of the correction of the vertical tissue deficiency.