Impact of time-to-compression on out-of-hospital cardiac arrest survival outcomes: A national registry study.

OBJECTIVE: We aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30th day. Our secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation. METHODS: All OHCAs from 2012 to 2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30th day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval. RESULTS: 12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function- aOR 0.98 (95%CI: 0.97-0.98); survival to discharge- aOR 0.98 (95%CI: 0.98-0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests. CONCLUSION: We demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (>7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional 'down-times', which could aid clinical decisions in TOR or OHCA management.

Comparison of postpartum incontinence outcomes after vacuum-assisted and forceps-assisted deliveries in a tertiary maternity unit.

INTRODUCTION AND HYPOTHESIS: Forceps-assisted deliveries are an established risk factor for pelvic organ prolapse and pelvic floor injury. However, specific comparison of incontinence outcomes between vacuum-assisted and forceps-assisted deliveries are scarce in the literature. We aimed to compare the initial impact of vacuum and forceps deliveries on new-onset urinary and faecal incontinence as well as pelvic floor muscle strength, with the hypothesis that incontinence outcomes were poorer after forceps- than after vacuum-assisted delivery. METHODS: This is a retrospective cohort study of incontinence outcomes in patients who had primary vacuum- or forceps-assisted delivery. The study population included 108 postpartum patients who had undergone operative vaginal delivery (63 vacuum-assisted, 45 forceps-assisted), met the inclusion criteria and attended the postpartum assessment service. Outcomes studied were the presence and severity of symptoms manifesting beyond 1 month postpartum - faecal incontinence and stress, urgency and mixed urinary incontinence - as well as pelvic floor muscle strength scores based on the modified Oxford scale. RESULTS: Prevalence of new-onset urinary and faecal incontinence was 35.6% in the forceps group and 30.2% in the vacuum group. The data suggest that there is no significant difference in the prevalence of new-onset incontinence symptoms (p = 0.70, difference in prevalence [forceps - vacuum]: 5.4%, 95% CI -0.25, +0.15), frequency (p = 0.40) and amount (p = 0.48) of urine leakage or mean muscle strength scores (p = 0.89). CONCLUSION: In our maternity unit, we observed that type of operative vaginal delivery was not associated with significant differences in urinary incontinence and pelvic floor muscle strength outcomes.

Defining prostate cancer size and treatment margin for focal therapy: does intralesional heterogeneity impact the performance of multiparametric MRI?

OBJECTIVES: To evaluate the impact of intralesional heterogeneity on the performance of multiparametric magnetic resonance imaging (mpMRI) in determining cancer extent and treatment margins for focal therapy (FT) of prostate cancer. PATIENTS AND METHODS: We identified men who underwent primary radical prostatectomy for organ- confined prostate cancer over a 3-year period. Cancer foci on whole-mount histology were marked out, coding low-grade (LG; Gleason 3) and high-grade (HG; Gleason 4-5) components separately. Measurements of entire tumours were grouped according to intralesional proportion of HG cancer: 0%, <50% and ≥50%; the readings were corrected for specimen shrinkage and correlated with matching lesions on mpMRI. Separate measurements were also taken of HG cancer components only, and correlated against entire lesions on mpMRI. Size discrepancies were used to derive the optimal tumour size and treatment margins for FT. RESULTS: There were 122 MRI-detected cancer lesions in 70 men. The mean linear specimen shrinkage was 8.4%. The overall correlation between histology and MRI dimensions was r = 0.79 (P < 0.001). Size correlation was superior for tumours with high burden (≥50%) compared to low burden (<50%) of HG cancer (r = 0.84 vs r = 0.63; P = 0.007). Size underestimation by mpMRI was more likely for larger tumours (51% for >12 mm vs 26% for ≤12 mm) and those containing HG cancer (44%, vs 20% for LG only). Size discrepancy analysis suggests an optimal tumour size of ≤12 mm and treatment margins of 5-6 mm for FT. For tumours ≤12 mm in diameter, applying 5- and 6-mm treatment margins would achieve 98.6% and 100% complete tumour ablation, respectively. For tumours of all sizes, using the same margins would ablate >95% of the HG cancer components. CONCLUSIONS: Multiparametric MRI performance in estimating prostate cancer size, and consequently the treatment margin for FT, is impacted by tumour size and the intralesional heterogeneity of cancer grades.

Metabolic and endocrinal effects of epidural glucocorticoid injections.

INTRODUCTION: Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. METHODS: 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. RESULTS: Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. CONCLUSION: Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.

Reperfusion treatment delays amongst patients with painless ST segment elevation myocardial infarction.

OBJECTIVE: Early reperfusion therapy in the treatment of ST segment elevation myocardial infarction (STEMI) patients can improve outcomes. Silent myocardial infarction is associated with poor prognosis, but little is known about its effect on treatment delays. We aimed to characterize STEMI patients presenting without complaints of pain to the emergency departments (EDs) in Singapore. METHODS: Retrospective data were requested from the Singapore Myocardial Infarction Registry (SMIR), a national level registry in Singapore. Painless STEMI was defined as the absence of pain (chest, back, shoulder, jaw, and epigastric pain) during ED presentation. The primary outcome was door-to-balloon (D2B) time, defined as the earliest time a patient arrived in the ED to balloon inflation. Secondary outcomes were 1-month and 1-year mortality and occurrence of adverse events. RESULTS: From January 2010 to December 2012, the SMIR collected 6412 cases; 10.9% of patients presented without any pain. These patients were older (median age =75 v. 58 years old), more likely to be females (39.9% v. 16.1%), Chinese (74.9% v. 62.7%), obese (median body mass index [BMI] =24.5 v. 22.1), and with history of hypertension (71.1% v. 54.6%), diabetes mellitus (48.6% v. 37.0%), and acute myocardial infarction (20.0% v. 12.3%). They had a longer median D2B (80.5 v. 63 minutes, p<0.001) and a higher occurrence of 30-day (38.4% v. 5.7%) and 1-year mortality rates (47.3% v. 8.5%). CONCLUSION: A small proportion of STEMI patients presented without any pain to the ED. They tended to have a higher D2B and risks of mortality. Targeted effort is required to improve diagnostic and treatment efficiency in this group.

Characteristics of patients who made a return visit within 72 hours to the emergency department of a Singapore tertiary hospital.

INTRODUCTION: 72-hour emergency department (ED) reattendance is a widely-used quality indicator for quality of care and patient safety. It is generally assumed that patients who return within 72 hours of ED discharge (72-hour re-attendees) received inadequate treatment or evaluation. The current literature also suggests considerable variation in probable causes of 72-hour ED reattendances internationally. This study aimed to understand the characteristics of these patients at the ED of a Singapore tertiary hospital. METHODS: We conducted a retrospective cohort study on all ED visits between 1 January 2013 and 31 December 2013. 72-hour re-attendees were compared against non-re-attendees based on patient demographics, mode of arrival, patient acuity category status (i.e. P1/P2/P3/P4), seniority ranking of doctor-in-charge and medical diagnoses. Multivariate analysis using the generalised linear model was conducted on variables associated with 72-hour ED re-attendance. RESULTS: Among 104,751 unique patients, 3,065 (2.93%) were in the 72-hour re-attendees group. Multivariate analysis showed that the following risk factors were associated with higher risk of returning within 72 hours: male gender, older age, arrival by ambulance, triaged as P2, diagnoses of heart problems, abdominal pain or viral infection (all p < 0.001), and Chinese ethnicity (p = 0.006). There was no significant difference in the seniority ranking of the doctor-in-charge between both groups (p = 0.419). CONCLUSION: Several patient and event factors were associated with higher risk of being a 72-hour re-attendee. This study forms the basis for hypothesis generation and further studies to explore reasons behind reattendances so that interventions can be developed to target high-risk groups.

Incidence of postoperative wound infections after open tendo Achilles repairs.

INTRODUCTION: Tendo Achilles (TA), which is the confluence of the gastrocnemius and soleus muscles, is one of the most commonly injured tendons. The surgical repair of TA ruptures is associated with a significant risk of infection. This study examined several factors (i.e. gender, age, body mass index, history of diabetes mellitus, steroid use, acute or chronic TA injuries, type of surgical incision and type of sutures used) that may be associated with postoperative wound infection after open TA repair. METHODS: This was a retrospective study involving 60 patients who underwent open TA repair over an 18-month period. Patients who had prior TA surgery or open TA injuries, or who needed soft tissues flaps were excluded. RESULTS: Among the patients, 7 (11.7%) developed superficial wound infections that were successfully treated with oral antibiotics, while 3 (5.0%) developed deep wound infections that required at least one debridement procedure. No significant association was found between the risk of postoperative wound infection and gender, age, the presence of diabetes mellitus, acute or chronic ruptures, site of surgical incision and type of deep or superficial sutures used. CONCLUSION: While diabetes mellitus and age did not appear to be associated with postoperative wound infections after open TA repair, obese patients were found to be two times more likely to develop a wound infection than normal-weight patients. The incidence of superficial wound infections in this study was similar to previously published results (11.7% vs. 8.2%-14.6%), but the incidence of deep infections was higher (5% vs. 1%-2%).

Factors affecting the ambulance response times of trauma incidents in Singapore.

OBJECTIVES: Time to definitive care is important for trauma outcomes, thus many emergency medical services (EMS) systems in the world adopt response times of ambulances as a key performance indicator. The objective of this study is to examine the underlying risk factors that can affect ambulance response times (ART) for trauma incidents, so as to derive interventional measures that can improve the ART. MATERIAL AND METHODS: This was a retrospective study based on two years of trauma data obtained from the national EMS operations centre of Singapore. Trauma patients served by the national EMS provider over the period from 1 January 2011 till 31 December 2012 were included. ART was categorized into "Short" (<4min), "Intermediate" (4-8min) and "Long" (>8min) response times. A modelling framework which leveraged on both multinomial logistic (MNL) regression models and Bayesian networks was proposed for the identification of main and interaction effects. RESULTS: Amongst the process-related risk factors, weather, traffic and place of incident were found to be significant. The traffic conditions on the roads were found to have the largest effect-the odds ratio (OR) of "Long" ART in heavy traffic condition was 12.98 (95% CI: 10.66-15.79) times higher than that under light traffic conditions. In addition, the ORs of "Long ART" under "Heavy Rain" condition were significantly higher (OR 1.58, 95% CI: 1.26-1.97) than calls responded under "Fine" weather. After accounting for confounders, the ORs of "Long" ART for trauma incidents at "Home" or "Commercial" locations were also significantly higher than that for "Road" incidents. CONCLUSION: Traffic, weather and the place of incident were found to be significant in affecting the ART. The evaluation of factors affecting the ART enables the development of effective interventions for reducing the ART.

MRI kinetics with volumetric analysis in correlation with hormonal receptor subtypes and histologic grade of invasive breast cancers.

OBJECTIVE. The aim of this study was to assess whether computer-assisted detection-processed MRI kinetics data can provide further information on the biologic aggressiveness of breast tumors. MATERIALS AND METHODS. We identified 194 newly diagnosed invasive breast cancers presenting as masses on contrast-enhanced MRI by a HIPAA-compliant pathology database search. Computer-assisted detection-derived data for the mean and median peak signal intensity percentage increase, most suspicious kinetic curve patterns, and volumetric analysis of the different kinetic patterns by mean percentage tumor volume were compared against the different hormonal receptor (estrogen-receptor [ER], progesterone-receptor [PR], ERRB2 (HER2/neu), and triple-receptor expressivity) and histologic grade subgroups, which were used as indicators of tumor aggressiveness. RESULTS. The means and medians of the peak signal intensity percentage increase were higher in ER-negative, PR-negative, and triple-negative (all p ≤ 0.001), and grade 3 tumors (p = 0.011). Volumetric analysis showed higher mean percentage volume of rapid initial enhancement in biologically more aggressive ER-negative, PR-negative, and triple-negative tumors compared with ER-positive (64% vs 53.6%, p = 0.013), PR-positive (65.4% vs 52.5%, p = 0.001), and nontriple-negative tumors (65.3% vs 54.6%, p = 0.028), respectively. A higher mean percentage volume of rapid washout component was seen in ERRB2-positive tumors compared with ERRB2-negative tumors (27.5% vs 17.9%, p = 0.020). CONCLUSION. Peak signal intensity percentage increase and volume analysis of the different kinetic patterns of breast tumors showed correlation with hormonal receptor and histologic grade indicators of cancer aggressiveness. Computer-assisted detection-derived MRI kinetics data have the potential to further characterize the aggressiveness of an invasive cancer.

Hypoxia increases adipogenesis and affects adipocytokine production in orbital fibroblasts-a possible explanation of the link between smoking and Graves' ophthalmopathy.

AIM: To assess the effects of hypoxia on human orbital fibroblasts (OF) on adipogenesis and adipocytokine production. METHODS: Human OF were derived from tissues obtained from patients with Graves' ophthalmopathy (GO) and from patients without known thyroid diseases undergoing blepharoplasty. The OF were cultured separately under normoxic and hypoxic conditions. Comparisons of adipocytokine concentrations using multiplex ELISA and lipid accumulation in the cells using Oil Red O staining were subsequently performed. RESULTS: There was increased adipogenesis in OF from GO subject when exposed to hypoxic culture conditions. This was not observed in OF from normal controls. Hypoxia led to an increase in leptin and a decrease in MCP-1 secretion in OF cultures. CONCLUSION: Hypoxia induces adipogenesis in OF and may represent a mechanism by which smoking contributes to deterioration of GO. We also found novel changes to leptin and MCP-1 production in OF cultures exposed to hypoxia suggesting important roles of these cytokines in the disease process.

A cross-sectional study of the demographic, cultural, clinical and rehabilitation associated variables predicting return to employment after disability onset in an Asian society.

OBJECTIVES: This study examined the rate of return to work, and to find demographic, clinical and functional factors associated with successful re-employment after in-patient rehabilitation. METHODS: We performed a cross-sectional cohort study of Singaporeans aged 15 and above who underwent inpatient rehabilitation in a Singapore hospital between 2000 and 2007. Phone interviews were conducted in 2007 to 2008, via a structured questionnaire to evaluate factors of return to work. RESULTS: Four hundred and eight patients met with the inclusion criteria, and 123 participants completed the questionnaire. Forty-five (44.7%) participants successfully returned to work with a mean time of 7 months post-discharge. Statistical significant differences were found between the "return to work" group and "non-return to work" group based on age group (p=0.04), education level (p=0.001), pre-morbid job category (0.013) and functional status (p<0.0005) as determined by Functional Independence Measure scores. Cox regression analysis controlling the period between discharge and survey indicated that higher FIM scores and higher education level predicted successful re-employment. CONCLUSION: This result re-affirmed the importance of functional status to the success of return-to-work in Singapore. Further qualitative studies might be useful in exploring the social or environmental factors affecting return-to-work outcomes.