Unraveling the genetic link: an umbrella review on HLA-B*15:02 and antiepileptic drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis.

PURPOSE: This umbrella review was conducted to summarize the association between HLA*1502 allele with antiepileptic induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). METHODS: Pubmed, Scopus and EMBASE were searched for eligible reviews in May 2023. Two authors independently screened titles and abstracts and assessed full-text reviews for eligibility. The quality of meta-analyses and case-control studies was appraised with Assessing the Methodological Quality of Systematic Reviews 2 and Newcastle-Ottawa Scale, respectively. Narrative summaries of each antiepileptic drug were analyzed. Preestablished protocol was registered on the International Prospective Register of Systematic Reviews Registry(ID: CRD42023403957). RESULTS: Included studies are systematic reviews, meta-analyses and case-control studies evaluating the association of HLA-B*1502 allele with the following antiepileptics. Seven meta-analyses for carbamazepine, three meta-analyses for lamotrigine (LTG), three case-control studies for oxcarbazepine, nine case-control studies for phenytoin and four case-control studies for phenobarbitone were included. The findings of this umbrella review suggest that there is a strong association between HLA-B-1502 with SJS/TEN for carbamazepine and oxcarbazepine and a milder association for lamotrigine and phenytoin. CONCLUSION: In summary, although HLA-B*1502 is less likely to be associated with phenytoin or lamotrigine-induced SJS/TEN compared to carbamazepine-induced SJS/TEN, it is a significant risk factor that if carefully screened, could potentially reduce the development of SJS/TEN. In view of potential morbidity and mortality, HLA-B*1502 testing may be beneficial in patients who are initiating lamotrigine/phenytoin therapy. However, further studies are required to examine the association of other alleles with the development of SJS/TEN and to explore the possibility of genome-wide association studies before initiation of treatment.

A Newly Proposed HbA1C-Hemoglobin Ratio - A Better Predictor of Outcomes in Cardiac Surgery When Compared to HbA1C and Anemia Alone.

HbA1C's predictive value for postoperative complications in cardiac surgery has been mixed. Studies did not account for HbA1C being over-read in anemic patients. This study proposes a novel way of using a ratio of HbA1C over hemoglobin (HH ratio). Retrospective recruitment of patients undergoing cardiac surgery was done with ethics approval. The primary objective of our study is to look for the correlation of HH ratio with 90-day (short-term) and 1-year (long-term) mortality. The secondary objective is to investigate its association with other adverse events. Statistical analysis was done using multivariable regressions and Cox proportional hazard models. Of the 974 patients recruited, 618 had a HH Ratio<0.5, 284 between 0.5-0.7 and 72 had the ratio >0.7. HH ratio of 0.5-0.7 and >0.7 was associated with 90-day mortality (HR 5.12, P = 0.033 and HR 7.25, P= 0.048 respectively) and 1-year mortality (HR 4.53, P = 0.028 and HR 9.20, P = 0.022 respectively). The higher HH ratio groups were also associated with increased length of stay (hours) in the intensive care unit (P < 0.001) and renal complications (P < 0.001). Our study showed a positive association of HH ratio with 90-day and 1-year mortality and postoperative adverse outcomes in patients undergoing cardiac surgery. The HH ratio has the potential to be a new perioperative target.

The clinical presentation and diagnosis of ketamine-associated urinary tract dysfunction in Singapore.

Ketamine is a short-acting anaesthetic agent that has gained popularity as a 'club drug' due to its hallucinogenic effects. Substance abuse should be considered in young adult patients who present with severe debilitating symptoms such as lower urinary tract symptoms, even though the use of controlled substances is rare in Singapore. Although the natural history of disease varies from person to person, a relationship between symptom severity and frequency/dosage of abuse has been established. It is important to be aware of this condition and have a high degree of clinical suspicion to enable early diagnosis and immediate initiation of multidisciplinary and holistic treatment. A delayed diagnosis can lead to irreversible pathological changes and increased morbidity among ketamine abusers.

Individual and area-level socioeconomic status and their association with depression amongst community-dwelling elderly in Singapore.

OBJECTIVES: Neighborhood socioeconomic status (SES) can be associated with depression. We aimed to assess prevalence of depression amongst community-dwelling elderly in a multiethnic, urban, low-SES, Asian neighborhood, comparing against a higher SES neighborhood. METHOD: The study population involved all residents aged ≥60 years in two Singaporean housing estates comprising owner-occupied public housing (higher SES) and public rental housing (low SES) in 2012. Having lifetime prevalence of depression was defined as having a score ≥5 on the Geriatric Depression Scale-15 or a history of depression. Demographic/clinical details were collected via questionnaire. Those with depression were referred to local polyclinics. Multilevel multivariate logistic regression determined predictors of depression and depression screening. RESULTS: Participation was 61.5% (559/909). In the low-SES community, 26.2% (104/397) had depression, compared with 14.8% (24/162) in the higher SES community. After adjusting for other sociodemographic variables, staying in a low-SES community (public rental housing) was independently a ssociated with depression [adjusted odds ratio (aOR) = 1.68, 95% confidence interval (CI) = 1.02-2.84]. Within the low-SES community, not being married (aOR = 2.27, CI = 1.35-3.70), falls (aOR = 2.72, CI = 1.59-4.67), visual impairment (aOR = 2.37, CI = 1.28-4.39), and poorer social network (aOR = 3.70, CI = 1.96-7.14) were associated with depression. CONCLUSION: Residing in a low-SES community was independently associated with depression after controlling for individual SES.

The deep inferior epigastric perforator and pedicled transverse rectus abdominis myocutaneous flap in breast reconstruction: a comparative study.

BACKGROUND: Our objective was to compare the complication rates of two common breast reconstruction techniques performed at our hospital and the cost-effectiveness for each test group. METHODS: All patients who underwent deep inferior epigastric perforator (DIEP) flap and transverse rectus abdominis myocutaneous (TRAM) flap by the same surgeon were selected and matched according to age and mastectomy with or without axillary clearance. Patients from each resultant group were selected, with the patients matched chronologically. The remainder were matched for by co-morbidities. Sixteen patients who underwent immediate breast reconstruction with pedicled TRAM flaps and 16 patients with DIEP flaps from 1999 to 2006 were accrued. The average total hospitalisation cost, length of hospitalisation, and complications in the 2 year duration after surgery for each group were compared. RESULTS: Complications arising from both the pedicled TRAM flaps and DIEP flaps included fat necrosis (TRAM, 3/16; DIEP, 4/16) and other minor complications (TRAM, 3/16; DIEP, 1/16). The mean hospital stay was 7.13 days (range, 4 to 12 days) for the pedicled TRAM group and 7.56 (range, 5 to 10 days) for the DIEP group. Neither the difference in complication rates nor in hospital stay duration were statistically significant. The total hospitalisation cost for the DIEP group was significantly higher than that of the pedicled TRAM group (P<0.001). CONCLUSIONS: Based on our study, the pedicled TRAM flap remains a cost-effective technique in breast reconstruction when compared to the newer, more expensive and tedious DIEP flap.