Hydration and nutritional status in patients on home-dialysis-A single centre study.

BACKGROUND: Over-hydration (OH) and malnutrition are prevalent among patients on dialysis therapy. The prevalence of OH and malnutrition as well as the risk factors associated with OH and malnutrition in our patients on home peritoneal dialysis (PD) and home haemodialysis (HD) are examined. DESIGN AND METHODS: This was a cross-sectional study. The hydration and nutritional status of the study groups were assessed by a Body Composition Monitor. Patients who were stable on home dialysis therapy for over one year were invited to participate. Univariate and multivariate analyses were performed to identify associated factors and determine the predictors of OH and malnutrition, respectively. RESULTS: Eighty-eight patients (41 PD and 47 home HD) were recruited. A 32.95% of our patients on home dialysis therapy were in OH status. There was a significance difference in the prevalence of hydration status between patients on PD and home HD (p = 0.014), as overhydration was more common in patients on PD than home HD (46.34 vs. 21.28%). Dehydration was more common in patients on home HD than PD (29.79 vs. 9.76%). Male gender, decreasing haemoglobin level and presence of diabetes mellitus (DM) were risk factors of OH on multivariable analysis. There was no significance difference in the prevalence of malnutrition between patients on PD and home HD (p = 0.27). Increasing Fat Tissue Index (FTI), height and patients on PD therapy were at higher risk of malnutrition. CONCLUSION: OH and malnutrition were prevalent patients on home dialysis therapy.

Multimorbidity in bullous pemphigoid: a case-control analysis of bullous pemphigoid patients with age- and gender-matched controls.

BACKGROUND: Bullous pemphigoid (BP) is the most common autoimmune blistering disease in the elderly and is associated with increased mortality. The extent of multimorbidity in patients with BP and its impact on survival are unclear. OBJECTIVES: To describe the extent and spectrum of multimorbidity in patients with BP and to ascertain its impact on survival. METHODOLOGY: This was a case-control study conducted in the setting of an academic medical centre. Cases defined as newly diagnosed BP patients referred to the inpatient dermatology service between 2005 and 2014. For every case, three age- and gender-matched controls were randomly selected. Retrospective review of medical records was performed. Univariate and multivariate comparisons of cases and controls were performed using conditional logistic regression. RESULTS: A total of 105 cases and 315 controls were included in this study. Eighty-eight cases (84%) were multimorbid (≥2 chronic diseases) as compared to 205 controls (65%) (P < 0.001), while the mean number of comorbid conditions was 3.2 ± 1.6 in cases compared to 2.4 ± 1.6 in controls (P < 0.001). 43% of cases had ≥4 comorbidities compared to 27% in controls (P = 0.003). On multivariate analysis (adjusting for age, gender and comorbidities), neurological disease (OR 10.93; CI: 5.74, 20.79) and hypertension (OR 2.38; CI: 1.18, 4.77) were positively associated with BP. Charlson comorbidity index was 6.0 ± 2.5 in cases compared to 5.0 ± 2.1 in controls (P = 0.002), and the 1-year mortality of cases and controls was 32.4% and 17.8%, respectively. CONCLUSION: Our study has shown that a significant proportion of patients with BP are multimorbid and individually have a higher number of comorbidities compared to matched controls. Disease burden and multimorbidity may well impact the prognosis of patients with BP.

Increased risk of strontium ranelate-related SJS/TEN is associated with HLA.

UNLABELLED: Severe adverse drug reactions (ADR) of Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) in some patients receiving strontium ranelate have been reported, but the risk factors are unclear. We show that HLA-A*33:03 and B*58:01 are significantly associated with patients who developed SJS/TEN; and provide the first evidence that genetic risk factors are involved in strontium ranelate-associated SJS/TEN. INTRODUCTION: In this study, HLA as a genetic risk factor was assessed among osteoporotic patients prescribed with strontium ranelate that developed severe cutaneous adverse drug reactions (SCARs) compared with those who were tolerant. METHODS: Genomic DNA isolated from peripheral blood mononuclear cells (PBMCs) of patients was HLA typed using sequencing-based typing method to determine their HLA profiles. RESULTS: Osteoporotic patients who are currently on strontium ranelate were enrolled in the study (n = 76). Tolerant controls were defined as patients who received strontium ranelate for a minimum of 3 months (range 3 months to 8 years) with no reports of any cutaneous reactions as these reactions usually occur within the first 12 weeks after starting treatment. Retrospective cases of SJS/TEN were also identified (n = 5). The majority of the accrued samples were of Han Chinese descent: controls (n = 72) and cases (n = 4). All cases and controls were genotyped at four HLA genes, namely HLA-A, HLA-B, HLA-C, and HLA-DRB1. In comparing the samples of Han Chinese descent (72 controls and 4 cases), we found significant associations with HLA-A*33:03 (p = 0.002) and HLA-B*58:01 (p = 0.023). There was no significant association with any HLA-C or HLA-DRB1 alleles. CONCLUSIONS: This study reveals that the occurrence of SJS/TEN in Han Chinese patients receiving strontium ranelate is HLA associated. This has important clinical implications for understanding the underlying mechanisms for this ADR as well as evaluating the potential role of genetic pre-screening for osteoporotic patients who may be prescribed strontium ranelate.

Clinical outcomes of bacteraemia in cellulitis of the leg.

BACKGROUND: Infections of the blood are associated with high mortality and morbidity. In cellulitis, the utility of blood cultures remains controversial because of their relatively low bacterial yield. However, some important but less well studied aspects include risk factors for bacteraemia, the effects of bacteraemia on the length of hospitalization and on morbidity and mortality rates. AIM: To determine the incidence of bacteraemia in cellulitis in an inpatient cohort; to identify risk factors for bacteraemia in cellulitis; and to assess length of hospitalization stay, rate of recurrence of cellulitis, and mortality in patients with cellulitis and bacteraemia. METHODS: Records of 214 patients diagnosed with cellulitis were reviewed. Blood cultures, length of hospitalization stay, rate of recurrence of cellulitis, mortality, coexistent dermatoses and local factors predisposing to cellulitis and comorbidities were analyzed. RESULTS: The incidence of bacteraemia was 10.8%. Mean duration of hospitalization was longer (P < 0.01) and recurrence (P < 0.01) was higher in patients with bacteraemia. There was no difference in mortality between patients with and patients without bacteraemia (P = 0.47). Risk factors for bacteraemia included lymphoedema (P < 0.01), presence of an ipsilateral orthopaedic implant (P < 0.01), total white blood cell (WBC) count > 13.5 × 10(6) µL (P < 0.01, liver cirrhosis (P = 0.02) and chronic kidney disease (P = 0.04). CONCLUSIONS: Blood cultures should be performed for patients with cellulitis who have factors increasing the risk of bacteraemia, such as presence of lymphoedema, ipsilateral orthopaedic device implantation, leucocytosis of > 13.5 × 10(6) µL, liver cirrhosis or chronic kidney disease, and other forms of immunosuppression. Bacteraemia in cases of cellulitis of the leg is a prognostic factor for increased length of hospitalization stay and recurrence of cellulitis.

Building pharmacogenetics into a pharmacovigilance program in Singapore: using serious skin rash as a pilot study.

To study the possible genetic associations with adverse drug reactions (ADR), the Singapore Health Sciences Authority (HSA) has piloted a program to collect DNA and phenotype data of ADR cases as part of its pharmacovigilance program. Between 2009 and 2012, HSA screened 158 cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). To assess the association between HLA-B*1502 and carbamazepine (CBZ)-induced SJS/TEN, 13 cases and 26 drug-tolerant controls were analyzed. All 13 CBZ-SJS/TEN cases and 3/26 controls were HLA-B*1502 positive (odds ratio 181, 95% confidence interval: 8.7-3785, P=6.9 × 10(-8)). Discussions of the finding with the Ministry of Health and an expert panel led to the decision to make HLA-B*1502 testing the standard of care prior to first use of CBZ in Asians and to subsidize the genotyping test at public hospitals. This program illustrates the role of a regulatory authority in advancing the use of pharmacogenetics for drug safety.

The role of intravenous immunoglobulin in toxic epidermal necrolysis: a retrospective analysis of 64 patients managed in a specialized centre.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with a mortality of 40%. Intravenous immunoglobulin (IVIg) is widely used as a specific treatment for this reaction, although evidence of its benefit is conflicting. OBJECTIVES: We sought to evaluate whether the use of IVIg improved mortality in patients with Stevens-Johnson syndrome (SJS)/TEN overlap and TEN. METHODS: We retrospectively analysed data for 64 patients with SJS/TEN overlap and TEN who were treated with IVIg at a single referral centre. The primary outcome analysed was in-hospital mortality. Predicted mortality was calculated based on severity-of-illness score for TEN (SCORTEN) values. Secondary analyses of survival based on IVIg dosages and prior corticosteroid exposure were also performed. RESULTS: There were 28 cases of SJS/TEN overlap and 36 cases of TEN, with a mean SCORTEN value of 2·6. The mean dose of IVIg given was 2·4 g kg(-1) and the mean delay from the onset of epidermal detachment to administration of IVIg was 3·2 days. There were 20 deaths (31%) in our cohort. The standardized mortality rate was 1·10 (95% confidence interval 0·62-1·58). Subgroup analysis comparing survivors and nonsurvivors showed a higher SCORTEN in nonsurvivors (3·4 vs. 2·2). There were no differences with regard to the dosage, delay and duration of IVIg administration. When stratified according to dosage, there was no mortality difference between patients who receive high-dose (≥ 3 g kg(-1) ) vs. low-dose (< 3 g kg(-1) ) IVIg. CONCLUSIONS: This study shows that the use of IVIg does not yield survival benefits in SJS/TEN overlap and TEN, even when corrected for IVIg dosages.

Laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse: with or without robotic assistance.

OBJECTIVE: To assess perioperative and medium-term outcome after laparoscopic sacrocolpopexy with or without robotic assistance for vaginal vault prolapse in a Hong Kong tertiary centre. DESIGN: Retrospective study. SETTING: An urogynaecology unit in Hong Kong. PATIENTS: All women who underwent laparoscopic sacrocolpopexy with or without robotic assistance for vaginal vault prolapse from March 2005 to May 2010. MAIN OUTCOME MEASURES: The perioperative and medium-term outcomes. RESULTS: A total of 36 women underwent the operation during the study period. The mean operating time was 205 minutes, mean blood loss was 144 mL. The median hospital stay was 4 days. Two women required early re-operation but recovered fully. In all, 35 women were followed up for 29 (standard deviation, 19) months. Three of them (9%) had a recurrence of stage II prolapse, but there was statistically significant improvement in the pelvic organ prolapse quantification assessment for all three compartments of the vagina, and the length of vagina was well preserved. There were no mesh exposure or erosions. The overall objective cure rate of 91% (32/35) was high, and 91% (32/35) were satisfied with the operative outcome. Stress incontinence and voiding difficulty were significantly reduced. CONCLUSION: Laparoscopic sacrocolpopexy for vaginal vault prolapse is safe, although complications arising from concomitant surgery should not be neglected. High rates of objective cures and patient satisfaction were achieved. There were no mesh exposure or erosions. Laparoscopic sacrocolpopexy should be considered an option for women with vaginal vault prolapse.

Dermatology referrals in an East Asian tertiary hospital: a need for inpatient medical dermatology.

BACKGROUND: Within hospitals, there is a need for dermatological expertise, as hospitalized patients have a wider spectrum of severe and serious dermatological conditions, associated with significant morbidity. AIM: To characterize the patient profile and referral pattern of inpatient dermatology consultations, and to evaluate the diagnostic accuracy of non-dermatologists. METHODS: This was a retrospective study reviewing all inpatient referrals for dermatology consultations during a 1-year period from July 2005 to June 2006 (inclusive), at the largest multi-disciplinary tertiary hospital in Singapore. RESULTS: Of the 731 referrals made for dermatology consultations, 26.9% of patients had ≥ 3 important underlying comorbidities. Eczema/dermatitis (33.1%; n = 242) and cutaneous infections (23.4%; n = 171) accounted for over half of the dermatological consultations, followed by cutaneous adverse drug reactions (12.3%; n = 90). The provisional diagnoses of the referring doctors agreed with the final diagnoses confirmed by dermatologists in only 30.2% of all referrals; incorrect diagnoses were made in 35.2% of cases, and no provisional diagnoses were made in the remaining 34.6% of cases. Most misdiagnosed skin diseases were in fact common dermatoses (such as eczemas, cutaneous infections, drug rash) that required only standard treatment. CONCLUSION: Our study reiterates the importance of inpatient medical dermatology in terms of both service and education. There should be continual efforts to ensure that dermatologists have the highest level of training and experience in medical dermatology, to provide collaborative optimum care for hospitalized patients with dermatological diseases.

Systemic lupus erythematosus presenting as Stevens-Johnson syndrome and toxic epidermal necrolysis: a report of three cases.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological conditions that are characterized by mucositis, epidermal detachment and erosions. The underlying etiology in SJS and TEN is almost invariably secondary to drugs. Rarely, other causes such as systemic lupus erythematosus (SLE), infections and vaccinations have been implicated. This report describes three patients with SLE who presented with manifestations of SJS/TEN without a clear drug causality. All three patients presented with photodistributed macular exanthema, which evolved to target lesions, bullae, erosions or sheet-like detachment. This was associated with oral mucositis and conjunctivitis. The onset of the rash was insidious with a protracted clinical course. Ultraviolet exposure and steroid tapering appear to be precipitating factors. In two of the patients, SJS and TEN were the initial presentation of lupus. Although SJS and TEN are almost invariably due to medications, they may, rarely, be an initial presentation of lupus, particularly when associated with an initial photodistribution, absence of genital involvement and a prolonged clinical course.

Cutaneous adverse drug reactions in hospitalised patients.

INTRODUCTION: Serious adverse drug reactions are common in hospitalised patients. There have been few studies examining the clinical presentation, implicated drugs and outcomes in Singapore. METHODS: The clinical and laboratory data of all inpatient dermatology consultations with a diagnosis of cutaneous adverse drug reaction were retrospectively analysed over a one-year period. RESULTS: A total of 97 patients were diagnosed with cutaneous adverse drug reactions. Eight different clinical reaction patterns were noted, namely drug exanthems (46.4 percent), drug rash with eosinophilia and systemic symptoms (18.6 percent), Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum (14.4 percent), urticaria/angioedema (11.3 percent), acute generalised exanthematous pustulosis (3.1 percent), fixed drug eruptions (3.1 percent), generalised exfoliative dermatitis (2.1 percent) and drug-induced vasculitis (1.0 percent). The putative medications included antibiotics (50.5 percent), anticonvulsants (11.3 percent), allopurinol (8.2 percent), chemotherapeutic agents (7.2 percent), nonsteroidal anti-inflammatory agents (7.2 percent), intravenous contrasts (3.2 percent), complementary medications (2.1 percent) and various other medications (10.3 percent). 30 patients were admitted primarily for their adverse drug reaction, with an average length of hospital stay of nine days, while the remaining 67 patients developed these reactions as a complication of their inpatient stay. A total of five deaths were recorded. CONCLUSION: The presentation of cutaneous adverse drug reactions in hospitalised patients is diverse, ranging from self-limiting and benign reaction patterns to those that are life-threatening. Early recognition, accurate diagnosis, withdrawal of putative medications and specific treatments when indicated may improve outcome.

Subacute cutaneous lupus erythematosus after immunotherapy for renal-cell carcinoma: the case for interferon-alpha.

Subacute cutaneous lupus erythematosus (SCLE) is a photosensitive dermatosis characterized by papulosquamous or annular lesions. It can be caused by a variety of medications. We report a case of SCLE in a patient after interferon-alpha treatment for metastatic renal-cell carcinoma and discuss the potential role of interferons in the pathogenesis of CLE.

Acute generalised exanthematous pustulosis and toxic epidermal necrolysis induced by carbamazepine.

Acute generalised exanthematous pustulosis and Stevens-Johnson syndrome (toxic epidermal necrolysis spectrum of severe cutaneous drug reactions) are believed to have distinct underlying pathophysiologies. Our patient, a 28-year-old Chinese woman, represents the first known reported case of clinically-consistent and histologically-proven acute generalised exanthematous pustulosis and toxic epidermal necrolysis overlap induced by carbamazepine in the English literature.

Possible role of gadolinium in nephrogenic systemic fibrosis: report of two cases and review of the literature.

Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy (NSF/NFD) is a rare fibrosing disorder that occurs in patients with renal failure. It is associated with significant mortality and morbidity. Patients typically present with painful or pruritic indurated plaques involving the limbs and trunk, with sparing of the face. Severity and rapidity of cutaneous progression correlate with poorer prognosis. To date, the management of NSF/NFD remains anecdotal. The aetiological link in NSF/NFD is also yet to be confirmed, but renal dysfunction seems a common feature. Following recent reports of a possible causative role of gadolinium, we present two patients with histologically confirmed NSF/NFD, who had exposure to gadolinium-containing contrast agents 1-2 months before onset of disease. Severity of renal impairment, lack of immediate dialysis after exposure and cumulative dose of gadolinium are possible factors influencing the development of NSF/NFD. The process of transmetallation of gadolinium chelates may occur in patients with renal impairment, leading to precipitation of free gadolinium in the dermis or other organs, causing tissue injury that ultimately leads to the clinical manifestations of NSF/NFD. Although the causative role is not proven, gadolinium-containing contrast agents should be used only if clearly necessary in patients with renal failure.

The effectiveness of using a lipido-colloid dressing for patients with traumatic digital wounds.

This study compares the effect of a daily gauze dressing with that of a lipido-colloid dressing on the time taken to make up the dressing and efficacy of the management of traumatic digital wounds. This is a randomized controlled trial of 28 patients (16 experimental and 12 control) with injuries to their fingers and loss of tissue. The patients in the experimental and control groups were given a lipido-colloid dressing and a daily gauze dressing, respectively. The patients'wounds were assessed in terms of the size of the wound and the time it took for the wound to heal. The findings showed that patients in the experimental group had a faster recovery time from the healing of their wound than the control group (p= .024). The findings can help to establish an evidence-based practice in the management of traumatic digital wounds in clinical settings.

Cyclosporin-induced sebaceous hyperplasia in renal transplant patients.

INTRODUCTION: Sebaceous hyperplasia is associated with immunosuppressive treatment with cyclosporin in male renal transplant patients. This has not been reported in the local context. CLINICAL PICTURE: This is a report on 2 Chinese renal transplant patients on cyclosporin who developed sebaceous hyperplasia. TREATMENT AND OUTCOME: One patient was treated with carbon dioxide laser. The result was good and the patient was satisfied with the procedure. CONCLUSION: Cyclosporin-induced sebaceous hyperplasia is likely to be a direct and casual effect of cyclosporin, and to be unrelated to immunosuppressive action. However, further studies are needed to find out whether sebaceous hyperplasia is a dysplastic process or tumour progression in genetically susceptible patients under the effect of immunosuppression.

Drawing a qualitative distinction of caring practices in a professional context: the case of Chinese nursing.

How to draw a qualitative distinction between nursing work and the work of a servant has been a major concern for nurses in China. This article explains the ways in which nurses in China articulate the meaning of caring in practice situations. Seventy nurses in Beijing were invited to share their experience about what caring meant to them as nurses and examples of caring in practice situations. Van Kaam's phenomenologic method of controlled explication was used to analyze the data. The findings reveal that these Chinese nurses are able to articulate the cheng and jing versions of caring practices that emphasize flexible, pluralist, contextualized, individualized, and subjectively informed practices. To further this study, we would suggest nurses be more proactive in starting a dialogue with society so as to seek nursing's legitimate practice that can foster responsive care to patients and society on the one hand and the professional integrity of nursing on the other.