Strengthening Muscle Health of Community-Dwelling Older Adults in Singapore: Evidence Towards Clinical Implementation.

The prevalence of sarcopenia will inevitably increase as the population ages in Singapore, rendering it a growing public health concern with a significant impact on healthcare resources. This article firstly summarizes the current understanding of the epidemiology, diagnosis and management of sarcopenia, focusing on community-dwelling older individuals. Early identification is key to preventing and minimizing muscle loss. Appropriate interventions, including resistance exercise training, nutritional interventions and prehabilitation program, should be tailored to each patient. We suggest several key actions to ultimately improve awareness and overcome challenges in identifying and managing sarcopenia to improve patient outcomes. A paradigm shift where muscle health is seen as an integral component to maintaining good health with longer lifespan is needed. Education - of healthcare professionals and the public - serves as the foundation to improving awareness of muscle health and sarcopenia, and to promoting physical exercise across the age spectrum for sarcopenia prevention. The use of cost-effective evidence-based modalities (e.g., calf circumference measurement, 5-times chair stand test or bioelectric impedance assessment) enable early identification of muscle loss in routine practice. Providing subsidies for nutritional interventions (e.g., oral nutritional supplements) and exercise (e.g., ActiveSG gym membership) would encourage uptake of and adherence to interventions. Further high-quality research on interventions and their outcomes is important to determine the optimal strategy in different patient populations and to demonstrate clinical significance and value of addressing sarcopenia. Having local champions within healthcare institution would facilitate the much-needed change in healthcare culture where muscle health is a part of routine clinical practice.

Alendronate use in older patients with reduced renal function: challenges and opportunities in clinical practice.

In this retrospective cohort study, alendronate use among older osteoporosis patients (age>65 years) with reduced renal function (creatinine clearance<35ml/min) was not associated with significant deterioration in renal function from baseline nor increased incidence of osteoporotic fractures or acute kidney injury, compared with patients conservatively managed with only calcium/vitamin D supplementation. INTRODUCTION: Oral bisphosphonates are not recommended in patients with creatinine clearance (CrCl) <35ml/min, although this is not supported by post hoc analyses of pivotal oral bisphosphonate studies. As both osteoporosis and renal insufficiency are more prevalent with advancing age, it is important to determine the safety and efficacy of oral bisphosphonates among these patients. METHODS: Patients with CrCl <35ml/min on alendronate (group A, n=98), with CrCl <35ml/min conservatively managed (group B, n=96), and with CrCl ≥35ml/min on alendronate (group C, n=96) were followed up to 22 months. Primary outcomes were mean change in CrCl from baseline in group A compared with groups B and C, respectively. Secondary outcomes were the incidence of osteoporotic fractures and adverse events between groups. RESULTS: There was no significant change in CrCl from baseline when comparing group A (-1.53±6.83ml/min) with group B (0.59±5.17ml/min) (p=0.075), and group A with group C (-3.71±7.54ml/min) (p=0.163). There was no significant increase in incidences of osteoporotic fractures in group A compared with group B (adjusted relative risk (aRR) 2.02, 95% confidence interval (CI) 0.64-6.37) and group A compared with group C (aRR 1.15, 95% CI 0.46-2.89). There was no significant difference in incidences of acute kidney injury (AKI) in group A compared with group B (aRR 0.48, 95% CI 0.20-1.12). Although statistically non-significant, there was an increase in AKI incidence in group A compared with group C (RR 7.84, 95% CI 0.98-62.66). CONCLUSION: Among patients with CrCl <35ml/min, alendronate therapy was not associated with significant deterioration in renal function from baseline. Although not powered for secondary outcomes, there were no statistically significant differences in osteoporotic fracture or AKI incidence between the groups.

A proposal for a new scoring system to predict difficult ventilation through a supraglottic airway.

BACKGROUND: The aim of this study was to propose and validate a new clinical score to predict difficult ventilation through a supraglottic airway device. METHODS: The score was proposed from our previously reported derivation data, and we prospectively validated the score in 5532 patients from November 2013 to April 2014. Predictive accuracy of the score was compared by the area under the receiver operating characteristic (ROC) curve (AUC). We assigned point values to each of the identified four risk factors: male, age >45 yr, short thyromental distance, and limited neck movement, their sum composing the score. The score ranged between 0 and 7 points. The optimal predictive level of the score was determined using ROC curve analysis. RESULTS: The AUC of the score was 0.75 (95% CI 0.66 to 0.84) in the validation data set, and was similar to that in the derivation data set (0.80; 95% CI 0.75 to 0.86). In derivation and validation data sets, the incidence of low risk categories (scores 0-3) was 0.42% vs 0.32% and of high risk categories (scores 4-7) was 3% vs 1.7% respectively. A score 4 or greater is associated with a six to seven fold increased risk of difficult ventilation through a supraglottic airway device. CONCLUSIONS: The new score for prediction of difficult ventilation through a supraglottic airway device is easy to perform and reliable, and could help anaesthetists plan for difficult airway management.

Miniaturized versus conventional cardiopulmonary bypass and acute kidney injury after cardiac surgery.

INTRODUCTION: Acute kidney injury (AKI) is a serious complication after coronary artery bypass grafting (CABG). There are conflicting reports whether a miniaturized cardiopulmonary bypass (MCPB) system is associated with a lower AKI incidence compared with conventional cardiopulmonary bypass (CCPB). It is unknown if AKI risk factors differ between the two groups. We assessed if MCPB decreases AKI after CABG and compared the risk factors between both groups. METHODS: Sixty-eight Asian patients presenting for elective CABG at a tertiary heart centre were enrolled. They were randomly assigned to MCPB (n=34) or CCPB group (n=34) and followed up in a single-blinded, prospective, randomized, controlled trial. The primary outcome was Acute Kidney Injury Network stage 1 AKI. RESULTS: The AKI incidence was 21.5% and was not significantly different between patients undergoing MCPB versus CCPB (21.9% versus 21.2%, p=0.948). The first CPB haematocrit was independently associated with AKI in the MCPB group (Relative Risk [RR]=0.484, 95% Confidence Interval [CI]=0.268-0.876, p=0.016); post-operative blood loss and inflammation were independently associated with AKI in the CCPB group (RR=1.005, 95%CI=1.003-1.007, p<0.001; RR=1.018, 95%CI=1.010-1.028, p<0.001). CONCLUSION: The MCPB system is not associated with a lower incidence of AKI in Asian patients undergoing CABG. Risk factors for AKI differed between patients using the MCPB and CCPB systems.

Incidence of and risk factors for difficult ventilation via a supraglottic airway device in a population of 14,480 patients from South-East Asia.

Difficult airway practice guidelines include the use of a supraglottic airway device as part of the armamentarium to provide and maintain ventilation and oxygenation. We retrospectively reviewed 14 480 patients aged ≥ 18 years who underwent general anaesthesia. We identified 74 (0.5%) patients whose lungs were identified as having been difficult to ventilate via a supraglottic airway device, and 29 (0.2%) patients in whom device placement failed. Multivariate analysis identified four risk factors for difficult ventilation via a supraglottic airway device: male sex (OR 1.75, 95% CI 1.07-2.86, p = 0.02); age > 45 years (OR 1.70, 95% CI 1.01-2.86, p = 0.04); short thyromental distance (OR 4.35, 95% CI 2.31-8.17, p < 0.001); and limited neck movement (OR 2.75, 95% CI 1.02-7.44, p = 0.04). Adverse respiratory events including oxygen desaturation, hypercapnoea, laryngospasm, and bronchospasm occurred in 17 patients (22%). The incidence of difficult ventilation via a supraglottic airway device was 0.5% in a large cohort of South-East Asian patients.

The inflammatory response between miniaturised and conventional cardiopulmonary bypass after cardiac surgery in an Asian population.

INTRODUCTION: We compared the systemic inflammatory response of the MCPB system to the CCPB system with cell salvage and phosphorylcholine-coated tubing amongst Asian patients undergoing coronary artery bypass grafting. METHODS: Seventy-eight patients were randomly assigned to the MCPB or the CCPB groups equally and followed up in a prospective, single-blinded, randomised, controlled trial. Levels of TNF-α, IL-6, CRP and LDH were measured peri-operatively. RESULTS: The systemic inflammatory response was similar in both groups (TNF-α: p=0.222; IL-6: p=0.991; CRP: p=0.258). Only haemolysis was significantly higher in the CCPB group (LDH: p=0.011). The MCPB system was twice more expensive, but had a near 4-fold cost saving in tranfusions. Overall, the MCPB system cost 20% more than the modified CCPB system. CONCLUSION: These results corroborate with studies that demonstrated the avoidance of cardiotomy suction rather than the MCPB system, itself, leads to an attenuated inflammatory response. The absence of obvious clinical benefit and the higher costs involved with the MCPB system would preclude its routine use.

Association of ethnicity and acute kidney injury after cardiac surgery in a South East Asian population.

BACKGROUND: Postoperative acute kidney injury (AKI) is a frequent and serious complication after cardiac surgery. Clinical factors alone have failed to accurately predict the incidence of AKI after cardiac surgery. Ethnicity has been shown to be a predictor of AKI in the Western population. We tested the hypothesis that ethnicity is an independent predictor of AKI in patients undergoing cardiac surgery in a South East Asian population. METHODS: A total of 1756 consecutive patients undergoing cardiac surgery were prospectively recruited. Among them, data of 1639 patients met the criteria for analysis. There were 1182 Chinese, 195 Indian, and 262 Malay patients. The main outcome was postoperative AKI, defined as a 25% or greater increase in preoperative to a maximum postoperative serum creatinine level within 3 days after surgery. RESULTS: Five hundred and seventy-nine patients (35.3%) developed AKI after cardiac surgery. Ethnicity was shown to be an independent predictor of AKI after cardiac surgery with Indians and Malays having a higher risk of developing AKI when compared with Chinese patients (odds ratio: Indian vs Chinese 1.44, Malay vs Chinese 1.51). CONCLUSIONS: Indians and Malays have a higher risk of developing AKI after cardiac surgery than Chinese in a South East Asian population. Ethnicity was shown to be an independent predictor of AKI after cardiac surgery.

Recovery following tonsillectomy a comparison between tramadol and morphine for analgesia.

BACKGROUND: The optimal method of intraoperative analgesia for adult tonsillectomy is uncertain. It is important that recovery should be rapid so that the airway is not compromised. Tramadol hydrochloride is an analgesic with mixed -mu and non-opioid activities which has less respiratory depression effects compared to morphine. PATIENTS AND METHODS: We compared the recovery characteristics of patients undergoing tonsillectomy after they were given either morphine or tramadol for intra-operative analgesia. Seventy-nine ASA (American Society of Anesthesiologists) I patients were randomised to receive either tramadol 1.5 mg/kg (n = 44) or morphine 0.1 mg/kg (n = 35). A standard propofol-desflurane based general anaesthetic technique was used. RESULTS: Patients given tramadol recovered faster compared to morphine as demonstrated by the earlier eye opening at reversal (mean +/- SD, 4.7 +/- 1.5 min versus 5.6 +/- 1.8 min, p = 0.04). There was also significantly less nausea and vomiting in the patients given tramadol as compared to those given morphine (6.8% versus 28.6%, p = 0.01). There were no other clinically important adverse effects in either group. CONCLUSION: We conclude that tramadol given for intra-operative analgesia during tonsillectomy results in faster recovery with significantly less nausea and vomiting in the early postoperative period.

Case reports of low dose cyclosporine. A therapy in adult minimal change nephrotic syndrome.

INTRODUCTION: Many centres still use steroids to induce remission in patients with minimal change nephrotic syndrome (MCNS) and failing that to give a course of cyclophosphamide, though some centres are already using cyclosporine A (CsA) as an alternative. We report the benefits of CsA therapy in 3 adults with difficult to treat MCNS in whom low dose CsA therapy proved to be efficacious. CLINICAL PICTURE AND OUTCOME: The first patient had her 1st relapse after 8 years and thereafter had 2 more relapses, within 3 months of each other, in spite of therapy with cyclophosphamide. With CsA therapy, at a dose of 3.5 mg/kg body weight (BW)/day, she achieved lasting remission of 22 months as of September 1999 and is still in remission. The second patient had his relapses of nephrotic syndrome over a period of 10 years when treated with prednisolone and cyclophosphamide. On the 13th relapse, he achieved a remission lasting 21 months after a 3 month course of CsA at a dose of 4 mg/kg BW/day. With the 14th relapse, he took half the dose of CsA prescribed [only the morning dose of neoral CsA (2 mg/kg BW/day)] and still achieved a remission and has been in remission since. The third patient was a young woman, married for 2 years without children. She could not tolerate prednisolone because of erosive gastritis and she responded to a pulse dose of intravenous cyclophosphamide for her 1st episode of nephrotic syndrome with complete remission. However, when she relapsed 5 months later she did not respond to a similar dose of i.v. cyclophosphamide and was therefore treated with CsA (4 mg/kg BW/day) which induced a prompt remission 1 month after commencement of therapy and she is still in remission. The trough CsA levels for the 3 patients (range 41 to 107 ng/mL) and the calculated average CsA levels were lower than that used for post renal transplant immunosuppression. The trough CsA levels were, however, similar to that used in patients with MCNS from other series, though achieved at lower CsA doses. CONCLUSION: Our study shows that low dose CsA is a useful agent for induction of remission of MCNS and maintenance of lasting remission. A low dose CsA regimen will make CsA more affordable.

Intravenous opioids reduce airway irritation during induction of anaesthesia with desflurane in adults.

Desflurane is not used for the induction of anaesthesia despite its favourable pharmacokinetic characteristics because it causes airway irritation. We investigated whether pretreatment with i.v. narcotics reduced unwanted effects. One hundred and eighty adults were randomized to three groups (60 per group) to receive i.v. saline, fentanyl 1 microgram kg-1 and morphine 0.1 mg kg-1, respectively, before inhalational induction with desflurane in nitrous oxide and oxygen. Mean time to loss of response to commands was 4.0 min, without significant differences between groups. The incidence of coughing was greater (25%) in the control group than in the fentanyl (5.0%) and morphine groups (8.3%). The incidence of apnoea was 20.0% in the control group versus 13.3 and 5.0% in the fentanyl and morphine groups, respectively. Laryngospasm developed in 11.7% of controls compared with 3.3 and 1.7% in the fentanyl and morphine groups, respectively. More patients in the control group had excitatory movements (46.7%) than in the fentanyl (16.7%) and morphine (8.3%) groups. These results demonstrate that i.v. opioids reduce airway irritability significantly during inhalational induction with desflurane in adults.

Preliminary report on the association of apolipoprotein E polymorphisms, with postoperative peak serum creatinine concentrations in cardiac surgical patients.

BACKGROUND: Renal dysfunction after cardiac surgery occurs in up to 8% of patients and is associated with major increases in morbidity, mortality, and cost. Genetic polymorphisms have been implicated as a factor in the progression of chronic renal disease, but a genetic basis for the development of acute renal impairment has not been investigated. The authors therefore tested the hypothesis that apolipoprotein E alleles are associated with different postoperative changes in serum creatinine after cardiac surgery. METHODS: The authors performed a prospective observational study with use of data from 564 coronary bypass surgical patients who were enrolled in an ongoing investigation of apolipoprotein E genotypes and organ dysfunction at a university hospital between 1989-1999. Renal function was assessed among apolipoprotein E genotype groups by comparisons of preoperative (CrPre), peak in-hospital postoperative (CrMax) and perioperative change (DCr) in serum creatinine values. RESULTS: The epsilon4 allele grouping (E2 = 2/2,2/3,2/4; E3 = 3/3; E4 = 3/4,4/4) was associated with a smaller increase in postoperative serum creatinine (perioperative change: E4, +0.17; E3, +0.26; E4, +0.27 mg/dl) and a lower peak postoperative creatinine than the epsilon2 and epsilon3 in univariate and multivariate analysis (peak in-hospital postoperative serum creatinine multivariate P = 0.015 vs. epsilon3, P = 0.038 vs. epsilon2). There was no difference in baseline creatinine among allele groups. CONCLUSIONS: Inheritance of the apolipoprotein epsilon4 allele is associated with reduced postoperative increase in serum creatinine after cardiac surgery, compared with the epsilon3 or epsilon2 allele. This is the first report of a possible genetic basis for acute renal impairment. These data may contribute to renal risk stratification for cardiac surgery and raise questions regarding apolipoprotein E and the pathophysiology of acute renal injury.

Role of urine and serum protein electrophoresis in evaluation of nephrotic-range proteinuria.

The usefulness of routine serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) screening in the evaluation of proteinuria is not known. The data on the clinical utility of these tests in 165 male patients with proteinuria greater than 3 g/d of protein who were screened for the presence of an M-spike are presented. Two hundred fifty-four studies were performed (SPEP, 155; UPEP 99) in these 165 patients. Twenty-four studies (9.8%) were positive for an M-spike (15 serum; 9 urine samples) in 19 patients (11.5%). Fourteen patients (8.5%) had an M-spike in either serum or urine, five patients (3%) in both studies. Two of these 19 patients were diagnosed with myeloma and 1 patient was diagnosed with primary amyloidosis. The other 16 patients were diagnosed with monoclonal gammopathy of unknown significance (MGUS). The group with a positive M-spike was significantly older (mean +/- SEM, 65 +/- 2 years; range, 39 to 78 years v 58 +/- 1 years; range, 25 to 84 years; P = 0.03), had a lower incidence of coexistent diabetes (21.1% v 61.6%; P = 0. 01), and a lower serum albumin level (3.2 v 3.6 g/dL; P = 0.05). Using a multivariable logistic regression model, the presence of an M band was positively correlated with age (odds ratio [OR], 1.056; 95% confidence interval [CI], 1.006 to 1.108) and negatively correlated for serum albumin level (OR, 0.386; 95% CI, 0.184 to 0. 810), hematocrit (OR, 0.923; 95% CI, 0.852 to 1.001), and the presence of diabetes mellitus (OR, 0.128; 95% CI, 0.038 to 0.434). In summary, routine SPEP and UPEP screening in patients with proteinuria greater than 3 g/d of protein detected an M-spike in 11. 5% and myeloma in 1.2% of the patients. The cost per case of myeloma or MGUS discovered was $1,192.

A survey of patients' knowledge of anaesthesia and perioperative care.

AIM: The present study was undertaken to assess patients' knowledge of anaesthesia and perioperative care as well as their perception of anaesthetics and their role. METHODOLOGY: A questionnaire survey of 23 items was developed and completed pre-operatively by 132 patients. Included in this study were 45 men and 87 women; 80% with at least secondary education with a mean age of 39.9 and 35.6 years, respectively. RESULTS: Results indicated that only 56.8% of patients understood that anaesthetists are doctors. There were significant misconceptions though in general, knowledge was good. Although all patients realised the importance of fasting, however only 74.2% of patients realised it meant limitation of both solids and liquids from a specified time. Pain was the major concern among the patients surveyed (39.4%), followed by fear of not waking up after surgery (18.9%). Twenty-one per cent of patients believed that postoperative pain was a necessary part of the healing process and 28% thought that pain was something that they had to put up with in the postoperative period. Only 23.5% correctly identified the anaesthetist as being responsible for analgesia in the recovery period. A majority (75.8%) wished to have more information about anaesthesia. CONCLUSION: When forthcoming surgery and anaesthesia are discussed, it is important that patients realise that they are being cared for by anaesthetists who are doctors and efforts must be taken to educate the profession and public on the anaesthetists' role in perioperative care. This should enhance the professional image of anaesthesia and more importantly, improve patient confidence and quality of care.

Random amplified polymorphic DNA (RAPD) fingerprints for identification of red meat animal species.

The random amplified polymorphic DNA (RAPD) method was used to generate fingerprint patterns for 10 meat species: wild boar, pig, horse, buffalo, beef, venison, dog, cat, rabbit and kangaroo. A total of 29 10-nucleotide primers, with GC contents ranging from 50-80%, were evaluated for their specificity and efficiency. The fingerprint patterns that were generated were found in some cases to be species-specific, i.e. one species could be differentiated from another. The advantages and disadvantages of using RAPD-PCR for the identification of red meat species are also discussed.

Preoperative versus postoperative pethidine for extraction of impacted third molars.

We have studied the pre-emptive analgesic effects of pethidine by comparing its analgesic effects given before or immediately after operation in a randomized, double-blind study of 40 patients undergoing removal of bilateral impacted third molars under general anaesthesia. Group 1 patients received pethidine 50 mg as a 1 ml injection 1 to 2 hours before operation and normal saline 1 ml intramuscularly immediately after surgery. Group 2 patients received normal saline 1 ml intramuscularly before operation and pethidine 50 mg as a 1 ml injection immediately after surgery. Outcome measures included perception of pain on a visual analogue scale (VAS), the number of patients who required postoperative pethidine, time to first postoperative pethidine injection and total dose of pethidine given. Four patients in group 1 compared to 8 in group 2 required postoperative pethidine but this was not statistically significant. The VAS scores, time to first postoperative pethidine injection and total dose of pethidine also did not differ significantly between the 2 groups. We concluded that preoperative administration of pethidine intramuscularly did not confer additional analgesic effects compared with a similar dose given after surgery.

Restriction fragment length polymorphism (RFLP) of Salmonella organisms.

Genetic relatedness of 20 Salmonella isolates comprising 16 serotypes was analysed by restriction endonuclease digestion of the total DNA with six endonucleases individually. The rDNA fingerprints generated by EcoRI were more polymorphic, each serotype showed a unique fingerprint sharing several core (monomorphic) bands with several polymorphic bands. Eight characteristic NciI rDNA fingerprints were found. Similar rDNA RFLP patterns were observed in strains of Salmonella from different serotypes.