The experience of older people living independently in Singapore.

BACKGROUND: Globally, older people are living independently either alone or with their spouse, population continues to age. In Singapore, some may live with an unrelated older person in a public rental apartment. In Asia, these older people are associated with increased risks of poor health and social isolation, have poorer social support and a poor quality of life. Few studies have explored why these older people choose such living arrangements, the challenges they encountered and what has helped or may help them overcome these challenges. AIM: To explore older people's experiences of living independently or with an unrelated older person. METHODS: This descriptive qualitative study involved face-to-face interviews with 25 informants, 65 years or older in Singapore. Thematic analysis was adopted. RESULTS: Five themes emerged: (1) making own choice--participants decided to live apart from their families, (2) contending with concerns--the availability of external resources for participants was shrinking, (3) coping with the available assistance--depending on available external resources from the community, (4) holding on to their values--participants rely on their internal resources to manage, and (5) preparing for the inevitable--participants were planning for their final years of life and for their death. CONCLUSION: Older people have such living arrangements for many reasons. They attain well-being and quality of life by devising strategies, tapping on their limited external resources and relying on their values to manage their diminishing resources and the foreseeable death. IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY: Understanding older people's experiences may help nurses and health professionals to develop health promotion programmes that support older people's everyday needs and help them to stay healthy. Public health policy must support older people to live in a safe environment near their extended family to reduce their need to relocate.

The extent of inflammation is a predictor for pouch-related complications in ileal pouches in patients with ulcerative or indeterminate colitis.

AIM: Limited data are available on the relationship between the histological features of the resected specimens in patients with ulcerative colitis (UC) or indeterminate colitis (IC) and the outcome of restorative proctocolectomy. The aim of our study was to determine if the histological features of the resected specimen in patients with UC and IC can predict ileal-pouch-related outcome. METHOD: A review of all patients who had a restorative proctocolectomy created following completion proctectomy or proctocolectomy for UC and IC was performed. RESULTS: Between 1992 and 2011, 142 patients (132 with UC and 10 with IC) were reviewed. After a median follow-up of 36 (3-149) months, 51 (35.9%) developed a pouch-related complication. Forty-two (29.7%) developed pouchitis while three (2.1%) developed a pouch-cutaneous fistula. Four (2.8%) had pouch failure, while stricture of the anastomosis was seen in three (2.1%) patients. The presence of extension of the inflammation into the muscularis propria of the resected specimen was associated with an increased risk of pouch-related complications (P = 0.01). The presence of submucosal oedema was also a significant risk factor (P = 0.03). CONCLUSION: The extension of inflammation into the muscularis propria appears to predict pouch-related complications following restorative proctocolectomy for UC or IC.

Patient and clinician preferences for surgical and medical treatment options in ulcerative colitis.

AIM: When treating patients with refractory ulcerative colitis (UC), the choice between escalating medical management or surgery can be difficult. The aim of this study was to quantify the preferences of patients and clinicians for the treatment options in UC. METHOD: Ulcerative colitis outpatients were interviewed to measure their preferences for five scenarios examining the management of acute and chronic UC, using a prospective measure of preference method that generates two utility scores: willingness and amount of expected life to trade or gamble. A self-administered questionnaire was mailed to Australian and New Zealand colorectal surgeons and gastroenterologists. RESULTS: Fifty-five patients (26 medical and 29 surgical), 91 surgeons and 78 gastroenterologists were surveyed. In the acute setting, 89% of patients, 69% of gastroenterologists and 55% of surgeons were willing to trade part of their life expectancy to avoid a permanent stoma, while for chronic disease 71% of patients were prepared to trade to avoid an operation with a permanent stoma compared with 55% for an operation with a pouch (P = 0.01). Both patients and gastroenterologists were more prepared to gamble or trade to avoid any surgery than were colorectal surgeons. All groups were aligned in their decision to undergo yearly colonoscopy surveillance rather than to undergo definitive surgery that would result in a stoma. CONCLUSION: Patient preferences for the treatment of UC were more aligned to those of gastroenterologists than those of colorectal surgeons. Despite postoperative studies revealing an equal quality of life for pouch and stoma patients, this study confirmed that a pouch is the preferred surgical option.

Long-term outcome of the anal fistula plug for anal fistula of cryptoglandular origin.

AIM: This study aimed to evaluate the long-term outcome of the anal fistula plug in the treatment of anal fistula of cryptoglandular origin. METHOD: A review of all patients who had at least one anal fistula plug inserted from March 2007 to August 2008 was performed. Only anal fistulae of cryptoglandular origin were included. Success was defined as the closure of the external opening with no further purulent discharge or collection. RESULTS: Thirty anal fistula plugs were inserted in 26 patients [median age 40 (26-70) years]. Twenty-six of the fistulae were transsphincteric and three were suprasphincteric. One patient had a high intersphincteric fistula, which was the only fistula that did not have a seton inserted. The median duration between seton insertion and the plug procedure was 12 (4-28) weeks. The median length of the fistula tract was 3 (1-7.5) cm. After a median follow-up of 59 (13-97) weeks, 26 (86.7%) fistulae recurred. Of the 26 failures, the median time to failure was 8 (2-54) weeks. Subsequent surgical interventions were performed in 20 of the failures. CONCLUSION: The role of the fistula plug in the management of anal fistula of cryptoglandular origin remains debatable and warrants further evaluation.

Identification of the internal anal opening and seton placement improves the outcome of deep postanal space abscess.

AIM: This study aimed to determine if successful seton placement at the initial drainage procedure improves outcomes in the management of deep postanal space abscesses. METHOD: A retrospective review was performed of all patients who underwent initial drainage of a DPA space abscess between December 2002 and August 2010. A seton was placed through the internal opening if it could be identified. RESULTS: Thirty-two patients of median age 41 (21-64) years formed the study group. Twenty-four (75.0%) had a seton inserted at the initial drainage procedure. The patients underwent a total of 56 operations. The median interval from the initial to the final operation was 5 (2-18) months with 17 (70.8%) patients having the final operation within 6 months. In the 8 (25.0%) patients whose internal opening could not be found, 26 operations were required with a median interval from the initial to the final surgery of 11 (3-24) months. Patients who had a seton successfully inserted at drainage underwent significantly earlier definitive surgery and required fewer operations (P < 0.038). CONCLUSION: Identification of an internal opening with placement of a seton at the initial drainage procedure is associated with earlier definitive surgery and fewer operations.

Gastrointestinal tract perforation following blunt abdominal trauma: an institution's experience.

PURPOSE: Traumatic perforation of the gastrointestinal tract (GIT) poses numerous challenges for surgeons worldwide. We aimed to review our institution's experience and highlight the pertinent issues in managing this problem. METHODS: A retrospective review was performed for all patients with perforation of the GIT following traumatic blunt injuries. RESULTS: Twenty-one patients, with a median age of 40 years, formed the study group, all of whom underwent surgery. Four patients were sent straight to the operating theater from the emergency department due to hemodynamic instability, while another two patients had pneumoperitoneum on their X-rays. Computed tomography (CT) scan was performed in 15 patients, with the findings of pneumoperitoneum (n = 7, 46.7%) and free fluid without solid organ injury (n = 9, 60.0%) being the most common result. The jejunum (n = 11, 52.4%) and ileum (n = 5, 23.8%) were the most common sites of perforation. Direct repair was performed in 9 (42.9%) patients, while resection of the perforated segment(s) was performed in the remaining 12 (57.1%) patients. Other associated intra-abdominal injuries included mesenteric (n = 6, 28.6%) and splenic lacerations (n = 4, 19.0%). Surgery was performed within 8 h of the accident in only 11 patients (52.4%). Some of the complications included wound infection (n = 7, 33.3%) and intra-abdominal abscesses (n = 3, 14.3%). Two patients underwent relook laparotomy after an initial damage control laparotomy. CONCLUSION: Prompt and early surgery for traumatic gastrointestinal perforation is advised. Any abnormal CT scans warrants either surgery or close monitoring. Direct repair of the perforation is preferred, if possible.

Kirschner Wire Migration to the Cervical Spine: AComplication of Clavicular Fixation in a Child

We report a case of a broken K wire migrating to the cervical spine from the right clavicle in a 9 year old child. The initial diagnosis, fracture of the clavicle with an acromioclavicular joint dislocation, was treated by open reduction and K wiring. One K wire broke and migrated to the neck, posterolateral to the C6 vertebra. The K wire was removed percutaneously under image intensification. Acromioclavicular joint dislocation in children is rare since the distal clavicle does not ossify until the age o

Strategy for generating tissue-engineered human bone construct

The strategy used to generate tissue-engineered bone construct, in view of future clinical application is presented here. Osteoprogenitor cells from periosteum of consenting scoliosis patients were isolated. Growth factors viz TGF-B2, bFGF and IGF-1 were used in concert to increase cell proliferation during in vitro cell expansion. Porous tricalcium phosphate (TCP)-hydroxyapatite (HA) scaffold was used as the scaffold to form 3D bone construct. We found that the addition of growth factors, greatly increased cell growth by 2 to 7 fold. TCP/HA proved to be the ideal scaffold for cell attachment and proliferation. Hence, this model will be further carried out on animal trial.

The use of bone marrow stem cells for bone tissue engineering

Bone marrow stem cells (BMSC), known for its multipotency to differentiate into various mesenchymal cells such as chodrocyte, osteoblasts, adipocytes, etc, have been actively applied in tissue engineering. BMSC have been successfully isolated from bone marrow aspirate and bone marrow scraping from patients of various ages (13-56 years) with as little as 2ml to 5ml aspirate. BMSC isolated from our laboratory showed the presence of a heterogenous population that showed varying prevalence of surface antigens and the presence of telomerase activity albeit weak. Upon osteogenic induction, alkaline phosphatase activity and mineralization activity were observed.

Robust on-line relay automatic tuning of PID control systems

In this paper, a robust on-line relay automatic tuning method for PID control systems is developed which expand on the application domain of Astrom's renowned relay autotuning method. In the proposed configuration, a relay is applied to an inner loop of a controller-stabilised process in the usual manner. Using the induced limit cycle oscillations from the closed-loop system, the controller settings may be re-tuned non-iteratively to achieve enhanced performance without disrupting closed-loop control. Two control tuning methodologies are developed -- a direct and an indirect method based on an explicit process model. Simulation examples and a real-time experiment are provided to illustrate the practical appeal and potential advantages of the proposed method over the basic one.

Simultaneous online automatic tuning of cascade control for open loop stable processes

In this paper, we present a new simultaneous online automatic tuning method for cascade control using a relay feedback approach. Departing from the traditional approach towards tuning of cascade control systems where the secondary and primary loops are tuned in strict sequence, the proposed approach is to carry out the entire tuning process in one experiment. For ease of practical applications, the entire procedure of controller design may be automated and carried out online. A direct controller tuning approach to tune the controllers is proposed here. Robustness analysis of the new cascade control design is further carried out in the paper by drawing on existing results for SISO feedback systems. Simulations are provided to illustrate the applicability and effectiveness of both the online autotuning approach and the new cascade control design.

Development of a GPC-based PID controller for unstable systems with deadtime

Till now, traditional low-order control schemes have never been applicable to unstable systems with deadtime. In this paper, we present the first application of a PID controller with time-scheduled gains to unstable systems with deadtime, consisting of a single unstable pole. The control gains are designed based on a generalised predictive control (GPC) approach. The only user specifications required are simple and classical desired properties as in the natural frequency and the damping ratio of the closed-loop system. An approach is further developed to subsequent on-line self-tuning of control weights so that the overall control system remains applicable and effective in the face of disturbances and slowly varying dynamics. A detailed analysis of the closed-loop stability of the thus designed control system is further provided in the paper. Based on stability conditions developed, the prediction horizon for the GPC-based controller may be effectively computed. Finally, simulation examples illustrate the performance of the control system.