Efficacy of high-dose intravenous iron in middle-aged to elderly iron-deficient patients.

Iron deficiency (ID) impacts about fifty percent of elderly patients with many symptoms present before iron deficiency anaemia . If left untreated, ID may increase morbidity and mortality. Oral iron is often not tolerated or the absorption is suboptimal. We describe our initial experiences of using high-dose intravenous ferric derisomaltose (Monofer®) infusions of 500 and 1000mg for iron deficiency and iron deficiency anaemia respectively in the outpatient setting. Rapid correction of laboratory parameters and improvement in common symptoms (such as fatigue) were observed. Intravenous iron may be an option for symptomatic iron deficient patients unsuitable for oral iron.

A review of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap for wound coverage during ray amputations of the toes.

INTRODUCTION: Exposure of the adjacent Metatarsal-Phalangeal Joint (MTPJ) commonly occurs after application of Topical Negative Pressure Wound Therapy (TNPWT) for a ray amputation wound. This is due to mechanical soft tissue erosion or trauma to the adjacent digital artery from direct pressure effect. This results in toe gangrene requiring a ray amputation and ultimately a larger wound bed. We describe the use of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap - a filleted toe flap to protect the adjacent MTPJ capsule combined with a novel Negative Pressure Wound Therapy with instillation and dwell-time (NPWTi-d) dressing technique. The flap protects the adjacent joint capsule and reduces the wound burden whilst allowing the wound to benefit from TNPWT, thereby accelerating wound healing. MATERIAL AND METHODS: A retrospective review was conducted of patients with toe gangrene requiring ray amputation that underwent the TOPHAT flap on in our institution from 2019 and 2020. Complications such as wound dehiscence, hematoma, flap necrosis and secondary infection were recorded. Other outcomes recorded were time taken to final skin grafting and time taken for complete wound epithelialization. RESULTS: 9 patients underwent treatment with the TOPHAT flap. 2 patients had flap necrosis. 7 patients progressed to definitive skin coverage with skin grafting. One patient subsequently had progressive arterial disease despite successful skin grafting and required above knee amputation. The mean time to final skin grafting and complete wound epithelialization was 49.5 days and 107.5 days respectively. All patients were satisfied with the outcomes and were able to return to their pre-morbid function. CONCLUSIONS: The TOPHAT flap has a consistent vascular supply that provides durable soft tissue coverage. It is a robust and easily reproducible technique to accelerate wound healing after ray amputations even in patients with peripheral vascular disease.

Helical stent (SUPERA™) and drug-coated balloon (Passeo-18 Lux™) for recurrent cephalic arch stenosis: Rationale and design of arch V SUPERA-LUX Study.

BACKGROUND: The treatment options for cephalic arch stenosis are limited and standard of care remains at crossroads - none are ideal and there is currently no gold standard. Endovascular techniques are now the preferred primary therapeutic option because they are minimally invasive and better tolerated by haemodialysis patients who have multiple comorbidities. However, conventional plain old balloon angioplasty, bare metal stenting and stent grafts all have their limitations. The aim of this trial is to evaluate whether the helical SUPERA™ stent (Abbott Vascular, Santa Clara, CA, USA), which has a higher degree of flexibility and resistance to compressive forces compared to traditionally laser-cut nitinol stents, combined with a drug-coated balloon (Biotronik Passeo-18 Lux™) to minimize the neointimal hyperplasia effect, can improve patency and reduce reintervention rates. METHODS AND RESULTS: Arch V SUPERA-LUX is a pilot investigator-initiated single-centre, single-arm prospective study. Twenty patients with a brachiocephalic fistula within 6 months of initial plain old balloon angioplasty for significant cephalic arch stenosis will be recruited for treatment with SUPERA and drug-coated balloon. The primary objectives are immediate angiographic and procedural success, primary patency and functional fistula at 1 week, 8 weeks, 6 and 12 months. The results from eight patients treated prospectively as proof of concept have shown primary patency of 83.3% at 1 year with 100% technical and procedural success rates. Enrolment for the Arch V SUPERA-LUX study is expected to be completed at the end of 2019. CONCLUSION: The Arch V SUPERA-LUX study is the first trial to evaluate whether SUPERA stent implantation and drug-coated balloon use can provide superior protection against restenosis compared to traditional angioplasty, bare metal stents and stent grafts in recurrent cephalic arch stenosis. Initial pilot results are encouraging but longer follow-up is required to truly test this technique. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov NCT03891693.

Risk factors and treatment outcomes of severe Clostridioides difficile infection in Singapore.

Severe Clostridioides difficile infection (CDI) is associated with poorer outcomes. We aimed to identify risk factors and treatment outcomes of severe CDI. This was a retrospective cohort study. Eligible patients from January to December 2012 were recruited. Severity definitions were in accordance with SHEA/IDSA 2010 guideline. Treatment outcomes were (1) diarrhoea persistence, (2) CDI recurrence, (3) major complications despite treatment and (4) 30-day mortality. Two hundred and seventy-two patients were included and 40% had severe CDI. High APACHE II score (aOR 1.112, 95% CI 1.014-1.219; p < 0.05), high C-reactive protein (aOR 1.011; 95% CI 1.004-1.019; p < 0.01) and carbapenem usage in past 90 days (aOR 3.259; 95% CI 1.105-9.609; p < 0.05) were independent risk factors of severe CDI. Majority received oral metronidazole as sole treatment (92.6% for mild-moderate, 83.9% for severe, 77% for severe-complicated). Diarrhoea persistence was 32% versus 50% (p < 0.01), CDI recurrence 16.6% versus 16.5% (p > 0.05), major complications 1.2% versus 11% (p < 0.001) and 30-day mortality 7.4% versus 20.2% (p < 0.01) in mild-moderate CDI and severe CDI groups respectively. Oral metronidazole for severe CDI was associated with persistent diarrhoea, major complications and mortality. Risk factors for severe CDI can guide doctors in diagnosing severe CDI earlier and instituting oral vancomycin treatment to improve outcomes from severe CDI.

Frailty predicts mortality in all emergency surgical admissions regardless of age. An observational study.

BACKGROUND: frail patients in any age group are more likely to die than those that are not frail. We aimed to evaluate the impact of frailty on clinical mortality, readmission rate and length of stay for emergency surgical patients of all ages. METHODS: a multi-centre prospective cohort study was conducted on adult admissions to acute surgical units. Every patient presenting as a surgical emergency to secondary care, regardless of whether they ultimately underwent a surgical procedure was included. The study was carried out during 2015 and 2016.Frailty was defined using the 7-point Clinical Frailty Scale. The primary outcome was mortality at Day 90. Secondary outcomes included: mortality at Day 30, length of stay and readmission within a Day 30 period. RESULTS: the cohort included 2,279 patients (median age 54 years [IQR 36-72]; 56% female). Frailty was documented in patients of all ages: 1% in the under 40's to 45% of those aged 80+. We found that each incremental step of worsening frailty was associated with an 80% increase in mortality at Day 90 (OR 1.80, 95% CI: 1.61-2.01) supporting a linear dose-response relationship. In addition, the most frail patients were increasingly likely to stay in hospital longer, be readmitted within 30 days, and die within 30 days. CONCLUSIONS: worsening frailty at any age is associated with significantly poorer patient outcomes, including mortality in unselected acute surgical admissions. Assessment of frailty should be integrated into emergency surgical practice to allow prognostication and implementation of strategies to improve outcomes.

3D reconstruction of the porcine and equine pulmonary veins, supplemented with the identification of telocytes in the horse.

The myocardial sleeve of the porcine and equine pulmonary veins were histologically investigated and reconstructed three dimensionally. Moreover, the localization of neuron cell bodies at the veno-atrial junction and alongside the myocardial sleeve was light microscopically visualized to depict the organization of nerve, myocardial and fat tissue. Finally, the presence of telocytes inside the equine pulmonary veins was demonstrated by use of transmission electron microscopy. These structures are thought to play a role in the induction of atrial fibrillation, which is frequently seen in horses, while pigs are often used as a cardiovascular model in this context. This data fills in remaining gaps in the literature concerning the histological build-up of the pulmonary veins wall in pigs and horses. In-depth knowledge on the myocardial sleeve and its surrounding cell types are important to understand the possible outcome of an ablation therapy as an atrial fibrillation treatment. In pigs and horses, the layout of the pulmonary veins wall concerning these structures is comparable to humans. However, neuron cell bodies were recovered at the veno-atrial junction in both species but not alongside the myocardial sleeve in horses.

The association between distance to public amenities and cardiovascular risk factors among lower income Singaporeans.

Existing evidence on the association between built environment and cardiovascular disease (CVD) risk factors focused on the general population, which may not generalize to higher risk subgroups such as those with lower socio-economic status (SES). We examined the associations between distance to 5 public amenities from residential housing (public polyclinic, subsidized private clinic, healthier eatery, public park and train station) and 12 CVD risk factors (physical inactivity, medical histories and unhealthy dietary habits) among a study sample of low income Singaporeans aged ≥ 40 years (N = 1972). Using data from the Singapore Heart Foundation Health Mapping Exercise 2013-2015, we performed a series of logistic mixed effect regressions, accounting for clustering of respondents in residential blocks and multiple comparisons. Each regression analysis used the minimum distance (in km) between residential housing and each public amenity as an independent continuous variable and a single risk factor as the dependent variable, controlling for demographic characteristics. Increased distance (geographical inaccessibility) to a train station was significantly associated with lower odds of participation in sports whereas greater distance to a subsidized private clinic was associated with lower odds of having high cholesterol diagnosed. Increasing distance to park was positively associated with higher odds of less vegetable and fruits consumption, deep fried food and fast food consumption in the preceding week/month, high BMI at screening and history of diabetes, albeit not achieving statistical significance. Our findings highlighted potential effects of health-promoting amenities on CVD risk factors in urban low-income setting, suggesting gaps for further investigations.

Identification of telocytes in the porcine heart.

Recently, a new interstitial cell type called telocyte has been identified. Telocytes are found in many organs including the heart, where they are especially well described. However, their presence in the porcine heart has not yet been proven. The pig is a valuable animal model in research because of its resemblance with man, making it interesting to determine whether telocytes can be found in pigs as well. The focus of this study is the identification and ultrastructural description of telocytes in the heart tissue of pig. Using transmission electron microscopy, telocytes were found in both left and right atrium and ventricle, usually close to cardiomyocytes and/or blood vessels. Their most important characteristic is the long cytoplasmic processes called telopodes, which have a moniliform aspect, measure tens of µm and usually have a thickness below 0.2 µm. This unique morphological feature enables telocytes to be recognized from other interstitial cells such as fibroblasts. Additional observations include the ability to release extracellular vesicles and to make contacts with other structures such as endothelial cells, suggesting a role in intercellular communication.

Gastric ulcer that turned out to be metastasis of a synovial sarcoma: A case report and literature review

Primary gastrointestinal synovial sarcoma or its metastases to the gastrointestinal tract is rare. Here we present a case of 56-year-old gentleman with left thigh synovial sarcoma and gastric metastases along with the literature review.

Transoral robotic resection of lingual thyroid: case report.

OBJECTIVE: We present a case of large, symptomatic lingual thyroid which was successfully and safely removed via a transoral approach, using the da Vinci robotic system, in an academic medical centre in Singapore. CASE REPORT: A 17-year-old female adolescent presented with a large lingual thyroid causing upper airway obstruction. She underwent robotic, minimally invasive, transoral resection using the da Vinci system. Post-operative recovery was uneventful; she was able to commence oral feeding almost immediately, and was discharged from hospital on the fourth post-operative day. CONCLUSION: It is surgically feasible and safe to undertake transoral robotic resection of a large lingual thyroid. This approach may allow faster recovery and shorter hospitalisation for patients. Surgical safety requires a full understanding of the intralingual neurovascular anatomy.

Tympanoplasty graft preparation using ear drops containing polyethylene glycol, flumethasone and clioquinol.

The aim of tympanoplasty graft preparation is to stiffen the fascia or perichondrium and thereby to optimise ease of manipulation. We report 39 cases utilising a novel technique in which the graft is prepared in ear drops containing polyethylene glycol, flumetasone pivalate (0.02 per cent) and clioquinol (1 per cent). This technique is useful in reducing the risk of desiccation if placement is delayed, and may pose less risk of infection and mechanical damage than alternative methods.

Fluoride toothpaste utilization behaviour among preschool children in Perlis, Malaysia.

BACKGROUND: Very mild fluorosis is quite prevalent in children and one of the sources may be attributed to poor fluoride toothpaste utilization habits. AIM: To investigate the frequency of toothbrushing, parental supervision, the person who usually applied the toothpaste, toothpaste swallowing and spitting habits, size of toothbrush, type of toothpaste used and amount of toothpaste used by shape and weight. METHODOLOGY: Observational cross-sectional study of a representative random sample of 373 children aged 5-6 year-old. The children were interviewed using a structured close ended questionnaire. Direct observations were made on their toothpaste dispensing habit during a toothbrushing exercise. RESULTS: All children reported practising toothbrushing with 90% on a daily basis. Almost all used fluoridated toothpaste (91.4%). About one-half (50.7%) reported that their parents never supervised them. More than one-third of children used adult toothpaste and 60.1% of the toothpaste was flavoured. Most (92%) used toothbrush meant for children. About 40% applied a pea-sized amount of toothpaste. The mean weight of toothpaste applied was 0.43 g (SID + 0.35 g). CONCLUSIONS: The majority used the recommended child-sized toothbrush and toothpaste that contained fluoride but less than one-half of the parents supervised their children. Most children used flavoured children's toothpaste but a sizable proportion used toothpastes meant for adults. The amount applied by shape and weight exceeded the amount recommended by experts.

Long-term results of endoscopic resection of nasopharyngeal tumours.

Traditional open approaches to the nasopharynx either provide limited access and risk significant morbidity. Here we describe our experience with endoscopic resection of nasopharyngeal tumours. Retrospective chart review was performed for all patients who underwent endoscopic nasopharyngeal resection from September 1993 to January 2007 at a tertiary rhinology centre. Six patients underwent endoscopic nasopharyngectomy for tumours arising from or involving the nasopharynx. The mean age was 49.8 years (range 23 - 70). The sex distribution was five males and one female. Four tumours were malignant and two were benign. The mean disease-free and overall survival for malignant tumors was 90.75 months (range 66 - 120 months). None of the benign tumors recurred. The endoscopic nasopharyngectomy technique may be successfully used for resection of tumors arising from or involving the nasopharynx with good efficacy and a decrease in morbidity when compared to open approaches.

Clinical pathways in primary dental care in Malaysia: clinicians' knowledge, perceptions and barriers faced.

The Oral Health Division, Ministry of Health in Malaysia piloted clinical pathways (cpath) in primary care in early 2003. This study investigated the knowledge, perception of cpaths and barriers faced by the clinicians involved in the pilot project. Self-administered questionnaires were sent to the clinicians (n=191). Dentists (67.9%) and dental nurses (70.6%) had good overall knowledge of cpaths. The majority of the clinicians (67.9% to 95.6%) perceived cpath positively in all areas. Only 9.2% of dentists encountered difficulties in using cpath forms compared to 28.4% of dental nurses. A higher proportion of dental nurses (73.5%) compared to dentists (64.8%) were willing to continue using cpath. The majority of dentists (76.7%) and dental nurses (73.1%) were willing to participate in future development of cpaths. Overall, there was evidence of managerial support for the pilot project. A follow-up of the pilot project was somewhat lacking as less than half (43.3%) of the clinicians reported that the state coordinator obtained feedback from them. The findings auger well for the future implementation of cpath should the Oral Health Division decide to adopt cpath routinely in the public oral health care service.

10th Yahya Cohen Memorial Lecture: Clinical predictors in obstructive sleep apnoea patients with computer-assisted quantitative videoendoscopic upper airway analysis.

AIM: To identify the clinical predictors and assist surgeons in their clinical management of obstructive sleep apnoea (OSA) - a prospective study with a new approach to analyse the static and dynamic upper airway morphology between patients with OSA and normal subjects. To introduce a new method of assessment for surgical outcome. MATERIALS AND METHODS: Quantitative computer-assisted videoendoscopy (validated with upper airway magnetic resonance imaging) was performed in 49 (43 males, 6 females) patients with OSA and compared with 39 (22 males, 17 females) controls (apnoea-hypopnoea index <5). Absolute cross-sectional areas, transverse and longitudinal diameters at the retro-palatal and retro-lingual levels were measured during end of quiet respiration and during Mueller's manoeuvre in the erect and supine positions, allowing us to study static and dynamic morphology (collapsibility) of the upper airway. We analysed 3744 parameters. RESULTS: In males, retro-palatal and retro-lingual areas during Mueller's manoeuvre in the supine position of 0.7981 cm2 [receiver operating characteristics (ROC) = 0.9284, positive predictive value (PPV) = 86.05%, negative predictive value (NPV) = 84.62%] and 2.0648 cm2 (ROC = 0.8183, PPV = 76%, NPV = 83.33%), respectively, were found to be good predictors/ cut-off values for OSA. Retro-palatal area measured in the supine position during Mueller's manoeuvre (AS1M) and collapsibility of retro-palatal area in the supine position calculated (CAS1) were found to have significant correlations with severity of OSA. In females, areas measured during Mueller's manoeuvre in the supine position of 0.522 cm2 at retropalatal level (ROC = 1, 100% PPV and NPV) and transverse diameter at retro-lingual level during erect Mueller's manoeuvre of 1.1843 cm (ROC = 0.9056, PPV = 100%, NPV = 83.33%) were found to be predictive. All measurements at the retro-palatal level and in the supine position had higher predictability. Area measurements obtained during Muller's manoeuvre were more predictive (ROC >0.9910) than resting measurements (ROC >0.8371). Several gender and anatomical-site specific formulas with excellent predictability (ROC close or equal to 1) were also devised. Examples of surgical outcome assessment were introduced. CONCLUSION: Upper airway Mueller's studies are predictive and useful (independent samples t-test/Mann Whitney U test, ROC) in identifying patients with OSA. With these gender and anatomical-site specific OSA predictors/formulas and this innovative clinical method, we hope to assist other surgeons with quantitative clinical diagnosis, assessment, surgical planning and outcome assessment tools for OSA patients.

Quantitative computer-assisted digital-imaging upper airway analysis for obstructive sleep apnoea.

This was a prospective study of a new objective method which quantitatively analyses the upper airways in patients with obstructive sleep apnoea (OSA). Video-nasopharyngoscopic examinations of the upper airways of 45 patients were carried out with an endoscopic calibrator. Images of the upper airway during quiet respiration and Mueller's manoeuvre in erect and supine positions were digitized by computer to generate the actual dimensions of obstructive sites. Measurements by the new method were validated by comparing 90 pairs of videoendoscopic images with upper airway magnetic resonance imaging (MRI) measurements at two identical levels. Quantitative precision is 100% for the retropalatal level and 95.6% for the retrolingual level with a tolerance of 0.5 cm(2) between the two methods. The absolute mean of the difference between the two methods of measurement is 0.08 cm(2) at the retropalatal level and 0.18 cm(2) at the retrolingual level. The agreement between the digital-imaging videoendoscopic and MRI measurements was 93.3% for the retropalatal level and 95.6% for the retrolingual level. Quantitative computer-assisted digital imaging is a reliable, cost-effective clinical method of upper airway evaluation in OSA patients. This method allows us to examine the dynamic and static morphology objectively, measure surgical outcomes of upper airway, opening up new avenues for OSA management.

Morphology and properties of denture acrylic resins cured by microwave energy and conventional water bath.

OBJECTIVES: This study examined the influence of microwave energy levels on the morphology and properties of an impact resistant denture material poly(methyl methacrylate) with a thickness of 10 mm. METHODS: A microwave flask containing two resin blocks was processed at 80, 160, 240, and 560 W for 15, 10, 7, and 2 min, separately. Each Flask was then turned over, and cured for an additional 2 min at 560 W. The process using conventional methods was carried out at 70 degrees C for 9 h. The blocks were tested for hardness, porosity, flexural properties, solubility, and molecular weight. The morphology of the specimens after staining with osmium tetroxide was examined by transmission electron microscope. RESULTS: The changes in temperature with time were recorded during microwave heating at 80, 160, and 240 W, respectively. A significantly large difference in the curing temperature was observed when comparing these two processing methods. There was little difference in the mean values of surface hardness and the weight percent of the insoluble parts. The mean domain size and the volume fraction of the rubber phase favor of the water-bath method. However, the porosity in the water-bath-cured specimens was much less than that in the microwave-cured specimens. Thus, the conventionally cured specimens showed better flexural strength and flexural modulus than the microwave-cured specimens. SIGNIFICANCE: This study has shown that microwave energy can efficiently polymerize denture base polymer. Highly statistical differences in morphology and flexural properties favor of the water-bath method. Choice of a suitable microwave power and polymerization time is important in order to reduce porosity to a minimum level and increase the domain size and volume of the rubber phase.

A prospective study of the clinical features, manometric findings, incidence and prevalence of achalasia in Singapore.

BACKGROUND: This study aimed to describe the clinical features, manometric findings, prevalence and incidence of achalasia in Singapore. METHODS: A total of 615 new patients referred for oesophageal manometry between 1989 and 1996 were examined prospectively. Twenty-four men and 25 women fulfilled the manometric and clinical criteria for achalasia. RESULTS: Their median age of onset of symptoms was 37 years (range 15-71) and 37% first developed symptoms after the age of 50 years. The presenting symptoms were dysphagia (100%), regurgitation (80%), weight loss (67%) and chest discomfort (33%). Five patients (10%) had a history of benign (mostly autoimmune) thyroid disorders. Endoscopy was reported as normal in 10/43 patients (23%) and achalasia was suggested in only 31 (72%) of 43 barium examinations. Lower oesophageal sphincter (LOS) dysfunction was present in 82% of cases. Using data from medical records and from a survey of gastroenterologists and surgeons in Singapore, the prevalence (in 1996) and incidence of achalasia in Singapore were estimated to be 1.8 per 100000, and 0.3 per 100000 per year, respectively. The incidence was significantly lower in Malays than Chinese or Indians. The age-specific incidence of achalasia for both genders followed a bimodal distribution with the larger peak in the sixth decade. No cases of oesophageal carcinoma were identified among these patients. CONCLUSION: Achalasia is an uncommon condition in Singapore. The clinical and manometric features were similar to those described in Western countries.

Aspirin, nonsteroidal anti-inflammatory drugs, and epistaxis. A regional record linkage case control study.

To assess the relationship between nonsteroidal anti-inflammatory drugs (NSAIDs) and spontaneous epistaxis in adults over 50 years old, a case control study was carried out by using a record linkage database for the population of Tayside, Scotland, which included 319,465 people. The study group consisted of 326 patients who were hospitalized with epistaxis between May 1989 and December 1992, but who had not previously been hospitalized with this diagnosis. Six community controls and 4 hospital controls, matched for age and sex to each case, were used. Previous exposure to prescribed aspirin and other NSAIDs was investigated. There was a significant association between aspirin exposure and epistaxis when either community or hospital controls were used (p < .001). Patients who had aspirin prescriptions had a relative risk of hospital admission for epistaxis of between 2.17 and 2.75, depending on the control group used. No association between non-aspirin NSAIDs and epistaxis was evident with either control group.