Original Article

Hung TH, Tsai CC, Tsai CC, Tseng CW, Hsieh YH
Correspondence:  Dr Yu-Hsi Hsieh, hsieh.yuhsi@msa.hinet.net

ABSTRACT
INTRODUCTION Necrotising fasciitis (NF) is often found in patients with diabetes mellitus, chronic renal failure, alcoholism, malignancy or liver cirrhosis. However, it remains unknown whether liver cirrhosis is an independent risk factor for the occurrence of NF. This study aimed to determine whether liver cirrhosis is an independent risk factor for the occurrence of NF, and to identify the relationship between severity of liver cirrhosis and occurrence of NF.
METHODS The National Health Insurance Research Database, maintained by Taiwan’s National Health Insurance programme, was retrospectively analysed, and the hospitalisation data of 40,802 cirrhotic patients and 40,865 randomly selected, age? and gender?matched non?cirrhotic control patients was collected. The medical records of all patients were individually followed for a three?year period from the patients’ first hospitalisation in 2004.
RESULTS During the three?year follow?up period, there were 299 (0.7%) cirrhotic patients with NF and 160 (0.4%) non?cirrhotic patients with NF. Cox regression analysis showed that liver cirrhosis was a risk factor for the occurrence of NF during the study period (hazard ratio 1.982; p < 0.001). Among cirrhotic patients, those with complicated liver cirrhosis had a higher risk for the occurrence of NF than patients with non?complicated liver cirrhosis (hazard ratio 1.320; p = 0.028).
CONCLUSION Cirrhotic patients had a higher risk for the occurrence of NF than non?cirrhotic patients, and the risk for NF was especially high among patients with complicated liver cirrhosis.

Keywords: cirrhosis, complicated liver cirrhosis, necrotising fasciitis
Singapore Med J 2014; 55(7): 378-382; http://dx.doi.org/10.11622/smedj.2014090

REFERENCES

Shih CJ, Tarng DC, Yang WC, Yang CY
Correspondence: Dr Chih-Yu Yang, cyyang3@vghtpe.gov.tw

ABSTRACT
INTRODUCTION Due to lifelong immunosuppression, renal transplant recipients (RTRs) are at risk of infectious complications such as pneumonia. Severe pneumonia results in respiratory failure and is life?threatening. We aimed to examine the influence of immunosuppressant dose reduction on RTRs with bacterial pneumonia and respiratory failure.
METHODS From January 2001 to January 2011, 33 of 1,146 RTRs at a single centre developed bacterial pneumonia with respiratory failure. All patients were treated using mechanical ventilation and aggressive therapies in the intensive care unit.
RESULTS Average time from kidney transplantation to pneumonia with respiratory failure was 6.8 years. In-hospital mortality rate was 45.5% despite intensive care and aggressive therapies. Logistic regression analysis indicated that a high serum creatinine level at the time of admission to the intensive care unit (odds ratio 1.77 per mg/dL, 95% confidence interval 1.01–3.09; p = 0.045) was a mortality determinant. Out of the 33 patients, immunosuppressive agents were reduced in 17 (51.5%). We found that although immunosuppressant dose reduction tended to improve in-hospital mortality, this was not statistically significant. Nevertheless, during a mean follow-up period of two years, none of the survivors (n = 18) developed acute rejection or allograft necrosis.
CONCLUSION In RTRs with bacterial pneumonia and respiratory failure, higher serum creatinine levels were a mortality determinant. Although temporary immunosuppressant dose reduction might not reduce mortality, it was associated with a minimal risk of acute rejection during the two-year follow-up. Our results suggest that early immunosuppressant reduction in RTRs with severe pneumonia of indeterminate microbiology may be safe even when pathogens are bacterial in nature.

Keywords: immunosuppressant, kidney transplant, mortality, pneumonia, respiratory failure
Singapore Med J 2014; 55(7): 372-377; http://dx.doi.org/10.11622/smedj.2014089

REFERENCES

Zueter AM, Mohamed Z, Abdullah AD, Mohamad N, Arifin N, Othman N, Noordin R
Correspondence: Dr Rahmah Noordin, rahmah8485@gmail.com

ABSTRACT
INTRODUCTION Strongyloidiasis is one of the most commonly neglected but clinically important parasitic infections worldwide, especially among immunocompromised patients. Evidence of infection among immunocompromised patients in Malaysia is, however, lacking. In this study, microscopy, real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assays (ELISAs) were used to detect Strongyloides stercoralis (S. stercoralis) infection among cancer patients in a Malaysian hospital.
METHODS A total of 192 stool and serum samples were collected from cancer patients who were receiving chemotherapy with or without steroid treatment at a hospital in northeastern Malaysia. Stool samples were examined for S. stercoralis using parasitological methods and real-time PCR. Serology by ELISA was performed to detect parasite-specific immunoglobulin G (IgG), IgG4 and immunoglobulin E (IgE) antibodies. For comparison, IgG4- and IgG-ELISAs were also performed on the sera of 150 healthy individuals from the same area.
RESULTS Of the 192 samples examined, 1 (0.5%) sample was positive for S. stercoralis by microscopy, 3 (1.6%) by real-time PCR, 8 (4.2%) by IgG-ELISA, 6 (3.1%) by IgG4-ELISA, and none was positive by IgE-ELISA. In comparison, healthy blood donors had significantly lower prevalence of parasite-specific IgG (2.67%, p < 0.05) and IgG4 (2.67%, p < 0.05) responses.
CONCLUSION This study showed that laboratory testing may be considered as a diagnostic investigation for S. stercoralis among immunocompromised cancer patients.

Keywords: cancer patients, ELISAs, microscopy, real-time PCR, Strongyloides stercoralis
Singapore Med J 2014; 55(7): 367-371; http://dx.doi.org/10.11622/smedj.2014088

REFERENCES

Chia C, Lim WP, Vu C
Correspondence: Dr Christopher Chia Tze Wei, christopher_tw_chia@ttsh.com.sg

ABSTRACT
INTRODUCTION There are growing concerns that the use of proton pump inhibitors (PPIs) may be inappropriate in instances that do not conform to evidence-based indications. This point-prevalence study aimed to investigate the frequency, indications and appropriateness of use of PPIs in hospitalised patients on a randomly chosen day.
METHODS On a randomly chosen day, all inpatients were documented, and those on any form of PPIs on that day were determined. Indications for maintaining these patients on PPIs were obtained from the electronic medical records, which were then recorded and cross-referenced against a list of accepted indications adapted from the US Food and Drug Administration (FDA)-approved list.
RESULTS In all, 1,025 inpatients were documented. Of the 477 (46.5%) inpatients using PPIs, only 219 (45.9%) fulfilled the FDA-approved indications, while the majority (n = 258, 54.1%) did not. Overall, PPIs were not strictly indicated for use in 206 (43.2%) inpatients, according to FDA criteria. Of the 477 inpatients on PPIs, 52 (10.9%) had borderline indications based on expert consensus/guidelines other than FDA criteria.
CONCLUSION Although the use of PPIs is prevalent in hospitals, less than half of the hospitalised patients using PPIs in our study had evidence-based indications that supported such use. The overuse of PPIs has a negative impact on healthcare costs and may lead to adverse effects. Steps to curb the inappropriate use of PPIs should address factors such as indications for the initiation of PPIs, and reassessment of the need for ongoing PPI use in inpatients upon discharge and during outpatient reviews.

Keywords: guidelines, hospitalised, inappropriate use, patients, proton pump inhibitors
Singapore Med J 2014; 55(7): 363-366; http://dx.doi.org/10.11622/smedj.2014087

REFERENCES

See KC, Phua J, Mukhopadhyay A, Lim TK
Correspondence: Dr Kay Choong See, Kay_Choong_SEE@nuhs.edu.sg

ABSTRACT
INTRODUCTION Distractions and interruptions of doctor’s work, although common and potentially deleterious in the intensive care unit (ICU), are not well studied.
METHODS We used a simple observational method to describe the frequency, sources and severity of such distractions, and explore at-risk situations in the ICU. Independent paired observers separately shadowed eight residents and three fellows for 38 sessions (over 100 hrs) in a 20-bed medical ICU.
RESULTS In total, 444 distractions were noted. Interobserver agreement was excellent at 99.1%. The mean number of distractions/doctor/hr was 4.36 ± 2.27. Median duration of each distraction was 2 mins (interquartile range 2–4 mins; range 1–20 mins). The top three initiators of distractions were other doctors (35.1%), nurses (30.4%) and oneself (18.7%). Of the 444 distractions, 107 (24.1%) were prolonged (lasting ≥ 5 mins), 210 (47.3%) led to a complete pause of current activity and 85 (19.1%) led to complete abandonment of the current activity. On multivariate analysis, physician seniority, time of session and day of week did not predict frequency of distraction. After adjusting for time of session, day of week and type of current activity, urgent distractions (to see another patient, perform immediate procedures or administer medications) and physician juniority were associated with major distractions (complete interruption or termination of current activity), while only urgent distractions were associated with prolonged distractions.
CONCLUSION Distractions are common in the ICU and junior doctors are particularly susceptible to major distractions.

Keywords: distraction, fellow, intensive care, interruption, resident
Singapore Med J 2014; 55(7): 358-362; http://dx.doi.org/10.11622/smedj.2014086

REFERENCES

Matsunuma R, Asai N, Ohkuni Y, Nakashima K, Iwasaki T, Misawa M, Norihiro K
Correspondence: Dr Ryo Matsunuma, manutsuma@gmail.com

ABSTRACT
INTRODUCTION The ability to predict the prognosis of patients with pneumonia is critical, especially when making decisions regarding treatment regimens and sites of care. However, prognostic guidelines for healthcare-associated pneumonia (HCAP) have yet to be established. I-ROAD is the prognostic guideline of the Japanese Respiratory Society for hospital-acquired pneumonia (HAP). This study compared available prognostic guidelines to determine the usefulness of I-ROAD as a prognostic tool for patients with HCAP.
METHODS We conducted a retrospective review of all patients with pneumonia admitted to Kameda Medical Center, Japan, from January 2006 to September 2009. Patients were categorised into two groups, namely those with communityacquired pneumonia (CAP) and those with HCAP. We compared the baseline characteristics, laboratory findings, identified pathogens, antibiotic regimens, clinical outcomes, pneumonic severity and prognostic accuracy of each guideline between the two patient groups. The severity of each disease was assessed on admission using the A-DROP, CURB-65, PSI and I-ROAD guidelines.
RESULTS Of the 302 patients evaluated, 228 (75.5%) were diagnosed with CAP and 74 (24.5%) with HCAP. Patients with HCAP were older and had a higher performance status than patients with CAP. The mortality rate in the CAP group tended to rise with increasing severity scores of prognostic guidelines. Although the severity scores of all prognostic guidelines could predict 30-day mortality in patients with CAP, I-ROAD exhibited a higher discriminatory power for patients with HCAP based on analysis of receiver-operating characteristic curves.
CONCLUSION I-ROAD could be more accurate than other prognostic guidelines for evaluating the severity of HCAP.

Keywords: community-acquired pneumonia, healthcare-associated pneumonia, I-ROAD, prognostic tools, severity
Singapore Med J 2014; 55(6): 318-324; http://dx.doi.org/10.11622/smedj.2014082

REFERENCES

Gupta P, Faridi MM, Goel N, Zaidi ZH
Correspondence: Dr Priyanka Gupta, drpriyankaguptakapil@gmail.com

ABSTRACT
INTRODUCTION The present study aimed to determine the epidemiology, maternal complications and adverse neonatal outcomes associated with twin births at a tertiary care hospital in India.
METHODS A prospective observational study was conducted on all successively born twin pairs (≥ 23 weeks of gestation) and their mothers from January to September 2005. Main outcome measures included maternal medical/obstetric complications, labour characteristics and the morbidities/mortality observed during the early neonatal period.
RESULTS The twinning rate was 1 in 54 deliveries. Around 10% of mothers had a predisposition for twinning in the form of familial tendency or consumption of clomiphene. Anaemia (85%) was the most common maternal complication, followed by gestational hypertension (17%). Nearly one-third of births were delivered via Caesarean section. Prematurity (61%) was the most common neonatal complication followed by early-onset neonatal sepsis (21%). The risk of early neonatal death was 27%. Shorter gestation and low birth weight were significantly associated with adverse neonatal outcome (p < 0.05). Factors such as chorionicity, mode of delivery, birth order, inter-twin delivery time interval, gender and intra-pair birth weight discordance did not affect neonatal morbidity or mortality (p ≥ 0.05).
CONCLUSION The rates of maternal complications and early neonatal morbidities/mortality were quite high in twin gestations. Except for the prematurity and low birth weight, none of the other factors, including inter-twin delivery time interval of more than 15 mins, were found to affect neonatal outcome.

Keywords: inter-twin delivery time interval, morbidities, mortality, twins
Singapore Med J 2014; 55(6): 310-317; http://dx.doi.org/10.11622/smedj.2014083

REFERENCES

Tan TY, Lau SK, Loh SF, Tan HH
Correspondence: Dr Matthew Lau Sie Kuei, matthew.lau.sk@kkh.com.sg

ABSTRACT
INTRODUCTION Fertility in women declines with increasing age. With the deferment of marriage and childbearing, couples are turning to assisted reproductive technology to counteract this decline. We aimed to evaluate the results of in vitrofertilisation (IVF)/intracytoplasmic sperm injection (ICSI) in women of different age groups, and highlight the cost-effectiveness of IVF treatment in these groups while assessing its implications on the national healthcare provision model.
METHODS Retrospective analysis of 3,412 stimulated IVF/ICSI cycles in a hospital-based IVF centre was performed from January 2008 to December 2010. Patients were stratified into seven age groups: < 30 years; 30–35 years; 36–37 years; 38 years; 39 years; 40–44 years; and ≥ 45 years.
RESULTS Age had a significant effect on the number of cycles leading to embryo transfer (p < 0.001). The number of oocytes retrieved decreased across the various age groups (p < 0.001) and was the highest among women aged < 30 (mean 18.5 ± 10.3) years. With increasing age, there was a trend toward a lower fertilisation rate. Age also had a significant effect on the rates of clinical pregnancy, live birth and multiple pregnancies (p < 0.001).
CONCLUSION Patients aged < 30 years had the best IVF outcomes, refl ecting optimal reproductive capacity. Age-related decline in fertility starts after 30 years. Women opting for IVF should be counselled about age-specific success rates while taking into account individual risk factors.

Keywords: clinical pregnancy rate, female ageing, in vitrofertilisation outcome, live birth rate, miscarriage rate
Singapore Med J 2014; 55(6): 305-309; http://dx.doi.org/10.11622/smedj.2014081

REFERENCES

Ang HL, Lim CW, Hia C, Yip J, Quek SC
Correspondence: Dr Quek Swee Chye, swee _chye _quek@nuhs.edu.sg

ABSTRACT
INTRODUCTION Coarctation of the aorta (CoA) accounts for 5%–8% of all congenital heart defects. If left untreated, most patients with significant CoA will have varying degrees of morbidity (e.g. hypertension, stroke, collateral formation and ventricular hypertrophy), possibly even mortality. Traditionally, treatment for this condition is surgical. Herein, we report stenting during catheterisation as an alternative nonsurgical treatment option for patients with CoA, and present the treatment outcomes of patients who underwent this treatment option.
METHODS We retrospectively reviewed four patients (2 men and 2 women; age range 20–41 years) who underwent CoA stenting under general anaesthesia for the treatment of native CoA or restenosis of CoA at our institution. Three patients had a 40-mm Palmaz stent inserted, while one had a 39-mm Cheatham-Platinum covered stent inserted. Angiography and measurement of pressure gradients were performed before and after stent implantation to ensure good treatment outcomes.
RESULTS The patients’ treatment outcomes were good, with a significant reduction in pressure gradients across the narrowed segments. Angiography showed relief of CoA. The patients were followed up for 1–3 years, during which no complications were noted.
CONCLUSION This is the first reported series in Singapore on the nonsurgical treatment of CoAs in adult patients using stents during interventional cardiac catheterisation. This less invasive procedure may lead to a new paradigm shift with regard to the treatment of CoA.

Keywords: angiogram, aortic coarctation, cardiac catheterisation, pressure gradients, stent
Singapore Med J 2014; 55(6): 302-304; http://dx.doi.org/10.11622/smedj.2014080

REFERENCES

Quaggiotto P, Tran H, Bhanugopan M
Correspondence: Dr Paul Quaggiotto, apollo13@netspace.net.au

ABSTRACT
INTRODUCTION The aim of the present study was to assess the prevalence of vitamin D deficiency and toxicity, the frequency of 25-hydroxyvitamin D (25[OH]D) testing, and 25(OH)D variations with respect to patient gender, patient age and season in New South Wales, Australia.
METHODS A retrospective analysis of pathology records was performed to ascertain patient age, patient gender, sample collection date, plasma or serum 25(OH)D levels, calcium and parathyroid hormone (PTH) levels, and test numbers between 2001 and 2010. Linear regression with Bonferroni correction was used to calculate and compare age-adjusted mean 25(OH)D levels. Relationships of 25(OH)D with PTH and calcium were tested using Spearman’s rank correlation.
RESULTS 25(OH)D testing increased by 730% over the ten-year study period. In 2010, many men (33%) and women (40%) were, to some degree, vitamin D deficient (≤ 50 nmol/L). Vitamin D toxicity was rare, with only one instance noted. 25(OH)D levels correlated positively with calcium and negatively with PTH levels. 25(OH)D levels decreased with age. In 2010, 25(OH)D levels were highest in February and lowest in September/October. Cyclical variation was observed for 25(OH)D levels between 2006 and 2010.
CONCLUSION We found that vitamin D deficiency was prevalent in both men and women, with a higher prevalence in the latter, despite the substantial increased demand for 25(OH)D testing in our population over the decade. Vitamin D deficiency was associated with elevated PTH levels. Vitamin D toxicity was rare and only observed once during our study period. 25(OH)D levels decreased with age and varied with season, with the highest levels observed in late summer and the lowest in early spring.

Keywords: 25-hydroxyvitamin D, age, calcium, deficiency, toxicity
Singapore Med J 2014; 55(5): 271-280; http://dx.doi.org/10.11622/smedj.2014071

REFERENCES