Original Article

Ibrahim I, Jacobs IG
Correspondence: Dr Irwani Ibrahim, irwani_ibrahim@nuhs.edu.sg

ABSTRACT
INTRODUCTION The emergency department (ED) is often the initial site of identification of patients with sepsis. We aimed to determine the characteristics of ED attendances that predict poor hospital outcomes.
METHODS We conducted a retrospective cohort study of adult patients in eight metropolitan EDs in Perth, Western Australia, from 2001 to 2006. Patients diagnosed with sepsis in the ED were identified using the International Classification of Diseases, 10th Revision-Australian Modification code in the Emergency Department Information System (EDIS) database. The EDIS database was subsequently linked to mortality and hospital morbidity records. The following characteristics were examined: triage category, mode of arrival, source of referral and hospital of presentation. Multivariate logistic regression was performed to identify predictors of hospital mortality, prolonged length of stay, and admission to the intensive care unit (ICU).
RESULTS In the 1,311 patients diagnosed with sepsis in the ED, the hospital mortality and ICU admission rates were 19.5% and 18.5%, respectively. The mean hospital length of stay was 12 ± 15 days. Acute triage categories predicted both hospital mortality and ICU admissions, while mode of arrival by ambulance was a predictor of all poor hospital outcomes (p < 0.001). Patients who presented to non-teaching hospitals had similar hospital outcomes as patients who presented to teaching hospitals. The source of referrals was not a predictor of poor hospital outcomes (p > 0.05).
CONCLUSION Mode of arrival and triage score, which are characteristics unique to the ED, may predict poor hospital outcomes in patients with sepsis.

Keywords: emergency medicine, medical record linkage, mortality, sepsis, triage
Singapore Med J 2013; 54(11): 634-638; http://dx.doi.org/10.11622/smedj.2013224

REFERENCES

Chua YP, Tan WJ, Ahmad TS, Saw A
Correspondence: Dr Chua Yeok Pin, yeokpin1@yahoo.com

ABSTRACT
INTRODUCTION Foot pain is a common problem, especially in women, and studies have shown that it is related to footwear. This study was conducted to establish the prevalence of nontraumatic foot pain and its contributing factors in young working Malaysian women in an urban setting.
METHODS The survey was conducted on a group of working women (age range 21–40 years) selected using convenience sampling. Data on foot problems was collected through an investigator-directed questionnaire and during clinical inspection of the foot.
RESULTS A total of 400 women, with a mean age of 29.4 years, were recruited. Half (n = 200) of the women had experienced recurrent nontraumatic foot pain in the past one year. Subjective assessments of foot pain using the Numeric Intensity Scale gave an average score of 4.89 ± 1.78 (range 2–10), with most episodes occurring at the heel. There was no statistically significant association between foot pain and age, ethnicity or body mass index. However, there was a higher incidence of foot pain in women wearing high-heeled footwear than those wearing non-high-heeled footwear (p = 0.027, odds ratio 1.591). 
CONCLUSION Nontraumatic foot pain is common among young working women in our society. More than half (68.4%) of the women with foot pain in our study attributed the pain to footwear. Wearing high-heeled shoes to work was a significant contributing factor. Increased public awareness on the importance of proper footwear may help to reduce the prevalence of nontraumatic foot pain in working women.

Keywords: high heels, nontraumatic foot pain, young women
Singapore Med J 2013; 54(11): 630-633; http://dx.doi.org/10.11622/smedj.2013223

REFERENCES

Lin CJ, Hung JW, Cho CY, Tseng CY, Chen HY, Lin FC, Li CY
Correspondence: Dr Jen-Wen Hung, hung0702@adm.cgmh.org.tw

ABSTRACT
INTRODUCTION Constipation is a common poststroke complication. This study was designed to document the incidence and clinical course of poststroke constipation in a rehabilitation ward, as well as identify the factors independently associated with the condition.
METHODS This retrospective study involved patients who were admitted to the rehabilitation ward of our institute due to an acute stroke between 1 August 2010 and 31 July 2011. The main outcome measured was the incidence of poststroke constipation, defined as the use of laxative after stroke, fulfilment of the Rome II diagnostic criteria for functional constipation and/or stool impaction. The variables examined were basic demographic data, presence of impairment, degree of disability (evaluated using the Barthel index), walking ability, medications taken and medical complications.
RESULTS Out of the 155 patients who met the inclusion criteria, 123 (79.4%) had poststroke constipation. All 123 patients used oral laxatives; 56 received additional rectal medications and 13 discontinued their use of laxatives at discharge. Patients with poststroke constipation were more likely to have major medical complications (p = 0.04). Those who used rectal medications had a higher risk of major medical complications than those who used only oral laxatives (p < 0.01). Infratentorial lesions were an independent predictor of poststroke constipation (p = 0.003). More severe disability increased the severity of constipation, as indicated by the use of rectal medication.
CONCLUSION Poststroke constipation is a common complication during inpatient rehabilitation. Healthcare providers should be aware of the incidence of poststroke constipation. Further studies are required to establish standard guidelines for screening and managing bowel function in patients with stroke. 

Keywords: constipation, incidence, medications, risk factors, stroke
Singapore Med J 2013; 54(11): 624-629; http://dx.doi.org/10.11622/smedj.2013222

REFERENCES

Joethy J, Sebastin SJ, Chong KS, Peng YP, Puhaindran ME
Correspondence: Dr Mark E Puhaindran, Mark_E_Puhaindran@nuhs.edu.sg

ABSTRACT
INTRODUCTION Early debridement and coverage has long been regarded as the standard of care for open fractures of the lower limb, as infection is a serious complication. However, the best time for wound closure remains controversial. Negative-pressure wound therapy (NPWT) is thought to result in reduced flap infection and failure. To determine the effect of NPWT, we reviewed patients with open fractures of the lower limb and compared the rates of infection and flap failure in two time-based cohorts.
METHODS Two cohorts of patients (periods 2003–2004 and 2008–2009) with Gustilo type IIIB open tibial fractures were recruited and their outcomes were compared. In the 2003–2004 cohort, wounds were dressed with occlusive dressing. In the 2008–2009 cohort, all patients underwent NPWT. Data was retrospectively analysed with regard to infection, failure, age, type of flap, comorbidities and defect size. The incidences of infection and flap failure were further analysed for any statistical difference between the different treatment protocols.
RESULTS In the 2003–2004 cohort, 33% of patients developed infection and 11% had flap failure. However, in the 2008–2009 cohort, 10% of patients developed infection and 6% had flap failure. The difference in the incidence of infection was statistically significant between the two cohorts (p = 0.029).
CONCLUSION Patients in the 2008–2009 cohort had better outcomes, and we are of the opinion that performing NPWT may have contributed to this result.

Keywords: free flap, negative-pressure wound therapy, occlusive dressing, open tibial fractures, vacuum-aided closure
Singapore Med J 2013; 54(11): 620-623; http://dx.doi.org/10.11622/smedj.2013221

REFERENCES

Ng A, Chew I, Narasimhalu K, Kandiah N
Correspondence: Dr Nagaendran Kandiah, Nagaendran_Kandiah@nni.com.sg

ABSTRACT
INTRODUCTION Mild cognitive impairment (MCI) is an important clinical entity with significant management implications. However, traditional screening tools lack the sensitivity needed to detect amnestic MCI (MCI-A). Montreal Cognitive Assessment (MoCA) has yet to be validated for the diagnosis of MCI in a multiracial society such as Singapore. We thus aimed to study the effectiveness of MoCA for the diagnosis of MCI-A in the Singapore population.
METHODS Data on patients with MCI-A and mild Alzheimer’s disease (AD) was obtained from a prospectively collected clinical database between January 2008 and January 2011. Patients with no cognitive impairment (NCI) were recruited from among the spouses and friends of patients attending the memory clinic.
RESULTS There were a total of 212 participants (103 NCI, 49 MCI-A, 60 mild AD). For the diagnosis of MCI-A, a MoCA score of < 26 for patients with ≤ 10 years of education, and a score of < 27 for patients with > 10 years of education provided a sensitivity of > 94%. For the diagnosis of mild AD, a MoCA score of < 24 for patients with ≤ 10 years of education, and a score of < 25 for patients with > 10 years of education provided a sensitivity of > 85%.
CONCLUSION In the Singapore population, we recommend cutoff scores of 26/27 and 24/25 be used to detect MCI-A and mild AD, respectively, when using MoCA. For patients with ≤ 10 years of education, a +1 point correction is needed.

Keywords: dementia, mild Alzheimer’s disease, mild cognitive impairment, neuropsychological assessment
Singapore Med J 2013; 54(11): 616-619; http://dx.doi.org/10.11622/smedj.2013220

REFERENCES

Justine M, Azizan A, Hassan V, Salleh Z, Manaf H
Correspondence: Dr Maria Justine, mar_physio@yahoo.com

ABSTRACT
INTRODUCTION Although the  benefits  of physical activity and exercise are  widely acknowledged,  many middleaged and elderly individuals remain sedentary. This cross-sectional study aimed to identify the external and internal barriers to physical activity and exercise participation among middle-aged and elderly individuals, as well as identify any differences in these barriers between the two groups.
METHODS Recruited individuals were categorised into either the middle-aged (age 45–59 years, n = 60) or elderly (age ≥ 60 years, n = 60) group. Data on demographics, anthropometry, as well as external and internal barriers to participation in physical activity and exercise were collected.
RESULTS Analysis showed no significant differences in the total scores of all internal barriers between the two groups (p > 0.05). The total scores for most external barriers between the two groups also showed no significant differences (p > 0.05); only ‘cost’ (p = 0.045) and ‘exercise interferes with social/family activities’ (p = 0.011) showed significant differences. The most common external barriers among the middle-aged and elderly respondents were ‘not enough time’ (46.7% vs. 48.4%), ‘no one to exercise with’ (40.0% vs. 28.3%) and ‘lack of facilities’ (33.4% vs. 35.0%). The most common internal barriers for middle-aged respondents were ‘too tired’ (48.3%), ‘already active enough’ (38.3%), ‘do not know how to do it’ (36.7%) and ‘too lazy’ (36.7%), while those for elderly respondents were ‘too tired’ (51.7%), ‘lack of motivation’ (38.4%) and ‘already active enough’ (38.4%).
CONCLUSION Middle-aged  and  elderly  respondents  presented  with  similar  external  and  internal  barriers  to physical activity and exercise participation. These factors should be taken into account when healthcare policies are  being  designed  and  when interventions such as the provision of facilities to promote physical activity and exercise among older people are being considered.

Keywords: barrier, elderly, exercise, middle-aged, physical activity
Singapore Med J 2013; 54(10): 581-586; http://dx.doi.org/10.11622/smedj.2013203

REFERENCES

Chin LF, Wang J, Ong CH, Lee WK, Kong KH
Correspondence: Ms Chin Lay Fong, lay_fong_chin@ttsh.com.sg

ABSTRACT
INTRODUCTION This study aimed to investigate the factors affecting the incidence of falls among individuals with stroke living in the community one year after discharge from a rehabilitation hospital in Singapore.
METHODS A cross-sectional telephone survey of individuals with stroke living in the community was carried out one year after discharge. The interview covered aspects such as incidence and circumstances of fall, use of walking aids, and presence of environmental obstacles. Each participant’s case record was retrospectively reviewed using discharge Fugl-Meyer (FM) assessment of the upper and lower limbs, functional independence measure (FIM) and Berg Balance Scale (BBS).
RESULTS A total of 126 individuals with stroke were interviewed. Overall, 24% fell in the year following their discharge. Factors associated with falls were longer length of hospital stay, lower BBS and lower-limb FM scores, and lower discharge FIM scores for the Bladder and Bowel Management, Transfer, Mobility, Communication, and Social Cognition domains (p < 0.05). The fallers were more likely to use walking aids, and required help with basic activities of daily living after discharge (p < 0.05). Multivariate logistic regression analysis revealed that only the Transfer domain was an independent factor for falls.
CONCLUSION Discharge FIM outcomes, especially for the Transfer domain, can be used to identify communitydwelling individuals with stroke who have a high fall risk after discharge. Identification of such individuals will enable early fall prevention management, which will in turn minimise fall events in the community.

Keywords: community, discharge, falls, stroke
Singapore Med J 2013; 54(10): 569-575; http://dx.doi.org/10.11622/smedj.2013202

REFERENCES

Low MH, Yeo SJ, Chin PL, Chia SL, Lo NN, Tay KJ
Correspondence: Dr Low Mun Hon, mhlow1@gmail.com

ABSTRACT
INTRODUCTION There is considerable controversy regarding the best method to prevent venous thromboembolism. In 2008, the American College of Chest Physicians (ACCP) published specific guidelines recommending the use of  ow-molecular-weight  heparin or warfarin, and a target international normalised ratio of 2.0–3.0 for a duration of at least 7–10 days, after elective knee arthroplasties. Many orthopaedic surgeons believe that these recommendations  are biased toward reducing deep venous thrombosis (DVT), but neglect the implicated possibility of a higher incidence of wound complications. In order to enable an objective evaluation of the fit of the ACCP recommendations to the needs of our local cohort of patients, we aimed to look at the incidence of DVT in our local population.
METHODS This study was a prospective observational study involving existing local patients in Singapore General Hospital,  Singapore, who underwent total knee arthroplasty (TKA) and were on a short course of chemothromboprophylaxis (< 7 days) after the operation. The incidence of DVT in patients was evaluated using DVT imaging 4–6 days after the operation and at one month after the operation.
RESULTS In our study cohort, the prevalence of DVT during the period between postoperative Days 4 and 6 was 12% (11% were distal DVT and 1% was proximal DVT). Only 9% of the patients had DVT one month after the operation. Using  chi-square  analysis, we found that there was no significant increase in the  number of DVT and pulmonary embolism cases 4–6 days and 1 month after the operation (p > 0.05).
CONCLUSION Contrary to the ACCP guidelines, a short course of chemothromboprophylaxis post TKA, lasting no more than 7 days, is safe and adequate in the low-risk Asian population.

Keywords: Asians, deep venous thrombosis, deep venous thrombosis incidence, deep venous thrombosis prophylaxis, total knee arthroplasty
Singapore Med J 2013; 54(10): 560-563; http://dx.doi.org/10.11622/smedj.2013200

REFERENCES

Lee KH, Soeharno H, Chew CP, Lie Denny TT
Correspondence: Dr Denny Tjiauw Tjoen Lie, denny.lie.t.t@sgh.com.sg

ABSTRACT
INTRODUCTION This study aimed to evaluate the two-year clinical outcomes of arthroscopic Bankart repair augmented by plication of the inferior glenohumeral ligament (IGHL) via horizontal mattress suturing.
METHODS This study was a retrospective analysis of 76 arthroscopic Bankart repairs by a single surgeon from 2004 to 2008. Bioabsorbable suture anchors were used, with anchors placed at the 5:30, 4 and 3 o’clock positions of the right shoulder (correspondingly at the 6:30, 8 and 9 o’clock positions for the left shoulder). The lower most anchor was tied via horizontal mattress suture with plication of the IGHL, while the remaining two anchors were tied using simple sutures. The patients were postoperatively assessed, clinically and using the University of California Los Angeles (UCLA) shoulder rating scale.
RESULTS The mean age of the patients at the time of presentation was 24.09 ± 7.98 years, and the mean duration of follow-up was 28.7 months. The postoperative recurrence rate of dislocation was 7.89% (six shoulders), of which five shoulders required revision surgeries. Excluding the revision cases, clinical assessment of the strength of the supraspinatus and the range of motion of the operated shoulders at two years post operation were either maintained or full in all  patients. Analysis of the UCLA results showed pre- and postoperative mean scores of 25.94 ± 3.43 and 33.77 ± 3.07, respectively (p < 0.05).
CONCLUSION Arthroscopic Bankart repair augmented by plication of the IGHL and anchored via horizontal mattress suturing is a safe and reliable treatment for shoulder instability, with good clinical outcomes and low recurrence rates.

Keywords: arthroscopic Bankart repair, horizontal mattress suture, inferior glenohumeral ligament, traumatic shoulder instability
Singapore Med J 2013; 54(10): 555-559; http://dx.doi.org/10.11622/smedj.2013199

REFERENCES

Loh C, Teo YW, Lim L
Correspondence: Dr Cheryl Loh, Cheryl_loh@cgh.com.sg

ABSTRACT
INTRODUCTION Deliberate self-harm (DSH) is frequently seen in adolescents with a range of mental health problems. The prevalence and features of DSH vary among different countries and settings. This study examines the prevalence of self-harm in a sample of adolescents seen at a psychiatric outpatient clinic in Singapore.
METHODS Information regarding self-harm, as well as its associated demographic and clinical risk factors, was extracted from the clinical records of 542 consecutive, new patients, aged 12–19 years, who presented between 2006 and 2010.
RESULTS DSH was reported in 23.6% of patients, and was positively associated with the female gender (odds ratio [OR] 4.54), mood disorders (OR 4.58), adjustment disorders (OR 3.41) and regular alcohol use (OR 4.80). However, there was no association with parental marital status, anxiety disorder, habitual smoking or family history of psychiatric illness.
CONCLUSION DSH is a significant clinical problem that may be influenced by biological and clinical factors. Adolescents presenting with DSH should be examined for mood and alcohol use disorders.

Keywords: adolescent outpatients, deliberate self-harm
Singapore Med J 2013; 54(9): 491-495; http://dx.doi.org/10.11622/smedj.2013170

REFERENCES