Singapore medical journal最新文献

Introduction: Thromboelastography (TEG) provides a global assessment of haemostasis and is potentially applicable to liver disease. The present study aimed to explore the utility of TEG for the evaluation of patients with chronic viral liver disease, which has previously not been investigated.

Methods: Demographic characteristics and TEG parameters were collected before surgery. Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were used to categorise stages of liver cirrhosis. Liver resections were classified as low, medium and high complexity.

Results: A total of 344 patients were included. Results showed significantly longer K-time, smaller α-angle and lower maximum amplitude (MA) with increasing liver disease severity as measured by the CTP and MELD scores ( P < 0.05 for all). After multivariable adjustment (including age, sex, liver disease aetiology, alanine aminotransferase [ALT], aspartate aminotransferase [AST], albumin, total bilirubin, haemoglobin and platelet count), TEG parameters (except R-times) were either weakly or inversely related to the severity of liver disease as defined by the MELD score (absolute r < 0.2 and P < 0.05 for all except R-times). R-times obtained before surgery were weakly correlated with perioperative blood loss ( r < 0.2 and P < 0.05 for all).

Conclusions: The correlation between TEG parameters and severity of liver disease was weak. In addition, R-times obtained before liver resection were weakly associated with perioperative blood loss after multivariable adjustments. TEG utility for haemostasis assessment and prediction of blood loss during liver resection should be further explored in high-quality studies.

Introduction: Chronic kidney disease-mineral and bone disease (CKD-MBD) is a complication of chronic kidney disease (CKD) involving derangements in serum calcium and phosphate. This study aims to evaluate hypo- and hypercalcaemia and their associated outcomes among pre-dialysis CKD patients.

Methods: A retrospective cohort study was performed and included all adult CKD stage 4-stage 5 patients who were on treatment for CKD-MBD between 2016 and 2017. Each patient was followed up for 3 years. Hypo- and hypercalcaemia were defined as serum corrected calcium (Ca 2+ ) <2.10 and >2.46 mmol/L, respectively. Outcomes evaluated included all-cause mortality and cardiovascular events. Multivariate Cox regression analysis was done to evaluate the association of hypocalcaemia and/or hypercalcaemia with the clinical outcomes. Severity of hypocalcaemia episode was classified as 'mild' (Ca 2+ : between 1.90 and 2.10 mmol/L) and 'severe' (Ca 2+ : <1.90 mmol/L). Severity of hypercalcaemia was classified as 'mild' (Ca 2+ : between 2.47 and 3.00 mmol/L), moderate (Ca 2+ : between 3.01 and 3.50 mmol/L) and severe (Ca 2+ : >3.50 mmol/L).

Results: Of the 400 patients, 169 (42.2%) and 94 (23.5%) patients experienced hypocalcaemia and hypercalcaemia, respectively. Severe hypocalcaemia was more prevalent in CKD stage 5 compared to CKD stage 4 (96 [40.5%] vs. 36 [25.9%], P = 0.004). Results from multivariate analyses after adjustment showed that hypocalcaemia and/or hypercalcaemia were not associated with all-cause mortality ( P > 0.05) or the occurrence of cardiovascular events ( P > 0.05).

Conclusion: Hypocalcaemia and hypercalcaemia episodes were prevalent among pre-dialysis CKD patients. Studies with longer follow-up durations are required to assess the effects of calcium derangements on clinical outcomes.

Introduction: Data on heart failure (HF) with mildly reduced ejection fraction (HFmrEF) is still emerging, especially in Asian populations. This study aims to compare the clinical characteristics and outcomes of Asian HFmrEF patients with those of HF patients with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).

Methods: Patients admitted nationally for HF between 2008 and 2014 were included in the study. They were categorised according to ejection fraction (EF). Patients with EF <40%, EF 40%-49% and EF ≥50% were categorised into the following groups: HFrEF, HFmrEF and HFpEF, respectively. All patients were followed up till December 2016. Primary outcome was all-cause mortality. Secondary outcomes included cardiovascular death and/or HF rehospitalisations.

Results: A total of 16,493 patients were included in the study - HFrEF, n = 7,341 (44.5%); HFmrEF, n = 2,272 (13.8%); and HFpEF n = 6,880 (41.7%). HFmrEF patients were more likely to be gender neutral, of mid-range age and have concomitant diabetes mellitus, hyperlipidaemia, peripheral vascular disease and coronary artery disease ( P < 0.001). The two-year overall mortality rates for HFrEF, HFmrEF and HFpEF were 32.9%, 31.8% and 29.1%, respectively. HFmrEF patients had a significantly lower overall mortality rate compared to HFrEF patients (adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.83-0.95; P < 0.001) and a significantly higher overall mortality rate (adjusted HR 1.25, 95% CI 1.17-1.33; P < 0.001) compared to HFpEF patients. This was similarly seen with cardiovascular mortality and HF hospitalisations, with the exception of similar HF hospitalisations between HFmrEF and HFpEF patients.

Conclusion: HFmrEF patients account for a significant burden of patients with HF. HFmrEF represents a distinct HF phenotype with high atherosclerotic burden and clinical outcomes saddled in between those of HFrEF and HFpEF. Further therapeutic studies to guide management of this challenging group of patients are warranted.

Introduction: Nurturing professional identities instils behavioural standards of physicians, and this in turn facilitates consistent professional attitudes, practice and patient care. Identities are socioculturally constructed efforts; therefore, we must account for the social, cultural and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aimed to forward a programme to nurture professionalism among physicians in Singapore.

Methods: A three-phase, evidenced-based approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created based on the findings of the SSR. Third, a modified Delphi approach, which involved local experts to identify socioculturally appropriate elements to nurture professionalism, was used.

Results: A total of 124 articles were identified from the SSR; these articles revealed definitions, knowledge, skills and approaches to nurturing professionalism. Through the modified Delphi approach, we identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

Conclusion: The results of this study formed the basis for a holistic and longitudinal programme focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. The findings will be of interest to medical communities in the region and beyond.

Introduction: During the last decade, measles has become an important re-emerging disease in Thailand. The objective of this study was to measure measles seroprevalence and its influencing factors so as to plan an improved vaccination programme.

Methods: A total of 600 participants aged between 9 months and 50 years were divided into seven groups representing birth cohorts that experienced different measles vaccination policies. Participants' blood samples were obtained to measure measles immunoglobulin G (IgG) levels.

Results: None of the participants in the age group of 9 months had measles IgG levels beyond a protective level. Participants in the age groups 2.5, 5-15, 16-29, 30-33, 34-40 and 41-50 years had 82% (95% confidence interval [CI] 73.3-90.7), 50% (95% CI 36.1-63.9), 52% (95% CI 42.3-62.7), 70% (95% CI 61.1-78.9), 88.8% (95% CI 84.1-93.5) and 98.8% (95% CI 96.4-100.0) measles seropositivity, respectively. The study did not find any significant factors affecting measles seropositivity.

Conclusion: Individuals aged 15-34 years are vulnerable to measles infections. Supplementary vaccination should be encouraged in special situations, including postexposure prophylaxis for young adults during an outbreak and for high-risk occupations such as healthcare personnel.

Introduction: Host immune responses may impact dengue severity in adults. Vitamin D has multiple immunomodulatory effects on innate and adaptive immunity.

Methods: We evaluated the association between systemic 25-hydroxyvitamin D [25-(OH) D] and dengue disease severity in adults. We measured plasma for total 25-(OH) D levels with an electrochemiluminescence immunoassay using stored samples from participants with laboratory-confirmed dengue, who were prospectively enrolled in 2012-2016 at our institution.

Results: A total of 80 participants (median age 43 years) were enrolled in the study. Six participants had severe dengue based on the World Health Organization (WHO) 1997 criteria (i.e. dengue haemorrhagic fever/dengue shock syndrome) and another six had severe dengue based on the WHO 2009 criteria. Median 25-(OH) D at the acute phase of dengue was 6.175 (interquartile range 3.82-8.21, range 3.00-15.29) mcg/L in all participants. The 25-(OH) D showed an inverse linear trend with severe dengue manifestations based on the WHO 2009 criteria (adjusted risk ratio 0.72, 95% confidence interval 0.57-0.91, P < 0.01) after adjustment for age, gender and ethnicity.

Conclusion: Limited studies have evaluated the role of systemic 25-(OH) D on dengue severity. Our study found low systemic 25-(OH) D was associated with increased dengue disease severity, particularly for severe bleeding that was not explained by thrombocytopenia. Further studies investigating the underlying immune mechanisms and effects on the vascular endothelium are needed.

Introduction: The experience and perception of pain may vary among individuals.This prospective cohort study aimed to determine the impact of injection pain/withdrawal movement of propofol and rocuronium in the induction of anaesthesia on postoperative pain outcomes in gynaecological laparoscopic surgery.

Methods: A total of 100 patients aged 19-60 years received propofol and rocuronium injections for the induction of anaesthesia. The incidence of propofol injection pain (PIP) and rocuronium-induced withdrawal movement (RIWM), postoperative pain scores and total opioid consumption were evaluated, and the associations between PIP/RIWM and postoperative pain outcomes were determined.

Results: Visual analogue scale (VAS) for pain after surgery and total opioid consumption after surgery were significantly higher in patients with PIP or RIWM than in patients without PIP or RIWM. The correlations of PIP/RIWM with VAS at 1 h, VAS at 24 h and total opioid consumption were significant and weakly positive ( r = 0.249, r = 0.234, r = 0.22 and r = 0.234, respectively). The RIWM correlated more positively with pain score compared to PIP at 1 h ( r = 0.408 vs. r = 0.234), PIP at 24 h ( r = 0.398 vs. r = 0.227) and with total opioid consumption for 48 h after surgery ( r = 0.457 vs. r = 0.234).

Conclusion: During anaesthesia induction, the occurrence of PIP and RIWM may predict the severity of postoperative pain and total opioid consumption, with RIWM emerging as a stronger predictor than PIP.