Pub Date : 2023-11-29DOI: 10.4103/singaporemedj.smj-2022-062
Denise Elizabeth Shi Yun Teo, Valerie Wei Ling Teong, R. Ramachandran, Su Lin Lim, Charlotte Xianghui Lin
Eating disorders (EDs) are debilitating mental illnesses that can lead to significant medical complications from malnutrition. Eating disorders are on the rise in Asia and the prevalence is expected to increase. The aim of this study was to understand the characteristics of local patients and evaluate our current inpatient nutritional rehabilitation protocol for anorexia nervosa (AN). Retrospective descriptive data were gathered from 47 patients diagnosed with AN. Patients with admissions were further stratified according to their nutritional management based on whether they were on the AN protocol or standard hospital care. Data on their rate of weight gain, length of stay and calorie prescription were collected. Similar to previous studies, the majority of AN patients were female (96.7%). However, the age at presentation of AN in this study, as compared with previous local studies, had decreased (14 vs. 16 years). We also found that patients on the AN protocol were prescribed a higher amount of calories than those given standard care (2,700 vs. 2,317 calories). Patients on the AN protocol achieved a higher rate of weight gain per week (1.15 vs. 0.29 kg) and had a shorter length of hospital stay (23 vs. 36 days). Patients with AN appear to be presenting at a younger age. Medical stabilisation of AN patients can be achieved more quickly through a higher calorie inpatient AN treatment protocol. Future local studies examining actual calorie consumption, its effect on weight gain trajectory, severity of refeeding syndrome and time to remission will be beneficial.
进食障碍（ED）是一种使人衰弱的精神疾病，可因营养不良而导致严重的医疗并发症。饮食失调症在亚洲呈上升趋势，预计发病率还会增加。本研究旨在了解本地患者的特点，并评估我们目前针对神经性厌食症（AN）的住院营养康复方案。 研究收集了47名被诊断为厌食症患者的回顾性描述数据。根据入院患者是接受厌食症方案治疗还是接受标准医院护理，对他们的营养管理进行了进一步分层。研究还收集了体重增加率、住院时间和卡路里处方等数据。 与之前的研究相似，大多数 AN 患者为女性（96.7%）。不过，与之前的本地研究相比，本研究中 AN 患者的发病年龄有所下降（14 岁对 16 岁）。我们还发现，与接受标准治疗的患者相比，接受 AN 方案治疗的患者获得的热量更高（2,700 卡路里对 2,317 卡路里）。AN 方案的患者每周体重增加率更高（1.15 千克对 0.29 千克），住院时间更短（23 天对 36 天）。 AN患者的发病年龄似乎越来越小。通过高热量的AN住院治疗方案，可以更快地稳定AN患者的病情。未来对实际卡路里消耗量、其对体重增加轨迹的影响、反食综合征的严重程度以及缓解时间进行本地研究将是有益的。
{"title":"Characteristics and outcome of patients with anorexia nervosa on medical nutritional therapy: an institutional study with review of literature","authors":"Denise Elizabeth Shi Yun Teo, Valerie Wei Ling Teong, R. Ramachandran, Su Lin Lim, Charlotte Xianghui Lin","doi":"10.4103/singaporemedj.smj-2022-062","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-062","url":null,"abstract":"Eating disorders (EDs) are debilitating mental illnesses that can lead to significant medical complications from malnutrition. Eating disorders are on the rise in Asia and the prevalence is expected to increase. The aim of this study was to understand the characteristics of local patients and evaluate our current inpatient nutritional rehabilitation protocol for anorexia nervosa (AN). Retrospective descriptive data were gathered from 47 patients diagnosed with AN. Patients with admissions were further stratified according to their nutritional management based on whether they were on the AN protocol or standard hospital care. Data on their rate of weight gain, length of stay and calorie prescription were collected. Similar to previous studies, the majority of AN patients were female (96.7%). However, the age at presentation of AN in this study, as compared with previous local studies, had decreased (14 vs. 16 years). We also found that patients on the AN protocol were prescribed a higher amount of calories than those given standard care (2,700 vs. 2,317 calories). Patients on the AN protocol achieved a higher rate of weight gain per week (1.15 vs. 0.29 kg) and had a shorter length of hospital stay (23 vs. 36 days). Patients with AN appear to be presenting at a younger age. Medical stabilisation of AN patients can be achieved more quickly through a higher calorie inpatient AN treatment protocol. Future local studies examining actual calorie consumption, its effect on weight gain trajectory, severity of refeeding syndrome and time to remission will be beneficial.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139214997","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-29DOI: 10.4103/singaporemedj.smj-2023-008
Jie Lin Soong, Hui Wen Ho, Leng Chuan Goh, Jiun Yu Christina Tan, Deborah Chia, Jun Long Marvin Sim
Polypharmacy is associated with increased prevalence of potentially inappropriate medications (PIMs), leading to higher risk of adverse drug events and medication errors. This study was the first multicentre cross-sectional study in Singapore that determined the prevalence of polypharmacy, its associated factors and the common drug classes involved, and evaluated prescribing appropriateness of drugs used by older adults. The prescriptions on two randomly selected days from five acute care hospitals and primary care polyclinics were retrospectively reviewed. Patients’ demographic characteristics, number of prescription line items and details of prescribed drugs were collected. Prescribing appropriateness was evaluated by identifying PIMs using the Beers Criteria. Logistic regression was used to assess the association of demographic characteristics and type of care setting with polypharmacy and PIM use. Prevalence of polypharmacy was significantly higher in hospitals than in polyclinics (66.6% vs. 35.0%, P < 0.001). On the contrary, prevalence of PIMs in older adults with polypharmacy was significantly higher in polyclinics than in hospitals (34.6% vs. 27.1%, P = 0.010). Patients aged ≥65 years and hospitalised patients had higher odds of having polypharmacy than patients aged 21–64 years and polyclinic patients, respectively. Drugs used for chronic conditions commonly contributed to polypharmacy in both care settings. The top PIMs in hospitals and polyclinics were drugs for functional gastrointestinal disorders and systemic antihistamines, respectively. With the ageing population and growing burden of chronic disease in Singapore, increase in prevalence of polypharmacy is expected. More focus should thus be placed on reducing inappropriate polypharmacy.
{"title":"Prevalence of polypharmacy: a cross-sectional study in Singapore public healthcare institutions","authors":"Jie Lin Soong, Hui Wen Ho, Leng Chuan Goh, Jiun Yu Christina Tan, Deborah Chia, Jun Long Marvin Sim","doi":"10.4103/singaporemedj.smj-2023-008","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2023-008","url":null,"abstract":"Polypharmacy is associated with increased prevalence of potentially inappropriate medications (PIMs), leading to higher risk of adverse drug events and medication errors. This study was the first multicentre cross-sectional study in Singapore that determined the prevalence of polypharmacy, its associated factors and the common drug classes involved, and evaluated prescribing appropriateness of drugs used by older adults. The prescriptions on two randomly selected days from five acute care hospitals and primary care polyclinics were retrospectively reviewed. Patients’ demographic characteristics, number of prescription line items and details of prescribed drugs were collected. Prescribing appropriateness was evaluated by identifying PIMs using the Beers Criteria. Logistic regression was used to assess the association of demographic characteristics and type of care setting with polypharmacy and PIM use. Prevalence of polypharmacy was significantly higher in hospitals than in polyclinics (66.6% vs. 35.0%, P < 0.001). On the contrary, prevalence of PIMs in older adults with polypharmacy was significantly higher in polyclinics than in hospitals (34.6% vs. 27.1%, P = 0.010). Patients aged ≥65 years and hospitalised patients had higher odds of having polypharmacy than patients aged 21–64 years and polyclinic patients, respectively. Drugs used for chronic conditions commonly contributed to polypharmacy in both care settings. The top PIMs in hospitals and polyclinics were drugs for functional gastrointestinal disorders and systemic antihistamines, respectively. With the ageing population and growing burden of chronic disease in Singapore, increase in prevalence of polypharmacy is expected. More focus should thus be placed on reducing inappropriate polypharmacy.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139209552","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-10DOI: 10.4103/singaporemedj.smj-2023-227
Efsun Somay, Busra Yilmaz, Erkan Topkan, Ugur Selek
Dear Sir, We found the article ‘Carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy: a retrospective analysis of treatment outcomes’ by Babu et al.[1] intriguing and informative.[1] The study shows that hypofractionated accelerated radiotherapy (HART) is effective in buccal mucosa carcinoma (BMC) patients. We wish to highlight two concerns, which we hope the authors can address and in so doing, contribute to future studies. First, although osteoradionecrosis of the jaw (ORNJ) is typically defined as exposed irradiated bone that fails to heal within 3–6 months without local tumour recurrence or proven metastasis,[2] the study by Babu et al.[1] had a follow-up period ranging from 1 to 134 months, emphasising that some patients require additional follow-up time to meet ORNJ definition since the lower margin was only 1 month. Hence, the presented data may have underrated ORNJ rates, which may be higher than 10.3%. Consequently, given the universally accepted definition of ORNJ,[2,3] it could be posited that implementing a time cut-off of no less than 6 months would likely result in the identification of substantially higher ORNJ rates. Second, despite radiation-induced trismus (RIT) being a more common complication of radiotherapy than ORNJ, no data is provided on its incidence in this high-risk patient population.[4,5] However, it is impossible to spare all the components of the masticatory apparatus when designing a two-dimensional radiotherapy for BMCs. Hence, most patients likely received high doses of radiation for the masticatory apparatus components. Concerning the potential of HART for severe complication risks, providing RIT-related outcomes may be valuable in determining the exact value of HART in such patients, which may aid in improving patient outcomes and future study designs in this field. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
{"title":"Comments on: Carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy: a retrospective analysis of treatment outcomes","authors":"Efsun Somay, Busra Yilmaz, Erkan Topkan, Ugur Selek","doi":"10.4103/singaporemedj.smj-2023-227","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2023-227","url":null,"abstract":"Dear Sir, We found the article ‘Carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy: a retrospective analysis of treatment outcomes’ by Babu et al.[1] intriguing and informative.[1] The study shows that hypofractionated accelerated radiotherapy (HART) is effective in buccal mucosa carcinoma (BMC) patients. We wish to highlight two concerns, which we hope the authors can address and in so doing, contribute to future studies. First, although osteoradionecrosis of the jaw (ORNJ) is typically defined as exposed irradiated bone that fails to heal within 3–6 months without local tumour recurrence or proven metastasis,[2] the study by Babu et al.[1] had a follow-up period ranging from 1 to 134 months, emphasising that some patients require additional follow-up time to meet ORNJ definition since the lower margin was only 1 month. Hence, the presented data may have underrated ORNJ rates, which may be higher than 10.3%. Consequently, given the universally accepted definition of ORNJ,[2,3] it could be posited that implementing a time cut-off of no less than 6 months would likely result in the identification of substantially higher ORNJ rates. Second, despite radiation-induced trismus (RIT) being a more common complication of radiotherapy than ORNJ, no data is provided on its incidence in this high-risk patient population.[4,5] However, it is impossible to spare all the components of the masticatory apparatus when designing a two-dimensional radiotherapy for BMCs. Hence, most patients likely received high doses of radiation for the masticatory apparatus components. Concerning the potential of HART for severe complication risks, providing RIT-related outcomes may be valuable in determining the exact value of HART in such patients, which may aid in improving patient outcomes and future study designs in this field. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135191501","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-10DOI: 10.4103/singaporemedj.smj-2021-412
Hui Jun Lim, Lester Chee Hao Leong, Yah Yuen Tan, Eugene Mun Wai Ong, Veronique Kiak Mien Tan, Sue Zann Lim, Evan Kok Yen Woo, Yien Sien Lee, Yirong Sim, Preetha Madhukumar, Benita Kiat Tee Tan, Llewellyn Shao-jen Sim, Tammy Hui Lin Moey, Thida Win, Geok Hoon Lim
INTRODUCTION Hookwires are commonly deployed under imaging guidance to localise non-palpable breast lesions for excision. However, the use of hookwires has some disadvantages, including patient discomfort, wire migration, damage to surrounding anatomical structures, surgery scheduling inconveniences and limited access to axillary nodes. Novel, alternative, non-radioactive wireless localisation devices using technologies such as radiofrequency identification, magnetic seed and radar have been developed to address these shortcomings.[1,2] While these devices have seen increasing usage in America and Europe, they were introduced to Asia only recently. One of these wireless techniques, the Savi Scout® (SS) surgical guidance system (Cianna Medical, Merit Medical Systems, Inc., South Jordan, UT, USA), was made available in Asia in 2019, and Singapore was the first Asian country to utilise it for breast and axillary localisations. Savi Scout employs radar technology, and it received the United States Food and Drug Administration clearance in 2014. The SS consists of a reflector implant, a needle introducer and an external check console. The reflector is a 12-mm metallic implant [Figure 1] consisting of thin nitinol antennae protruding from either end of a central transistor body. It is inserted percutaneously into the soft tissue via a single-use, preloaded, 16-gauge needle introducer and is deployed by uncovering the overlying sheath at the distal end of the introducer. This passive reflector delivery mechanism prevents damage to the thin antennae. The introducer is unsheathed by first unlocking the release button to either left or right and then retracting it along a sliding track [Figure 1]. Once the reflector is deployed, it cannot be repositioned. A handheld probe connected to the check console is used to locate the deployed reflector by transmitting a radio wave signal (radar), which is received and reflected back by the reflector. The signal capture and reflection mechanism of the reflector is multidirectional and is used to guide direction and distance to the target up to a depth of 6 cm. Unlike hookwires, SS does not have any components protruding from the skin. In addition, there is no placement expiry after deployment and it can be deployed at any time before surgery day, which provides flexibility in procedural scheduling.Figure 1: Photograph shows the parts and functions of the Savi Scout® needle introducer system and the 12-mm-long reflector (inset).Studies from America and Europe have evaluated SS to be a safe and convenient localisation technique for the breast and axilla.[3-8] However, to the best of our knowledge, there have been no published reports evaluating its performance in Asian women, and it is unclear if dense breast tissue, which is more prevalent in Asian women, may affect SS deployment and signal detection. We described our experience in the initial use of SS in Singapore women with the aims of providing an assessment on it
通常在影像学指导下使用钩线定位不可触及的乳腺病变进行切除。然而，使用钩丝有一些缺点，包括患者不适、丝移位、破坏周围解剖结构、手术安排不便和限制进入腋窝淋巴结。使用诸如射频识别、磁种子和雷达等技术的新颖、替代、非放射性无线定位设备已经被开发出来以解决这些缺点。[1,2]虽然这些设备在美国和欧洲的使用越来越多，但它们最近才被引入亚洲。其中一种无线技术是Savi Scout®(SS)手术引导系统(Cianna Medical, Merit Medical Systems, Inc.， South Jordan, UT, USA)，于2019年在亚洲推出，新加坡是第一个将其用于乳房和腋窝定位的亚洲国家。Savi Scout采用雷达技术，并于2014年获得了美国食品和药物管理局的批准。SS由一个反射器植入，一个针头导入器和一个外部检查控制台组成。反射器是一个12毫米的金属植入物[图1]，由从中央晶体管体的两端伸出的薄镍钛诺天线组成。它通过一次性使用的，预加载的，16号针头导入器经皮插入软组织，并通过揭开导入器远端覆盖的鞘来部署。这种被动反射器传送机制可以防止对薄天线的损坏。首先将释放按钮向左或向右解锁，然后沿着滑动轨道将其收回，即可将介绍器打开[图1]。一旦反射器被部署，它就不能被重新定位。连接到检查台的手持探头通过发射无线电波信号(雷达)来定位部署的反射器，该信号被反射器接收并反射回来。反射器的信号捕获和反射机制是多向的，用于引导目标的方向和距离，深度可达6cm。与钩线不同，SS没有任何从皮肤突出的部件。此外，部署后没有放置期限，可以在手术前的任何时间部署，这为程序调度提供了灵活性。图1:照片显示了Savi Scout®引针系统和12毫米长的反射器的部件和功能(插入)。美国和欧洲的研究已经评价SS是一种安全、方便的乳房和腋窝定位技术。[3-8]然而，据我们所知，目前还没有发表过评估其在亚洲女性中的表现的报告，也不清楚在亚洲女性中更为普遍的致密乳腺组织是否会影响SS的部署和信号检测。我们描述了我们在新加坡妇女中最初使用SS的经验，目的是对其在亚洲妇女中的表现进行评估，并找到优化其使用的方法。方法:这是一项机构性、审查委员会批准的回顾性研究，研究对象是2019年7月至2021年6月在新加坡多个中心接受成像引导SS定位的患者。13名用户对性能进行了评估，其中6名是专门从事乳房成像的放射科医生，7名是乳房外科医生。评估反射镜部署的难易程度、部署时间、部署后信号检测、反射镜损伤发生率、反射镜错位发生率、反射镜迁移发生率、反射镜的放射可见性、术中定位的难易程度、手术回收率、并发症发生率和总体用户满意度。定位错误被定义为反射器的中心位置超过10毫米，从病灶的震中部署。反射器偏移是指从其原始部署位置位移超过10mm。部署时间是引入器进入皮肤和退出皮肤之间的持续时间间隔。评估按无、低/轻度、中度和高/严重4个等级进行分级。使用GraphPad QuickCalcs在线软件(https://www.graphpad.com/quickcalcs/)进行统计检验。使用学生t检验比较连续变量。分类变量的比较采用Fisher精确检验。P < 0.05认为差异有统计学意义。结果40例女性患者共对31个乳腺病变和13个腋窝淋巴结部署44个反射器。另外五名有镍过敏史的妇女的计划部署不得不取消。超声引导下部署反射器38例(86.4%)，乳房x光引导下部署反射器6例(13.6%)。4例(9.1%)乳房放置在新辅助化疗开始前，平均放置时间为184天。 总之，SS在亚洲女性中效果良好，有一些临床益处，但使用者需要意识到它的局限性。我们已经就如何排除故障并优化其使用提出了建议，我们希望我们的早期经验能够帮助亚洲的其他机构在临床实践中实施SS或其他无线定位设备，并应对潜在的挑战。感谢新加坡综合医院研究室的Permeen Akhtar和Mohamed Yusoff博士对本文的编辑和排版提供的帮助。财政支持及赞助无。利益冲突没有利益冲突。
{"title":"Savi Scout® wireless localisation of breast and axillary lesions: lessons learned from Singapore’s early experience","authors":"Hui Jun Lim, Lester Chee Hao Leong, Yah Yuen Tan, Eugene Mun Wai Ong, Veronique Kiak Mien Tan, Sue Zann Lim, Evan Kok Yen Woo, Yien Sien Lee, Yirong Sim, Preetha Madhukumar, Benita Kiat Tee Tan, Llewellyn Shao-jen Sim, Tammy Hui Lin Moey, Thida Win, Geok Hoon Lim","doi":"10.4103/singaporemedj.smj-2021-412","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2021-412","url":null,"abstract":"INTRODUCTION Hookwires are commonly deployed under imaging guidance to localise non-palpable breast lesions for excision. However, the use of hookwires has some disadvantages, including patient discomfort, wire migration, damage to surrounding anatomical structures, surgery scheduling inconveniences and limited access to axillary nodes. Novel, alternative, non-radioactive wireless localisation devices using technologies such as radiofrequency identification, magnetic seed and radar have been developed to address these shortcomings.[1,2] While these devices have seen increasing usage in America and Europe, they were introduced to Asia only recently. One of these wireless techniques, the Savi Scout® (SS) surgical guidance system (Cianna Medical, Merit Medical Systems, Inc., South Jordan, UT, USA), was made available in Asia in 2019, and Singapore was the first Asian country to utilise it for breast and axillary localisations. Savi Scout employs radar technology, and it received the United States Food and Drug Administration clearance in 2014. The SS consists of a reflector implant, a needle introducer and an external check console. The reflector is a 12-mm metallic implant [Figure 1] consisting of thin nitinol antennae protruding from either end of a central transistor body. It is inserted percutaneously into the soft tissue via a single-use, preloaded, 16-gauge needle introducer and is deployed by uncovering the overlying sheath at the distal end of the introducer. This passive reflector delivery mechanism prevents damage to the thin antennae. The introducer is unsheathed by first unlocking the release button to either left or right and then retracting it along a sliding track [Figure 1]. Once the reflector is deployed, it cannot be repositioned. A handheld probe connected to the check console is used to locate the deployed reflector by transmitting a radio wave signal (radar), which is received and reflected back by the reflector. The signal capture and reflection mechanism of the reflector is multidirectional and is used to guide direction and distance to the target up to a depth of 6 cm. Unlike hookwires, SS does not have any components protruding from the skin. In addition, there is no placement expiry after deployment and it can be deployed at any time before surgery day, which provides flexibility in procedural scheduling.Figure 1: Photograph shows the parts and functions of the Savi Scout® needle introducer system and the 12-mm-long reflector (inset).Studies from America and Europe have evaluated SS to be a safe and convenient localisation technique for the breast and axilla.[3-8] However, to the best of our knowledge, there have been no published reports evaluating its performance in Asian women, and it is unclear if dense breast tissue, which is more prevalent in Asian women, may affect SS deployment and signal detection. We described our experience in the initial use of SS in Singapore women with the aims of providing an assessment on it","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135191928","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-10DOI: 10.4103/singaporemedj.smj-2023-228
Geethu Babu, Cessal Thommachan Kainickal
Dear Sir, This is in response to a letter to the editor[1] regarding our article, ‘Carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy: a retrospective analysis of treatment outcomes’.[2] Being a retrospective analysis, our study reported data on morbidity based on the information available in the case files, and this the main limitation of the study. Therefore, this data may have underrated the rates of osteoradionecrosis of the jaw (ORNJ). The minimum follow-up period was reported as 1 month as one patient was lost to follow-up and the data on toxicity of this patient were not captured. In addition, radiation-induced trismus (RIT) is a more common complication of radiotherapy than ORNJ, but no data was provided on its incidence in this high-risk patient population as the data have not been properly documented in the case files. The data regarding acute and late toxicity can be obtained only in a properly designed prospective trial where the patients are closely followed up by the investigator. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
{"title":"Response to comments on: Carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy: a retrospective analysis of treatment outcomes","authors":"Geethu Babu, Cessal Thommachan Kainickal","doi":"10.4103/singaporemedj.smj-2023-228","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2023-228","url":null,"abstract":"Dear Sir, This is in response to a letter to the editor[1] regarding our article, ‘Carcinoma buccal mucosa treated with definitive hypofractionated accelerated radiotherapy: a retrospective analysis of treatment outcomes’.[2] Being a retrospective analysis, our study reported data on morbidity based on the information available in the case files, and this the main limitation of the study. Therefore, this data may have underrated the rates of osteoradionecrosis of the jaw (ORNJ). The minimum follow-up period was reported as 1 month as one patient was lost to follow-up and the data on toxicity of this patient were not captured. In addition, radiation-induced trismus (RIT) is a more common complication of radiotherapy than ORNJ, but no data was provided on its incidence in this high-risk patient population as the data have not been properly documented in the case files. The data regarding acute and late toxicity can be obtained only in a properly designed prospective trial where the patients are closely followed up by the investigator. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135191500","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-10DOI: 10.4103/singaporemedj.smj-2021-341
Weishan Ivy Ng, K. Yuen, Tian Meng, Chee Seong Jeremy Tey, Yu Yang Soon, Cho Hao Francis Ho, S. Yoong, Brent Gibbons, B. Vellayappan
Cancer survivors may experience financial toxicity (FT) arising from diagnosis, treatment and potential employment loss. The prevalence of FT in the context of Singapore healthcare model is unknown. We investigate whether higher out-of-pocket (OOP) expenditure correlates positively with FT, and whether higher FT correlates with a worse quality of life (QoL). In this pilot study, a cross-sectional survey was conducted on survivors of nasopharyngeal or breast cancer at the National University Hospital Singapore. Patients’ FT and QoL were measured using the COmprehensive Score on financial Toxicity (COST) and Functional Assessment of Cancer Therapy-General (FACT-G) questionnaires. Two multivariate regression models estimated (a) the association between FT and a range of variables, and (b) the association between FT and QoL. Sixty-three percent of our cohort of 76 patients experienced mild–moderate FT. Overall, the mean COST and FACT-G scores were 18.0 (out of 44) and 68.3 (out of 108), respectively. There was a positive correlation between COST and FACT-G scores (r = 0.45). We did not find any significant association between OOP expenditure and FT. Predictors for FT included government-subsidised housing, lower education levels, hire of a formal caregiver and the need for household members to take on extra employment. Greater FT correlated with a decline in QoL. Patients of lower socioeconomic status were at higher risk of FT. OOP expenditure was not directed related to FT, likely in view of the effective means-tested subsidies. Additional resources should be considered for this at-risk population. Based on this pilot study, our methodology to quantify FT and OOP expenditure can be scaled up to other cancer primaries.
{"title":"Financial toxicity among adult cancer survivors in Singapore: does it exist?","authors":"Weishan Ivy Ng, K. Yuen, Tian Meng, Chee Seong Jeremy Tey, Yu Yang Soon, Cho Hao Francis Ho, S. Yoong, Brent Gibbons, B. Vellayappan","doi":"10.4103/singaporemedj.smj-2021-341","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2021-341","url":null,"abstract":"Cancer survivors may experience financial toxicity (FT) arising from diagnosis, treatment and potential employment loss. The prevalence of FT in the context of Singapore healthcare model is unknown. We investigate whether higher out-of-pocket (OOP) expenditure correlates positively with FT, and whether higher FT correlates with a worse quality of life (QoL). In this pilot study, a cross-sectional survey was conducted on survivors of nasopharyngeal or breast cancer at the National University Hospital Singapore. Patients’ FT and QoL were measured using the COmprehensive Score on financial Toxicity (COST) and Functional Assessment of Cancer Therapy-General (FACT-G) questionnaires. Two multivariate regression models estimated (a) the association between FT and a range of variables, and (b) the association between FT and QoL. Sixty-three percent of our cohort of 76 patients experienced mild–moderate FT. Overall, the mean COST and FACT-G scores were 18.0 (out of 44) and 68.3 (out of 108), respectively. There was a positive correlation between COST and FACT-G scores (r = 0.45). We did not find any significant association between OOP expenditure and FT. Predictors for FT included government-subsidised housing, lower education levels, hire of a formal caregiver and the need for household members to take on extra employment. Greater FT correlated with a decline in QoL. Patients of lower socioeconomic status were at higher risk of FT. OOP expenditure was not directed related to FT, likely in view of the effective means-tested subsidies. Additional resources should be considered for this at-risk population. Based on this pilot study, our methodology to quantify FT and OOP expenditure can be scaled up to other cancer primaries.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139281379","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-10DOI: 10.4103/singaporemedj.smj-2021-392
Presaad Pillai, Mazliha Mashor, Min Moon Tang, F. Hiew
The revised European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2017 criteria and European Neuromuscular Centre’s (ENMC) 2018 criteria have improved diagnostic accuracy for dermatomyositis (DM). However, electromyography (EMG) was not included in the diagnostic criteria. We evaluated the usefulness of EMG under both criteria in the classification of DM and its amyopathic subtypes for patients who had rash with or without muscle weakness. In this retrospective study, 20 patients who were classified into DM and alternative diagnoses groups based on the Bohan and Peter (BP) criteria and histopathological findings of muscle and/or skin were included. We then compared the diagnostic accuracy to that of the EULAR/ACR and ENMC criteria. Differences in proportion were determined using Fisher’s exact test. Two patients who had weakness with elevated creatine kinase but no typical DM features on muscle biopsies were incorrectly excluded as alternative diagnoses using BP criteria. Both EMGs demonstrated presence of myopathic recruitment pattern and spontaneous activity in the proximal and distal muscles, consistent with the clinical phenotype. Two patients with a final diagnosis of systemic lupus erythematosus were incorrectly classified as DM by EULAR/ACR and ENMC criteria, but EMG demonstrated no evidence of muscle inflammation. Electromyography is valuable in identifying mild myopathy among DM patients with subtle clinical muscle weakness, allowing better classification of DM subtypes. Absence of EMG signs indicating muscle involvement provides clues for alternative diagnosis. In addition, EMG aids in interpretation of inconclusive muscle biopsy results. Therefore, EMG should be performed for every suspected DM patient.
{"title":"Diagnostic classification of dermatomyositis with and without electrodiagnostic study: real-world clinical practice","authors":"Presaad Pillai, Mazliha Mashor, Min Moon Tang, F. Hiew","doi":"10.4103/singaporemedj.smj-2021-392","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2021-392","url":null,"abstract":"The revised European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2017 criteria and European Neuromuscular Centre’s (ENMC) 2018 criteria have improved diagnostic accuracy for dermatomyositis (DM). However, electromyography (EMG) was not included in the diagnostic criteria. We evaluated the usefulness of EMG under both criteria in the classification of DM and its amyopathic subtypes for patients who had rash with or without muscle weakness. In this retrospective study, 20 patients who were classified into DM and alternative diagnoses groups based on the Bohan and Peter (BP) criteria and histopathological findings of muscle and/or skin were included. We then compared the diagnostic accuracy to that of the EULAR/ACR and ENMC criteria. Differences in proportion were determined using Fisher’s exact test. Two patients who had weakness with elevated creatine kinase but no typical DM features on muscle biopsies were incorrectly excluded as alternative diagnoses using BP criteria. Both EMGs demonstrated presence of myopathic recruitment pattern and spontaneous activity in the proximal and distal muscles, consistent with the clinical phenotype. Two patients with a final diagnosis of systemic lupus erythematosus were incorrectly classified as DM by EULAR/ACR and ENMC criteria, but EMG demonstrated no evidence of muscle inflammation. Electromyography is valuable in identifying mild myopathy among DM patients with subtle clinical muscle weakness, allowing better classification of DM subtypes. Absence of EMG signs indicating muscle involvement provides clues for alternative diagnosis. In addition, EMG aids in interpretation of inconclusive muscle biopsy results. Therefore, EMG should be performed for every suspected DM patient.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139280993","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-09DOI: 10.4103/singaporemedj.smj-2022-222
Rugaiyah Fuad Alkhatib, Robert Chun Chen, CAQ Neuroradiology, Benjamin Wei Heng Sing, Sarat Kumar Sanamandra
Dear Sir, While abducens nerve palsy is commonly seen in clinical practice, abducens nerve palsy secondary to an avulsion injury is uncommon. In a retrospective study documenting the causes of abducens nerve palsy, only up to 3.1% were attributed to trauma; the most common cause in adults was related to vascular ischaemia.[1] Unilateral abducens nerve palsy is found in only 1%–2.7% of all head traumas.[2] Here, we present a case of unilateral abducens nerve injury following trauma. A 60-year-old woman with no significant medical history was involved in a road traffic accident. Initial computed tomography (CT) of the brain revealed bilateral acute subarachnoid haemorrhage, as well as an acute subdural haemorrhage along the posterior interhemispheric falx. Multiple facial bone fractures were identified [Figure 1], including fractures of both orbital floors and lateral walls, lamina papyracea, maxilla and left zygomatic process. No fracture was identified along the course of the left abducens nerve. Of note, the left petrous apex in the region of Dorello’s canal, cavernous sinus and lateral rectus muscle appeared unremarkable.Figure 1: Axial CT images in the bone windows. (a) Acute fractures of both lateral orbital walls, lamina papyracea and left zygomatic process (circles). (b) There is also an acute fracture of the left lateral sphenoid wall (circle). Of note, the left petrous apex appears unremarkable, with no acute fracture.The patient subsequently underwent open reduction internal fixation of both zygomaticomaxillary complex fractures with left orbital floor reconstruction 26 days after the accident. Intraoperatively, forced duction test did not reveal any restriction on eye movement. Postoperatively, it was noted that the patient possessed signs of left abducens nerve palsy, with persistent medial deviation and failure of abduction of the left eye. These were likely not detected during the initial few weeks in view of extensive periorbital soft tissue swelling from the facial and orbital fractures, which resolved after surgical fixation. Contrast-enhanced CT of the brain did not demonstrate any new finding to explain the left abducens nerve palsy. Magnetic resonance imaging of the brain and orbits, including a three-dimensional constructive interference in steady-state (3D CISS) sequence of the cranial nerves was performed 35 days after the accident. This showed a discontinuous left abducens nerve in the prepontine cistern, with subtle linear enhancement corresponding to its root exit zone [Figure 2]. Findings pointed towards a traumatic unilateral left abducens nerve avulsion injury resulting from the road traffic accident. An iatrogenic aetiology of the left abducens nerve avulsion was deemed less likely, as the surgery was mainly focused on facial and orbital fracture repairs, with no surgical intervention performed along the course of the left abducens nerve. The patient was subsequently referred to ophthalmology and managed conservativel
{"title":"Unilateral abducens nerve avulsion injury following trauma","authors":"Rugaiyah Fuad Alkhatib, Robert Chun Chen, CAQ Neuroradiology, Benjamin Wei Heng Sing, Sarat Kumar Sanamandra","doi":"10.4103/singaporemedj.smj-2022-222","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-222","url":null,"abstract":"Dear Sir, While abducens nerve palsy is commonly seen in clinical practice, abducens nerve palsy secondary to an avulsion injury is uncommon. In a retrospective study documenting the causes of abducens nerve palsy, only up to 3.1% were attributed to trauma; the most common cause in adults was related to vascular ischaemia.[1] Unilateral abducens nerve palsy is found in only 1%–2.7% of all head traumas.[2] Here, we present a case of unilateral abducens nerve injury following trauma. A 60-year-old woman with no significant medical history was involved in a road traffic accident. Initial computed tomography (CT) of the brain revealed bilateral acute subarachnoid haemorrhage, as well as an acute subdural haemorrhage along the posterior interhemispheric falx. Multiple facial bone fractures were identified [Figure 1], including fractures of both orbital floors and lateral walls, lamina papyracea, maxilla and left zygomatic process. No fracture was identified along the course of the left abducens nerve. Of note, the left petrous apex in the region of Dorello’s canal, cavernous sinus and lateral rectus muscle appeared unremarkable.Figure 1: Axial CT images in the bone windows. (a) Acute fractures of both lateral orbital walls, lamina papyracea and left zygomatic process (circles). (b) There is also an acute fracture of the left lateral sphenoid wall (circle). Of note, the left petrous apex appears unremarkable, with no acute fracture.The patient subsequently underwent open reduction internal fixation of both zygomaticomaxillary complex fractures with left orbital floor reconstruction 26 days after the accident. Intraoperatively, forced duction test did not reveal any restriction on eye movement. Postoperatively, it was noted that the patient possessed signs of left abducens nerve palsy, with persistent medial deviation and failure of abduction of the left eye. These were likely not detected during the initial few weeks in view of extensive periorbital soft tissue swelling from the facial and orbital fractures, which resolved after surgical fixation. Contrast-enhanced CT of the brain did not demonstrate any new finding to explain the left abducens nerve palsy. Magnetic resonance imaging of the brain and orbits, including a three-dimensional constructive interference in steady-state (3D CISS) sequence of the cranial nerves was performed 35 days after the accident. This showed a discontinuous left abducens nerve in the prepontine cistern, with subtle linear enhancement corresponding to its root exit zone [Figure 2]. Findings pointed towards a traumatic unilateral left abducens nerve avulsion injury resulting from the road traffic accident. An iatrogenic aetiology of the left abducens nerve avulsion was deemed less likely, as the surgery was mainly focused on facial and orbital fracture repairs, with no surgical intervention performed along the course of the left abducens nerve. The patient was subsequently referred to ophthalmology and managed conservativel","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135291099","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-09DOI: 10.4103/singaporemedj.smj-2022-132
Jinghao Nicholas Ngiam, Tze Sian Liong, Thanawin Pramotedham, Ching-Hui Sia, Eric Jou, William Kok-Fai Kong, Kian-Keong Poh
Abstract Vortex formation during left ventricular diastolic filling may provide clinically useful insights into cardiac health. In recent years, there has been growing interest in the measurement of vortex formation time (VFT), especially because it is derived noninvasively. There are important applications of VFT in valvular heart disease, athletic physiology, heart failure and hypertrophic cardiomyopathy. The formation of the vortex as fluid propagates into the left ventricle from the left atrium is important for efficient fluid transport. Quantifying VFT may thus help in evaluating and understanding disease and pathophysiological processes.
{"title":"Left ventricular vortex formation time: emerging clinical applications and limitations","authors":"Jinghao Nicholas Ngiam, Tze Sian Liong, Thanawin Pramotedham, Ching-Hui Sia, Eric Jou, William Kok-Fai Kong, Kian-Keong Poh","doi":"10.4103/singaporemedj.smj-2022-132","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-132","url":null,"abstract":"Abstract Vortex formation during left ventricular diastolic filling may provide clinically useful insights into cardiac health. In recent years, there has been growing interest in the measurement of vortex formation time (VFT), especially because it is derived noninvasively. There are important applications of VFT in valvular heart disease, athletic physiology, heart failure and hypertrophic cardiomyopathy. The formation of the vortex as fluid propagates into the left ventricle from the left atrium is important for efficient fluid transport. Quantifying VFT may thus help in evaluating and understanding disease and pathophysiological processes.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135290961","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-03DOI: 10.4103/singaporemedj.smj-2022-072
Zainura Che Isa, Jo Anne Lim, Amelia Mohamed Ain, Fatin Aliaa Othman, Yee Cheng Kueh, Mei Mei Tew, Maz Jamilah Masnan, Aznita Ibrahim
Abstract Introduction: Dengue is endemic in tropical countries. Severe dengue has a high risk of morbidity and mortality. We aimed to identify factors associated with dengue survival among our intensive care unit (ICU) patients. Methods: A retrospective study was conducted among dengue cases admitted to the ICU of Hospital Sultan Abdul Halim, Kedah, Malaysia from 2016 to 2019. Results: Out of 1,852 dengue cases admitted to the hospital, 7.2% of patients required ICU admission. Survival rate was 88.6% among severe dengue cases. The majority of severe dengue patients were obese, while other notable comorbidities included hypertension and diabetes mellitus. Also, 73% of patients presented in the critical phase, at a median of Day 4 of illness. All patients admitted to the ICU had a history of fever. The predominant warning signs were lethargy, fluid accumulation and haemoconcentration with rapid platelet reduction. Among nonsurvivors, 69.2% had fulminant hepatitis, 53.8% had massive bleeding or disseminated intravascular coagulation, 38.5% had haemophagocytic lymphohistiocytosis and 30.8% had myocarditis. The predominant serotypes were DENV-3 and DENV-1. The least number of cases was seen in 2017, when all serotypes were equally presented. Multiple logistic regression showed that Sequential Organ Failure Assessment (SOFA) score, peak international normalised ratio, peak partial thromboplastin time and aspartate aminotransferase on admission were independent risk factors for survival. This model had an area under the curve of 0.98, giving an overall 98.2% accuracy. Conclusions: Specific warning signs and blood investigations in dengue patients may aid in early decision for ICU admission. Monitoring of SOFA scores plus coagulation and liver enzyme profiles could improve dengue survival rates.
{"title":"Clinical profiles and predictors of survival in severe dengue cases","authors":"Zainura Che Isa, Jo Anne Lim, Amelia Mohamed Ain, Fatin Aliaa Othman, Yee Cheng Kueh, Mei Mei Tew, Maz Jamilah Masnan, Aznita Ibrahim","doi":"10.4103/singaporemedj.smj-2022-072","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-072","url":null,"abstract":"Abstract Introduction: Dengue is endemic in tropical countries. Severe dengue has a high risk of morbidity and mortality. We aimed to identify factors associated with dengue survival among our intensive care unit (ICU) patients. Methods: A retrospective study was conducted among dengue cases admitted to the ICU of Hospital Sultan Abdul Halim, Kedah, Malaysia from 2016 to 2019. Results: Out of 1,852 dengue cases admitted to the hospital, 7.2% of patients required ICU admission. Survival rate was 88.6% among severe dengue cases. The majority of severe dengue patients were obese, while other notable comorbidities included hypertension and diabetes mellitus. Also, 73% of patients presented in the critical phase, at a median of Day 4 of illness. All patients admitted to the ICU had a history of fever. The predominant warning signs were lethargy, fluid accumulation and haemoconcentration with rapid platelet reduction. Among nonsurvivors, 69.2% had fulminant hepatitis, 53.8% had massive bleeding or disseminated intravascular coagulation, 38.5% had haemophagocytic lymphohistiocytosis and 30.8% had myocarditis. The predominant serotypes were DENV-3 and DENV-1. The least number of cases was seen in 2017, when all serotypes were equally presented. Multiple logistic regression showed that Sequential Organ Failure Assessment (SOFA) score, peak international normalised ratio, peak partial thromboplastin time and aspartate aminotransferase on admission were independent risk factors for survival. This model had an area under the curve of 0.98, giving an overall 98.2% accuracy. Conclusions: Specific warning signs and blood investigations in dengue patients may aid in early decision for ICU admission. Monitoring of SOFA scores plus coagulation and liver enzyme profiles could improve dengue survival rates.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135873724","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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