Pub Date : 2023-09-27DOI: 10.1177/20101058231204703
Geraldine Pei Yi Koo, Aliviya Dutta, Yuan Helen Zhang
Metformin-associated lactic acidosis (MALA) and euglycaemic diabetic ketoacidosis (EKA) are both life-threatening endocrine emergencies. MALA is a well-documented complication of anti-glycaemic therapy in diabetics while EKA is an increasingly recognized disease entity with the advent of use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. However, the occurrence of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis (MALKA) is uncommon and rarely reported in the literature. We report an unusual case of MALKA, in a 74-year-old gentleman with no previous history of chronic kidney disease and SGLT-2 inhibitor use, who presented with altered mental status, acute renal failure and profound high anion-gap metabolic acidosis (HAGMA) with lactaemia, ketonaemia and normoglycaemia (pH 6.965, bicarbonate 3.1, creatinine 522, glucose 6.6, lactate 17.5, ketones >8). The patient was initiated on intravenous insulin infusion with dextrose-containing drip and continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The patient had a prolonged hospital stay but was eventually discharged with a normalised renal function without need for long-term dialysis. The parallel occurrence of MALA and EKA suggest a metformin-associated inhibition of gluconeogenesis. This case highlights the importance of early recognition and investigation of concurrent diabetic ketoacidosis in the presence of MALA and vice versa as MALKA benefits from both prompt institution of parenteral glucose therapy and insulin infusion and consideration of initiation of haemodialysis.
{"title":"Unusual case of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis","authors":"Geraldine Pei Yi Koo, Aliviya Dutta, Yuan Helen Zhang","doi":"10.1177/20101058231204703","DOIUrl":"https://doi.org/10.1177/20101058231204703","url":null,"abstract":"Metformin-associated lactic acidosis (MALA) and euglycaemic diabetic ketoacidosis (EKA) are both life-threatening endocrine emergencies. MALA is a well-documented complication of anti-glycaemic therapy in diabetics while EKA is an increasingly recognized disease entity with the advent of use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. However, the occurrence of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis (MALKA) is uncommon and rarely reported in the literature. We report an unusual case of MALKA, in a 74-year-old gentleman with no previous history of chronic kidney disease and SGLT-2 inhibitor use, who presented with altered mental status, acute renal failure and profound high anion-gap metabolic acidosis (HAGMA) with lactaemia, ketonaemia and normoglycaemia (pH 6.965, bicarbonate 3.1, creatinine 522, glucose 6.6, lactate 17.5, ketones >8). The patient was initiated on intravenous insulin infusion with dextrose-containing drip and continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The patient had a prolonged hospital stay but was eventually discharged with a normalised renal function without need for long-term dialysis. The parallel occurrence of MALA and EKA suggest a metformin-associated inhibition of gluconeogenesis. This case highlights the importance of early recognition and investigation of concurrent diabetic ketoacidosis in the presence of MALA and vice versa as MALKA benefits from both prompt institution of parenteral glucose therapy and insulin infusion and consideration of initiation of haemodialysis.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135536488","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-25DOI: 10.1177/20101058231204709
Rachel Zui Chih Teo, Anne Lay Choo Ng, Vincent See, Hua Yan, Tripti Singh, Behram Ali Khan
Background Sucroferric oxyhydroxide has been used in the treatment of hyperphosphataemia in adult patients with chronic kidney disease receiving haemodialysis or peritoneal dialysis since 2013. However, there is a paucity of data on sucroferric oxyhydroxide use in Asian populations. Objective We aim to provide real-world experience of sucroferric oxyhydroxide use in our local cohort on maintenance haemodialysis. Methods A retrospective clinical audit was performed to review laboratory parameters of haemodialysis patients who received sucroferric oxyhydroxide over a 14-month period from December 2020 to January 2022. Sucroferric oxyhydroxide reduced serum phosphate levels effectively, with a more than 3-fold increase in the proportion of patients who were able to achieve phosphate levels of ≤5.5 mg/dL. Ferritin levels and transferrin saturation were increased, but there were no significant differences in haemoglobin levels and erythropoietin used in the long term. We showed that sucroferric oxyhydroxide was highly effective in reducing serum phosphate to recommended levels in patients receiving haemodialysis. Further prospective studies in Asian populations are warranted to confirm our findings.
{"title":"Sucroferric oxyhydroxide use in patients on haemodialysis – real-world experience from an Asian cohort","authors":"Rachel Zui Chih Teo, Anne Lay Choo Ng, Vincent See, Hua Yan, Tripti Singh, Behram Ali Khan","doi":"10.1177/20101058231204709","DOIUrl":"https://doi.org/10.1177/20101058231204709","url":null,"abstract":"Background Sucroferric oxyhydroxide has been used in the treatment of hyperphosphataemia in adult patients with chronic kidney disease receiving haemodialysis or peritoneal dialysis since 2013. However, there is a paucity of data on sucroferric oxyhydroxide use in Asian populations. Objective We aim to provide real-world experience of sucroferric oxyhydroxide use in our local cohort on maintenance haemodialysis. Methods A retrospective clinical audit was performed to review laboratory parameters of haemodialysis patients who received sucroferric oxyhydroxide over a 14-month period from December 2020 to January 2022. Sucroferric oxyhydroxide reduced serum phosphate levels effectively, with a more than 3-fold increase in the proportion of patients who were able to achieve phosphate levels of ≤5.5 mg/dL. Ferritin levels and transferrin saturation were increased, but there were no significant differences in haemoglobin levels and erythropoietin used in the long term. We showed that sucroferric oxyhydroxide was highly effective in reducing serum phosphate to recommended levels in patients receiving haemodialysis. Further prospective studies in Asian populations are warranted to confirm our findings.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135814988","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-04DOI: 10.1177/20101058231192781
Christine Shi Min Chau, Huimin Lin, Fuyin Li, Sigaya Kenneth Villan
Comprehensive Geriatric Assessment (CGA) is a validated multidomain assessment of an older person’s myriad issues that has shown positive medical outcomes in surgical settings. However, there is paucity of evidence in older Vascular inpatients. To determine if a Geriatric Liaison Service using CGA improves medical outcomes in older Vascular inpatients in Singapore. This is a quality improvement prospective cross-sectional study. Vascular patients aged ≥65 years admitted between November 2018 to October 2019 were referred to the Vascular-Geriatric Service (VGS) at the surgeon’s discretion if they had acute medical issues, cognitive concerns, or functional decline. Patients admitted under Vascular Surgery during the preceding year but not referred to VGS were used as control. A pre- and post-analysis was conducted for outcomes of medical complications, while a multivariate analysis was done to look at LOS, 30-day unplanned medical readmissions and 30-day mortality rates. Patients had significantly lower rates of pneumonia (2.2% vs 10.8%, p = .021) and delirium (1.1% vs 18.3%, p < .001) post-VGS compared to pre-VGS. VGS decreased the odds of 30-day mortality by 79% as compared to the control group (OR = 0.21, 95% CI: 0.05-0.86, p = .030). The intervention group had increased risk of a longer hospital stay by 48% as compared to control (RR: 1.48 95% CI: 1.11 to 1.97, p = .008). VGS was associated with reduction in some medical complications, and 30-day mortality in older frail Vascular inpatients with multimorbidity.
{"title":"Comprehensive geriatric assessment in older vascular patients in a tertiary hospital","authors":"Christine Shi Min Chau, Huimin Lin, Fuyin Li, Sigaya Kenneth Villan","doi":"10.1177/20101058231192781","DOIUrl":"https://doi.org/10.1177/20101058231192781","url":null,"abstract":"Comprehensive Geriatric Assessment (CGA) is a validated multidomain assessment of an older person’s myriad issues that has shown positive medical outcomes in surgical settings. However, there is paucity of evidence in older Vascular inpatients. To determine if a Geriatric Liaison Service using CGA improves medical outcomes in older Vascular inpatients in Singapore. This is a quality improvement prospective cross-sectional study. Vascular patients aged ≥65 years admitted between November 2018 to October 2019 were referred to the Vascular-Geriatric Service (VGS) at the surgeon’s discretion if they had acute medical issues, cognitive concerns, or functional decline. Patients admitted under Vascular Surgery during the preceding year but not referred to VGS were used as control. A pre- and post-analysis was conducted for outcomes of medical complications, while a multivariate analysis was done to look at LOS, 30-day unplanned medical readmissions and 30-day mortality rates. Patients had significantly lower rates of pneumonia (2.2% vs 10.8%, p = .021) and delirium (1.1% vs 18.3%, p < .001) post-VGS compared to pre-VGS. VGS decreased the odds of 30-day mortality by 79% as compared to the control group (OR = 0.21, 95% CI: 0.05-0.86, p = .030). The intervention group had increased risk of a longer hospital stay by 48% as compared to control (RR: 1.48 95% CI: 1.11 to 1.97, p = .008). VGS was associated with reduction in some medical complications, and 30-day mortality in older frail Vascular inpatients with multimorbidity.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.5,"publicationDate":"2023-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45271705","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-16DOI: 10.1177/20101058231196398
Delphina Yeo, Qi Xuan Tan, J. Ch'ng
Central vein stenosis is commonly encountered in end stage renal disease patients on hemodialysis. Most are manageable with repeated procedures and venoplasty, however in some cases, venoplasty may not be successful. We discuss a rare case of persistent upper limb swelling due to severe central vein stenosis from compression of an aortic arch stent. Despite attempt at prolonged balloon inflation during venoplasty of the central vein, the stenosis still persisted. The arteriovenous fistula was then ligated and other forms of vascular access for hemodialysis were sought after. Central venograms may be useful in end stage renal failure patients as part of pre-operative arteriovenous fistula creation so as to anticipate the possibility of central vein stenosis and its associated complications.
{"title":"A rare case of an aortic arch stent causing central vein stenosis","authors":"Delphina Yeo, Qi Xuan Tan, J. Ch'ng","doi":"10.1177/20101058231196398","DOIUrl":"https://doi.org/10.1177/20101058231196398","url":null,"abstract":"Central vein stenosis is commonly encountered in end stage renal disease patients on hemodialysis. Most are manageable with repeated procedures and venoplasty, however in some cases, venoplasty may not be successful. We discuss a rare case of persistent upper limb swelling due to severe central vein stenosis from compression of an aortic arch stent. Despite attempt at prolonged balloon inflation during venoplasty of the central vein, the stenosis still persisted. The arteriovenous fistula was then ligated and other forms of vascular access for hemodialysis were sought after. Central venograms may be useful in end stage renal failure patients as part of pre-operative arteriovenous fistula creation so as to anticipate the possibility of central vein stenosis and its associated complications.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.5,"publicationDate":"2023-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41779458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-02DOI: 10.1177/20101058231192784
Ezra Ho, H. C. Oh, Chau Sian Lim, S. Soon, Nang Ei Ei Khaing
Hospital workers have borne a large burden of the COVID-19 pandemic, exposed to risks of infection, while enduring elevated workloads, increased workplace stress, prolonged hours in uncomfortable working conditions, and public stigmatisation. In this cross-sectional study, we examined the psychological stressors of COVID-19 on hospital essential services workers and their needs at a tertiary hospital in Singapore. Methods: We conducted a study of 246 outsourced essential workers comprising housekeeping, maintenance staff, and porting staff. Psychological distress was measured by the Kessler-6 scale. We also surveyed respondents through a questionnaire on the main concerns that worried them, supportive resources available, and additional resources that would most help them. Among the survey respondents, concerns related to employment, finances, accommodation, transportation, and likelihood of receiving medical attention for COVID-19 were significantly associated with moderate to severe psychological distress ( p<0.05). Stress from isolation and fear of COVID-19 infection constituted the greatest psychosocial burdens. Respondents felt that main supportive resources came from their employers and social circles. They also listed enhanced individual ability to cope, and additional financial aid from their employers and the government would help them the most. Financial and accommodation-related stressors reflect structural factors that exacerbated the psychosocial burdens faced by non-medical hospital workers. Most respondents tended to individualise their coping strategies, which point towards the need for stronger social protections and mental health provisions for hospital essential services workers.
{"title":"Psychological stressors and needs among essential workers at a Singapore hospital during the COVID-19 pandemic","authors":"Ezra Ho, H. C. Oh, Chau Sian Lim, S. Soon, Nang Ei Ei Khaing","doi":"10.1177/20101058231192784","DOIUrl":"https://doi.org/10.1177/20101058231192784","url":null,"abstract":"Hospital workers have borne a large burden of the COVID-19 pandemic, exposed to risks of infection, while enduring elevated workloads, increased workplace stress, prolonged hours in uncomfortable working conditions, and public stigmatisation. In this cross-sectional study, we examined the psychological stressors of COVID-19 on hospital essential services workers and their needs at a tertiary hospital in Singapore. Methods: We conducted a study of 246 outsourced essential workers comprising housekeeping, maintenance staff, and porting staff. Psychological distress was measured by the Kessler-6 scale. We also surveyed respondents through a questionnaire on the main concerns that worried them, supportive resources available, and additional resources that would most help them. Among the survey respondents, concerns related to employment, finances, accommodation, transportation, and likelihood of receiving medical attention for COVID-19 were significantly associated with moderate to severe psychological distress ( p<0.05). Stress from isolation and fear of COVID-19 infection constituted the greatest psychosocial burdens. Respondents felt that main supportive resources came from their employers and social circles. They also listed enhanced individual ability to cope, and additional financial aid from their employers and the government would help them the most. Financial and accommodation-related stressors reflect structural factors that exacerbated the psychosocial burdens faced by non-medical hospital workers. Most respondents tended to individualise their coping strategies, which point towards the need for stronger social protections and mental health provisions for hospital essential services workers.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.5,"publicationDate":"2023-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41442181","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-31DOI: 10.1177/20101058231192797
Khairul Aliff Khairuman, Ahmad Danial Shahrir, S. Suppiah, R. Vashu, S. E. Shamim
Chronic cerebral ischaemia (CCI) is a potentially life-threatening condition caused by carotid artery occlusion, hypotension and other causes. Moyamoya Syndrome (MMS) is an example of CCI, in which there is progressive narrowing of the branches of the internal carotid artery. Conventionally, magnetic resonance angiography (MRA) or digital subtraction angiogram (DSA) are utilised to visualise the vascular abnormalities. However, nuclear medicine imaging can help to give more functional information that can improve the management and surgical outcome of patients. There is a need to highlight the role of single-photon emission computed tomography/computed tomography (SPECT/CT) imaging using 99mTc-Ethyl Cysteinate Dimer (99mTc-ECD) with Acetazolamide (ACZ) challenge to diagnose MMS and decide on further surgical or medical intervention. We illustrate a case of a young woman who benefited from this imaging for the management of her condition.
{"title":"Brain perfusion imaging using 99mTc-Ethyl cysteinate dimer with acetazolamide challenge reveals “steal phenomenon” in suspected stroke: A case report","authors":"Khairul Aliff Khairuman, Ahmad Danial Shahrir, S. Suppiah, R. Vashu, S. E. Shamim","doi":"10.1177/20101058231192797","DOIUrl":"https://doi.org/10.1177/20101058231192797","url":null,"abstract":"Chronic cerebral ischaemia (CCI) is a potentially life-threatening condition caused by carotid artery occlusion, hypotension and other causes. Moyamoya Syndrome (MMS) is an example of CCI, in which there is progressive narrowing of the branches of the internal carotid artery. Conventionally, magnetic resonance angiography (MRA) or digital subtraction angiogram (DSA) are utilised to visualise the vascular abnormalities. However, nuclear medicine imaging can help to give more functional information that can improve the management and surgical outcome of patients. There is a need to highlight the role of single-photon emission computed tomography/computed tomography (SPECT/CT) imaging using 99mTc-Ethyl Cysteinate Dimer (99mTc-ECD) with Acetazolamide (ACZ) challenge to diagnose MMS and decide on further surgical or medical intervention. We illustrate a case of a young woman who benefited from this imaging for the management of her condition.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.5,"publicationDate":"2023-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41637046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-17DOI: 10.1177/20101058231188867
Kar Yee Catrin Kong, C. Y. Ting, Khurshid Merchant, A. Lai, S. Chowdhury
Background: While common in the elderly population, abdominal aortic aneurysms (AAAs) are rare in the paediatric population and reported to be more common in patients with connective tissue disorders or certain genetic conditions such as tuberous sclerosis complex (TSC). Presenting symptoms of an AAA can be varied, and can range from being completely asymptomatic, to symptoms including a pulsatile abdominal mass, hypertension, back pain and even rupture. Aortic aneurysms in patients with TSC have been reported presenting at varying age groups. Case description: We report a case of TSC associated with an incidental finding of an abdominal aortic aneurysm in a child. Ultrasound of the abdomen revealed a renal aortic abdominal aneurysm. Computed tomographic angiogram and magnetic resonance imaging of the abdomen confirmed this finding with wall thinning over its right lateral aspect. The child underwent surgical repair of her abdominal aortic aneurysm and recovered uneventfully. Discussion: This case highlights the importance of monitoring patients with TS closely for signs and symptoms of aortic aneurysms and to proceed with screening scans for an early diagnosis. If left untreated, AAA carries a high-risk of morbidity and mortality in the event of a rupture.
{"title":"Incidental finding of an aortic aneurysm in a paediatric patient with tuberous sclerosis - A case report with literature review","authors":"Kar Yee Catrin Kong, C. Y. Ting, Khurshid Merchant, A. Lai, S. Chowdhury","doi":"10.1177/20101058231188867","DOIUrl":"https://doi.org/10.1177/20101058231188867","url":null,"abstract":"Background: While common in the elderly population, abdominal aortic aneurysms (AAAs) are rare in the paediatric population and reported to be more common in patients with connective tissue disorders or certain genetic conditions such as tuberous sclerosis complex (TSC). Presenting symptoms of an AAA can be varied, and can range from being completely asymptomatic, to symptoms including a pulsatile abdominal mass, hypertension, back pain and even rupture. Aortic aneurysms in patients with TSC have been reported presenting at varying age groups. Case description: We report a case of TSC associated with an incidental finding of an abdominal aortic aneurysm in a child. Ultrasound of the abdomen revealed a renal aortic abdominal aneurysm. Computed tomographic angiogram and magnetic resonance imaging of the abdomen confirmed this finding with wall thinning over its right lateral aspect. The child underwent surgical repair of her abdominal aortic aneurysm and recovered uneventfully. Discussion: This case highlights the importance of monitoring patients with TS closely for signs and symptoms of aortic aneurysms and to proceed with screening scans for an early diagnosis. If left untreated, AAA carries a high-risk of morbidity and mortality in the event of a rupture.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.5,"publicationDate":"2023-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42178773","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-15DOI: 10.1177/20101058231188875
Lok Hui Lu, Hana Arbab, Choo Suet Cheng, Ong Lin Yin, Ong Choo Phaik Caroline
Children commonly present at the emergency department with abdominal pain and it is challenging to identify urgent surgical conditions. An audit conducted at a tertiary children’s hospital showed that 70% of patients admitted to Department of Pediatric Surgery (PAS) for abdominal pain had non-surgical diagnoses and wide variation in management. Our quality improvement (QI) project aimed to reduce length of stay (LOS) and unnecessary investigations performed for patients admitted to PAS with abdominal pain, without causing complications or delayed diagnosis of surgical conditions. The QI project consists of a standardised management workflow with stringent discharge criteria. We reviewed outcome measures of LOS, number of investigations ordered, compliance to workflow and readmission within 1-week post discharge at the end of each Plan-Do- Study-Act (PDSA) cycle and iteratively improved the workflow following QI principles. 61% of patients were admitted to PAS for non-surgical abdominal pain throughout three PDSA cycles conducted. The third cycle showed improved compliance to workflow (80.7%) with reduced median LOS by 1 day, reduced median number of blood, stool and urine investigations by 1 and reduced range of investigations ordered. Readmission and CE attendance rate 1 week after discharge was 1.6% ( n = 3), which was comparable to audit at 2.3% ( n = 4), p = 0.709. The workflow reduced LOS, number of unnecessary investigations and variability in investigations ordered, without causing misdiagnosis. It improved patient experience with sizeable cost savings for the patient and the hospital. QI projects can improve patient outcomes by introducing standard protocols that aid clinical management.
{"title":"Standardized management of pediatric abdominal pain admissions improves patient outcomes – A quality improvement project","authors":"Lok Hui Lu, Hana Arbab, Choo Suet Cheng, Ong Lin Yin, Ong Choo Phaik Caroline","doi":"10.1177/20101058231188875","DOIUrl":"https://doi.org/10.1177/20101058231188875","url":null,"abstract":"Children commonly present at the emergency department with abdominal pain and it is challenging to identify urgent surgical conditions. An audit conducted at a tertiary children’s hospital showed that 70% of patients admitted to Department of Pediatric Surgery (PAS) for abdominal pain had non-surgical diagnoses and wide variation in management. Our quality improvement (QI) project aimed to reduce length of stay (LOS) and unnecessary investigations performed for patients admitted to PAS with abdominal pain, without causing complications or delayed diagnosis of surgical conditions. The QI project consists of a standardised management workflow with stringent discharge criteria. We reviewed outcome measures of LOS, number of investigations ordered, compliance to workflow and readmission within 1-week post discharge at the end of each Plan-Do- Study-Act (PDSA) cycle and iteratively improved the workflow following QI principles. 61% of patients were admitted to PAS for non-surgical abdominal pain throughout three PDSA cycles conducted. The third cycle showed improved compliance to workflow (80.7%) with reduced median LOS by 1 day, reduced median number of blood, stool and urine investigations by 1 and reduced range of investigations ordered. Readmission and CE attendance rate 1 week after discharge was 1.6% ( n = 3), which was comparable to audit at 2.3% ( n = 4), p = 0.709. The workflow reduced LOS, number of unnecessary investigations and variability in investigations ordered, without causing misdiagnosis. It improved patient experience with sizeable cost savings for the patient and the hospital. QI projects can improve patient outcomes by introducing standard protocols that aid clinical management.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.5,"publicationDate":"2023-07-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41830126","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-10DOI: 10.1177/20101058231188877
Chee Wui Ong, Z. J. Lo, Shanying Liang, Q. Hong, Li Zhang, Pravin Lingam, L. Chong, S. Chandrasekar, G. Tan, E. Yong
Post-operative upper extremity exercise is recommended to patients with arteriovenous fistulas. It is postulated that increased blood flow to vessels improves maturation and patency rates. Recent studies favour pre-operative exercise therapy to improve the outcomes of arteriovenous fistula creation. To investigate if pre-operative exercise therapy increases vessel diameter and maturation in patients undergoing distal arteriovenous fistula creation. 34 patients planned for radiocephalic arteriovenous fistula creation were recruited at a tertiary university hospital Vascular Surgery Unit. Patients underwent a 6-week period of self-directed daily upper extremity exercises before surgery. Patients were reviewed up to 6 months post-surgery. The primary outcome investigated was change in venous and arterial diameters following exercise intervention. The secondary outcome investigated was the primary failure rate of the newly created arteriovenous fistulas. After exercise therapy, mean hand grip strength increased from 20.3 ± 6.62 kg to 21.9 ± 7.16 kg ( p=.01). There was a statistically significant increase in basilic vein diameter amongst those who demonstrated strict compliance to at least 42 days of pre-operative exercise therapy by 0.51 mm from 3.23 ± 1.09 mm to 3.74 ± 1.31 mm ( p=.03). Primary failure rate of newly created radiocephalic arteriovenous fistulas was 25% (7 of 28), comparable to our previous series of 436 distal arteriovenous fistulas created which had a failure rate of 26%. There was a trend of increase in vein diameters after pre-operative exercise therapy. Although not statistically significant, patients with successful arteriovenous fistula creation had longer mean completion of exercise days.
{"title":"Pre-operative exercise therapy to increase blood vessel diameter in patients undergoing radiocephalic arteriovenous fistula creation","authors":"Chee Wui Ong, Z. J. Lo, Shanying Liang, Q. Hong, Li Zhang, Pravin Lingam, L. Chong, S. Chandrasekar, G. Tan, E. Yong","doi":"10.1177/20101058231188877","DOIUrl":"https://doi.org/10.1177/20101058231188877","url":null,"abstract":"Post-operative upper extremity exercise is recommended to patients with arteriovenous fistulas. It is postulated that increased blood flow to vessels improves maturation and patency rates. Recent studies favour pre-operative exercise therapy to improve the outcomes of arteriovenous fistula creation. To investigate if pre-operative exercise therapy increases vessel diameter and maturation in patients undergoing distal arteriovenous fistula creation. 34 patients planned for radiocephalic arteriovenous fistula creation were recruited at a tertiary university hospital Vascular Surgery Unit. Patients underwent a 6-week period of self-directed daily upper extremity exercises before surgery. Patients were reviewed up to 6 months post-surgery. The primary outcome investigated was change in venous and arterial diameters following exercise intervention. The secondary outcome investigated was the primary failure rate of the newly created arteriovenous fistulas. After exercise therapy, mean hand grip strength increased from 20.3 ± 6.62 kg to 21.9 ± 7.16 kg ( p=.01). There was a statistically significant increase in basilic vein diameter amongst those who demonstrated strict compliance to at least 42 days of pre-operative exercise therapy by 0.51 mm from 3.23 ± 1.09 mm to 3.74 ± 1.31 mm ( p=.03). Primary failure rate of newly created radiocephalic arteriovenous fistulas was 25% (7 of 28), comparable to our previous series of 436 distal arteriovenous fistulas created which had a failure rate of 26%. There was a trend of increase in vein diameters after pre-operative exercise therapy. Although not statistically significant, patients with successful arteriovenous fistula creation had longer mean completion of exercise days.","PeriodicalId":44685,"journal":{"name":"Proceedings of Singapore Healthcare","volume":null,"pages":null},"PeriodicalIF":0.5,"publicationDate":"2023-07-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44968223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-07DOI: 10.1177/20101058231188865
Eka Prasetya Budi Mulia, Mahrus A Rahman
Total anomalous pulmonary venous connection (TAPVC) is a rare cyanotic abnormality that accounts for about 1%–3% of congenital heart disease malformations. TAPVC is a condition in which there is no direct connection between all four pulmonary veins and the left atrium but makes abnormal connections to the right atrium or systemic venous system. TAPVC caused a high mortality rate of 80% in the first year of life, and 50% of them die within 3 months after birth without intervention. The aim of this review is to elucidate the various treatment considerations of TAPVC. A literature search was conducted on PubMed, ScienceDirect and Google Scholar using various combinations of keywords related to treatment of TAPVC. The citations from all selected articles were reviewed for additional studies. TAPVC intervention, including medical and surgical, is tailored to each type of TAPVC. Catheter-based interventions are frequently used to temporize neonates and provide time to optimize patients medically prior to definite repair. Corrective surgery is required for all patients with this condition. Several latest catheter-based or surgical intervention technique modifications have also been reported.
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