Singapore medical journal最新文献

Introduction: Remote monitoring (RM) for cardiac implantable electronic devices is on the rise and has been shown to reduce the burden of in-clinic follow-up visits. We aimed to investigate the long-term clinical outcomes of RM versus no RM.

Methods: This was a prospective, single-centre cohort study of consecutive patients with an implantable cardioverter-defibrillator (ICD) or cardiac resynchronisation therapy-defibrillator (CRT-D) followed up from 2018 to 2023. Patients who received non-ICD devices were excluded. In general, RM was offered to all patients, but uptake depended on patient preference. For data analysis, patients were stratified according to whether RM was used. The primary outcome was all-cause mortality; secondary outcomes were hospitalisation for heart failure and device therapy (shocks and electrical storm).

Results: Of 551 patients, 284 (51.5%) received RM and 267 (49.5%) did not. Baseline demographics were similar between the two arms. All-cause mortality was significantly lower in RM versus non-RM patients (hazard ratio [HR] 0.45, 95% confidence interval [CI] 0.33-0.60, P <0.001), as was hospitalisation for heart failure (HR 0.39, 95% CI 0.25-0.59, P <0.001); these remained significant after adjustment for baseline covariates. More patients on RM received appropriate antitachycardia pacing (ATP) (17.6% vs. 10.7%, P = 0.035) and appropriate shocks (24.1% vs. 14.7%, P = 0.017). The incidences of inappropriate ATP, inappropriate shocks and electrical storm were similar. More patients on RM underwent pulse generator change (34.1% vs. 10.1%, P <0.001).

Conclusion: Remote monitoring was associated with significantly lower mortality in both ICDs and CRT-Ds and in primary and secondary indications, as well as fewer heart failure hospitalisations. This supports current guidelines recommending the use of RM in all patients with ICD or CRT-D.

Background: Total knee arthroplasty (TKA) is a common procedure with an increasing demand, especially among the elderly. Frailty is known to be associated with adverse perioperative outcomes in the older population. In this article, we aimed to understand the associations of preoperative frailty status and comorbid conditions in relation to their clinical and healthcare outcomes after TKA, and to describe the perioperative factors leading to improvement in a patient's frailty status after TKA.

Methods: This is a retrospective cohort study, and the outcomes were assessed over 2 years. Frailty is defined by the Clinical Frailty Score.

Results: A total of 96 patient records were assessed, of which 13 (13.5%) patients were robust and 83 (86.5%) patients were prefrail or frail. Two years after TKA, the number of robust patients increased to 58 (61.7%) patients, showing a reversal of frailty in 48.2% of patients.

Conclusion: Total knee arthroplasty in prefrail and frail patients is a safe procedure that leads to improvement of frailty status, with an increase in the proportion of patients becoming robust within 2 years after the operation.

Introduction: Interstitial lung disease (ILD) in systemic sclerosis (SSc) is heterogeneous with varied progression rate. This study aimed to identify the baseline clinical characteristics associated with ILD progression within 1, 3 and 5 years of the diagnosis of ILD.

Methods: This was a prospective, multicentre study - Systematic Sclerosis Cohort Singapore - conducted from January 2008 to February 2021, which included SSc patients with ILD diagnosed by high-resolution computed tomography. Progression of ILD was defined by forced vital capacity (FVC) decline ≥10% predicted or FVC decline 5%-9% predicted, with diffusing lung capacity of carbon monoxide decline ≥15% from the time of ILD diagnosis. Multivariable logistic and Cox regression analyses, adjusting for malignancy and treatment, were performed to determine independent risk factors of ILD progression.

Results: Of 124 SSc patients with ILD, 47.6% had limited cutaneous SSc, 33.9% had diffuse SSc and 18.5% had SSc-overlap. Progression of ILD was seen in 6%, 15% and 23% of patients within 1, 3 and 5 years, respectively. After adjusting for malignancy and treatment, anti-La was associated with ILD progression within 1 year (odds ratio [OR] 6.94, 95% confidence interval [CI]: 1.14-42.2; P = 0.04) and 3 years (OR 5.98, 95% CI: 1.31-27.4; P = 0.02), and anti-Scl-70 was associated with ILD progression within 5 years (OR 2.54, 95% CI: 1.05-6.12; P = 0.04). Analysing time to ILD progression as an outcome, anti-La was significantly associated with higher risk of ILD progression (hazard ratio 3.47, 95% CI: 1.18-10.2; P = 0.02). Time to ILD progression was 1.4 years in patients with anti-La versus 6.9 years in patients without anti-La (P = 0.02), and 4.7 years in patients with anti-Scl-70 versus 8.9 years in patients without anti-Scl-70 (P = 0.12).

Conclusion: In this Asian cohort of SSc patients, autoantibodies may help to predict ILD progression rates.

Introduction: The current literature is mixed on which patient factors, if any, predict the rate of successful discharge within 24 h of enhanced recovery after surgery (ERAS) total knee arthroplasty (TKA). This study aimed to investigate the influence of timing of surgery and physiotherapy on the rate of successful 24-h discharge.

Methods: All 342 patients who underwent ERAS day surgery TKA from August 2020 to July 2021 were followed up prospectively. Patient characteristics and postoperative outcomes, such as number of physiotherapy sessions required before clearance for home, time taken after surgery to ambulate >10 m and length of stay (LOS), were recorded. Patients were grouped based on surgical end time (morning/afternoon/ evening) and time of physiotherapy review (morning/afternoon/evening/morning after). Patients successfully passed ERAS day surgery protocol if they were discharged within 24 h.

Results: With regard to the timing of operation, the morning group had the shortest LOS (P = 0.001) and a higher ERAS day surgery pass rate than the afternoon group (P = 0.016). With regard to the timing of physiotherapy, the afternoon group took the shortest time to ambulate >10 m (P < 0.001), had the shortest LOS (P < 0.001) and had a higher ERAS day surgery pass rate as compared to the morning after the operation group (P = 0.005).

Conclusion: Patients who ended their operations in the morning and received physiotherapy review in the same afternoon were the most likely to be discharged within 24 h due to early ambulation and adequate time for spinal anaesthesia to wear off.

Introduction: There is limited research on the psychosocial health of Asian adolescents undergoing obesity treatment. Our study examined the predictors of psychological distress, disordered eating and poor health-related quality of life (HRQoL) in these adolescents and the associations between them.

Methods: A total of 82 adolescents aged 11-17 years were recruited from the Weight Management Clinic in KK Women's and Children's Hospital between June 2022 and January 2023. Participants completed the following questionnaires: (a) Young Person's Clinical Outcomes in Routine Evaluation (YP-Core) assessing for psychological distress, (b) Children's Eating Attitude Test (ChEAT) evaluating for disordered eating behaviours, and (c) Pediatric Quality of Life Inventory (PedsQL) measuring HRQoL.

Results: Participating adolescents had a mean body mass index of 31.9 ± 5.1 kg/m2. Of the participants, 40% reported significantly symptomatic psychological distress (YP-Core score ≥14) and 16% were at risk of eating disorders (ChEAT score ≥20). A higher YP-Core score was the only significant determinant of poorer HRQoL, after controlling for demographic variables and ChEAT scores. Malay (regression coefficient: 6.6, 95% confidence interval [CI]: 0.6-12.6, P = 0.031) and Indian (regression coefficient: 8.9, 95% CI: 3.8-14.0, P = 0.001) adolescents were more likely to report disordered eating and psychological distress, respectively, as compared to Chinese adolescents. Adolescents whose parent(s) had obesity (regression coefficient: 3.4, 95% CI: 0.1-6.7, P = 0.043) were also more likely to experience greater psychological distress.

Conclusion: Understanding the determinants of psychological distress, disordered eating and HRQoL will facilitate targeted screening and management of the psychosocial complications of adolescent obesity.

Introduction: One in three Singaporeans is at risk of developing DM (DM) in their lifetime. The majority of those with DM experience other comorbidities that often affect the course of their DM. This study explored: (a) the prevalence of DM-related complications, (b) their sociodemographic correlates, and (c) their association with health-related quality of life (HRQOL).

Methods: Participants with DM (n = 387) were recruited from a population-based survey. Type 2 DM was self-reported as diagnosed by a doctor. The DM-related complications and comorbidities were assessed using the DM knowledge questionnaire and chronic conditions checklist. Short-Form health survey was used to examined HRQOL. Multiple logistic regressions were performed to examine the association between DM-related complications and sociodemographic factors and body mass index. Multiple linear regressions examined the association of complications with HRQOL.

Results: Approximately 31.6% of the participants had DM-related complications. The top three complications were nephropathy (54.4%), neuropathy (42.2%) and retinopathy (40.8%). Younger participants (aged 18-49 years) and those with higher education were less likely to develop DM-related complications. Physical HRQOL was adversely affected in participants with any chronic condition, DM for 4-9 years, DM-related neuropathy, lower leg/foot ulcers and gangrene. Mental HRQOL was adversely affected by gangrene. Younger participants had better physical HRQOL.

Conclusion: Physical HRQOL is adversely affected when individuals develop DM-related complications. Understanding the sociodemographic corelates of DM-related complications could aid clinicians in identifying and assisting at-risk populations to prevent adverse outcomes. Educating individuals on the risk of developing DM-related complications could encourage better DM management.

Introduction: The last national emergency department (ED) inventory was performed in 2007, and major changes in population demographics, healthcare needs and infrastructure have since occurred. We sought to obtain an updated inventory of EDs in Singapore to identify and describe changes in their characteristics and capabilities across the years.

Methods: In 2021, the National Emergency Department Inventories (NEDI) instrument was administered to the leadership of Singapore EDs. Emergency departments in Singapore are opened round the clock, have no restrictions on who can access care and are equipped to handle general medical emergencies. The questionnaire comprises 16 items across three categories: (a) general characteristics, (b) patient volume and (c) medical capabilities.

Results: We achieved 100% response rate from all 17 EDs - nine EDs in public hospitals and eight in private hospitals. In 2021, the EDs saw a total of 1,140,388 visits, an increase of 27% from 2007, with the median number of visits almost doubling (from 39,450 to 77,989); 41% and 59% of the EDs reported over 20% of visits arriving by ambulance and over 20% of visits resulting in inpatient admission, respectively. A clear distinction between public and private EDs across these metrics remained. Medical capabilities grew: 59% had access to a dedicated computed tomography scanner (up from 46%) and 82% had negative pressure isolation facilities (up from 54%). Overall, 41% of EDs self-assessed to be operating above their capacity.

Conclusion: Singapore EDs have progressed in capabilities and capacity. Despite this, the increasing volume, complexity and acuity of patients are imposing strains on the emergency care system, signalling potential for systems improvement.