Singapore medical journal最新文献

Introduction: The effects of emergency department (ED) transition care programmes on health-related quality of life (HRQoL) remain underexplored. This single-centre study examined the changes in HRQoL following the implementation of the Case management for At-Risk patients in the ED (CARED) programme, explored associations with frailty and identified factors linked to low HRQoL.

Methods: A quasi-experimental pre-post design was employed. Participants were recruited from the ED over 6 months as part of the CARED programme. At intake, trained case managers verified demographic and medical details and conducted a comprehensive geriatric assessment incorporating the Clinical Frailty Scale (CFS; version 2.0). The EQ-5D-5L was administered at baseline and repeated 3 months post-CARED. Analyses included the chi-square test, Mann-Whitney U test, Wilcoxon signed-rank test and logistic regression (α = 0.05).

Results: The final sample comprised 151 participants (mean age 77.4 ± 6.9 years; 75.5% female). Most (80.1%) had no-to-mild frailty, while 19.9% exhibited moderate-to-very severe frailty. Post-CARED, significant within-group improvements were observed in the overall cohort and those with no-to-mild frailty across EQ-5D-5L scores and domains (P < 0.001), whereas improvements among individuals with greater frailty were limited. Between-group comparisons showed significantly poorer baseline and follow-up HRQoL among those with greater frailty, particularly in mobility, self-care and usual activities (P < 0.05). Logistic regression identified male sex as the sole independent risk factor for low post-CARED EQ-5D-5L index scores (adjusted odds ratio 3.14, 95% confidence interval 1.40, 7.00).

Conclusion: The CARED programme was associated with improved HRQoL, particularly among less frail individuals, while male participants had a three-fold higher likelihood of low post-intervention HRQoL.

Abstract: By examining key milestones, challenges and future directions, this review chronicles the evolution of clinical toxicology in Singapore into a recognised subspeciality and thriving community of practice. Poisoning trends have transitioned alongside socioeconomic changes from agricultural toxins to pharmaceuticals, substance misuse and prescription drugs. Currently, toxicology services have expanded across public hospitals, offering 24/7 consultations and managing selected cases in short-stay observation units to optimise resources. Singapore's hazardous material (HazMat) preparedness includes specialised HazMat Medical Life Support training, antidote and personal protective equipment (PPE) stockpiling, and deployment of semi-automated decontamination facilities. Research has focused on case reports and description of local poisoning epidemiology. Toxicology has also been integrated into nursing, undergraduate medical and residency curricula, with a national fellowship programme in the pipeline. Challenges include the latent HazMat threat, rising burden of poisoning cases, continual evolution of synthetic drugs and occupational hazards from emerging industries. Future directions should emphasise interdisciplinary collaboration, regional partnerships and leveraging artificial intelligence and toxicogenomics to enhance care.

Introduction: Diabetes mellitus (DM) is closely associated with pancreatic cancer. We aimed to describe the prevalence of pancreatic cancer among patients with DM in Singapore, compare their profiles and identify variables associated with pancreatic cancer in this population.

Methods: We conducted a case-control study using data from a multi-institutional diabetes registry in Singapore from 2013 to 2019. Subjects with pancreatic cancer were identified and matched with cancer-free controls. Data such as demographics, clinical parameters, laboratory results, medications and comorbidities were analysed. Logistic regression was used to identify variables associated with pancreatic cancer.

Results: A total of 1079 subjects with pancreatic cancer were identified. Pancreatic cancer was the seventh most common cancer, with a prevalence of 0.45%, and accounted for 7.5% of all cancers in patients with DM. Independent variables associated with higher odds of pancreatic cancer were insulin use (odds ratio [OR] 7.60; 95% confidence interval [CI] 5.63-10.40; P < 0.001), absence of hyperlipidaemia (OR 2.08, 95% CI 1.32-3.33; P = 0.002), absence of cardiovascular disease (OR 1.43; 95% CI 1.09-1.89; P = 0.012), higher haemoglobin A1c (OR 1.15; 95% CI 1.06-1.23; P < 0.001), shorter DM duration (OR 0.98; 95% CI 0.96-0.99; P = 0.002) and lower body mass index (OR 0.92; 95% CI 0.89-0.94; P < 0.001).

Conclusion: Patients with DM and pancreatic cancer had poorer DM control, lower body mass index, a lower prevalence of hypertension, hyperlipidaemia and micro- and macrovascular complications, and higher insulin use compared with matched controls.

Abstract: Over the last decade, the use of e-cigarettes (colloquially known as 'vaping') has risen sharply worldwide. Although e-cigarettes were initially promoted in some countries as a tool for nicotine replacement and restricted in others due to concerns about potential misuse, there is now growing concern over drug-laced e-cigarettes containing illicit substances such as etomidate, ketamine, heroin and methamphetamine, which pose serious public health risks. In Singapore, there has been a rise in the consumption of drug-laced e-cigarettes (also referred to as 'Kpods', 'zombie vapes' or 'space oil'), predominantly affecting young people in the community. In this review, we sought to provide practical guidance for frontline clinicians in the identification and management of suspected cases of drug-laced e-cigarette use and its associated medical complications. We also highlight the current preventative and mitigating strategies adopted by the government to address this public health epidemic.

Introduction: Anaemia frequently coexists in patients with aortic stenosis (AS). Several mechanisms, such as multiple comorbidities, haemolysis and acquired coagulopathy, have been postulated. We aimed to address the knowledge gap regarding survival outcomes of Southeast Asians patients with AS and anaemia.

Methods: Six hundred and fifty-one consecutive patients in a tertiary academic centre with index echocardiographic diagnosis of AS were stratified into three groups based on haemoglobin (Hb) levels. Baseline demographics, comorbidities, echocardiographic findings and clinical outcomes were compared.

Results: Of the 651 patients with AS, 256 had mild anaemia (mean Hb 11.2 g/dL, standard deviation [SD] ± 0.8), 122 patients had moderate-severe anaemia (Hb 8.7 ± 1.2 g/dL) and 273 patients had no anaemia (Hb 13.8 ± 1.3 g/dL). Patients with more severe anaemia presented with higher-grade New York Heart Association IV symptoms ( P = 0.002). More profound degrees of anaemia were independent predictors of increased all-cause mortality (mild anaemia: adjusted hazard ratio (aHR) 1.84, 95% confidence interval [CI] 1.42-2.39, P < 0.001; moderate/severe anaemia: aHR 2.77, 95% CI 2.00-3.82, P < 0.001) and increased composite endpoints (mild anaemia: aHR 1.25, 95% CI 1.01-1.55, P = 0.047; moderate/severe anaemia: aHR 1.33, 95% CI 1.33-1.76, P < 0.001) compared to no anaemia. Anaemia was a significant effect modifier of aortic valve replacement on all-cause mortality in AS on the additive scale (relative excess risk due to interaction 2.16, 95% CI 0.21-4.54, P = 0.04).

Conclusion: Anaemia in AS was associated with worse symptomology, all-cause mortality and composite endpoints of cardiovascular outcomes in Southeast Asian patients.

Introduction: Upper extremity (UE) impairment is common after stroke. In a cohort of stroke survivors, we sought to evaluate UE impairment before and after rehabilitation, correlate UE impairment with performance of UE-dependent activities of daily living (ADL) and establish the clinical factors associated with UE impairment.

Methods: This is a retrospective review of the data of stroke survivors admitted to a rehabilitation centre in Singapore over a 1-year period. Outcome measures included Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Functional Independence Measure-ADL (FIM-ADL). Based on the FMA-UE score, upper limb function was classified into 'no to poor', 'limited', 'notable' or 'full' arm-hand capacity.

Results: A total of 259 stroke survivors with a mean age of 62.9 ± 12.3 years were studied. Significant improvements were noted in FMA-UE and FIM-ADL scores after rehabilitation (P < 0.01). Of the 135 (52.1%) stroke survivors with no to poor arm-hand capacity, only 32 (23.7%) had good UE outcome, defined as improvement to notable or full arm-hand capacity. Of the stroke survivors with limited arm-hand capacity, 72.2% achieved good UE outcome. Better cognition, less severe stroke and better truncal balance were associated with higher admission FMA-UE scores.

Conclusion: Significant improvements in UE impairment and related UE-dependent ADL were noted after inpatient rehabilitation. The findings of this study can serve as a guide in educating stroke survivors and caregivers on expected UE outcomes and caregiving needs upon discharge from rehabilitation.

Introduction: The clinical outcomes of open-wedge high-tibial osteotomy (HTO) combined with bone marrow stimulation techniques (BMSTs) (microfracture [MF], subchondral drilling [SD], microdrilling [MD] and abrasion arthroplasty[AA]) in patients with knee osteoarthritis are unclear. The aim of this systematic review was to present an up-to-date summary of the clinical outcomes associated with HTO combined with BMST in patients with knee osteoarthritis.

Methods: A systematic database search on PubMed, Embase, Web of Science, and CINAHL was performed from inception up to 3 March 2024 in accordance with the PRISMA guideline. A narrative synthesis was undertaken to complement the quantitative analysis done.

Results: A total of 11 studies involving 516 patients were included. Six studies reported HTO with MF, one reported HTO with SD, two reported HTO with MD, one reported HTO with AA, and one reported HTO with chondral resurfacing. The average mean follow-up period was 33 months (range 12-120). Overall, most of the studies reported an improvement in cartilage regeneration and clinical scores above the minimal clinically important difference.

Conclusion: While HTO with BMST shows good clinical outcomes and postoperative cartilage regeneration, the reported outcomes are highly heterogeneous. More comparative studies are needed to establish whether HTO with BMST should be recommended over isolated HTO in practice.

Introduction: Deprescribing antihypertensives is recommended when the treatment risks outweigh benefits, but evidence on the long-term outcomes in real-world multimorbidity populations remains limited. This study examined the clinical effects of deprescribing antihypertensives on blood pressure (BP) control and safety outcomes at 3 and 12 months of follow-up.

Methods: From January 2021 to December 2022, we conducted a retrospective review of 108 polyclinic patients aged ≥60 years who had antihypertensives deprescribed. The primary outcome was the proportion of patients who remained within individualised BP targets. Secondary outcomes were maintenance of deprescribing and changes in absolute BP, number of antihypertensives and pill count. Safety outcomes assessed included giddiness, postural hypotension, falls and hospital admissions.

Results: Among the 108 patients (mean age 77.3 years, 54.6% female, 80.6% Chinese), 93.5% and 69.4% maintained deprescribing at 3 and 12 months, respectively. There was no difference in the proportion who remained within BP targets at 12 months (86.1% vs. 94.4%, P = 0.0636) despite an initial decrease in the proportion at 3 months (74.1% vs. 94.4%, P < 0.0001). Systolic BP increased from a baseline of 124.2 mmHg to 133.9 mmHg at 3 months, stabilising at 133.5 mmHg by 12 months. The proportion with postural hypotension decreased ( P = 0.0009), while giddiness ( P = 0.0872) and falls ( P = 0.2100) showed no difference at 12 months. Hospital admissions increased marginally in the study population ( P = 0.0490) but not in the subgroup that maintained deprescribing.

Conclusion: There was no difference in BP control at 12 months after deprescribing despite a transient decline at 3 months. This supports the feasibility of deprescribing antihypertensives in older adults in primary care. Further research is needed to evaluate the safety outcomes in larger populations with specific cardiovascular comorbidities.