Singapore medical journal最新文献

Introduction: Perioperative hypothermia (PH) is common in children and associated with adverse clinical outcomes. Guidelines to prevent PH are mainly developed for adults and differ among institutions. We aimed to evaluate the effectiveness of customised guidelines in reducing PH in our paediatric population and the impact of cost considerations on physician practice.

Methods: Patients aged ≤16 years undergoing general anaesthesia in our tertiary paediatric hospital were prospectively recruited in this cohort study. Patient demographics, surgical procedures, anaesthesia details and temperature control measures were recorded. Data collection occurred over four phases: Phases 1 and 2 comprised standard management, while Phases 3 and 4 occurred following guidelines implementation. Sensors for continuous core temperature monitoring were provided free to patients during Phases 1 and 3, but were charged during Phases 2 and 4. The main outcome was occurrence of PH, defined as core temperature <36°C at any point from induction of anaesthesia to discharge from the postanaesthetic care unit. The impact of guidelines implementation and cost considerations influencing physician practice on PH outcomes was also analysed.

Results: Data from 3917 patients was analysed (1766 in Phase 1, 679 in Phase 2, 706 in Phase 3 and 766 in Phase 4). Guidelines implementation decreased PH incidence from 11.0% to 6.79% (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.50-0.80, P = 0.0002). Free sensors increased the odds of detecting PH (OR 1.48, 95% CI 1.17-1.88, P = 0.001). With guidelines implementation, there was greater reduction in PH with free sensors (OR 0.64, 95% CI 0.47-0.88, P = 0.0055) compared to chargeable sensors (OR 0.75, 95% CI 0.50-1.11, P = 0.1471).

Conclusions: Customised guidelines facilitated a sustained reduction of hypothermia in our paediatric surgical patients, although its impact was reduced by cost considerations.

Introduction: The anion gap (AG) is commonly used to screen for acid-base disorders. It was proposed that the cut-off for high anion gap metabolic acidosis (HAGMA) may be lower with current laboratory techniques, although modern laboratory equipment are still calibrated to familiar reference ranges established with earlier techniques. The appropriate cut-off for HAGMA is unclear. This study aimed to assess the performance of AG as a screening test for HAGMA and to determine the optimal diagnostic threshold of AG for HAGMA.

Methods: This was a retrospective analysis of a large, anonymised dataset extracted by computerised protocol from 2017 to 2019. All inpatients with blood samples taken for organic acids (lactate, ketone or salicylate) paired with a metabolic panel were included. The target condition was HAGMA secondary to elevated blood lactate, ketone and/or salicylate. Sensitivity for HAGMA was explored at various AG cut-off levels.

Results: Of 16,475 patients, 2,621 had organic acidosis. Median age was 65 years, and median estimated glomerular filtration rate was 70 mL/min/1.73 m2. With organic acidosis, the median AG was 23 (interquartile range [IQR] 20-29) mEq/L, while without organic acidosis, the median AG was 16 (IQR 14-19) mEq/L. The area under the curve-receiver operating characteristic of AG for HAGMA was 0.873. Desired sensitivity for HAGMA was set at ≥95%, and this was found with an AG threshold of ≥15 mEq/L (sensitivity 98.1%, specificity 34.0%).

Conclusion: The recommended AG threshold value is ≥15 mEq/L with a high sensitivity for HAGMA. The AG should always be interpreted with the clinical context, and it should be repeated as the clinical picture evolves.

Abstract: Overexpression of human epidermal growth factor receptor 2 (HER2) protein in breast cancers carries significant prognostic and therapeutic implications. Anti-HER2 blockade has shown to be a useful adjunct to surgery in treating HER2-positive tumours. Up till today, the HER2 immunohistochemistry (IHC) and in situ hybridisation (ISH) scoring algorithms are geared towards identifying HER2-positive cases. A recently published Phase III clinical trial (DESTINY-Breast04) has demonstrated that an antibody-drug conjugate (trastuzumab-deruxtecan) significantly reduced disease progression and death in patients with metastatic disease with IHC score 1+ or 2+ and without ISH amplification, defining a new category of cases known as HER2 low. At present, IHC scores 0, 1+ and 2+ show significant interobserver variability, and identifying HER2-low breast cancers may pose significant challenges with the current algorithms. More work is needed in this area to better define HER2-low breast cancers, target the appropriate group of patients and assess treatment efficacy.

Abstract: Due to the narrow window of opportunity for stroke therapeutics to be employed, effectiveness of stroke care systems is predicated on the efficiency of prehospital stroke systems. A robust prehospital stroke system of care that provides a rapid and well-coordinated response maximises favourable poststroke outcomes, but achieving this presents a unique set of challenges dependent on demographic and geographical circumstances. Set in the context of a highly urbanised first-world nation with a rising burden of stroke, Singapore's prehospital stroke system has evolved to reflect the environment in which it operates. This review aims to characterise the current state of prehospital stroke care in Singapore, covering prehospital aspects of the stroke survival chain from symptom onset till arrival at the emergency department. We identify areas for improvement and innovation, as well as provide insights into the possible future of prehospital stroke care in Singapore.