Application of legal principles and medical ethics: multifetal pregnancy and fetal reduction

In the management of complex medical cases such as a multifetal pregnancy, knowledge of the ethical and legal implications is important, alongside having competent medical skills. This article reviews these principles and applies them to scenarios of multifetal pregnancy and fetal reduction. Such a discussion is not solely theoretical, but is also relevant to clinical practice. The importance of topics such as bioethical principles and informed consent are also herein addressed.     

Clinics in diagnostic imaging (154). Carbon monoxide (CO) poisoning.

A 59-year-old man with a history of major depression was found by his wife to be unconscious and foaming at the mouth. On arrival at the emergency department, the patient was noted to be unresponsive. Computed tomography of the brain showed symmetrical ill-defined areas of hypoattenuation involving the medial aspects of both lentiform nuclei, while magnetic resonance images of the brain showed symmetrical increased signal in the bilateral globi pallidi on diffusion weighted, T2-weighted and fluid attenuated inversion recovery sequences. These findings were those of acute carbon monoxide poisoning. Despite aggressive treatment, the patient’s condition continued to deteriorate and he eventually passed away. The various imaging findings of carbon monoxide poisoning in the brain and the differential diagnoses are discussed.     

Novel oral anticoagulants for atrial fibrillation

Anticoagulation therapy is effective in preventing primary and secondary thromboembolic events due to atrial fibrillation. Warfarin, which was approved by the United States in 1954, was the only long-term oral anticoagulation therapy till the approval of dabigatran in 2010, and of rivaroxaban and other direct factor Xa inhibitors from 2011, forming a group known as novel oral anticoagulants (NOAC). NOAC have fewer food and drug interactions compared to warfarin; hence, the patient will require fewer clinic visits. However, the short half-life of NOAC means that twice-a-day dosing is needed and there is higher risk of a prothrombotic state when doses are missed. Other disadvantages are the lack of long-term data on NOAC, their high cost and the current lack of locally available antidotes.     

Assessment of the effect of probiotic curd consumption on salivary pH and streptococcus mutans counts

Background:

Antimicrobial methods of controlling dental caries that include probiotic agents can play a valuable role in establishing caries control in children at moderate to high risk for developing dental caries. Several studies have demonstrated the beneficial effects of use of various Probiotic products including curd. The objective of this study was to compare the effect of short-term consumption of probiotic curd containing Lactobacillus acidophilus and normal curd on salivary Streptococcus Mutans counts, as well as salivary pH.

Materials and Methods:

Forty, caries-free, 10-12 years old children were selected and randomly allocated to two groups. Test Group consisted of 20 children who consumed 200ml of probiotic curd daily for 30 days. Control Group consisted of 20 children who were given 200ml of regular curd for 30 days. Salivary pH and salivary Streptococcus Mutans counts were recorded at baseline and after 30 days and statistically compared using the Student''s t-test.

Results:

Consumption of probiotic curd resulted in a statistically significant reduction in S. Mutans colony counts (P<0.001) as compared to regular curd. However, there was a slight reduction in pH (P>0.05) in both the groups.

Conclusion:

Short-term consumption of probiotic curds can reduce oral S. Mutans counts. However, this caused a slight reduction in salivary pH.     

Challenges in the management of a rare case of extensive retroperitoneal haemangioma in a pregnant woman

Haemangioma of the retroperitoneal space is a rare benign capillary malformation, which can grow significantly in pregnancy due to the multiple associated cardiovascular changes. We herein describe the case of a pregnant woman with an extensive right retroperitoneal haemangioma extending from the level of the renal hilum, across the lateral anterior abdominal wall and into the thigh. We also highlight the challenges faced in the management of the patient’s delivery process. To the best of our knowledge, this is the first case of such nature and severity described in the English literature.     

Prevalence of faecal incontinence in the community: a cross-sectional study in Singapore

INTRODUCTION

Faecal incontinence (FI) is a stigmatised condition that remains a silent affliction for many populations. To date, no local study has been performed to determine its prevalence in our population. The existing literature from the West has shown highly variable rates, ranging from 0.8% to 18.0%. The aim of this study was to determine the cross-sectional prevalence of FI in Singapore and to identify at-risk groups.

METHODS

A door-to-door questionnaire survey was performed between February and March 2013. We randomly selected 1,000 individuals from the electoral roll to be surveyed using the validated Comprehensive Fecal Incontinence Questionnaire.

RESULTS

A total of 381 participants agreed to be enrolled in the study. The mean age of the participants was 52 (range 21–86) years, and slightly more than half of the participants were female (52.8%). Among the female participants, 73.1% had children (78.8% underwent normal vaginal delivery). The overall prevalence of FI in our study population was 4.7%. The prevalence of FI was observed to be significantly associated with increasing age (p = 0.004) and female gender (p = 0.029); women were three times more likely to suffer from FI than men.

CONCLUSION

With the ageing population of Singapore, the results of the present study provide further impetus to continue public outreach efforts as well as develop clinical programmes that address the growing need for specialist treatments for people with FI.     

A review of oral food challenges in children presenting to a single tertiary centre with perceived or true food allergies

INTRODUCTION

The prevalence of perceived food allergies exceeds that of true food allergies. Unnecessary food avoidance may increase parental and patient anxiety, reduce quality of life and increase the risk of nutritional deficiency. An oral food challenge (OFC) can provide an objective measure regarding the presence or absence of food allergies in a child. This study reviews the indications for and outcomes of OFCs performed on children.

METHODS

A retrospective review was performed on all children who underwent OFCs at the Allergy Unit of the National University Hospital, Singapore, over a three-year period.

RESULTS

A total of 197 OFCs were performed among 58 patients (34 male, 24 female). Most of the tests were for allergies to tree nuts (n = 107). Among the OFCs, 43.1% were for foods that were avoided and never eaten due to perceived food allergies, 25.9% were for foods that had previously resulted in positive skin prick tests (SPTs) and/or immunoassay results, 16.2% were for foods thought to worsen eczema and 14.7% were for foods thought to have caused a previous reaction. Of all the OFCs, 5% were positive, although adverse reactions were mostly cutaneous. Challenge-positive patients had either positive SPTs (wheal > 3 mm) or raised serum immunoglobulin E levels to specific foods that they reacted to during the challenges. No episodes of anaphylaxis were reported after the challenge. Most of the patients were able to safely introduce the avoided foods into their diets.

CONCLUSION

OFCs provide an objective assessment for suspected food allergies.     

Leptospirosis in pregnancy with pathological fetal cardiotocography changes

We report the case of a 33-year-old primigravida who presented at 37 weeks of gestation with symptoms suggestive of acute fatty liver of pregnancy, but was later diagnosed with leptospirosis (i.e. Weil''s disease or syndrome) on serological testing. Cardiotocography showed fetal distress, and an emergency Caesarean section was performed. A healthy neonate with no evidence of congenital leptospirosis was delivered. The patient was treated with intravenous ceftriaxone and discharged well 13 days after admission. Herein, we discuss the patient''s clinical presentation and the cardiotocography changes observed in leptospiral infection, and review the current literature.     

Prevalence of dysglycaemic events among inpatients with diabetes mellitus: a Singaporean perspective

INTRODUCTION

As the effectiveness of intensive glycaemic control is unclear and recommended glycaemic targets are inconsistent, this study aimed to ascertain the prevalence of dysglycaemia among hospitalised patients with diabetes mellitus in an Asian population and evaluate the current standards of inpatient glycaemic control.

METHODS

A retrospective observational study was conducted at a secondary hospital. Point-of-care blood glucose (BG) values, demographic data, medical history, glycaemic therapy and clinical characteristics were recorded. Dysglycaemia prevalence was calculated as proportions of BG-monitored days with at least one reading exceeding the cut points of 8, 10 and 15 mmol/L for hyperglycaemia, and below the cut point of 4 mmol/L for hypoglycaemia.

RESULTS

Among the 288 patients recruited, hyperglycaemia was highly prevalent (90.3%, 81.3% and 47.6% for the respective cut points), while hypoglycaemia was the least prevalent (18.8%). Dysglycaemic patients were more likely than normoglycaemic patients to have poorer glycated haemoglobin (HbA1c) levels (8.4% ± 2.6% vs. 7.3% ± 1.9%; p = 0.002 for BG > 10 mmol/L) and longer lengths of stay (10.1 ± 8.2 days vs. 6.8 ± 4.7 days; p = 0.007 for BG < 4 mmol/L). Hyperglycaemia was more prevalent in patients on more intensive treatment regimens, such as basal-bolus combination therapy and the use of both insulin and oral hypoglycaemic agents (100.0% and 96.0%, respectively; p < 0.001 for BG > 10 mmol/L).

CONCLUSION

Inpatient glycaemic control is suboptimal. Factors (e.g. type of treatment regimen, discipline and baseline HbA1c) associated with greater prevalence of dysglycaemia should be given due consideration in patient management.     

An unusual presentation of recurrent uterine rupture during pregnancy

We describe a case of recurrent uterine rupture at the site of a previous rupture. Our patient had a history of right interstitial pregnancy with spontaneous uterine fundal rupture at 18 weeks of pregnancy. During her subsequent pregnancy, she was monitored closely by a senior consultant obstetrician. The patient presented at 34 weeks with right hypochondriac pain. She was clinically stable and fetal monitoring showed no signs of fetal distress. Ultrasonography revealed protrusion of the intact amniotic membranes in the abdominal cavity at the uterine fundus. Uterine rupture is a rare but hazardous obstetric complication. High levels of caution should be exercised in patients with a history of prior uterine rupture, as they may present with atypical symptoms. Ultrasonography could provide valuable information in such cases where there is an elevated risk of uterine rupture at the previous rupture site.     

Adverse effects of young maternal age on neonatal outcomes

INTRODUCTION

Teenage pregnancy is associated with poor neonatal outcomes, which may burden the young mothers and their families. The aim of this study was to determine the effect young maternal age and single motherhood has on neonatal outcomes.

METHODS

We conducted a retrospective cohort study of 267 infants born to mothers aged ≤ 21 years in National University Hospital, Singapore, from January 2011 to December 2012. We compared the maternal demographics and neonatal outcomes of single mothers with those of married mothers. The neonatal outcomes of our study cohort were also compared to the hospital’s birth cohort during the same period.

RESULTS

Unsatisfactory antenatal care was more prevalent among the young single mothers than among the young married mothers (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.71–4.92, p < 0.01). The infants of the young single mothers had a lower mean birth weight (p = 0.01), with a significant proportion weighing < 2.5 kg (OR 2.91, 95% CI 1.35–6.37, p < 0.01). Young maternal age was linked to a higher incidence of prematurity (OR 1.70, 95% CI 1.18–2.43, p < 0.01), major congenital defects (OR 4.68, 95% CI 2.10–10.13, p < 0.01), and a perinatal mortality of 18.7 per 1,000 births (OR 3.76, 95% CI 1.26–10.32, p = 0.02).

CONCLUSION

Young single mothers were more likely to have unsatisfactory antenatal care and lighter infants. Young maternal age was associated with a higher risk of prematurity, major congenital malformations and perinatal mortality. More studies are needed to ascertain the cause of these adverse outcomes.     

Prevalence of abnormal liver function tests and comorbid psychiatric disorders among patients with anorexia nervosa and eating disorders not otherwise specified in the anorexia nervosa DSM-IV criteria

INTRODUCTION

Anorexia nervosa (AN) and eating disorders not otherwise specified (EDNOS) are on the rise in Singapore. Abnormal liver function tests have been reported for up to 12.2% of patients with AN. These patients are also known to present with comorbid psychiatric disorders. This study aims to investigate the correlation between body mass index (BMI) and the severity of abnormal liver function tests, and between BMI and the presence of comorbid psychiatric disorders.

METHODS

A retrospective cohort analysis of 373 patients diagnosed with AN or EDNOS at a tertiary hospital was performed. The clinical course of transaminitis and comorbid psychiatric disorders was correlated with the patient’s BMI.

RESULTS

Patients with a BMI of ≥ 16.6 kg/m² at their first consult had a significantly lower risk of having comorbid psychiatric disorders (χ² = 32.08, p < 0.001). These patients were five times less likely to have comorbid psychiatric disorders as compared to patients from the other BMI groups (odds ratio [OR] 0.21). On the other hand, patients with a BMI of < 14.6 kg/m² had a significantly higher risk of having transaminitis (χ² = 72.5, p < 0.001). They were 11.1 times more likely to develop transaminitis as compared to patients with a BMI of ≥ 14.6 kg/m² (OR 11.05).

CONCLUSION

Severity of BMI can be used by clinicians as an indicator to assess for secondary psychiatric comorbidities and/or transaminitis during the first consultation. This could help reduce the morbidity and mortality rates in patients with AN or EDNOS.     

Effect of GnRH antagonists on clinical pregnancy rates in ovulation induction protocols with gonadotropins and intrauterine insemination

INTRODUCTION

Intrauterine insemination (IUI) after controlled ovarian hyperstimulation (COH) was applied to selected infertile patients to determine the effect of gonadotropin-releasing hormone (GnRH) antagonists in IUI cycles, in which recombinant follicle-stimulating hormone (rFSH) had been used for COH.

METHODS

This study was conducted between April 1, 2009 and June 10, 2009, and involved a total of 108 patients. These patients had primary or secondary infertility, which resulted in an indication for IUI, and they each received two cycles of ovarian stimulation treatment with clomiphene citrate. The patients were randomised into two groups – patients in group A received rFSH + GnRH antagonist (n = 45), while those in group B received only rFSH (n = 63).

RESULTS

The mean age of the patients was 31.84 ± 3.73 years and the mean body mass index (BMI) was 24.40 ± 1.88 kg/m². The mean age and BMI of the patients in groups A and B were not significantly different. There was no significant difference in the mean total rFSH dose administered (988.33 IU in group A and 871.83 IU in group B). When compared to group B, the mean number of follicles that were > 16 mm on the human chorionic gonadotropin (HCG) trigger day was significantly higher in group A (1.58 and 1.86, respectively; p < 0.05). When the two groups were compared, there were no statistically significant differences in the number of cancelled cycles due to premature luteinisation (none in group A vs. two in group B) and the rate of clinical pregnancy (8.9% in group A vs. 7.9% in group B).

CONCLUSION

No significant improvement in the clinical pregnancy rates was observed when GnRH antagonists were used in COH + IUI cycles, despite the significant increase in the number of follicles that were > 16 mm on HCG trigger day.     

Prevalence of obesity and its associated risk factors among Chinese adults in a Malaysian suburban village

INTRODUCTION

Obesity is a major modifiable risk factor associated with most chronic diseases. The aim of this study was to determine the prevalence of obesity, and its associated risk factors, among apparently healthy Chinese adults in a Malaysian suburban village.

METHODS

This was a cross-sectional study conducted among the Chinese residents in Seri Kembangan New Village, Klang Valley, Selangor, Malaysia. Convenience sampling was used for the selection of participants. Body weight, height, waist and hip circumferences, and blood pressure were measured. Fasting venous plasma was drawn for the measurement of fasting glucose level and lipid profile. Data on sociodemographic factors, dietary habits, physical activity, perceived stress level and sleep duration were collected using interviewer-administered, pretested and validated questionnaires.

RESULTS

Among the 258 Chinese residents (mean age 41.4 ± 10.0 years) recruited, the prevalence of obesity was 40%. The obese participants had significantly higher mean blood pressure, and triglyceride and fasting plasma glucose levels than the non-obese participants (p < 0.05). The obese participants also had a significantly lower high-density lipoprotein cholesterol level than the non-obese participants. Logistic regression analysis showed that drinking soy milk (adjusted odds ratio [OR] 0.447; 95% confidence interval [CI] 0.253–0.787; p < 0.05) and the perception that a balanced diet consists mainly of vegetables (adjusted OR 0.440; 95% CI 0.215–0.900; p < 0.05) were associated with a reduced risk of obesity. The risk of obesity was higher in younger participants (adjusted OR 2.714; 95% CI 1.225–6.011; p < 0.05).

CONCLUSION

The prevalence of obesity was high among the apparently healthy suburban Chinese. Our findings suggest that soy milk consumption and the perception that a balanced diet consists mainly of vegetables are associated with a lower risk of developing obesity in this population.     

High-grade culprit lesions are a common cause of ST-segment elevation myocardial infarction

INTRODUCTION

Conventional knowledge holds that the majority of ruptured atherosclerotic plaques causing ST-segment elevation myocardial infarction (STEMI) are found in moderate stenoses that produce < 50% loss of arterial diameter. This study aimed to analyse the culprit lesions in patients who presented with STEMI and underwent primary percutaneous coronary intervention (PPCI) at our institution.

METHODS

Patients who underwent PPCI between June 2008 and August 2010 at our institution were included in the analysis. Quantitative coronary angiography was performed for the culprit lesions immediately after antegrade flow was restored by thrombectomy, low-profile balloon predilatation or guidewire crossing.

RESULTS

A total of 1,021 patients were included in the study. The mean age was 57 ± 12 years and 85.2% were male. Lesion measurement was done after coronary flow was restored by thrombectomy (73.1%), balloon dilatation (24.1%) and following guidewire passage across the lesion (2.8%). Mean minimal luminal diameter was 1.1 ± 0.5 mm, mean reference vessel diameter was 2.8 ± 0.6 mm, mean diameter stenosis was 61 ± 16% and mean lesion length was 16 ± 6 mm. Most (80.2%) of the culprit lesions had diameter stenoses > 50% (p < 0.01). Although balloon angioplasty was performed in 24.1% of the patients, the majority (64.2%) still had diameter stenoses > 50%. High-grade stenoses (> 50%) were more frequently observed in male patients (p = 0.04).

CONCLUSION

Contrary to the existing paradigm, we found that most of the patients with STEMI in our institution had culprit lesions with diameter stenosis > 50%.     

Application of a standardised protocol for hepatic venous pressure gradient measurement improves quality of readings and facilitates reduction of variceal bleeding in cirrhotics

INTRODUCTION

Hepatic venous pressure gradient (HVPG) measurement is recommended for prognostic and therapeutic indications in centres with adequate resources and expertise. Our study aimed to evaluate the quality of HVPG measurements at our centre before and after introduction of a standardised protocol, and the clinical relevance of the HVPG to variceal bleeding in cirrhotics.

METHODS

HVPG measurements performed at Singapore General Hospital from 2005–2013 were retrospectively reviewed. Criteria for quality HVPG readings were triplicate readings, absence of negative pressure values and variability of ≤ 2 mmHg. The rate of variceal bleeding was compared in cirrhotics who achieved a HVPG response to pharmacotherapy (reduction of the HVPG to < 12 mmHg or by ≥ 20% of baseline) and those who did not.

RESULTS

126 HVPG measurements were performed in 105 patients (mean age 54.7 ± 11.4 years; 55.2% men). 80% had liver cirrhosis and 20% had non-cirrhotic portal hypertension (NCPH). The mean overall HVPG was 13.5 ± 7.2 mmHg, with a significant difference between the cirrhosis and NCPH groups (p < 0.001). The proportion of quality readings significantly improved after the protocol was introduced. HVPG response was achieved in 28 (33.3%, n = 84) cirrhotics. Nine had variceal bleeding over a median follow-up of 29 months. The rate of variceal bleeding was significantly lower in HVPG responders compared to nonresponders (p = 0.025).

CONCLUSION

The quality of HVPG measurements in our centre improved after the introduction of a standardised protocol. A HVPG response can prognosticate the risk of variceal bleeding in cirrhotics.     

口腔扁平苔藓患者心理因素与唾液脱氢表雄酮水平的关联性分析

目的: 分析口腔扁平苔藓(OLP)患者的焦虑、抑郁心理量表评分与唾液脱氢表雄酮(DHEA)水平的关系,阐明二者之间的关联性。 方法: 对71例OLP患者 [其中充血糜烂型OLP(EOLP)患者31例,非EOLP患者40例]和31例对照组受试者采用汉密尔顿焦虑量表(HAMA)和汉密尔顿抑郁量表(HAMD)评定,并在早晨采集唾液,采用放射免疫法测定唾液DHEA水平,分析各组受试者焦虑、抑郁心理量表评分与唾液DHEA水平的相关性。 结果: EOLP组患者的HAMA评分和HAMD评分均明显高于对照组和非EOLP组(P<0.01),唾液DHEA浓度虽低于正常对照组,但差异无统计学意义 (P=0.054);非EOLP组患者的HAMA评分、 HAMD评分和唾液DHEA水平与对照组比较差异均无统计学意义(P>0.05)。EOLP组患者唾液DHEA水平与HAMA评分和HAMD评分呈负相关关系(r=-0.948,r=-0.966),非EOLP组患者的唾液DHEA水平与HAMA评分和HAMD评分亦呈负相关关系(r=-0.962,r=-0.971)。 结论: EOLP的发生、发展与患者的焦虑、抑郁等情绪障碍有关,其作用机制可能与患者唾液DHEA水平的降低有关。     

Recurrent and persistent pityriasis rosea: an atypical case presentation

We report a case of atypical pityriasis rosea in a 24-year-old Malay man. He presented with an 11-month history of three recurrent and persistent episodes of pityriasis rosea associated with oral ulcers. The first episode lasted for one month and recurred within 14 days. The second episode lasted for three months and recurred within nine days. The third episode lasted for seven months. Although all three episodes were not preceded by any prodromal symptoms, a herald patch was noted on three different sites (the left iliac fossa, abdomen and chest) on each successive episode. Recurrent pityriasis rosea and its association with oral ulcers, although quite uncommon, have been reported in the literature. However, reports of multiple recurrences, with prolonged duration of each episode and very short remissions in between, have not been made. To the best of our knowledge, this is the first report of such unique presentation.