Electrocardiographic findings in pulmonary embolism

Pulmonary embolism (PE) poses a challenge to physicians, as it can be difficult to diagnose but results in significant mortality and morbidity in patients. Diagnosing PE requires an integrated approach using clinical findings, electrocardiography (ECG), blood investigations and imaging modalities. Abnormalities in ECG are common among patients with massive acute PE and can serve as a prognostic indicator. In this article, we describe the ECG presentations of two patients diagnosed with PE, and review the literature on the various types of ECG presentations and their role in predicting the prognosis of PE.     

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%.     

Extracorporeal life support for cardiac arrest in a paediatric emergency department

The initiation of extracorporeal membrane oxygenation (ECMO) in the emergency department (ED) is a rare event. Herein, we report a case of acute fulminant myocarditis in a nine-year-old girl who was successfully resuscitated by early initiation of ECMO support in the paediatric ED of KK Women’s and Children’s Hospital, Singapore. The patient had rapidly progressed into a witnessed pulseless ventricular tachycardia on presentation, and ECMO was started in the ED following the failure of standard resuscitation measures to establish spontaneous circulation. ECMO was continued for nine days. The patient recovered well with normal neurocognitive function. The initiation of ECMO in the ED is potentially life-saving in the resuscitation of children with witnessed in-hospital cardiac arrest due to a reversible cause.     

Not all unexplained hypoxia is pulmonary embolism

Acute myocardial infarction is one of the conditions frequently managed in the emergency department. There are many complications associated with right ventricular infarction, and the incidence of right ventricular infarction associated with inferior myocardial infarction is as high as 51% based on electrocardiographic findings. We herein report the case of a 45-year-old Chinese man with inferior myocardial infarction complicated by right ventricular failure. He had hypoxaemia refractory to supplemental oxygen due to an acute right-to-left shunting through a patent foramen ovale (PFO). He underwent coronary angioplasty and closure of the PFO. It is crucial for the attending physician to consider the presence of a right-to-left shunt when there is persistent uncorrectable hypoxaemia despite maximal oxygen supplementation in the setting of right ventricular infarction, as there are clinical implications and certain clinical managing principles that should be applied.     

Recurrent myocardial infarction secondary to Prinzmetal’s variant angina

Prinzmetal’s variant angina describes chest pain secondary to reversible coronary artery vasospasm in the context of both diseased and non-diseased coronary arteries. Symptoms typically occur when the patient is at rest and are associated with transient ST-segment elevation. Acute episodes respond to glyceryl trinitrate, but myocardial infarction and other potentially fatal complications can occur, and long-term management can be challenging. Although it is not well understood, the underlying mechanism appears to involve a combination of endothelial damage and vasoactive mediators. In this case, a 35-year-old woman with myocardial infarction secondary to coronary artery vasospasm experienced recurrent chest pain. Coronary angiography revealed severe focal stenosis in the mid left anterior descending artery, which completely resolved after administration of intracoronary glyceryl trinitrate. The patient was discharged on nitrates and calcium channel blockers. The patient re-presented with another myocardial infarction, requiring up-titration of medical therapy.     

Increased serum visfatin as a risk factor for atherosclerosis in patients with ischaemic cerebrovascular disease

INTRODUCTION

The present study aimed to investigate the possible associations between serum levels of visfatin, an adipokine, and atherosclerosis in patients with ischaemic cerebrovascular disease.

METHODS

A total of 95 participants were recruited for this study. Group A comprised 35 individuals with no history of cerebrovascular disease (control group) and Group B comprised 60 patients with ischaemic cerebrovascular disease. Group B was further categorised into two subgroups based on the ultrasonographic findings of the common carotid artery intima-media thickness (CCA-IMT) – Group B1 consisted of 21 patients with no atherosclerosis (i.e. CCA-IMT ≤ 0.9 mm) and Group B2 consisted of 39 patients with atherosclerosis (i.e. CCA-IMT > 0.9 mm). The body mass index, fasting blood total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and glucose levels of each patient were measured. Serum visfatin levels were determined using enzyme-linked immunosorbent assays. Visfatin levels were compared between groups, and stepwise logistic regression analysis was used to identify risk factors for atherosclerosis, including visfatin levels.

RESULTS

The mean serum visfatin level of the patients in Group B was higher than that in Group A (75.5 ± 77.80 ng/mL vs. 8.6 ± 4.69 ng/mL; p < 0.05) and the level was higher in patients from Group B2 than those from Group B1 (89.0 ± 80.68 ng/mL vs. 50.4 ± 72.44 ng/mL; p < 0.05). Multivariate regression analysis showed that CCA-IMT values were not significantly associated with visfatin levels. However, logistic regression analysis showed that serum visfatin was an independent risk factor for atherosclerosis (odds ratio 37.80; p = 0.004).

CONCLUSION

Serum visfatin may be an independent risk factor for cerebral infarction, as high serum visfatin levels are positively associated with the underlying pathogenic mechanisms of ischaemic cerebrovascular disease.     

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.     

Imaging of acute cholecystitis and cholecystitis-associated complications in the emergency setting

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting at the emergency department. Early diagnosis and recognition of associated complications, though challenging, are essential for timely management. Imaging studies, including ultrasonography, computed tomography and magnetic resonance imaging, are increasingly utilised for the evaluation of suspected cases of cholecystitis. These investigations help in diagnosis, identification of complications and surgical planning. Imaging features of acute cholecystitis have been described in the literature and are variable, depending on the stage of inflammation. This article discusses the spectrum of cholecystitis-associated complications and their imaging manifestations. We also suggest a checklist for the prompt and accurate identification of complications in acute cholecystitis.     

Anaesthetic management of acute airway obstruction

The acutely obstructed airway is a medical emergency that can potentially result in serious morbidity and mortality. Apart from the latest advancements in anaesthetic techniques, equipment and drugs, publications relevant to our topic, including the United Kingdom’s 4th National Audit Project on major airway complications in 2011 and the updated American Society of Anesthesiologists’ difficult airway algorithm of 2013, have recently been published. The former contained many reports of adverse events associated with the management of acute airway obstruction. By analysing the data and concepts from these two publications, this review article provides an update on management techniques for the acutely obstructed airway. We discuss the principles and factors relevant to the decision-making process in formulating a logical management plan.     

Imaging of the spleen: what the clinician needs to know

The spleen is considered ‘the forgotten organ’ among radiologists and clinicians, although it is well visualised on abdominal computed tomography and magnetic resonance imaging. Moreover, the spleen is commonly involved in a wide range of pathologic disorders. These include congenital anomalies, infectious and inflammatory diseases, vascular disorders, benign and malignant tumours, and systemic disorders. In this review, we focus on the key imaging findings of the normal spleen, its variants, as well as relevant congenital and acquired abnormalities. It is of utmost importance to recognise and correctly interpret the variable spectrum of abnormalities that may involve the spleen, in order to avoid unnecessary invasive procedures and to guide adequate treatment.     

Clear cell chondrosarcoma with secondary aneurysmal bone cyst changes

Clear cell chondrosarcoma is a rare cartilaginous tumour of low-grade malignancy. Although it has a characteristic histological appearance, its radiological features and clinical presentation often mimic a benign lesion. Herein, we describe the case of a patient with a clear cell chondrosarcoma of the right proximal femur that had an atypical appearance of chronic avascular necrosis on initial plain radiographs, which made preoperative diagnosis a challenge. In addition, the tumour also had extensive areas of aneurysmal bone cyst-like changes, which is not only a rare histologic phenomenon in clear cell chondrosarcoma, but also a confounding factor in the interpretation of the radiologic findings.     

Acute myocardial infarction and subclavian artery occlusion in a 41-year-old woman with Beh?et’s disease: coronary and large vessel arteritis

We report the case of a 41-year-old Chinese woman with Behçet’s disease (BD) complicated by acute myocardial infarction, requiring inotropic and ventilatory support. Angiography showed critical left anterior descending coronary artery stenosis, a blocked left subclavian artery and left carotid artery stenosis. The patient was successfully treated with a high dose of immunosuppressants, standard anti-ischaemic therapy and percutaneous coronary intervention. Although life-threatening, coronary arteritis is a treatable manifestation of BD. We suggest that the diagnosis of coronary arteritis be considered in patients with BD who present with chest pain. Involvement of other arteries should also be looked out for in these patients.     

Clinical characteristics,outcome and early induction deaths in patients with acute promyelocytic leukaemia: a five-year experience at a tertiary care centre

INTRODUCTION

Acute promyelocytic leukaemia (APL) is a distinct clinical and biological subtype of acute myeloid leukaemia. APL is notorious for causing early death during induction therapy, resulting in induction failure. The aim of our study was to report the clinical characteristics, outcome and early induction deaths with regard to patients with APL seen at our hospital.

METHODS

This was a retrospective study carried out at Aga Khan University Hospital, Karachi, Pakistan. Patients aged > 15 years diagnosed with APL within the period September 2007–September 2012 were included in the study.

RESULTS

Within the study period, 26 patients were diagnosed with APL based on morphology and the detection of t(15;17)(q24.1;q21.1) and promyelocytic leukaemia-retinoic acid receptor alpha (PML-RARA). The male to female ratio was 1:1. The median age of the patients was 41 (range 16–72) years. In all, there were 13 (50.0%) high-risk patients, and early induction death rate was 61.5%. Causes of early induction deaths (n = 16) included haemorrhage in 7 (43.8%) patients, differentiation (ATRA) syndrome in 7 (43.8%) and infection in 2 (12.5%). The survival rate among patients who survived the early period was 70% at 42 months. The relapse rate was 30%.

CONCLUSION

Early induction death rate was very high in patients with APL. The most common cause of early induction death in our study was haemorrhage. Outcome among patients with APL was found to be better among those who survived the initial period.     

From divination to madness: features of acute intoxication with Salvia use

Salvia divinorum is a psychoactive botanical plant that is increasingly used for the ‘legal’ highs that it can produce. It is readily available for purchase on the Internet, and most abusers are unaware of the toxicity and abuse potential associated with its use. As the use of novel compounds among abusers is not uncommon, physicians need to increase their awareness and recognition of these new substances. Herein, we report a case of an acute presentation of Salvia intoxication.     

Cost of post-stroke outpatient care in Malaysia

INTRODUCTION

This study aimed to investigate the direct cost of outpatient care for patients with stroke, as well as the relationship between the aforementioned cost and the sociodemographic and stroke characteristics of the patients.

METHODS

This was a cross-sectional study involving patients with first-ever stroke who were attending outpatient stroke rehabilitation, and their family members. Participants were interviewed using a structured questionnaire designed to obtain information regarding the cost of outpatient care. Stroke severity was measured using the National Institute of Health Stroke Scale.

RESULTS

This study comprised 49 patients (28 men, 21 women) with a mean age of 60.2 (range 35–80) years. The mean total cost incurred was USD 547.10 (range USD 53.50–4,591.60), of which 36.6% was spent on attendant care, 25.5% on medical aids, 15.1% on travel expenses, 14.1% on medical fees and 8.5% on out-of-pocket expenses. Stroke severity, age > 70 years and haemorrhagic stroke were associated with increased cost. The mean cost of attending outpatient therapy per patient was USD 17.50 per session (range USD 6.60–30.60), with travelling expenses (41.8%) forming the bulk of the cost, followed by medical fees (38.1%) and out-of-pocket expenses (10.9%). Multiple regression analysis showed that stroke severity was the main determinant of post-stroke outpatient care cost (p < 0.001).

CONCLUSION

Post-stroke outpatient care costs are significantly influenced by stroke severity. The cost of attendant care was the main cost incurred during the first three months after hospital discharge, while travelling expenses was the main cost incurred when attending outpatient stroke rehabilitation therapy.     

Haematological abnormalities in mitochondrial disorders

INTRODUCTION

This study aimed to assess the kind of haematological abnormalities that are present in patients with mitochondrial disorders (MIDs) and the frequency of their occurrence.

METHODS

The blood cell counts of a cohort of patients with syndromic and non-syndromic MIDs were retrospectively reviewed. MIDs were classified as ‘definite’, ‘probable’ or ‘possible’ according to clinical presentation, instrumental findings, immunohistological findings on muscle biopsy, biochemical abnormalities of the respiratory chain and/or the results of genetic studies. Patients who had medical conditions other than MID that account for the haematological abnormalities were excluded.

RESULTS

A total of 46 patients (‘definite’ = 5; ‘probable’ = 9; ‘possible’ = 32) had haematological abnormalities attributable to MIDs. The most frequent haematological abnormality in patients with MIDs was anaemia. 27 patients had anaemia as their sole haematological problem. Anaemia was associated with thrombopenia (n = 4), thrombocytosis (n = 2), leucopenia (n = 2), and eosinophilia (n = 1). Anaemia was hypochromic and normocytic in 27 patients, hypochromic and microcytic in six patients, hyperchromic and macrocytic in two patients, and normochromic and microcytic in one patient. Among the 46 patients with a mitochondrial haematological abnormality, 78.3% had anaemia, 13.0% had thrombopenia, 8.7% had leucopenia and 8.7% had eosinophilia, alone or in combination with other haematological abnormalities.

CONCLUSION

MID should be considered if a patient’s abnormal blood cell counts (particularly those associated with anaemia, thrombopenia, leucopenia or eosinophilia) cannot be explained by established causes. Abnormal blood cell counts may be the sole manifestation of MID or a collateral feature of a multisystem problem.     

Food allergy in Singapore: opening a new chapter

With the exception of shellfish, the overall food allergy rates in Singapore have not reached the epidemic proportions of the West. The rates of egg, milk and fish allergies remain low. However, the patterns of some food allergies in Singapore have changed over the last decade. For example, peanut allergy, once rare in Singapore, is now the most common cause of anaphylaxis in children. Studies analysing lifestyle practices, particularly with respect to prevention of food allergy, are necessary in order for practitioners to understand global differences and maintain this low prevalence.     

An audit of preoperative fasting compliance at a major tertiary referral hospital in Singapore

INTRODUCTION

To avoid the risk of pulmonary aspiration, fasting before anaesthesia is important. We postulated that the rate of noncompliance with fasting would be high in patients who were admitted on the day of surgery. Therefore, we surveyed patients in our institution to determine the rate of fasting compliance. We also examined patients’ knowledge on preoperative fasting, as well as their perception of and attitudes toward preoperative fasting.

METHODS

Patients scheduled for ‘day surgery’ or ‘same day admission surgery’ under general or regional anaesthesia were surveyed over a four-week period. The patients were asked to answer an eighteen-point questionnaire on demographics, preoperative fasting and attitudes toward fasting.

RESULTS

A total of 130 patients were surveyed. 128 patients fasted before surgery, 111 patients knew that they needed to fast for at least six hours before surgery, and 121 patients believed that preoperative fasting was important, with 103 believing that preoperative fasting was necessary to avoid perioperative complications. However, patient understanding was poor, with only 44.6% of patients knowing the reason for fasting, and 10.8% of patients thinking that preoperative fasting did not include abstinence from beverages and sweets. When patients who did and did not know the reason for fasting were compared, we did not find any significant differences in age, gender or educational status.

CONCLUSION

Despite the patients’ poor understanding of the reason for fasting, they were highly compliant with preoperative fasting. This is likely a result of their perception that fasting was important. However, poor understanding of the reason for fasting may lead to unintentional noncompliance.     

Short-term result of arthroscopic synovial excision for dorsal wrist pain in hyperextension associated with synovial hypertrophy

INTRODUCTION

Arthroscopic excision of the hypertrophic dorsal synovium is performed on patients with dorsal wrist pain in hyperextension. Although dorsal wrist impingement has been described in cadaveric studies, to our knowledge, there is no published clinical data on its treatment with arthroscopic synovial excision. Herein, we present the results of arthroscopic management of this condition in our hospital.

METHOD

A total of 13 patients underwent arthroscopic excision of the hypertrophic dorsal impinging synovium. All patients presented with the cardinal symptom of dorsal-radial wrist pain in extreme extension. The diagnoses were made after excluding other causes and confirmed on wrist arthroscopy. Arthroscopy was offered after nonoperative measures failed. The mean postoperative follow-up period was 14 (range 6–31) months.

RESULTS

Mean pre-and postoperative quick Disabilities of the Arm, Shoulder and Hand scores were 49 (range 34–82) and 17 (range 0–48), respectively; paired t-test revealed a significant difference between the two (p < 0.001). Mean postoperative flexion-extension arc and radial-ulnar deviation arc were 120º and 46º, respectively. Postoperatively, one patient developed complex regional pain syndrome, with tethering of the dorsal branch of the ulnar nerve, which required surgical release, while another patient required revision arthroscopic excision of the impinging tissue. Both patients had good postoperative outcomes.

CONCLUSION

When treating patients with dorsal wrist pain, dorsal wrist impingement caused by synovial hypertrophy should be included in the differential diagnosis. Arthroscopic excision of the impinging synovium can achieve reliable pain relief with significant functional improvement in the short term, although further research on its long-term benefits is required.     

Intra-articular glucocorticoid injections in patients with juvenile idiopathic arthritis in a Singapore hospital

INTRODUCTION

This study aimed to evaluate the efficacy and safety of intra-articular glucocorticoid (IAG) injections in our institution in children with juvenile idiopathic arthritis (JIA).

METHODS

This is a retrospective assessment of IAG injections performed by the Department of Paediatrics, National University Hospital, Singapore, from October 2009 to October 2011. A total of 26 procedures were evaluated for efficacy, considering parameters such as clinical response, changes in systemic medication, length of time between repeat injections, safety, consent-taking, pre- and post-procedural advice, compliance with aseptic technique, and post-procedural complications.

RESULTS

A total of 26 IAG injections of triamcinolone hexacetonide were administered over 17 occasions (i.e. patient encounters) to ten patients with JIA during the study period. After the injections, clinical scoring by a paediatric rheumatologist showed overall improvement by an average of 2.62 points out of 15. Besides six patient encounters that had an increase in systemic medication on the day of the injection, five required an increase within six months post injection, two required no adjustments, and one resulted in a decrease in medications. In all, 21 injections did not require subsequent injections. The mean interval between repeat injections was 7.8 months. Cutaneous side effects were noted in three anatomically difficult joints. Medical documentation with regard to patient progress was found to be lacking.

CONCLUSION

As per the recommendations of the American College of Rheumatology, we safely used IAG injections as the first-line therapy in our group of patients with oligoarticular JIA, and/or as an adjunct to systemic therapy in our patients with JIA.