Cerebrovascular ischaemia after carbon monoxide intoxication

Carbon monoxide intoxication is the most prevalent cause of death from carbon monoxide poisoning. We herein report the case of a 56-year-old man who was found unconscious and smelled of smoke after exposure to carbon monoxide from a heater. He scored 5 on the Glasgow Coma Scale, and had respiratory insufficiency and elevated troponin I, creatine kinase-MB fraction and carboxyhaemoglobin levels. He was treated by mechanical ventilation. After regaining consciousness, brain magnetic resonance imaging showed diffusion restriction in the left occipital lobe; there was a loss of vision (right temporal hemianopsia), which improved by the follow-up session. Carbon monoxide intoxication may cause neurologic and cardiac sequelae, and the initial treatment includes oxygen therapy. Acute carbon monoxide poisoning can cause serious injury to the brain, heart and other organs; the most severe damages that could be inflicted to the brain include cerebral ischaemia and hypoxia, oedema, and neural cell degeneration and necrosis.     

Surveillance of childhood blood lead levels in Chengdu,China in 2010–2011

INTRODUCTION

Lead poisoning has been receiving great attention around the world. The Child Hygiene Cooperation Center of the World Health Organization in China has been conducting investigations to monitor blood lead levels (BLLs) from as early as 2004. However, only several lead poisoning studies have been conducted in China since August 2009. The aim of the present study was to investigate the BLLs in children aged < 7 years and to analyse the risk factors of high BLLs in Chengdu, China.

METHODS

Questionnaires were distributed to children in Chengdu from 2010 to 2011. A total of 2,271 children were included in this study – 1,157 received BLL tests in 2010 and the remaining received the tests in 2011. BLL was measured using a tungsten atomiser absorption spectrophotometer.

RESULTS

The mean BLL of the 2,271 children was 6.2 µg/dL and 2.03% of the children had BLLs ≥ 10 µg/dL. Mean BLL seemed to increase with age. Unhygienic habits (e.g. not washing hands frequently, biting of toys and pencils), history of pica, use of coal and residence in an industrial zone were found to be the main risk factors contributing to high BLL (p < 0.05). Children with high BLLs have a higher risk of manifesting anorexia and/or abdominal pain as compared to those with low BLLs (p < 0.05).

CONCLUSION

The mean BLL of children in Chengdu (i.e. 6.2 µg/dL) was found to be higher than that of children in developed countries. Childhood lead poisoning remains a public health problem.     

Neurogenic heterotopic ossification after a stroke: diagnostic and radiological challenges

Heterotopic ossification (HO) is the aberrant formation of ectopic bone within the soft tissues, of which the aetiology is usually either traumatic or neurogenic. Neurogenic HO is a known but uncommon complication that occurs after a cerebral or spinal insult. The condition may present with a spectrum of symptoms and is often difficult to diagnose clinically. Although different imaging modalities have been used to diagnose HO, clinicians and radiologists may occasionally encounter radiological features of HO that may mimic other disease conditions. We herein report a rare case of neurogenic HO occurring in the non-paretic limb of a patient, and the diagnostic and radiological challenges encountered.     

Thoracic endometriosis with catamenial haemoptysis and pneumothorax: computed tomography findings and long-term follow-up after danazol treatment

Thoracic endometriosis (TE) is an uncommon disorder affecting women of childbearing age. We herein report clinical and thin-section computed tomography (CT) findings of two cases, in which one woman presented with catamenial haemoptysis (CH) alone and another woman presented with bilateral catamenial pneumothoraces (CP) coinciding with CH, a rare manifestation of TE. The dynamic changes demonstrated on thin-section chest CT performed during and after menses led to accurate localisation and presumptive diagnosis of TE in both patients. Following danazol treatment, the patient with CH alone had a complete cure, while the patient with CP and CH had an incomplete cure and required long-term danazol treatment. We discuss the role of imaging studies in TE, with an emphasis on the appropriate timing and scanning technique of chest CT in women presenting with CH, potential mechanisms, treatment and patient outcomes.     

Patient satisfaction after total knee arthroplasty: an Asian perspective

INTRODUCTION

Total knee arthroplasty (TKA) is an effective method for alleviating pain and restoring knee function in patients with severe osteoarthritis. However, despite the improvements in surgical technique and postoperative care, it has been reported that up to 19% of patients are dissatisfied after their operations. The aim of this study was to evaluate patient satisfaction levels after TKA in an Asian cohort, as well as assess the correlation between patient satisfaction levels and the results of traditional physician-based scoring systems.

METHODS

The medical data of 103 Asian patients who underwent 110 TKAs between December 2008 and June 2009 were obtained from our hospital’s Joint Replacement Registry. The minimum follow-up period was one year and patient expectations were assessed before TKA. Patient satisfaction was assessed postoperatively using a 5-point Likert scale. Reasons for patient dissatisfaction were recorded. Standardised instruments (e.g. the Knee Society Score, the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and the generic Short Form-36 health survey) were used to assess the patient’s functional status and the severity of symptoms pre- and postoperatively.

RESULTS

Among the 110 TKAs performed, 92.8% resulted in patient satisfaction. Patient satisfaction correlated with postoperative WOMAC function scores (p = 0.028), postoperative WOMAC final scores (p = 0.040) and expectations being met (p = 0.033).

CONCLUSION

Although there was a high level of patient satisfaction following TKA in our cohort of Asian patients, a significant minority was dissatisfied. Patient satisfaction is an important outcome measure and should be assessed in addition to traditional outcome scores.     

High STOP-BANG questionnaire scores predict intraoperative and early postoperative adverse events

INTRODUCTION

Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder associated with multisystemic organ involvement. The STOP-BANG questionnaire is a concise, validated questionnaire that is used to screen for OSA. This study aimed to establish the use of the STOP-BANG questionnaire for perioperative patient risk stratification.

METHODS

In this retrospective cohort study, we extracted the demographic, medical and perioperative outcome data of all patients who underwent elective surgery, excluding ophthalmic surgeries, from January to December 2011. Multivariate regression analysis was used to predict independent risk factors for intraoperative and early postoperative adverse events.

RESULTS

Of the 5,432 patients analysed, 7.4% had unexpected intraoperative and early postoperative adverse events. We found that the risk of unexpected intraoperative and early postoperative adverse events was greater in patients with STOP-BANG scores ≥ 3 compared to those with a STOP-BANG score of 0 (score 3: odds ratio [OR] 3.6, 95% confidence interval [CI] 2.1–6.3, p < 0.001; score 4: OR 3.4, 95% CI 1.8–6.5, p < 0.001; score 5: OR 6.4, 95% CI 2.7–15.0, p < 0.001; score ≥ 6: OR 5.6, 95% CI 2.1–15.4, p < 0.001). Patients with STOP-BANG scores ≥ 5 had a fivefold increased risk of unexpected intraoperative and early postoperative adverse events, while patients with STOP-BANG scores ≥ 3 had a ‘one in four’ chance of having an adverse event. Other independent predictors included older age (p < 0.001), American Society of Anesthesiologists class ≥ 2 (p < 0.003) and uncontrolled hypertension (p = 0.028).

CONCLUSION

STOP-BANG score may be used as a preoperative risk stratification tool to predict the risk of intraoperative and early postoperative adverse events.     

Delayed presentation of port-site metastasis from an unknown gastrointestinal malignancy following laparoscopic cholecystectomy

Port-site metastasis (PSM) is often encountered during laparoscopic surgery in patients with malignancy. We report a 45-year-old woman who presented with a single PSM from papillary adenocarcinoma after undergoing laparoscopic cholecystectomy for calculus cholecystitis. Post cholecystectomy, a diagnosis of chronic cholecystitis was confirmed on histopathology. The patient presented with a mass at the site of epigastric port 28 months after surgery. PSM was suspected on clinical examination, which was supported by findings on computed tomography and further confirmed by fine-needle aspiration cytology of the lump. The patient underwent surgical clearance of the mass, and histopathological examination proved the lesion to be papillary adenocarcinoma. The site of the primary tumour was not detected even after thorough examination. Based on the histopathology report following local surgical clearance, the patient was started on chemotherapy. This case is unusualbecause of the long delay prior to the presentation of PSM and the unknown primary malignancy.     

Optimal head rotation and puncture site for internal jugular vein cannulation after laryngeal mask airway insertion

INTRODUCTION

We studied the effect of head rotation on the relative position of the right common carotid artery (CCA) and the right internal jugular vein (IJV) in patients with laryngeal mask airway (LMA) insertion to evaluate the accuracy of anatomical landmarks for right IJV cannulation.

METHODS

We simulated needle insertion to the right IJV on sonograms via the central landmark approach and an approach using the external jugular vein, in patients with LMA insertion (n = 50) or endotracheal intubation (E-tube, n = 50). Overlap index and successful simulation rates were measured according to the different degrees of head rotation.

RESULTS

The overlap index between the right CCA and the right IJV increased with greater degrees of head rotation. It was significantly greater in the LMA insertion group than in the E-tube group in the following head rotation positions: neutral, 15° and 45°. The success rate of the simulation was lower in the LMA insertion group than in the E-tube group. In the LMA insertion group, the success rate of the simulation was highest (62%) with the central landmark approach and in the 15° head rotation position.

CONCLUSION

In the LMA insertion group, the overlap index increased incrementally with greater head rotation degrees (from neutral to 45°). The central landmark approach and 15° head rotation position appear to be the optimal puncture site and degree of head rotation for right IJV cannulation in patients with LMA insertion.     

Awake tracheal intubation in a patient with a supraglottic mass with the Bonfils fibrescope after failed attempts with a flexible fibrescope

Awake intubation with a flexible fibrescope is usually done electively in patients with a known difficult airway. Herein, we describe the case of an elective awake tracheal intubation that was performed on a patient with a large, obstructive supraglottic mass. The intubation was successfully performed using the Bonfils fibrescope after several failed attempts with a flexible fibrescope. This case highlights the usefulness of the Bonfils fibrescope and the limitations of the flexible fibrescope in certain clinical situations.     

How patients fare after anaesthesia for elective surgery: a survey of postoperative nausea and vomiting,pain and confusion

INTRODUCTION

Postoperative nausea and vomiting (PONV), and postoperative pain are common during the early postoperative period. In addition to these problems, elderly patients risk developing postoperative confusion. This study aimed to identify the risk factors associated with these problems, and the extent of these problems, in a Singapore inpatient surgical population.

METHODS

Over a period of six weeks, we surveyed 707 elective surgical inpatients aged ≥ 18 years who received general anaesthesia and/or regional anaesthesia.

RESULTS

The incidence of PONV was 31.8%(95% confidence interval [CI] 34.8–41.9). The incidence increased with increasing Apfel score (p < 0.001) and were higher in female patients (odds ratio [OR] 1.74, 95% CI 1.28–2.36), non-smokers (OR 1.72, 95% CI 1.04–2.88), patients with a history of PONV and/or motion sickness (OR 3.45, 95% CI 2.38–5.24), patients who received opioids (OR 1.39, 95% CI 1.03–1.88), and patients who received general anaesthesia (OR 1.76, 95% CI 1.11–2.79). Moderate to severe pain at rest and with movement were reported in 19.9% and 52.5% of patients, respectively. Among the patients who were predicted to experience mild pain, 29.5% reported moderate pain and 8.1% reported severe pain. The prevalence of postoperative confusion was 3.9% in the geriatric population.

CONCLUSION

Higher Apfel scores were associated with a higher risk of PONV and multimodal treatment for postoperative pain management was found to be insufficient. The incidence of postoperative confusion was low in this study.     

Improvement in left ventricular function assessed by tissue Doppler imaging after aortic valve replacement for severe aortic stenosis

INTRODUCTION

The effects of reduction of left ventricular (LV) systemic afterload following aortic valve replacement (AVR) for severe aortic valve stenosis (AS) were investigated, using echocardiography and tissue Doppler imaging (TDI).

METHODS

We compared the preoperative and postoperative echocardiographic assessments of 23 patients with severe AS who had undergone isolated AVR (n = 13) or concomitant AVR with coronary artery bypass grafting (CABG) (n = 10). Conventional echocardiographic evaluations and TDI at the lateral mitral annulus were performed.

RESULTS

Echocardiography was performed at a median of 120 (interquartile range: 66–141) days after AVR. There was significant reduction in aortic transvalvular mean pressure gradient after AVR. Although LV dimensions, mass and ejection fraction remained unchanged, LV diastolic and systolic functions improved (as observed on TDI). Early diastolic (E’), late diastolic (A’) and systolic (S’) mitral annular velocities increased significantly (p < 0.05). There was significant improvement in TDI-derived parameters among the patients who had isolated AVR, while among the patients who had concomitant AVR with CABG, only S’ had significant improvement (p = 0.028).

CONCLUSION

TDI was able to detect improvements in LV systolic and diastolic function after AVR for severe AS. There was less improvement in the TDI-derived diastolic parameters among patients who underwent concomitant AVR with CABG than among patients who underwent isolated AVR.     

Anticoagulation in the treatment of portovenous emboli after cyanoacrylate injection for a bleeding gastric varix

We herein report the use of endoscopic n-butyl-2-cyanoacrylate injections to obliterate a gastric varix, which led to cyanoacrylate embolisation in the splenic and portal veins in a single patient. Cyanoacrylate embolisation is a known but uncommonly reported complication of endoscopic sclerotherapy. This case report illustrates the successful management of this complication (i.e. cyanoacrylate embolisation in the splenic and portal veins) with anticoagulation and analyses the presentation and management of other cases of cyanoacrylate embolisation reported in the literature.     

Dislocation of the penis: a rare complication after traumatic pelvic injury

Traumatic injury to the male external genitalia is frequently encountered, but acute traumatic dislocation of the penile structure is extremely rare, with only a few reports found in the literature. We herein report the case of a 21-year-old man who sustained blunt trauma to the pelvis following a motor vehicle accident, and had features suspicious of penile dislocation. With the use of computed tomography and bedside ultrasonography, a diagnosis of penile dislocation was made, which was subsequently confirmed intraoperatively. Immediate surgical intervention via gentle manipulation of the penile tissue back to its native position was performed in order to restore normal anatomy. The exact mechanism of penile dislocation is not known. However, circumferential laceration around the foreskin causing degloving injury of the penis is suggested in our patient.     

Burden of blood transmitted infections in substance users admitted for inpatient treatment in Singapore and the associated factors

INTRODUCTION

There is a paucity of local data on the prevalence of blood transmitted infections (BTIs), such as hepatitis B, hepatitis C and human immunodeficiency virus (HIV) infections, among illicit drug users. This study aimed to examine the prevalence of BTIs among substance-dependent inpatients and identify the factors associated with BTIs.

METHODS

We conducted a retrospective case note analysis of 170 inpatients who had a history of substance dependence and were seen at the National Addictions Management Service, Singapore, between 1 June 2009 and 31 May 2010.

RESULTS

The majority of the 170 inpatients were male (88.2%) and Chinese (58.2%). The mean age of the patients was 43.1 years, and the main drug of abuse was opioids (86.5%). BTIs were found in 70 (41.2%) inpatients; the prevalence of hepatitis B, hepatitis C and HIV infections was 3.7%, 39.6% and 0%, respectively. Lifetime intravenous drug use, but not needle-sharing, was more common among inpatients who were positive for BTIs (p < 0.01). Logistic regression analysis showed that lifetime intravenous drug use (OR 4.3, 95% CI 1.7–10.8, p < 0.01) was the only significant predictor of BTI.

CONCLUSION

41.2% of the substance users seeking help were positive for at least one BTI. Lifetime intravenous drug users were found to be more than four times more likely to have a BTI. Early detection and prevention is essential to improve prognosis.     

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.     

Spontaneous rupture of the ureter

Spontaneous rupture of the ureter is a very rare condition and usually results from ureteral obstruction by a calculus. Only theoretical mecha­nisms have been proposed and no possible explanation has yet been reported in the literature. Intravenous contrast-enhanced computed tomography is the most informative study with high sensitivity. Treatment should be individualised, and depends on the state of the patient. Minimally invasive endourological procedures with double-J catheter placement and percutaneous drainage offer excellent results. Conservative management with analgesics and antibiotic coverage may be an alternative to surgery. Herein, we present a case of spontaneous rupture of the proximal ureter with no evidence of an underlying pathological condition.     

Demographic profile,clinical characteristics,motivations and weight loss outcomes of patients in a nonsurgical weight management programme

INTRODUCTION

Weight management programmes (WMPs) can help overweight individuals lose weight, and thus prevent complications associated with obesity. Herein, we describe the demographic profile, clinical characteristics, motivations and expectations, and outcomes of patients enrolled in a nonsurgical WMP.

METHODS

This was a retrospective study of consecutive patients with a body mass index (BMI) of > 23 kg/m² enrolled in the four-month WMP at the Health For Life Clinic, Alexandra Hospital, Singapore, between 1 and 31 August 2009. Demographic data, medical history and source of referral were recorded. Details on personal motivations and weight loss goals were obtained from the completed self-administered questionnaires of the WMP participants. Weight, waist circumference, fat percentage and BMI were measured at the start and end of the WMP. A weight loss of ≥ 5% was deemed as a successful outcome.

RESULTS

A total of 58 patients (mean age 37.2 years) were included in our study. Of these 58 patients, 58.6% were of Chinese ethnicity and 55.2% were male. Many patients (32.8%) attributed their weight gain to work- or study-related stress, and a minority to poor eating habits (12.1%) or a lack of exercise (10.3%). Patients’ motivations included a desire for better health (53.4%) and better fitness (15.5%). However, only 53.4% patients scored their motivation as high (i.e. a score of > 7). The mean expected weight loss was 9.9 kg at 4 months, and 14.1 kg at 12 months. Among the 40 patients (69.0%) who completed the programme, the mean percentage weight loss was 1.8 ± 4.3%. A weight loss of ≥ 5% was achieved by 8 (13.8%) patients.

CONCLUSION

Although the patients in our study cohort were young and educated, only a portion of them appeared to be highly motivated to lose weight, despite joining the WMP. There is a need for patients to be guided on how to set realistic weight loss goals.     

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.     

Understanding patients’ perspective of statin therapy: can we design a better approach to the management of dyslipidaemia? A literature review

INTRODUCTION

Dyslipidaemia leads to atherosclerosis and is a major risk factor for cardiovascular diseases. In clinical trials, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, or statins, have been shown to effectively reduce dyslipidaemia. Despite the availability and accessibility of statins, myocardial infarctions and cerebrovascular accidents remain among the top causes of mortality in developed countries, including Singapore. This enigma could be attributed to suboptimal adherence to statin therapy. The present literature review aimed to evaluate patients’ perceptions of statin therapy.

METHODS

We searched PubMed and other databases for articles published in English from October 1991 to May 2012 containing keywords such as ‘patient’, ‘views’, ‘perceptions’, ‘adherence’, ‘statin’ and ‘dyslipidaemia’. Of the 122 eligible studies retrieved, 58 were reviewed. The findings were categorised and framed in accordance with the Health Belief Model.

RESULTS

Patients with dyslipidaemia appeared to underestimate their susceptibility to dyslipidaemia-related complications, partly due to their demographic profiles. Failure to appreciate the severity of potential complications was a major hindrance toward adherence to statin therapy. Other factors that affected a patient’s adherence included lack of perceived benefits, perceived side effects, the cost of statins, poor physician-patient relationship, and overestimation of the effectiveness of diet control as a treatment modality.

CONCLUSION

Existing evidence suggests that the cause of poor adherence to statin therapy is multifactorial. The use of the Health Belief Model to present the results of our literature review provides a systematic framework that could be used to design a patient-centric approach for enhancing adherence to statin therapy.