Inappropriate use of proton pump inhibitors

Background

Proton pump inhibitors (PPIs) are widely used expensive medications.

Aims

We performed a cross-sectional study to determine the extent and indication of PPI use in Irish acute medical wards.

Methods

Fifty-five medical charts were reviewed at the beginning and end of 1 month.

Results and conclusions

Thirty-three patients were prescribed PPIs; 26 prior to admission. The prescribing of PPIs was concordant with guideline recommendations in only 30% of cases. Two-thirds of PPI use was unlicensed.     

Incidence of discontinuation of angiotensin-converting enzyme inhibitors due to cough,in a primary healthcare centre in Singapore

INTRODUCTION

The incidence of cough induced by angiotensin-converting enzyme (ACE) inhibitors has been reported to be 5%–20%, with less than half of affected patients requiring discontinuation due to persistent cough. However, the incidence in the local Asian population has not been studied. This study aimed to objectively evaluate the incidence of discontinuation of ACE inhibitors due to cough, in a primary healthcare centre in Singapore.

METHODS

We retrospectively reviewed the medical records, both electronic and written, of patients who attended Tampines Polyclinic to identify those who were newly prescribed ACE inhibitors. The written medical records were analysed to identify patients who discontinued the use of ACE inhibitors and to find out the reasons for discontinuation.

RESULTS

A total of 424 patients were identified during the study period. Out of the 424 patients, 129 (30.4%) discontinued the use of ACE inhibitors due to cough. Overall, 90 (21.2%) patients who were initially started on ACE inhibitors were eventually switched to angiotensin receptor blockers (ARBs).

CONCLUSION

In our cohort, the incidence of discontinuation of ACE inhibitors due to cough is higher than most other studies. The relationship between ethnicity and tolerance of medications should not be underestimated. As there is a high incidence of discontinuation of ACE inhibitors due to cough in the local population, ARBs may be a reasonable substitute as a first-line medication, if clinically indicated.     

老年患者长期应用质子泵抑制剂对骨质疏松的影响研究

目的 探讨老年患者长期应用质子泵抑制剂(PPI)对骨质疏松的影响.方法 选取2011年1月至2015年1月期间该院收治的消化性溃疡患者150例为观察组,选取同期健康体检老年人150例为对照组.记录两组人群年龄、身高、体质量、PPI用药时间,采用骨密度测定仪检测患者治疗前后骨密度变化情况,包括腰椎L1～4、桡骨密度及尺骨骨密度.观察并记录观察组老年患者治疗前、治疗半年、治疗1年及2年后骨密度变化情况.结果 治疗后,观察组患者胃泌素明显增多,血钙水平及骨密度明显下降,差异有统计学意义(P＜0.05).观察组老年患者腰椎、桡骨及尺骨骨密度明显低于对照组(P＜0.05).随着PPI用药时间的延长,老年患者腰椎、桡骨及尺骨骨密度均呈下降趋势.结论 老年患者长期应用PPI会造成骨密度降低.     

The prevalence of albuminuria among diabetic patients in a primary care setting in Singapore

INTRODUCTION

Microalbuminuria is an early sign of kidney damage. The prevalence of microalbuminuria in Singapore has been reported to be 36.0%–48.5%. However, the prevalence of microalbuminuria reported in these studies was determined with one urine sample using a qualitative urine test. The aim of this study was to determine the prevalence of micro- and macroalbuminuria using a more stringent criterion of two positive quantitative urine albumin-creatinine ratio (ACR) tests.

METHODS

We conducted a cross-sectional study of patients with type 2 diabetes mellitus (T2DM) who were followed up at a primary care clinic in Singapore. Patients were diagnosed to have albuminuria if they had two positive ACR tests within a seven-month period.

RESULTS

A total of 786 patients with T2DM met the study’s inclusion criteria. 55.7% were already on an angiotensin-converting enzyme inhibitor (ACEI) and/or angiotensin receptor blocker (ARB). The prevalence rates of micro- and macroalbuminuria were 14.2% and 5.7%, respectively. Patients with albuminuria were more likely to have hypertension (odds ratio [OR] 3.47, 95% confidence interval [CI] 1.55–7.80). Diabetics with poorer diabetic control (OR 1.88, 95% CI 1.26–2.79), and higher systolic (OR 1.69, 95% CI 1.14–2.49) and diastolic (OR 1.96, 95% CI, 1.20 to 3.22) blood pressures were more likely to have albuminuria.

CONCLUSION

In the present study, the prevalence of microalbuminuria is significantly lower than that previously reported in Singapore. The presence of hypertension, poor diabetic control and suboptimal blood pressure control are possible risk factors for albuminuria in patients with T2DM.     

Detection of Strongyloides stercoralis infection among cancer patients in a major hospital in Kelantan,Malaysia

INTRODUCTION

Strongyloidiasis is one of the most commonly neglected but clinically important parasitic infections worldwide, especially among immunocompromised patients. Evidence of infection among immunocompromised patients in Malaysia is, however, lacking. In this study, microscopy, real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assays (ELISAs) were used to detect Strongyloides stercoralis (S. stercoralis) infection among cancer patients in a Malaysian hospital.

METHODS

A total of 192 stool and serum samples were collected from cancer patients who were receiving chemotherapy with or without steroid treatment at a hospital in northeastern Malaysia. Stool samples were examined for S. stercoralis using parasitological methods and real-time PCR. Serology by ELISA was performed to detect parasite-specific immunoglobulin G (IgG), IgG4 and immunoglobulin E (IgE) antibodies. For comparison, IgG4- and IgG-ELISAs were also performed on the sera of 150 healthy individuals from the same area.

RESULTS

Of the 192 samples examined, 1 (0.5%) sample was positive for S. stercoralis by microscopy, 3 (1.6%) by real-time PCR, 8 (4.2%) by IgG-ELISA, 6 (3.1%) by IgG4-ELISA, and none was positive by IgE-ELISA. In comparison, healthy blood donors had significantly lower prevalence of parasite-specific IgG (2.67%, p < 0.05) and IgG4 (2.67%, p < 0.05) responses.

CONCLUSION

This study showed that laboratory testing may be considered as a diagnostic investigation for S. stercoralis among immunocompromised cancer patients.     

质子泵抑制剂引发骨质疏松的病变机制和治疗策略

质子泵抑制剂的长期使用会抑制机体对钙的吸收,从而干扰骨代谢、导致骨质疏松或骨折,对老年患者尤其明显。长期使用质子泵抑制剂导致骨折的风险可能与用药剂量和时间相关。目前对预防和治疗质子泵抑制剂引起的骨质疏松主要根据原发性骨质疏松的治疗原则而采取措施,对长期使用质子泵抑制剂的患者应补充钙剂和维生素D以预防骨质疏松,对于已导致的骨质疏松的患者可根据具体病情选择双膦酸盐、降钙素、雌激素和甲状旁腺类似物等治疗。本文对质子泵抑制剂引发骨质疏松的机制及预防和治疗策略的研究进展进行综述。     

质子泵抑制剂与小肠细菌过生长关系的研究

目的：探讨质子泵抑制剂（PPIs）的使用与小肠细菌过生长（SIBO）发生之间的关系。方法：采用前瞻性对照性研究收集30例服用低剂量PPI的患者、28例服用高剂量PPI的患者,20例健康志愿者作为对照,通过乳果糖呼气H2试验连续观察SIBO的发生情况。结果：低剂量PPI组中SIBO阳性18例,阴性12例,高剂量PPI组阳性22例,阴性6例,对照组阳性1例,阴性19例,低剂量与高剂量PPI组分别与健康对照组比较差异有统计学意义（P〈0.01）,高剂量PPI组与低剂量组比较差异有统计学意义（P〈0.05）;两个服药组的SIBO阳性率随服药时间的增加而增加（P〉0.05）;同一时间段,高剂量PPI组的SIBO阳性率高于低剂量PPI组（P〉0.05）;两组PPI的使用时间与SIBO阳性率均存在正相关。结论：长期、大量使用PPI的患者可增加小肠细菌过生长的阳性率,可能进一步增加疾病发生的风险。     

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.     

Penile cancer: a local case series and literature review

INTRODUCTION

Penile cancer is an uncommon disease affecting only about one in 100,000 men worldwide in a year. The diagnosis of the condition is frequently delayed, and the disease and its treatment frequently result in significant morbidity in patients.

METHODS

We herein describe seven cases of penile tumours: six cases of squamous cell carcinomas and one case of B-cell lymphoma that presented to our hospital’s urology department between March 2011 and October 2012. We reviewed the literature to discuss the clinical presentation, natural history and current management of penile cancer.

RESULTS

The patients were followed up for 1–24 months. They were managed according to their disease stage and lymph node status. Four out of seven patients showed disease progression during the follow-up period.

CONCLUSION

The accurate staging of inguinal nodes in cases of low-risk disease is important to prescribe appropriate surgery for the inguinal nodes. Aggressive management of inguinal and pelvic lymph nodes remains the cornerstone in the treatment of high-risk disease cases.     

Co-prescription of H2 receptor blockers and proton pump inhibitors with warfarin in general practice

Acid-suppressing drugs and anticoagulants are used increasingly in general practice. Warfarin is potentiated by some acid-suppressing drugs, notably cimetidine and omeprazole, through interference of the cytochrome P450 system. This study aimed to ascertain the extent of co-prescribing of warfarin and acid-suppressing drugs in general practice. We conducted a retrospective survey of the records of all patients prescribed acid-suppressing drugs over a 2-year period to ascertain those who had also taken warfarin; we also made a cross-sectional survey of all patients on warfarin to ascertain those who had taken acid-suppressing drugs. From a general practice population of 45 574 patients in northern England, 3423 (7.5%) had been prescribed acid-suppressing drugs during the previous 24 months. Of 274 patients who had been on warfarin, 44 (16.1%) had also taken acid-suppressing drugs (26 H2 receptor blockers and 18 proton-pump inhibitors). The commonest reasons for anticoagulation were thrombo-embolic disease (40.9%), atrial fibrillation (36.4%), valvular heart disease (18.2%), and surgical prophylaxis (4.5%). The indications for concurrent acid-suppressing drugs were: 'dyspepsia' 38.6%, reflux 22.7%, oesophagitis 13.6%, duodenal ulcer 13.6%, gastric ulcer 4.5%, unknown 6.8%. There have been no studies from primary care to evaluate the possible clinical effects of the concomitant use of acid-suppressing drugs and warfarin; some fluctuations in coagulation control, particularly in patients taking the combinations intermittently, may be due to this.     

Predictors of poor glycaemic control in older patients with type 2 diabetes mellitus

INTRODUCTION

We assessed the predictors of poor glycaemic control among older patients with type 2 diabetes mellitus (T2DM) in Malaysia.

METHODS

This cross-sectional study used the data of 21,336 patients aged ≥ 60 years with T2DM from the Adult Diabetes Control and Management Registry 2008–2009.

RESULTS

Predictors of poor glycaemic control were: age groups 60–69 years (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.66–2.33) and 70–79 years (OR 1.43, 95% CI 1.20–1.71); Malay (OR 1.53, 95% CI 1.41–1.66) and Indian (OR 1.32, 95% CI 1.19–1.46) ethnicities; T2DM durations of 5–10 years (OR 1.46, 95% CI 1.35–1.58) and > 10 years (OR 1.75, 95% CI 1.59–1.91); the use of oral antidiabetic agents only (OR 5.86, 95% CI 3.32–10.34), insulin only (OR 17.93, 95% CI 9.91–32.43), and oral antidiabetic agents and insulin (OR 29.42, 95% CI 16.47–52.53); and elevated blood pressure (OR 1.10, 95% CI 1.01–1.20), low-density lipoprotein cholesterol (OR 1.48, 95% CI 1.38–1.59) and triglycerides (OR 1.61, 95% CI 1.51–1.73). Hypertension (OR 0.71, 95% CI 0.64–0.80), hypertension and dyslipidaemia (OR 0.68, 95% CI 0.61–0.75), pre-obesity (OR 0.89, 95% CI 0.82–0.98) and obesity (OR 0.76, 95% CI 0.70–0.84) were less likely to be associated with poor glycaemic control.

CONCLUSION

Young-old and middle-old age groups (i.e. < 80 years), Malay and Indian ethnicities, longer T2DM duration, the use of pharmacological agents, and elevated blood pressure and lipid levels were associated with poor glycaemic control. The presence of comorbidities, pre-obesity and obesity were less likely to be associated with poor glycaemic control.     

5 种质子泵抑制剂联合健胃愈疡胶囊治疗消化性溃疡的成本- 效果分析

目的 探讨5 种质子泵抑制剂分别联合健胃愈疡胶囊治疗幽门螺杆菌（Hp）阳性消化性溃疡的成本—效果及长期疗效。方法 275 例Hp 阳性消化性溃疡患者按照随机数字表分为奥美拉唑组（A 组）,雷贝拉唑（B 组）、泮托拉唑（C 组）、兰索拉唑（D 组）以及埃索美拉唑（E 组）,每组55 例。观察不同组别的成本/ 效果比（C/E）、增量成本/ 效果比（△ C/ △ E）、敏感性分析效果以及随访1 年后的长期疗效。结果 成本- 效果分析及敏感性分析结果显示B 组C/E 最低,E 组△ C/ △ E 最高;随访1 年结果显示,A、B、C、D、E 组HP 再次感染率分别为83.7%、41.3%、85.5%、64.5% 和61.4%,溃疡复发率分别为2.05%、0.48%、2.61%、1.18% 和1.07%,组间比较差异有统计学意义（P <0.05）,其中B 组低于A、C 及E 组（P <0.05）,而B 组与D 组比较差异无统计学意义（P >0.05）。结论 雷贝拉唑联合健胃愈疡胶囊在治疗HP 阳性消化性溃疡的成本- 效果及长期疗效优于其他各组,为最佳治疗方案,临床上值得推广。     

Exogenous ochronosis in a Chinese patient: use of dermoscopy aids early diagnosis and selection of biopsy site

The diagnosis of exogenous ochronosis is often challenging and requires a high index of suspicion. Herein, we report a case of exogenous ochronosis in a Chinese patient. The condition was caused by the use of bleaching agents, including creams containing hydroquinone. We demonstrate the use of dermoscopy as an invaluable tool for the early recognition of the condition, as well as in the selection of an appropriate site for a skin biopsy.     

300例住院患者质子泵抑制剂的合理用药评价

目的 通过对住院患者质子泵抑制剂（proton pump inhibitors,PPIs）进行合理用药评价,促进医院质子泵抑制剂的合理应用,保障患者用药安全。方法 回顾性分析2021年1月至2022年6月安顺市西秀区人民医院治疗使用PPIs的出院患者300例,根据PPIs临床应用指南、药品说明书等循证依据,从治疗原则、适应症、给药途径等多方面对PPIs进行合理用药评价。结果 共有79份（26.33%）病历使用PPIs存在不合理用药,包括给药途径不适、治疗用药无指征、围手术期预防用药无指征、缺少相关诊断、更换PPIs无依据、适应症不适宜等。其中,治疗用药不合理65例,预防用药不合理14例。结论 针对PPIs使用存在的问题持续开展用药评价,对规范临床合理使用此类药物具有较大意义。     

Perioperative glycaemic control in diabetic patients undergoing cataract surgery under local anaesthesia: a survey of practices of Singapore ophthalmologists and anaesthesiologists

INTRODUCTION

Perioperative glycaemic control is an important aspect of clinical management in diabetic patients undergoing cataract surgery under local anaesthesia. While poor long-term glycaemic control has significant implications for surgery, perioperative hypoglycaemia or hyperglycaemia may also compromise patient safety and surgical outcomes. We aimed to survey ophthalmologists and anaesthesiologists on their approach and to identify the prevalent practice patterns in Singapore.

METHODS

This was a cross-sectional questionnaire-based survey conducted in four public hospitals in Singapore with established ophthalmology and anaesthesia units. Respondents were approached individually, and the self-administered questionnaires comprised questions related to practice patterns, clinical scenarios and awareness of pre-existing guidelines.

RESULTS

A total of 129 doctors responded to the questionnaire survey. 76 (58.9%) were from ophthalmology departments and 53 (41.1%) were from anaesthesia departments. The majority chose to withhold oral hypoglycaemic agents (82.9%) and/or insulin (69.8%), and keep the patient fasted preoperatively. A blood glucose level ≥ 17 mmol/L prompted 86.0%–93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%–96.9% of respondents to cancel the cataract surgery. The respondents were consistently more concerned about perioperative hyperglycaemia (n = 99, 76.7%) than intraoperative hypoglycaemia (n = 83, 64.3%).

CONCLUSION

The current study presented the prevalent practice patterns of ophthalmologists and anaesthesiologists in the perioperative management of diabetic patients undergoing cataract surgery in four public hospitals in Singapore. Further research in this field is required, and may be useful for the future formulation of formal guidelines and protocols.     

Comparison between elderly inpatient fallers with and without dementia

INTRODUCTION

This study aimed to examine the various factors associated with inpatient falls among patients with and without dementia in a hospital setting.

METHODS

This was a retrospective one-year study using data collected from Singapore General Hospital''s electronic reporting system for inpatient falls.

RESULTS

In the study period, 298 patients aged ≥ 65 years fell during their hospital stay. The majority of the patients (n = 248) did not have dementia. In our study, fallers with dementia were more likely to use ambulatory aids, be visually impaired and have urinary incontinence. More patients with dementia than those without had a history of previous falls, and were placed on fall precaution with restricted freedom of movement, which at times, included restraints. However, the difference between patients who were put on restraints and those who were allowed to move freely was not statistically significant. The majority of falls in both groups occurred at the bedside. We found that fallers without dementia were more likely to fall during the morning shift, whereas fallers with dementia were more likely to fall during the night shift. Fallers with dementia were more likely to be confused at the time of the fall.

CONCLUSION

In our study, we found that fallers with dementia were more likely to have visual impairment, have urinary incontinence, use walking aids, and to be confused and physically restrained at the time of the fall. The fallers without dementia in our study may have undiagnosed dementia.     

Managing the ‘picky eater’ dilemma

Picky eating is a common cause of concern for parents of young children. Paediatricians and family physicians are in a key position to help parents learn ways to feed their children effectively. Despite the high prevalence of picky eating, the growth of the majority of picky eaters does not suffer adversely. In the absence of worrying signs and symptoms, reassurance of the child’s normal growth would help allay parental anxieties. Reinforcement of basic feeding principles and providing healthy dietary advice are important strategies to help parents manage children who are picky eaters.     

CYP2C19基因多态性对质子泵抑制剂治疗NVUGIB疗效的影响

目的观察细胞色素P450(CYP)2C19基因多态性对质子泵抑制剂治疗非静脉曲张上消化道出血(NVUGIB)疗效的影响。方法选择102例NVUGIB患者,随机分为奥美拉唑组(n＝51)和雷贝拉唑组(n＝51),奥美拉唑组在常规治疗基础上给予奥美拉唑,雷贝拉唑组在常规治疗基础上给予雷贝拉唑,连续用药5天,检测两组患者CYP2C19基因型,分析CYP2C19基因型对治疗总有效率、止血时间、住院时间以及不良反应发生率的影响。结果奥美拉唑组内慢代谢型(PM)治疗总有效率高于快代谢型(EM)(P＜0.05);雷贝拉唑组EM型治疗总有效率高于奥美拉唑组(P＜0.05)。雷贝拉唑组内不同基因型间止血时间差异无显著性(P＞0.05)。奥美拉唑组EM型止血时间长于中间代谢型(IM)、PM型,且IM型止血时间长于PM型(P＜0.05)。雷贝拉唑组EM型止血时间短于奥美拉唑组,而PM型止血时间长于奥美拉唑组(P＜0.05)。奥美拉唑组PM型住院时间短于EM型、IM型,且PM型住院时间短于IM型(P＜0.05)。雷贝拉唑EM型住院时间短于奥美拉唑组,而PM型住院时间长于奥美拉唑组(P＜0.05)。结论CYP2C19基因多态性会影响质子泵抑制剂治疗NVUGIB患者的治疗总有效率、止血时间和住院时间,临床可针对不同的CYP2C19基因型患者,采取针对性的药物治疗。     

A feasible ambulatory mini-incision microsurgical vasovasostomy under local anaesthesia using a specially designed double-ringed clamp that simplifies surgery

INTRODUCTION

In line with the effort to evaluate feasible surgical options for vasectomy reversal and to increase patients’ willingness to undergo the procedure, this study reported on a technique for ambulatory mini-incision microsurgical vasovasostomy using a double-ringed clamp (i.e. Moon’s clamp). This technique does not require the use of dilators, approximators and other accessory devices.

METHODS

Ambulatory mini-incision microsurgical vasovasostomy was conducted on 263 patients who satisfied the surgical eligibility requirements for vasovasostomy and the safety criteria for local anaesthesia. The operation time, details on postoperative recovery and results of the postoperative semen analysis were recorded and retrospectively analysed.

RESULTS

The mean time used to isolate the bilateral vas deferens was 25.5 minutes. All patients were discharged on the day of surgery and all patients returned to their normal activities within 24–48 hours after surgery. No haematoma or infection occurred except in one patient. Postoperative semen analysis showed that the surgery was successful in 182 (96.8%) of the 188 patients who complied with the postoperative patient instructions.

CONCLUSION

Ambulatory mini-incision microsurgical vasectomy reversal using Moon’s clamp and under local anaesthesia is a surgically feasible option that offers the advantages of a low-risk operation. It also achieves successful vasovasostomy without other accessory devices and allows patients to return to their daily activities quickly with minimal complications.