Anomalous composition of musculature of the first dorsal fibro-osseous compartment of the wrist

The anomalous orientation of musculature of the first dorsal fibro-osseous compartment of the wrist is clinically relevant to De Quervian's stenosing tenosynovitis and reconstructive surgeries. Split insertion of the abductor pollicis longus (APL) is commonly found in chimpanzees, gorillas and gibbons. A comparable identical pattern of anomalous slips in humans is of anthropological and phylogenetic importance and could be a result of atavism. This case report describes an unusual fused muscle belly of the APL and extensor pollicis brevis (EPB), which split into three slips--medial, intermediate and lateral. Further, the medial slip was seen to divide into two tendons, inserting on the base of the first metacarpal along with the intermediate slip. The lateral slip divided into three tendons, inserting into the base of the proximal phalanx, base of the first metacarpal and abductor pollicis brevis muscle. The fusion and unusual insertion pattern of the APL and EPB merits documentation for reconstructive procedures such as tendon transfer and interposition arthroplasty.     

Anatomical study of the suprascapular notch: quantitative analysis and clinical considerations for suprascapular nerve entrapment

INTRODUCTION

Detailed anatomical knowledge of the suprascapular notch (SSN) is important for the management of entrapment neuropathy and interventional procedures. The objective of the present study was to collect data on the morphological features and anatomical variations of the SSN in an Indian population.

METHODS

We studied 268 human scapulae of unknown sex (126 right-sided, 142 left-sided) taken from the Department of Anatomy, Dayanand Medical College and Hospital, India. SSNs were classified as either type I, II, III, IV or V, based on the shape of the inferior border of the incisura, and comparison of the SSN''s vertical and transverse diameters. The shape of the SSN (i.e V-or U-shaped), if present, was also recorded.

RESULTS

Type II SSN was the most common (50.00%), followed by type I, type IV and type III (32.46%, 9.70% and 7.84%, respectively). For right-sided type II SSNs, the transverse and vertical diameters were 9.1 ± 3.2 mm and 5.2 ± 1.9 mm, respectively, while those for left-sided type ll SSNs were 9.2 ± 2.4 mm and 5.1 ± 1.8 mm, respectively. Generally, the transverse diameter of type II SSN was found to be greater than that of type III SSN. The incidence of U-shaped SSN was 51.49%, while that of V-shaped SSN was 2.99%.

CONCLUSION

This study of the morphometrical characteristics and anatomical variations of SSN provides an anatomical database of SSN in the Indian context. This database will be of use in surgical procedures, as the information can be used to ensure adequate access to and complete decompression of the suprascapular nerve.     

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.     

Morphological study of the attachment of the sternocleidomastoid muscle

INTRODUCTION

The sternocleidomastoid (SCM) muscle is a major muscle of the neck. Classically, this muscle is attached below the sternum and clavicle, although the mode of attachment might vary. As the SCM is related to numerous important neurovascular structures, its variable anatomy is clinically relevant, particularly for neck surgeries. A cadaveric study was performed to establish the variations present in the mode of attachment of the SCM muscle in an Indian population.

METHODS

We studied the variations in the attachment of the SCM muscle during the dissection of 18 cadavers for undergraduate teaching in two medical colleges in West Bengal, India.

RESULTS

Variations in the attachment of the SCM muscle were found in 5 (27.8%) specimens. Of these five specimens, three had unilateral variations and two had bilateral variations. In each specimen, the modes of presentation of the SCM and its fusion with the major bulk were also different.

CONCLUSION

In this study, we found variations in the attachment of the SCM muscle in more than a quarter of the specimens dissected. Surgeons should bear in mind such variations when performing neck surgeries.     

Granular cell tumour: malignant or benign?

INTRODUCTION

Granular cell tumours (GrCTs) are uncommon soft tissue tumours that are usually benign (approximately 0.5%–2.0% have been reported as malignant). They are very rarely found at the extremities. Differentiating a malignant GrCT from a benign one is important as the former is aggressive and has a poor prognosis, whereas the latter, after surgical resection, has excellent outcomes. A malignant lesion can be suspected on clinical presentation and confirmed via histopathological examination using the Fanburg-Smith criteria.

METHODS

This was a retrospective review of all cases of GrCT of the extremities that presented to the Orthopaedic Oncology Unit of University Malaya Medical Centre, Malaysia, from September 2006 to March 2013.

RESULTS

There were a total of five cases, all of which involved female patients aged 13–40 (mean age 24) years. Three cases involved the upper limbs and two involved the lower limbs. Using the Fanburg-Smith criteria, three cases were classified as benign, one as atypical and one as malignant. Wide local excision was performed in all five cases and the outcomes were excellent except for the patient with a malignant tumour. That patient presented with lung metastasis about three months after surgery.

CONCLUSION

Malignant and benign GrCTs can be differentiated on clinical presentation and by using the Fanburg-Smith criteria. We believe that wide local excision is the best treatment for both benign and malignant tumours. The role of adjuvant chemotherapy and radiotherapy in malignant GrCTs should be studied. All patients with GrCTs should receive follow-up to check for recurrence and metastasis.     

The Little India riot: experience of an emergency department in Singapore

INTRODUCTION

Singapore experienced its second riot in 40 years on 8 December 2013, in the area known as Little India. A retrospective review of 36 casualties treated at the emergency department was conducted to evaluate injury patterns.

METHODS

Characteristics including the rate of arrival, injury severity, type and location, and disposition of the casualties were analysed.

RESULTS

The injuries were predominantly mild (97.2%), with the most common injuries involving the head (50.0%) and limbs (38.9%). 97.2% of the casualties were managed as outpatient cases.

CONCLUSION

The majority of the injuries in this incident were mild and could be managed as outpatient cases. Important lessons were learnt from the incident about the utilisation of manpower and safety of staff in the emergency department.     

Coronary anatomy,anatomic variations and anomalies: a retrospective coronary angiography study

INTRODUCTION

The incidence of coronary artery anomalies (CAAs) varies from 0.2% to 8.4%. Knowledge of such anatomical variations is important as coronary procedures are regularly performed these days. We aimed to find the coronary dominance pattern, intermediate artery (IMA) frequency and CAA incidence in our clinic, and compare them to those in the literature.

METHODS

The medical reports of 5,548 patients who had undergone coronary angiography (CAG) between 2005 and 2009 were retrospectively investigated. Dominance pattern and presence of IMA and CAA were recorded. CAAs were described using two different classifications: Angelini and Khatami’s classification, and a new modified classification that was derived from Angelini and Khatami’s classification. Some procedural details and clinical features of the patients with CAA were also investigated.

RESULTS

Coronary dominance pattern was: 81.6% right coronary artery, 12.2% circumflex artery and 6.2% co-dominant. IMA was present in 613 (11.0%) patients. The incidences of overall anomaly were 2.7% and 1.4%, according to the different classifications. Absent left main coronary artery, which was the most common anomaly in the present study, was found in 51 (0.9%) patients. Incidences of myocardial bridge, coronary arteriovenous fistulae and aneurysms were 1.1%, 0.2% and 0.3%, respectively.

CONCLUSION

CAAs are generally asymptomatic, isolated lesions. Some may lead to anginal symptoms, myocardial infarction or sudden death. We found that CAA was associated with increased radiation and contrast exposure in patients who underwent CAG. This risk could be reduced if appropriate catheters were designed and training programmes on ostial cannulation were developed.     

Unusual morphology of scapulae: incidence and dimensions of ossified ligaments and supraspinous bony tunnels for clinical consideration

INTRODUCTION

Knowledge of morphological variations of the suprascapular region is important in the management of entrapment neuropathy and interventional procedures. The objective of this study was to collect data on the morphological features and dimensions of ossified ligaments and unusual bony tunnels of scapulae from a North Indian population.

METHODS

A total of 268 adult human scapulae of unknown gender were obtained from the bone bank of the Department of Anatomy, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. The scapulae were evaluated for the incidence of ossified superior transverse scapular ligaments (STSLs), ossified inferior transverse scapular ligaments (ITSLs) and bony tunnels (i.e. the bony canal between the suprascapular notch and spinoglenoid notch), found along the course of the suprascapular nerve (SSN). The dimensions of these structures were measured and noted down. Ossified STSLs were classified based on their shape (i.e. fan- or band-shaped) and the dimensions of the ossified suprascapular openings (SSOs) were measured.

RESULTS

Ossified STSLs were present in 26 (9.7%) scapulae. Among the 26 scapulae, 16 (61.5%) were fan-shaped (mean area of SSO 16.6 mm²) and 10 (38.5%) were band-shaped (mean area of SSO 34.2 mm²). Bony tunnels were observed in 2 (0.75%) specimens, while an ossified ITSL was observed in 1 (0.37%) specimen.

CONCLUSION

The data obtained in the present study augments the reference literature for SSN decompression and the existing anatomical databases, especially those on Indian populations. This data is useful to clinicians, radiologists and orthopaedic surgeons.     

Coarctation of the aorta: nonsurgical treatment using stent implantation

INTRODUCTION

Coarctation of the aorta (CoA) accounts for 5%–8% of all congenital heart defects. If left untreated, most patients with significant CoA will have varying degrees of morbidity (e.g. hypertension, stroke, collateral formation and ventricular hypertrophy), possibly even mortality. Traditionally, treatment for this condition is surgical. Herein, we report stenting during catheterisation as an alternative nonsurgical treatment option for patients with CoA, and present the treatment outcomes of patients who underwent this treatment option.

METHODS

We retrospectively reviewed four patients (2 men and 2 women; age range 20–41 years) who underwent CoA stenting under general anaesthesia for the treatment of native CoA or restenosis of CoA at our institution. Three patients had a 40-mm Palmaz stent inserted, while one had a 39-mm Cheatham-Platinum covered stent inserted. Angiography and measurement of pressure gradients were performed before and after stent implantation to ensure good treatment outcomes.

RESULTS

The patients’ treatment outcomes were good, with a significant reduction in pressure gradients across the narrowed segments. Angiography showed relief of CoA. The patients were followed up for 1–3 years, during which no complications were noted.

CONCLUSION

This is the first reported series in Singapore on the nonsurgical treatment of CoAs in adult patients using stents during interventional cardiac catheterisation. This less invasive procedure may lead to a new paradigm shift with regard to the treatment of CoA.     

Factors associated with inter-institutional variations in sepsis rates of very-low-birth-weight infants in 34 Malaysian neonatal intensive care units

INTRODUCTION

This study aimed to determine whether patient loads, infant status on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis rates in very-low-birth-weight (VLBW) infants in the Malaysian National Neonatal Registry (MNNR).

METHODS

This was a retrospective study of 3,880 VLBW (≤ 1,500 g) infants admitted to 34 neonatal intensive care units (NICUs) in the MNNR. Sepsis was diagnosed in symptomatic infants with positive blood culture.

RESULTS

Sepsis developed in 623 (16.1%) infants; 61 (9.8%) had early-onset sepsis (EOS) and 562 (90.2%) had late-onset sepsis (LOS). The median EOS rate of all NICUs was 1.0% (interquartile range [IQR] 0%, 2.0%). Compared with NICUs reporting no EOS (n = 14), NICUs reporting EOS (n = 20) had significantly higher patient loads (total live births, admissions, VLBW infants, outborns); more mothers with a history of abortions, and antenatal steroids and intrapartum antibiotic use; more infants requiring resuscitation procedures at birth; higher rates of surfactant therapy, pneumonia and insertion of central venous catheters. The median LOS rate of all NICUs was 14.5% (IQR 7.8%, 19.2%). Compared with NICUs with LOS rates below the first quartile (n = 8), those above the third quartile (n = 8) used less intrapartum antibiotics, and had significantly bigger and more mature infants, more outborns, as well as a higher number of sick infants requiring ventilator support and total parenteral nutrition.

CONCLUSION

Patient loads, resuscitation at birth, status of infants on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis.     

Evaluation of the Patient Safety Leadership Walkabout programme of a hospital in Singapore

INTRODUCTION

The Patient Safety Leadership Walkabout (PSLWA) programme is a commonly employed tool in the West, in which senior leaders visit sites within the hospital that are involved in patient care to talk to healthcare staff about patient safety issues. As there is a lack of perspective regarding PSLWA in Asia, we carried out an evaluation of its effectiveness in improving the patient safety culture in Tan Tock Seng Hospital, Singapore.

METHODS

A mixed methods analysis approach was used to review and evaluate all documents, protocols, meeting minutes, post-walkabout surveys, action plans and verbal feedback pertaining to the walkabouts conducted from January 2005 to October 2012.

RESULTS

A total of 321 patient safety issues were identified during the study period. Of these, 308 (96.0%) issues were resolved as of November 2012. Among the various categories of issues raised, issues related to work environment were the most common (45.2%). Of all the issues raised during the walkabouts, 72.9% were not identified through other conventional methods of error detection. With respect to the hospital''s patient safety culture, 94.8% of the participants reported an increased awareness in patient safety and 90.2% expressed comfort in openly and honestly discussing patient safety issues.

CONCLUSION

PSLWA serves as a good tool to uncover latent errors before actual harm reaches the patient. If properly implemented, it is an effective method for engaging leadership, identifying patient safety issues, and supporting a culture of patient safety in the hospital setting.     

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.     

Morphology of distal radius curvatures: a CT-based study on the Malaysian Malay population

INTRODUCTION

The purpose of this study was to examine the differing curves of the volar distal radius of healthy Malaysian Malays, so as to obtain detailed morphological information that will further the understanding of volar plate osteosynthesis in Malaysian Malays.

METHODS

Computed tomography with three-dimensional reconstruction was performed on the wrists of 16 healthy Malaysian Malay volunteers. Profile measurements were made using a software program. A novel parameter, the pronator quadratus curve angle, was explored and introduced in this study. Interclass correlation coefficients were calculated to assess the level of agreement between the data collected by the principal investigator and that collected by an independent radiologist.

RESULTS

The mean ± standard deviation of the arc radii on the radial aspect was 17.50° ± 5.40°, while the median (interquartile range [IQR]) of the arc radii on the ulnar aspect was 25.27° (IQR 5.80°). The mean ± standard deviation of the curvature of the pronator quadratus line was 40.52° ± 2.48°. The arc radii on the radial aspect was significantly lower than the arc radii on the ulnar aspect (p = 0.001). Different radial and ulnar arcs were observed in 56.25% of the radii; the arc was deeper on the ulnar aspect in 93.75% of the radii.

CONCLUSION

Based on the findings of this study, the likelihood of achieving anatomical reduction with uniformly curved, fixed-angle volar plates is questionable. Changes in the design of these implants may be needed to optimise their usage in the Malaysian Malay population.     

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.     

Review of sleep studies of patients with chronic insomnia at a sleep disorder unit

INTRODUCTION

Chronic insomnia is associated with many physical and psychiatric illnesses, and its underlying aetiology needs to be identified in order to achieve safe and effective treatment. Obstructive sleep apnoea (OSA) and periodic limb movement disorder (PLMD) are common primary sleep disorders that can lead to chronic insomnia. Patients with these conditions are evaluated using polysomnography (PSG).

METHODS

The PSG records of 106 patients with chronic insomnia who presented to a multidisciplinary sleep clinic in Singapore over a five-year period were reviewed. To examine the utility of PSG in the evaluation of chronic insomnia, the clinical diagnoses of the patients before and after the sleep studies were compared.

RESULTS

Among the 106 patients, 69 (65.4%) were suspected to have primary sleep disorders based on clinical history and examination alone. Following PSG evaluation, 42.5% and 4.7% of the study population were diagnosed with OSA and PLMD, respectively. OSA was found in 35.9% of the 39 patients who had underlying psychiatric conditions.

CONCLUSION

This study illustrates that many patients with chronic insomnia have underlying primary sleep disorders. It also highlights the danger of attributing chronic insomnia in psychiatric patients to their illness, without giving due consideration to other possible aetiologies. Clinicians should maintain a high index of suspicion for the presence of other aetiologies, and make timely and targeted referrals for sleep studies where appropriate.     

A prospective study of epidemiological risk factors for ingestion of fish bones in Singapore

INTRODUCTION

Ingestion of fish bones is a common clinical complaint among adult patients. The aim of this study was to evaluate the epidemiological and behavioural risk factors for fish bone ingestion.

METHODS

Between 2009 and 2010, a physician-administered questionnaire was administered to 112 consecutive patients who presented to the emergency department of an adult tertiary hospital with the complaint of fish bone ingestion.

RESULTS

The wearing of dentures, the use of utensils to eat fish and the practice of deboning fish in one’s mouth were found to be associated with an increased risk of fish bone ingestion.

CONCLUSION

To prevent the occurrence of fish bone ingestion and its possible complications, at-risk populations should be advised on the precautions to take when eating boned fish.     

Treatment of severe,disabling spasticity with continuous intrathecal baclofen therapy following acquired brain injury: the experience of a tertiary institution in Singapore

INTRODUCTION

Intrathecal baclofen (ITB) therapy is a proven, effective treatment for disabling cortical spasticity. We describe the first local series of five patients with acquired brain injury (ABI) who received ITB and were followed up for 63.8 months.

METHODS

A retrospective review of medical and rehabilitation records of patients who received ITB therapy was carried out. Data studied included baseline demographic and injury variables, implantation data, spasticity and function, ITB dosage over time and complications.

RESULTS

From 2006 to 2010, a total of five patients received ITB therapy via implanted pumps about 39.4 months after ABI. Four out of five patients experienced significant reductions in their lower limb spasticity scores and improvements in global function and dependency. One patient had minor adverse events associated with baclofen-related sedation. The mean ITB dose at one year was 182.7 ± 65.6 mcg/day.

CONCLUSION

Our preliminary study showed encouraging long-term outcomes and safety for ITB therapy after ABI-related intractable spasticity. Individual ITB responses over time were variable, with gender differences. The outcomes experienced by our centre were comparable to those in the general ABI population, supporting the efficacy of ITB therapy for chronic disabling spasticity.     

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 perioperative anaphylaxis at a Singapore tertiary hospital

INTRODUCTION

Perioperative anaphylaxis is an anaesthetic emergency, but its incidence is not well described in the local literature. This retrospective study aims to look at a group of patients who had perioperative anaphylaxis in our institution.

METHODS

We conducted a retrospective review of electronic databases and clinical case sheets, and identified 34 patients who had possible perioperative anaphylaxis during anaesthesia in our institution between 1 January 2007 and 30 April 2012.

RESULTS

After reviewing clinical and biochemical data, we found that 16 out of 151,876 patients who underwent surgery had confirmed perioperative anaphylaxis, an incidence of 1:10,000. Neuromuscular blockers were identified as the most common causative agent for perioperative anaphylaxis. The offending agent could not be identified in seven patients.

CONCLUSION

To the best of our knowledge, this is the first study in Southeast Asia on the incidence of perioperative anaphylaxis. Having a preoperative history of allergy did not seem to predispose patients to the subsequent development of perioperative anaphylaxis.