Surgical management of elevated intracranial pressures due to stroke or traumatic brain injury has classically been through decompressive craniectomy (DC). There is significant morbidity associated with DC including subdural hygromas, syndrome of the trephined, and the need for subsequent cranioplasty. Alternative techniques including the hinged and floating craniotomy have shown promise though can still suffer from complications associated with an unsecured bone flap. We report a case in which a patient who presented with an acute subdural hematoma and associated midline shift that was successfully treated with decompression via thinning and re-securing of the bone flap in a “split-thickness decompression.”

Public health nursing is a specialized nursing combining both nursing and public health principles with the primary focus of improving the health of the whole community rather than just an individual. Its documented history started in the 1800s and has evolved from home visiting to the varied settings that public health nurses find themselves working in as members of public health teams in clinics, schools, workplaces and government health departments.Public health nursing has been a critical component of the country’s health care system, uplifting of the health status of Malaysians and playing a dominant role in the fight against communicable diseases, and is set to face the challenges of the 21st century with public health nurses practising to the full capacity of their training in a restructured Malaysian health system – 1Care for 1Malaysia. The health sector reform allows for optimisation of scarce health care resources to deliver expansion of quality services based on needs, appropriateness, equity &allocative efficiency. The proposed model will be better than the current system, preserving the strengths of the current system but able to respond to increasing population health needs and expectations. There will be increased autonomy for healthcare providers with incentives in place for greater performance. Some of the implications of reform include allowing public- private integration, a slimmer Ministry of Health with a stronger governance role, enhancing the gatekeeping role of the primary care providers and the autonomous management of the public healthcare providers. In this restructured health system, the roles of the public health nurses are no less important than in the current one. In fact, with the increasing emphasis placed on prevention and primary care as the hub of community care with nurses as part of the primary care team delivering continuous comprehensive person-centered care,public health nurses in the future will be able to meet the challenge of refocusing on the true mission of public health: to look at the health problems of a community as a whole and work with the community in alleviating those problems by applying the nursing process to improve health, not just as providers of personal care only.
Public Health Nursing

Humans ; Diabetes Mellitus/epidemiology*

Adult ; Humans ; Hyperoxaluria, Primary ; enzymology ; genetics ; Male ; Transaminases ; deficiency

INTRODUCTIONThe use of an additional biopsy from the gastric body may help improve the detection of Helicobacter pylori during endoscopy. This study aimed to determine whether such an additional biopsy is necessary in routine rapid urease test (RUT), and whether acid suppression and antibiotic therapy affect RUT results.

METHODSPatients recruited had two gastric mucosal biopsies taken - one from the gastric antrum and the other from the gastric body. Each biopsy was placed into separate RUT kits. Information on previous or current use of proton-pump inhibitors, H2 receptor antagonist, bismuth and antibiotics was obtained. Patients on any of those drugs one week prior to endoscopy were considered to have a positive drug history (PDH).

RESULTSOf the 400 patients recruited, 311 had negative RUTs and 89 had at least one positive RUT. Between the PDH and negative drug history (NDH) groups, there was a significant difference in the distribution of the location of the biopsies that yielded positive RUTs (p = 0.023). The NDH group had a higher proportion of patients who had positive RUTs for both locations, whereas the PDH group had a higher proportion of patients who had positive RUTs for only one location.

CONCLUSIONAs RUT results are significantly affected by the use of acid suppression and antibiotic therapies, biopsies for RUT should be taken from both the gastric antrum and body to minimise false negative results.

Adult ; Aged ; Antacids ; pharmacology ; Anti-Bacterial Agents ; pharmacology ; Endoscopy ; Endoscopy, Gastrointestinal ; Female ; Gastric Mucosa ; microbiology ; pathology ; Gastrointestinal Diseases ; diagnosis ; epidemiology ; microbiology ; Helicobacter Infections ; diagnosis ; Helicobacter pylori ; drug effects ; isolation & purification ; History, Ancient ; Humans ; Middle Aged ; Singapore ; epidemiology ; Urease ; analysis

BACKGROUNDSingle incision laparoscopic colectomy has been performed in recent years, and has been shown to be feasible and safe. This study was to assess the feasibility of single incision laparoscopic right hemicolectomy and to compare the differences in different approaches.

METHODSThis retrospective study included eighteen patients with carcinoma of caecum and ascending colon, undergoing single incision laparoscopic right hemicolectomy. This study also compared single incision laparoscopic right hemicolectomy using different approaches: (1) single incision multiport, (2) single access port and (3) glove port.

RESULTSThere was no statistical difference in surgical outcomes. Concerning the surgeon's satisfaction toward three methods, overcrowding and durability were similar but the single incision multiport was associated with the highest gas-leak and the "glove" port was associated with poor durability. However, the method of single incision multiport has the lowest average cost of the special trocar or port in each operation. The operative time and blood loss of the operations in this study were comparable to previous publications.

CONCLUSIONThere was no significant difference between different approaches of single incision laparoscopic right hemicolectomy for colonic cancer in right side colon.

Aged ; Cecal Neoplasms ; surgery ; Colectomy ; methods ; Colonic Neoplasms ; surgery ; Female ; Humans ; Laparoscopy ; methods ; Male ; Middle Aged ; Retrospective Studies

INTRODUCTION: The National Early Warning Score (NEWS) is well established in acute medical units to identify acutely deteriorating patients and is shown to have good prognostic value. NEWS, however, has only been used in the Emergency Department as a triage tool. We aimed to evaluate the validity of NEWS in Acute Medical Ward (AMW) that treats predominantly acute infection-related conditions to the Internal Medicine service. MATERIALS AND METHODS: We undertook a retrospective cohort study and analysed NEWS records of all patients admitted to AMW at Singapore General Hospital between 1 August 2015 and 30 July 2017. The outcome was defined as deterioration that required transfer to Intermediate Care Area (ICA), Intensive Care Unit (ICU) or death within 24 hours of a vital signs observation set. RESULTS: A total of 298,743 vital signs observation sets were obtained from 11,300 patients. Area under receiver operating characteristic curve for any of the 3 outcomes (transfer to ICA, ICU or death) over a 24-hour period was 0.896 (95% confidence interval, 0.890-0.901). Event rate was noted to be high above 0.250 when the score was >9. In the medium-risk group (score of 5 or 6), event rate was <0.125. CONCLUSION NEWS accurately triages patients according to the likelihood of adverse outcomes in infection-related acute medical settings.

STUDY DESIGN: A retrospective review of patients who underwent 2-level anterior cervical discectomy and fusion (ACDF) with standalone polyetheretherketone (PEEK) cages for cervical spondylotic myelopathy (CSM). PURPOSE: To evaluate the efficacy of stand-alone PEEK cage in 2-level cervical interbody fusion for CSM. OVERVIEW OF LITERATURE: ACDF is a standard surgical procedure to treat degenerative disc disease. However, the use of additional anterior plating for 2-level ACDF remains controversial. METHODS: We reviewed outcomes of patients who underwent 2-level ACDF with stand-alone PEEK cages for CSM over a 7-year period (2007–2015) in a regional hospital. Japanese Orthopaedic Association (JOA) score, fusion rate, subsidence rate, cage migration, and cervical alignment by the C2–7 angle as well as the local segmental angle (LSA) of the cervical spine were assessed. RESULTS: In total, 31 patients (mean age, 59 years; range, 36–87 years) underwent 2-level ACDF with a cage-only construct procedure between 2007 and 2015. The minimum follow-up was 24 months; mean follow-up was 51 months. C3–5 fusion was performed in 45%, C4–6 fusion in 32%, and C5–7 fusion in 23%. Mean JOA score improved from 10.1±2.2 to 13.9±2.1 (p<0.01) at the 24-month follow-up. Fusion was achieved in all patients. Subsidence occurred in 22.5% of the cages but was not associated with differences in JOA scores, age, sex, or levels fused. Lordosis of the C2–7 angle and LSA increased after surgery, which were maintained for up to 1 year but subsequently disappeared after 2 years, yet the difference was not statistically significant. No cage migration was noted; two patients developed adjacent segment disease requiring posterior laminoplasty 3 years after ACDF. CONCLUSIONS: The use of a stand-alone PEEK cage in a 2-level cervical interbody fusion achieves satisfactory improvements in both clinical outcomes and fusion.
Animals ; Asian Continental Ancestry Group ; Diskectomy ; Follow-Up Studies ; Humans ; Laminoplasty ; Lordosis ; Retrospective Studies ; Spinal Cord Diseases ; Spine

BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction (STEMI) improves outcomes. System delay is that between first medical contact and reperfusion therapy, comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore. METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services (EMS), ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique. RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5 minutes (interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes (IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes (IQR=1.30, 22.13); between arrival-at- and departure-from-patient-location was 13.12 minutes (IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes (IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulance-dispatch and arrival-at-patient-location was shorter (5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter (10.78 vs. 14.37 minutes, P<0.01). CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.

OBJECTIVESince human mast cell is an important source of cytokines, it is of importance to understand the effects of anti-allergic drugs on cytokines modulation in mast cells. In the present study, we aimed at observing whether IL-4 could be released from human mast cell line (HMC-1) after the stimulation of PMA + A23187, and the effects of systemic glucocorticosteroid, dexamethasone, topical glucocorticosteroid, budesonide and H1 antagonist, desloratadine on IL-4 release and mRNA expression.

METHODSHMC-1 was stimulated with 25 ng/ml phorbol 12-myristate 13-acetate (PMA) and 2.5 x 10(-7) mol/L ionomycin (A23187) and cultured for 6 hours, 12 hours and 24 hours respectively in the presence or absence of 10(-6)-10(-10) mol/L concentrations of test drugs. Culture supernatants were collected and the levels of IL-4 were assayed by enzyme-linked immunosorbent assays (ELISA). The mRNA expression of IL-4 was measured by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR).

RESULTSHMC-1 expressed IL-4 mRNA and the resulting protein production of IL-4 released after being stimulated with PMA plus A23187. Dexamethasone, budesonide and desloratadine had potent inhibitory effect on IL-4 release at any concentrations and time points, with significant deference (P < 0.05) compared to the control cells. The inhibitory effect did not show time-dependent and concentration-dependent manner. Desloratadine and budesonide showed neither up-regulatory nor down-regulatory effects on IL-4 mRNA expression at the test concentrations, however, desloratadine could down-regulate IL-4 mRNA expression.

CONCLUSIONSHMC-1 could express and produce IL4 after stimulation. Dexamethasone, budesonide and desloratadine all had inhibitory effects on IL-4 release from HMC-1. In addition, desloratadine could also inhibit the IL-4 mRNA expression.

Budesonide ; pharmacology ; Cell Line ; Dexamethasone ; pharmacology ; Humans ; Interleukin-4 ; biosynthesis ; Loratadine ; analogs & derivatives ; pharmacology ; Mast Cells ; drug effects ; metabolism ; Tetradecanoylphorbol Acetate ; pharmacology