Introduction: Patients with asthma-like symptoms pose a diagnostic dilemma when physical examination is normal. The usual practice in Malaysia would be to give empirical asthma treatment. Bronchial challenge test (BCT) is widely used in many countries to diagnose asthma objectively but it is not widely available in Malaysia. Objective: To describe our experience with BCT using methacholine at Queen Elizabeth Hospital as a supporting tool in the investigation of patients with asthma-like symptoms. Methodology: Review of case notes of patients who underwent BCT from July 2008 till April 2009. BCT was performed via dosimeter technique. Results were classified as high hyper responsiveness if the provocative dose of methacholine required to achieve 20% fall in FEV1 (PD20) was less than or equal to 0.125 μmol, moderate hyper responsiveness if PD20 was between 0.125 to 1.99 μmol or mild hyper responsiveness if PD20 was between 2.00 to 6.6 μmol. PD20 of more than 6.6 μmol constitutes a negative MCT. Results: 29 patients had BCT during the study period. 19 cases were included in this review. The age ranged from 13 to 70 years old. There were 12 males and 7 females. Duration of symptoms ranged from 2 weeks to 23 years. BCT was positive (mild or moderate hyper responsiveness) in 10 out of 19 patients. No patient had high bronchial hyper responsiveness. Conclusions: BCT is a useful adjunctive tool in the investigation of patients presenting with asthma-like symptoms. This test obviates empirical asthma treatment. BCT should be made available in all major hospitals in Malaysia.

Aged ; Aging ; Databases, Factual ; Femoral Neck Fractures ; epidemiology ; Geriatrics ; Hip Fractures ; epidemiology ; Humans ; Registries ; Singapore ; Treatment Outcome

Carcinoma ; diagnostic imaging ; secondary ; Humans ; Male ; Middle Aged ; Nasopharyngeal Neoplasms ; pathology ; Pancreatic Neoplasms ; diagnostic imaging ; secondary ; Ultrasonography

INTRODUCTIONEmergency gastrectomy has been shown to be associated with poor morbidity and mortality rates. The aims of this study were to review the outcomes of emergency gastrectomy in our institution and to determine any factors that were associated with worse perioperative outcomes.

MATERIALS AND METHODSA retrospective review of all patients who underwent emergency gastrectomy for various indications from October 2003 to April 2009 was performed. All the complications were graded according to the classification proposed by Clavien and group.

RESULTSEighty-fi ve patients, median age 70 (range, 27 to 90 years), underwent emergency gastrectomy. The indications for the surgery included perforation, bleeding and obstruction in 45 (52.9%), 32 (37.6%) and 8 (9.4%) patients, respectively. The majority of the patients (n = 46, 54.1%) had an American Society of Anesthesiologists (ASA) score of 3. Partial or subtotal, and total gastrectomy were performed in 75 (88.2%) and 10 (11.8%) patients, respectively. Malignancy was the underlying pathology in 33 (38.8%) patients. The perioperative mortality rate was 21.2% (n = 18) with another 27 (31.8%) patients having severe complications. Twelve (14.1%) patients had a duodenal stump leak. The independent factors predicting worse perioperative complications included high ASA score and in perforation cases. Other factors such as malignancy, age and extent of surgery were not signifi cantly related. The presence of a duodenal stump leak was the only independent factor predicting mortality.

CONCLUSIONEmergency gastrectomy is associated with dismal morbidity and mortality rates. Patients with high ASA scores and perforations fared worse, and duodenal stump leak increases the risk of mortality.

Adult ; Aged ; Aged, 80 and over ; Emergencies ; Female ; Gastrectomy ; mortality ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Postoperative Complications ; epidemiology ; etiology ; Retrospective Studies ; Risk Factors ; Severity of Illness Index ; Stomach Diseases ; mortality ; surgery ; Treatment Outcome

BACKGROUND/AIMS: Surveillance for hepatocellular carcinoma (HCC) with ultrasound in high-risk populations is generally believed to improve opportunities for treatment. However, tumors are still missed due to various factors. This study explores success versus failure of HCC surveillance. METHODS: This is a retrospective study of 1,125 HCC cases. Categories considered for successful detection were largest tumor ≤3.0 cm, single tumors ≤3.0 cm and ≤2.0 cm, and adherence to Milan criteria. Examined factors were age <60 years, gender, rural residence, body-mass index (BMI), hepatitis infection, smoking, diabetes, hyperlipidemia, cirrhosis, ascites, and Model for End-Stage Liver Disease <10. RESULTS: HCC was found on surveillance in 257 patients with a mean tumor size of 3.17 cm; multiple tumors were seen in 28% of cases, bilateral tumors in 7.4%, and vascular invasion in 3.7%. Surveillance was successful in 61.5% of cases involving a largest tumor ≤3.0 cm, with BMI ≥35 negatively affecting detection (odds ratio [OR] 0.28, P=0.014) and cirrhosis positively affecting detection (OR 2.31, P=0.036). Ultrasound detected 19.1% of single tumors ≤2.0 cm with ascites improving the detection rate (OR 3.89, P=0.001). Finally, adherence to Milan criteria occurred in 75.1% of cases, revealing negative associations with diabetes (OR 0.48, P=0.044 and male gender (OR 0.49, P=0.08). CONCLUSIONS: Although surveillance is recommended for HCC, not all surveillance ultrasound are ideal. Tumor detection can depend on gender, BMI, diabetes, cirrhosis, and ascites and is achieved in 19.1–75% of cases depending on the definition of success. Closer follow-up or additional imaging might be necessary for some patient subgroups.
Ascites ; Carcinoma, Hepatocellular* ; Early Detection of Cancer ; Fibrosis ; Follow-Up Studies ; Hepatitis ; Humans ; Hyperlipidemias ; Liver Diseases ; Male ; Population Surveillance ; Retrospective Studies ; Smoke ; Smoking ; Ultrasonography

Translational research (TR) can be defined as research where a discovery made in the laboratory (bench) can be applied in the diagnosis, treatment or prevention of a disease. Examples of medical discoveries contributing to translational medicine (TM) include the isolation of insulin by Banting (Nobel Laureate, 1923), the discovery of penicillin by Alexander Fleming (Nobel Laureate, 1945) and recently the discovery of the role of bacterium Helicobacter pylori in the causation of gastritis and peptic ulcer by Marshall and Warren (Nobel Laureates, 2005). Clinical research (CR) would be a more appropriate term for the bulk of research work undertaken by doctors. CR embraces both clinical based and laboratory-based research. The terminology "bedside to bench" applies more to CR as opposed to "bench to bedside" in the case of TR. But regardless of who does it, as long as the discovery can be translated to the bedside and results in improvement in patient care it can be considered a contribution to TM. Our work spans a 30-year period, involving laboratory-based research, clinical trials and genomics of IgA nephritis (Nx). This is a series of work to elucidate the pathogensis and therapy of IgANx. Plasma beta-thromboglobulin (BTG) an in-vivo index of platelet aggregation and anti-thrombin III increase due to a constant thrombogenecity resulting from platelet degranulation formed the basis for anti-platelet and low-dose warfarin therapy. A study of the natural history of IgANx revealed 2 courses, a slowly progressive course with end-stage renal failure (ESRF) at 7.7 years and a more rapid course at 3.3 years. Triple therapy (cyclophosphamide, persantin and low-dose warfarin) delayed progression to ESRF by about 8 years and for some patients up to 20 years. Documentation of abnormal suppressor T cell function provided the basis for immune therapy. Four patterns of proteinuria were present in IgANx and it is the quality and not so much the quantity of proteinuria which determined the prognosis. Low molecular weight proteinuria was a bad prognostic marker. A controlled therapeutic trial using ACEI/ATRA showed that therapy decreases proteinuria, improves renal function and converts non-selective to selective proteinuria. Subsequent work confirmed that it was the ATRA, not the ACEI which contributed to improved renal function. Individual anti proteinuria response to ATRA varies depending on ACE gene polymorphism. We found that the II genotype of the ACE gene was renoprotective and patients with this genotype had significantly reduced incidence of ESRF compared to those with the DD genotype. Patients responsive to ATRA therapy can retard progression to ESRF by up to 32 years. Mild renal failure can be reversed with possible regression of glomerulosclerosis because of glomerular remodelling by ATRA.
Disease Progression ; Evidence-Based Medicine ; history ; Genetic Predisposition to Disease ; Genomics ; history ; Glomerulonephritis, IGA ; genetics ; history ; History, 20th Century ; History, 21st Century ; Humans ; Polymorphism, Genetic ; Singapore

INTRODUCTION: Frontline healthcare workers (HCWs) exposed to coronavirus disease 2019 (COVID-19) are at risk of psychological distress. This study evaluates the psychological impact of COVID-19 pandemic on HCWs in a national paediatric referral centre. METHODS: This was a survey-based study that collected demographic, work environment and mental health data from paediatric HCWs in the emergency, intensive care and infectious disease units. Psychological impact was measured using the Depression, Anxiety, Stress Scale-21. Multivariate regression analysis was performed to identify risk factors associated with psychological distress. RESULTS: The survey achieved a response rate of 93.9% (430 of 458). Of the 430 respondents, symptoms of depression, anxiety and stress were reported in 168 (39.1%), 205 (47.7%) and 106 (24.7%), respectively. Depression was reported in the mild (47, 10.9%), moderate (76, 17.7%), severe (23, 5.3%) and extremely severe (22, 5.1%) categories. Anxiety (205, 47.7%) and stress (106, 24.7%) were reported in the mild category only. Collectively, regression analysis identified female sex, a perceived lack of choice in work scope/environment, lack of protection from COVID-19, lack of access to physical activities and rest, the need to perform additional tasks, and the experience of stigma from the community as risk factors for poor psychological outcome. CONCLUSION A high prevalence of depression, anxiety and stress was reported among frontline paediatric HCWs during the COVID-19 pandemic. Personal psychoneuroimmunity and organisational prevention measures can be implemented to lessen psychiatric symptoms. At the national level, involving mental health professionals to plan and coordinate psychological intervention for the country should be considered.
Adult ; Anxiety/etiology* ; COVID-19/psychology* ; Depression/etiology* ; Female ; Health Surveys ; Hospitals, Pediatric ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Occupational Diseases/etiology* ; Pandemics ; Personnel, Hospital/psychology* ; Prevalence ; Risk Factors ; Self Report ; Severity of Illness Index ; Singapore/epidemiology* ; Stress, Psychological/etiology*

INTRODUCTION: Psychiatric comorbidity is common in patients with functional dyspepsia (FD) but a good screening tool for psychiatric disorders in gastrointestinal clinical practice is lacking. Aims: 1) Evaluate the performance and optimal cut-off of 12-item General Health Questionnaire (GHQ-12) as a screening tool for psychiatric disorders in FD patients; 2) Compare health-related quality of life (HRQoL) in FD patients with and without psychiatric comorbidities. METHODS: Consecutive patients fulfilling Rome III criteria for FD without medical co-morbidities and gastroesophageal reflux disease were recruited in a gastroenterology clinic. The followings were conducted at 4 weeks after index oesophagogastroduodenoscopy: self-administrated questionnaires on socio-demographics, dyspeptic symptom severity (4-point Likert scale), GHQ-12, and 36-item short-form health survey (SF-36). Psychiatric disorders were diagnosed with Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) by a trained psychiatrist, which served as reference standard. RESULTS: 55 patients underwent psychiatrist-conducted interview and questionnaire assessment. 27 (49.1%) had current psychiatric disorders as determined by SCID (anxiety disorders: 38.2%, depressive disorders: 16.4%). Receiver operating characteristic curve analysis of GHQ-12 revealed an area under curve of 0.825 (95%CI: 0.698-0.914). Cut-off of GHQ-12 at > or =3 gave a sensitivity of 63.0% (95%CI = 42.4-80.6%) and specificity of 92.9% (95%CI = 76.5%-98.9%). Subjects with co-existing psychiatric disorders scored significantly lower in multiple domains of SF-36 (mental component summary, general health, vitality and mental health). By multivariate linear regression analysis, current psychiatric morbidities (Beta = -0.396, p = 0.002) and family history of psychiatric illness (Beta = -0.299, p = 0.015) were independent risk factors for poorer mental component summary in SF-36, while dyspepsia severity was the only independent risk factor for poorer physical component summary (Beta = -0.332, p = 0.027). CONCLUSIONS: Concomitant psychiatric disorders adversely affect HRQoL in FD patients. The use of GHQ-12 as a reliable screening tool for psychiatric disorders allows early intervention and may improve clinical outcomes of these patients.
Area Under Curve ; Axis, Cervical Vertebra ; Comorbidity ; Diagnostic and Statistical Manual of Mental Disorders ; Dyspepsia ; Early Intervention (Education) ; Gastroenterology ; Gastroesophageal Reflux ; Health Surveys ; Humans ; Linear Models ; Mass Screening ; Mental Disorders ; Psychiatry ; Quality of Life ; Surveys and Questionnaires ; Risk Factors ; ROC Curve ; Rome ; Sensitivity and Specificity

OBJECTIVE: The study aims to describe factors that contribute to the Length of Stay (LOS) in the Emergency Department (ED) patients of a Tertiary Private Hospital in Philippines.

METHODS: This is a retrospective descriptive study from September 1, 2015 to March 31, 2016 on the factors of ED consultations specifically on demographics (age and sex), payment schemes (Out of Pocket (OOP) and third party payer), shift times (morning, afternoon and night) and triage-levels were associated with LOS.

RESULTS: Our ED consultations with age (mean 40.75 years, SD 16.8, N 20,687, range 95) were dominated by females (56%), two age-range, 21-30 (28.4%) & 31-40 and third party payer (57%). LOS (mean of 4,40 hours, SD 3,89, N 18540, range 68) was significantly higher (p<0.001) on OOP patients, older age-range; 71-80, (3.5%) and 81-90, (2.3%). Emergent cases had higher incidence (X2= 30.2, p<0.001) on morning shift, urgent cases on afternoon shift and trauma cases on evening shift. Non-urgent cases were consistent on all time frames. LOS was significantly higher (X2=p<0.001) on urgent and emergent cases and on morning and afternoon shifts and significantly lowest, (p<0.001) on night shifts.

CONCLUSION: Higher LOS was associated on the following: urgent and emergent triage- levels, older age range, OOP, and morning and afternoon shifts.

Emergency Service, Hospital ; Length Of Stay ; Triage

Objective: The study aims to describe factors that contribute to the Length of Stay (LOS) in the Emergency Department (ED) patients of a Tertiary Private Hospital in Philippines. Methods: This is a retrospective descriptive study from September 1, 2015 to March 31, 2016 on the factors of ED consultations specifically on demographics (age and sex), payment schemes (Out of Pocket (OOP) and third party payer), shift times (morning, afternoon and night) and triage-levels were associated with LOS. Results: Our ED consultations with age (mean 40.75 years, SD 16.8, N 20,687, range 95) were dominated by females (56%), two age-range, 21-30 (28.4%) & 31-40 and third party payer (57%). LOS (mean of 4,40 hours, SD 3,89, N 18540, range 68) was significantly higher (p<0.001) on OOP patients, older age-range; 71-80, (3.5%) and 81-90, (2.3%). Emergent cases had higher incidence (X2= 30.2, p<0.001) on morning shift, urgent cases on afternoon shift and trauma cases on evening shift. Non-urgent cases were consistent on all time frames. LOS was significantly higher (X2=p<0.001) on urgent and emergent cases and on morning and afternoon shifts and significantly lowest, (p<0.001) on night shifts. Conclusion Higher LOS was associated on the following: urgent and emergent triage- levels, older age range, OOP, and morning and afternoon shifts.
Emergency Service, Hospital ; Length of Stay ; Triage