INTRODUCTION: Patients referred for chest pain from primary care have increased, along with demand for outpatient cardiology consultations. We evaluated 'Triage Protocol' that implements standardised diagnostic testing prior to patients' first cardiology consultation. MATERIALS AND METHODS: Under the 'Triage Protocol', patients referred for chest pain were pretriaged using a standardised algorithm and subsequently referred for relevant functional diagnostic cardiology tests before their initial cardiology consultation. At the initial cardiology consultation scheduled by the primary care provider, test results were reviewed. A total of 522 triage patients (mean age 55 ± 13, male 53%) were frequency-matched by age, gender and risk cohort to 289 control patients (mean age: 56 ± 11, male: 52%). Pretest risk of coronary artery disease was defined according to a Modified Duke Clinical Score (MDCS) as low (<10), intermediate (10-20) and high (>20). The primary outcome was time from referral to diagnosis (days). Secondary outcomes were total visits, discharge rate at first consultation, patient cost and adverse cardiac outcomes. RESULTS: The 'Triage Protocol' resulted in shorter times from referral to diagnosis (46 vs 131 days; <0.0001) and fewer total visits (2.4 vs 3.0; <0.0001). However, triage patients in low-risk groups experienced higher costs due to increased testing (S$421 vs S$357, = 0.003). Adverse cardiac event rates under the 'Triage Protocol' indicated no compromise to patient safety (triage vs control: 0.57% vs 0.35%; = 1.000). CONCLUSION By implementing diagnostic cardiac testing prior to patients' first specialist consultation, the 'Triage Protocol' expedited diagnosis and reduced subsequent visits across all risk groups in ambulatory chest pain patients.
Algorithms ; Cardiology Service, Hospital ; Chest Pain ; therapy ; Clinical Protocols ; Female ; Humans ; Male ; Middle Aged ; Primary Health Care ; Treatment Outcome ; Triage ; methods

PURPOSE: Mesenteric embolization is an integral part in the management of acute lower gastrointestinal (GI) bleeding. The aim of this study was to highlight our experience after adopting mesenteric embolization in the management of acute lower GI hemorrhage. METHODS: A retrospective review of all cases of mesenteric embolization for acute lower GI bleeding from October 2007 to August 2012 was performed. RESULTS: Twenty-seven patients with a median age of 73 years (range, 31 to 86 years) formed the study group. More than half (n = 16, 59.3%) of the patients were on either antiplatelet and/or anticoagulant therapy. The underlying etiology included diverticular disease (n = 9), neoplasms (n = 5) and postprocedural complications (n = 6). The colon was the most common bleeding site and was seen in 21 patients (left, 10; right, 11). The median hemoglobin prior to the embolization was 8.6 g/dL (6.1 to 12.6 g/dL). A 100% technical success rate with immediate cessation of hemorrhage at the end of the session was achieved. There were three clinical failures (11.1%) in our series. Two patients re-bled, and both underwent a successful repeat embolization. The only patient who developed an infarcted bowel following embolization underwent an emergency operation and died one week later. There were no factors that predicted clinical failure. CONCLUSION: Mesenteric embolization for acute lower GI bleeding can be safely performed and is associated with a high clinical success rate in most patients. A repeat embolization can be considered in selected cases, but postembolization ischemia is associated with bad outcomes.
Colon ; Emergencies ; Gastrointestinal Hemorrhage* ; Hemoglobins ; Hemorrhage ; Humans ; Ischemia ; Retrospective Studies

PURPOSE: Mesenteric embolization is an integral part in the management of acute lower gastrointestinal (GI) bleeding. The aim of this study was to highlight our experience after adopting mesenteric embolization in the management of acute lower GI hemorrhage. METHODS: A retrospective review of all cases of mesenteric embolization for acute lower GI bleeding from October 2007 to August 2012 was performed. RESULTS: Twenty-seven patients with a median age of 73 years (range, 31 to 86 years) formed the study group. More than half (n = 16, 59.3%) of the patients were on either antiplatelet and/or anticoagulant therapy. The underlying etiology included diverticular disease (n = 9), neoplasms (n = 5) and postprocedural complications (n = 6). The colon was the most common bleeding site and was seen in 21 patients (left, 10; right, 11). The median hemoglobin prior to the embolization was 8.6 g/dL (6.1 to 12.6 g/dL). A 100% technical success rate with immediate cessation of hemorrhage at the end of the session was achieved. There were three clinical failures (11.1%) in our series. Two patients re-bled, and both underwent a successful repeat embolization. The only patient who developed an infarcted bowel following embolization underwent an emergency operation and died one week later. There were no factors that predicted clinical failure. CONCLUSION: Mesenteric embolization for acute lower GI bleeding can be safely performed and is associated with a high clinical success rate in most patients. A repeat embolization can be considered in selected cases, but postembolization ischemia is associated with bad outcomes.
Colon ; Emergencies ; Gastrointestinal Hemorrhage* ; Hemoglobins ; Hemorrhage ; Humans ; Ischemia ; Retrospective Studies

INTRODUCTIONA paradigm shift appears to have occurred worldwide in surgery for primary hyperparathyroidism with the advent of sensitive preoperative imaging techniques. Preoperative imaging for parathyroid adenoma localisation was not found to be useful in a study conducted in Singapore in the 1990s. This study aimed to explore what the change has been in preoperative localisation tools compared to the previous study and if the ability of these tools to correctly localise pathologic parathyroid glands has improved.

MATERIALS AND METHODSA retrospective review of patients who had surgery for primary hyperparathyroidism at our institution during the period 2005 to 2014 was carried out. Individuals with positive, as opposed to those with negative preoperative imaging, were compared with regard to whether they underwent limited focal or bilateral neck exploration. Length of hospital stay (LOHS) was also compared between patients who underwent limited versus bilateral exploration.

RESULTSFifty-eight patients who had preoperative imaging and surgery were evaluated. True positive rates of sestamibi, ultrasound and 4-dimensional (4D) computed tomography (CT) scans were 63.8%, 72.4% and 90%, respectively. Eighty percent of patients who had positive localisation had limited exploration. LOHS was 2.8 days (1.6, 4.8) and 4.3 days (2.1, 9.0) for limited and bilateral exploration respectively, P = 0.011.

CONCLUSIONOur study highlights the marked change in the surgical landscape for primary hyperparathyroidism in the last 2 decades in Singapore. Improved preoperative localisation has resulted in a swing from predominantly bilateral, to limited exploration in almost all cases of primary hyperparathyroidism due to solitary adenoma. LOHS was significantly shorter in patients who had limited as compared to those who had bilateral exploration.

Adenoma ; diagnostic imaging ; surgery ; Four-Dimensional Computed Tomography ; Humans ; Hyperparathyroidism, Primary ; diagnostic imaging ; surgery ; Length of Stay ; Parathyroid Neoplasms ; diagnostic imaging ; surgery ; Parathyroidectomy ; Practice Patterns, Physicians' ; Radionuclide Imaging ; Radiopharmaceuticals ; Retrospective Studies ; Sensitivity and Specificity ; Singapore ; Technetium Tc 99m Sestamibi ; Ultrasonography

Recent therapeutic advances, in particular the use of anti-tumour necrosis factor (anti-TNF) agents, have revived interest in the seronegative spondyloarthropathies (SpA), a group of arthritides characterised by axial skeletal involvement and the absence of rheumatoid factor. The purpose of this article is to review the studies that have been done in the Asia Pacific region, as a broad understanding of the scope and severity of this group of diseases would enable rheumatologists and physicians in this part of the world to better manage their patients. The majority of genetic studies have focused on the associations of HLA-B27 with ankylosing spondylitis (AS) and SpA, while a few studies examined the associations of the CARD, IL-1, LMP2, TAP and TGF with AS. There are a handful of studies on the immunological responses to bacteria and cytokine levels in AS. The onset and clinical features of SpA have been reported from most countries in the region, but no data on patient outcomes, using current measurement tools such as the Bath Ankylosing Spondylitis Disease Activity index (BASDAI), is available. Validation of these instruments of measurement as well as classification criteria in different ethnic populations is necessary where no prior data exist. Future studies will likely be focused on better clinical characterisation of patient cohorts, particularly with regard to the use of currently used measurement tools for disease activity and spinal function and mobility, and the identification of the need for biologic therapy in each country.
Arthritis ; epidemiology ; genetics ; immunology ; therapy ; Asian Continental Ancestry Group ; Genetic Predisposition to Disease ; HLA-B27 Antigen ; genetics ; Humans ; Sensitivity and Specificity ; Spinal Diseases ; epidemiology ; genetics ; immunology ; therapy ; Spondylitis, Ankylosing ; genetics ; immunology ; Transforming Growth Factor beta1 ; immunology

INTRODUCTION: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to measure lung compliance and examine other factors associated with mortality in COVID-19 patients with ARDS. METHODS: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8 hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences between high (<40mL/cm H RESULTS: A total of 102 patients with COVID-19 who required invasive mechanical ventilation were analysed; 15 (14.7%) did not survive. Non-survivors were older (median 70 years, interquartile range [IQR] 67-75 versus median 61 years, IQR 52-66; CONCLUSION COVID-19 ARDS patients with higher compliance on the day of intubation and a longitudinal decrease over time had a higher risk of death.
COVID-19 ; Humans ; Lung Compliance ; Phenotype ; Respiratory Distress Syndrome/therapy* ; SARS-CoV-2

Trimetazidine as adjunctive therapy in cardioischemic patients has shown improvement in angina and left ventricular ejection fraction, but with conflicting evidence on hard clinical outcomes. This meta-analysis aims to compare the efficacy of trimetazidine versus placebo in reducing cardiac mortality and major adverse cardiac events (MACEs) in coronary artery disease patients after reperfusion strategies, whether percutaneous coronary intervention or thrombolysis. The primary outcomes examined were cardiac mortality and combined MACEs; secondary outcomes were repeat revascularization, heart failure after reperfusion, stent restenosis, recurrence of angina, and reinfarction. Trimetazidine in comparison to placebo was associated with lower cardiac mortality and combined MACEs, but results were not significant. Among secondary outcomes, only stent restenosis was significantly reduced (risk ratio, 0.53; 95% confidence interval, 0.34-0.83; P = 0.006). Further trials should be conducted with more standard dosing regimens, duration of therapy, and similar severities of ischemic disease.

Objectives: The highly polymorphic nature of the CYP2D6 gene and its central role in the metabolism of commonly used drugs make it an ideal candidate for pharmacogenetic screening. This study aims to determine the prevalence of CYP2D6 polymorphisms among Filipinos and their association to lung cancer. Method: Forty seven single nucleotide polymorphisms (SNPs) of the CYP2D6 gene were genotyped from DNA samples of 115 cases with lung cancer and age- and sex-matched 115 controls. Results: Results show that 18 out of 47 polymorphisms have significant genotypic variability (>1% for at least 2 genotypes). No variant is associated with lung cancer. However, rs1135840, rs16947 and rs28360521, were found to be highly variable among Filipinos. Conclusion This study demonstrated that CYP2D6 polymorphisms are present among Filipinos, which, although not found to be associated with lung cancer, can be useful biomarkers for future pharmacogenetic studies. The SNP rs16947 is found to be associated with cancer and timolol-induced bradycardia; the SNP rs1135840, on the other hand, is only shown to be linked with cancer. The genetic variant rs28360521 is known to be associated with low-dose aspirin-induced lower gastrointestinal bleeding.
Pharmacogenetics ; Cytochrome P-450 CYP2D6 ; Lung Neoplasms ; Biomarkers

Objectives. Polymorphisms in metabolic genes which alter rates of bioactivation and detoxification have been shown to modulate susceptibility to colorectal cancer. This study sought to evaluate the colorectal cancer risk from environmental factors and to do polymorphism studies on genes that code for Phase I and II xenobiotic metabolic enzymes among Filipino colorectal cancer patients and matched controls. Methods. A total of 224 colorectal cancer cases and 276 controls from the Filipino population were genotyped for selected polymorphisms in GSTM1, GSTP1, GSTT1, NAT1 and NAT2. Medical and diet histories, occupational exposure and demographic data were also collected for all subject participants.Results. Univariate logistic regression of non-genetic factors identified exposure to UV (sunlight) (OR 1.99, 95% CI: 1.16-3.39) and wood dust (OR 2.66, 95% CI: 1.21-5.83) and moldy food exposure (OR 1.61, 95% CI:1.11-2.35) as risk factors; while the NAT2*6B allele (recessive model OR 1.51, 95% CI :1.06-2.16; dominant model OR 1.87, 95% CI: 1.05-3.33) and homozygous genotype (OR 2.19, 95% CI: 1.19-4.03) were found to be significant among the genetic factors. After multivariate logistic regression of both environmental and genetic factors, only UV radiation exposure (OR 2.08, 95% CI: 1.21-3.58) and wood dust exposure (OR 2.08, 95% CI: 0.95-5.30) remained to be significantly associated with increasing colorectal cancer risk in the study population.Conclusion. This study demonstrated that UV sunlight and wood dust exposure play a greater role in influencing colorectal cancer susceptibility than genotype status from genetic polymorphisms of the GST and the NAT` genes.
Colorectal Neoplasms ; Polymorphism, Genetic

BACKGROUND Hypertension is the most common risk factor for cardiovascular disease in the Philippines. Despite the availability of antihypertensive medications that are effective, safe, and tolerated by Filipino patients, the numbers of uncontrolled hypertensives are still increasing. Several factors play in the poor control of blood pressure, particularly resistant hypertension and hyperactive sympathetic nervous system. Renal denervation therapy is a novel device that has been shown to lower blood pressure in patients with resistant and difficult-to-treat hypertension and is deemed safe in clinical trials. A Philippine Working Group composed of specialists in cardiology, hypertension, vascular surgery, and clinical epidemiology has come up with consensus statements in identifying patients who will benefit from the procedure. Locally, there is a need to have hypertension centers treating uncontrolled and resistant hypertension and offer renal denervation therapy to appropriate Filipino patients.
Blood Pressure