Anti-Inflammatory Agents ; therapeutic use ; Aspirin ; therapeutic use ; Child ; Facial Nerve Diseases ; diagnosis ; etiology ; Facial Paralysis ; diagnosis ; etiology ; Humans ; Immunoglobulins, Intravenous ; Male ; Mucocutaneous Lymph Node Syndrome ; complications ; diagnostic imaging ; Platelet Aggregation Inhibitors ; therapeutic use ; Prednisolone ; therapeutic use ; Ultrasonography ; Warfarin ; therapeutic use

Angioplasty, Balloon, Coronary ; Bradycardia ; etiology ; Cardiac Pacing, Artificial ; adverse effects ; Carotid Artery, Common ; abnormalities ; Heart Block ; etiology ; Humans ; Jugular Veins ; abnormalities ; Male ; Middle Aged ; Shock, Cardiogenic ; etiology ; Thromboembolism ; complications ; Torsades de Pointes ; etiology

INTRODUCTIONThe treatment of aortic valve stenosis (AS) is seeing renewed interest mainly due to the availability of transcatheter therapies. However, the number of epidemiological studies of this disease in Singapore is limited. We aimed to describe the aetiology and clinical presentation of AS in Singapore, as well as patients' attitudes toward it. Our findings may facilitate the future planning and utilisation of resources to better manage these patients.

METHODS249 consecutive patients who underwent transthoracic echocardiography (from April 1999 to April 2008) and diagnosed with severe AS were assessed. Demographic and clinical data were collected, and patients' decisions on surgery were determined.

RESULTSThe mean patient age was 71 (range 23-98) years. 50.2% of patients were male. The commonest presenting symptom was dyspnoea, and 40 (16.0%) patients had coexistent atrial fibrillation. The aetiology of AS was degenerative in 216 (86.7%), rheumatic in 11 (4.4%) and related to a bicuspid valve in 22 (8.9%) patients. The average peak velocity across the aortic valve was 4.2 ± 0.8 m/s and the mean aortic valve area was 0.76 ± 0.13 cm2. The overall mean logistic EuroSCORE was 10.7 ± 12.3. 105 (42.2%) patients who were offered surgery refused. 87 (35%) deaths were seen during the follow-up period (mean duration 14.5 months), which also saw 68 (27%) patients undergo surgery and 86 (34%) patients hospitalised for heart failure.

CONCLUSIONDegenerative AS was the commonest aetiology in this contemporary cohort of patients. Despite the known benefits of surgery, the refusal rate for surgery remained high.

Adult ; Aged ; Aged, 80 and over ; Aortic Valve ; pathology ; Aortic Valve Stenosis ; complications ; diagnosis ; epidemiology ; Asian Continental Ancestry Group ; Atrial Fibrillation ; complications ; diagnosis ; Cohort Studies ; Dyspnea ; complications ; diagnosis ; Echocardiography ; methods ; Electrocardiography ; methods ; Female ; Humans ; Male ; Middle Aged ; Singapore

INTRODUCTIONInfection-related complications after transrectal ultrasound guided prostatic biopsy (TRPB) could be life threatening. Our centre observed sepsis after TRPB despite prophylactic oral ciprofloxacin. We reviewed all cases of post-TRPB sepsis with their bacteriology and evaluated if the addition of intramuscular (I/M) gentamicin to standard prophylaxis before TRPB could reduce its incidence.

MATERIALS AND METHODSIn a single urological centre, we performed an interventional study that compared a prospective group with retrospective control. The latter is known as the "cipro-only" group included consecutive patients who underwent TRPB between 1 September 2003 and 31 August 2004. The addition of I/M gentamicin 80 mg half an hour before TRPB started on 1 September 2004. All subsequent patients who underwent TRPB until 31 August 2005 were included in the "cipro+genta" group. Patients who did not receive the studied antibiotics were excluded.

RESULTSThere were 374 patients in the "cipro+genta" group and 367 patients in the "cipro-only" group with comparable profiles. There were 12 cases of post-TRPB sepsis in the "cipro-only" group and 5 cases in the "cipro+genta" group. Ciprofloxacin-resistant Escherichia coli (E. coli) was the only pathogen isolated in both groups. In the "cipro-only" group, 9 patients had positive blood cultures and 8 were sensitive to gentamicin. In the "cipro+genta" group, the only positive E. coli was gentamicin-resistant. One patient in the "cipro+genta" group was admitted to the intensive care unit with septicaemia.

CONCLUSIONThe addition of I/M gentamicin to oral ciprofloxacin is a safe and effective prophylactic antibiotic regime in reducing the incidence of post-TRPB sepsis.

Administration, Oral ; Adult ; Aged ; Antibiotic Prophylaxis ; methods ; Biopsy ; Ciprofloxacin ; administration & dosage ; therapeutic use ; Drug Resistance, Bacterial ; Escherichia coli ; drug effects ; isolation & purification ; Gentamicins ; administration & dosage ; Humans ; Injections, Intramuscular ; Male ; Middle Aged ; Prospective Studies ; Prostate ; diagnostic imaging ; pathology ; Rectum ; Ultrasonography

OBJECTIVE: Angioplasty and Stenting of intracranial atherosclerotic lesions have a higher complication rate and a large proportion of this is attributable to side branch arterial occlusion from forceful displacement of the atheroma into the ostia or snowplowing effect. This can result in severe disabilities when it result in small infarcts involving eloquent areas in the posterior circulation or the motor tracts. MATERIALS AND METHODS: We present a series of 6 cases utilizing a new dual catheter technique for maintaining the patency of at-risk vessels during angioplasty and stenting. There are several methods previously described to help reduce the incidence of stroke but because they do not have a physical presence in the ostia to protect it, they are unable to guarantee the patency of the vessel. RESULTS: All 6 patients underwent angioplasty and stenting with the technique. The patients were assessed for complications with post-procedure magnetic resonance imaging and no complications were found. CONCLUSION: In this preliminary series, the dual catheter technique appears to safe and effective in preventing occlusion of the adjacent branch arteries. This technique may facilitate the use of the Wingspan stent in the treatment of intracranial atherosclerotic stenotic segments by reducing the risk of peri-procedural stroke.
Angioplasty* ; Arteries ; Catheters* ; Humans ; Incidence ; Magnetic Resonance Imaging ; Plaque, Atherosclerotic ; Stents* ; Stroke

INTRODUCTIONBreast cancer is the most common malignancy in pregnant women, occurring at a rate of about 1 in 3000 pregnancies. Unfortunately, this will sometimes occur during the first trimester of pregnancy and this situation warrants discussion of management options with regard to the mother and child, especially with the current trend of deferring child bearing to a later age.

CLINICAL PICTUREWe present a 34-year-old primigravida who had a breast lump prior to confirmation of her pregnancy and received her diagnosis of invasive breast cancer at 7 weeks' amenorrhoea. The oncologic management options of this pregnant patient with breast cancer are discussed.

TREATMENTThe patient eventually opted to undergo wide excision of the breast cancer with sentinel lymph node biopsy and possible axillary clearance together with termination of her pregnancy.

RESULTSThe patient successfully underwent surgery for her breast cancer and was subsequently treated with adjuvant therapy as per normal protocol for a non-pregnant patient.

CONCLUSIONThe management of breast cancer and pregnancy occurring concurrently is a complex problem fraught with many dilemmas for both the medical team, the patient and her family. The option chosen must involve a multidisciplinary team and have full informed consent of the patient.

Abortion, Induced ; Adult ; Breast Neoplasms ; diagnosis ; drug therapy ; surgery ; Female ; Humans ; Pregnancy ; Pregnancy Trimester, First ; Sentinel Lymph Node Biopsy

INTRODUCTIONTotal knee arthroplasty (TKA) is one of the most successful orthopaedic procedures to date. It is estimated that over 130,000 of TKAs are performed in the United States every year. Whilst the procedure is safe, it nevertheless carries a risk of perioperative mortality and morbidity. This study aimed to report the mortality rate within 30 days after a TKA, as well as to assess the incidence of early postoperative morbidities.

MATERIALS AND METHODSWe reviewed a total of 2219 TKAs performed by multiple surgeons in our centre from 1998 to 2001. All mortalities within 30 days of a TKA were recorded. Morbidities such as infection, thromboembolic phenomenon, and any re-admissions within 30 days of operation or 15 days of discharge were recorded.

RESULTSThe mortality rate within 30 days of a TKA was 0.27% (6 of 2219 patients). The incidence of early postoperative infection was 1.8%, of which 1.44% were superficial and 0.36% were deep infections. There were 3 cases (0.13%) of pulmonary embolism and 22 cases (0.99%) of deep vein thrombosis.

CONCLUSIONSThe 30-day mortality rate, and the incidence of infection after TKA performed in our institution is comparable to other centres around the world, and further emphasises that TKA is a safe procedure. However, the small number of mortalities in this study does not allow us to identify a predominant cause of perioperative mortality.

Aged ; Aged, 80 and over ; Arthroplasty, Replacement, Knee ; adverse effects ; mortality ; Female ; Humans ; Incidence ; Male ; Middle Aged ; Mortality ; trends ; Patient Readmission ; Postoperative Complications ; Pulmonary Embolism ; Retrospective Studies ; Thromboembolism ; Treatment Failure ; Venous Thrombosis

BACKGROUND: This study evaluated outcomes following total knee arthroplasty for severely stiff knees in Asians. METHODS: Registry data of patients undergoing primary total knee arthroplasty between 2004 and 2013 were collected and retrospectively reviewed. Sociodemographic and anthropometric data together with the Oxford Knee Score and the Knee Society Score (Knee Society Knee Score and the Knee Society Function Score) were collected both preoperatively and postoperatively for up to 2 years. Case subjects consisted of patients with a preoperative flexion range of ≤ 20°. Control subjects consisted of patients with a preoperative flexion range of > 90°. Patients were matched for age, sex, and all preoperative scores in a 2:1 fashion. Two-year outcomes and 5-year revision rates were then compared between cases and controls. RESULTS: There were 28 cases and 56 controls. Cases had a significantly lower body mass index than the controls (p = 0.003) and had a longer hospital stay (p < 0.0001). At 2 years, cases had a significantly lower flexion range (p < 0.001) and a lower Knee Society Function Score (p = 0.020) than the controls. Cases had a significantly greater improvement in the flexion range (p < 0.001) postoperatively than controls. The mean change in functional outcomes at 2 years was comparable between the two groups. Seventy-one percent of the cases and 88% of controls were satisfied. There was a significant difference in the 5-year revision rate (10% vs 0%, p = 0.013). More cases were discharged to a rehabilitation facility compared to controls (p = 0.011). There were no differences in inpatient complication rates. CONCLUSIONS: Functional outcomes and patient satisfaction were acceptable following total knee arthroplasty in Asian patients with severe knee stiffness.
Ankylosis ; Arthroplasty ; Arthroplasty, Replacement, Knee* ; Asian Continental Ancestry Group* ; Body Mass Index ; Humans ; Inpatients ; Knee* ; Length of Stay ; Patient Satisfaction* ; Rehabilitation ; Retrospective Studies

Herniation of the temporomandibular joint (TMJ) into the external auditory canal (EAC) has been reported to occur spontaneously or as a result of trauma, neoplasia, infection, or inflammatory processes. It was postulated that spontaneous herniations were attributable to a patent foramen of Huschke, which represents a non-ossified portion of the tympanic plate. Eight cases of spontaneous herniation of the TMJ into the EAC were reported internationally. Recently, we experienced a case of a patent foramen of Huschke confirmed during a tympanoplasty. We reviewed the intimate relation of the TMJ to the temporal bone as well as the characteristic location, clinical and radiographic findings of a patent foramen of Huschke.
Ear Canal ; Temporal Bone ; Temporomandibular Joint ; Tympanoplasty*

INTRODUCTIONThe aim of the study was to describe the prevalence and risk factors for diabetic retinopathy in a multi-ethnic diabetic patient cohort referred for retinal evaluation from a nationwide diabetic retinopathy screening programme in Singapore.

MATERIALS AND METHODSSeven hundred and forty-two patients, aged 21 to 95, referred for suspected diabetic retinopathy on annual one-field non-mydriatic 45 degree retinal photographs (Topcon TRC-NW6, Topcon Corporation, Tokyo, Japan) from primary care to the Singapore National Eye Centre diabetic retinopathy clinic were included. The photographs had been interpreted by 24 trained family physicians accredited every 2 years with a training programme. Patients underwent a standardised interview and examination. Fundi were examined with indirect ophthalmoscopy by 2 examiners. Presence and severity of diabetic retinopathy was graded into none, mild, moderate, severe, very severe non-proliferative diabetic retinopathy and proliferative diabetic retinopathy. Macular oedema and clinically significant macular oedema were also graded.

RESULTSNinety-nine per cent of patients were type 2 diabetics. The prevalence of diabetic retinopathy was 38.1%, visionthreatening retinopathy was 11.8% and macular oedema was 6.9%. There were no racial differences. Significant predictors of any retinopathy were longer duration of diabetes, lower body mass index, being on treatment for hypertension, hypercholesterolaemia and use of diabetic medication. Predictors for vision-threatening retinopathy were younger age, longer duration of diabetes and lower body mass index.

CONCLUSIONSThe use of one-field non-mydriatic 45 degree photography as a screening tool for diabetic retinopathy resulted in a cohort of which 38.1% had diabetic retinopathy. Risk factors for diabetic retinopathy of this cohort are also presented.

Adult ; Aged ; Diabetic Retinopathy ; diagnosis ; epidemiology ; ethnology ; Female ; Humans ; Male ; Mass Screening ; Middle Aged ; Referral and Consultation ; Singapore ; epidemiology