Introduction: Peripheral arterial disease(PAD) and abdominal aortic aneurysm(AAA) are two important underdiagnosed vascular pathologies. As they share common risk factors with coronary arterial disease, we conducted a study to look at their prevalence among patients with acute coronary syndrome(ACS). Materials and Methods: Patients with ACS admitted to Queen Elizabeth Hospital, Malaysia, from February 2009 till August 2009 were screened prospectively for PVD and AAA. Patients’ data and clinical findings were gathered and analyzed. Measurements of ankle brachial index (ABI) and abdominal aortic diameter were performed by a single assessor. PAD was defined as ABI ≤ 0.9 or diabetic patients with signs and symptoms of PAD and absence of pedal pulses. AAA was defined as abdominal aortic diameter ≥ 3cm. Results: 102 patients were recruited with mean age of 59.5 years old. Male: female ratio was 6:1. 40.2% of patients had NSTEMI; 45.1%, STEMI and 14.7%, unstable angina. Risk factors profile is as follows: hypertension- 68.6%, smoking-56.9%, hypercholesterolemia- 52.9%, diabetes mellitus-35.3% and history of stroke- 5.9%. Median ABI was 1.1 with lowest reading of 0.4. Mean abdominal aortic size was 2.0cm with largest diameter of 3.3cm. PAD was present in 24.5% of patients and AAA in 2.0%. 68.0% of patients with PAD were asymptomatic. Smoking and age more than 60 years were independent predictors for PAD among ACS patients. Conclusions: PAD is strongly correlated with CAD with old age and smoker as independent predictors. However, association between AAA and ACS could not be established.

Bone Neoplasms ; diagnosis ; secondary ; Carcinoma, Renal Cell ; diagnosis ; secondary ; Humans ; Kidney Neoplasms ; pathology ; Male ; Middle Aged ; Patella ; Sternum

INTRODUCTIONThe near terminal patient with skeletal metastasis may suitably be palliated with an intramedullary nail whereas another patient with good survival potential may benefit from a more extensive resection and reconstructive procedure. In a previous study by the senior author (Nathan et al, 2005), life expectancy in patients operated on for bone metastases correlated with clinical and haematological parameters in a normogram. We performed a cross-cultural comparison to validate this normogram.

MATERIALS AND METHODSWe randomly selected 73 patients who had undergone surgery for metastatic bone disease between 28 December 2000 and 11 March 2009. The time to deaths was recorded from hospital records and telephone interviews. Multiple parameters including clinical, radiological and haematological were evaluated for significant prognostic value using Kaplan-Meier survivorship analysis. Statistically significant parameters were entered into a Cox regression model for statistically independent significance. A multi-tier prediction of survival was performed by workers from various levels of seniority.

RESULTSAt the time of analysis, there were 40 deaths (55%). Median survival was 15.8 (95% CI, 7.9 to 23.7) months. Kaplan-Meier analysis showed that low haemoglobin (P = 0.0000005), presence of lymph node metastases (P = 0.00008), multiple bone metastases (P = 0.003), presence of visceral metastases, (P = 0.007), low lymphocyte count (P = 0.02) and low serum albumin (P = 0.02) were significantly associated with poor survival. By Cox regression analysis, presence of visceral metastases (P = 0.002), presence of lymph node metastases (P = 0.0002) and low haemoglobin (P = 0.01) were shown to be independent factors in the prediction of survival. Survivorship readings were superimposed onto the previous normogram and found to be similar. Independent blinded use of the normogram allowed good prediction of survival. There was a tendency to underestimate survival when patients survived beyond 1 year of skeletal metastasis.

CONCLUSIONOur findings are similar to that of the previous study in showing a relationship between the above-mentioned parameters and survival. This is despite differences in patient demographic characteristics and management protocols. Use of the tools may allow better siting of most appropriate surgery in metastatic bony disease.

Bone Neoplasms ; mortality ; surgery ; Decision Support Systems, Clinical ; Female ; Humans ; Male ; Middle Aged ; Prognosis ; Proportional Hazards Models ; Survival Analysis ; Terminal Care

INTRODUCTIONWith the increased use of filler and fat injections for aesthetic purposes, there has been a corresponding increase in the incidence of complications. Vision loss as an uncommon but devastating vascular side effect of filler injections was the focus of this paper.

METHODSA review committee, consisting of plastic surgeons, aesthetic medical practitioners, ophthalmologists and dermatologists from Singapore, was convened by the Society of Aesthetic Medicine (Singapore) to review and recommend methods for the prevention and management of vision loss secondary to filler injections.

RESULTSThe committee agreed that prevention through proper understanding of facial anatomy and good injection techniques was of foremost importance. The committee acknowledged that there is currently no standard management for these cases. Based on existing knowledge, injectors may follow a proposed course of action, which can be divided into immediate, definitive and supportive. The goals were to reduce intraocular pressure, dislodge the embolus to a more peripheral location, remove or reverse central ischaemia, preserve residual retinal function, and prevent the deterioration of vision. Dissolving a hyaluronic acid embolus remains a controversial option. It is proposed that injectors must be trained to recognise symptoms, institute immediate actions and refer patients without delay to dedicated specialists for definitive and supportive management.

CONCLUSIONSSteps to prevent and manage vision loss based on current evidence and best clinical practices are outlined in this paper. Empirical referral to any emergency department or untrained doctors may lead to inordinate delays and poor outcomes for the affected eye.

Blindness ; etiology ; prevention & control ; Dermal Fillers ; adverse effects ; Embolism ; Esthetics ; Humans ; Hyaluronic Acid ; adverse effects ; Iatrogenic Disease ; Incidence ; Injections ; adverse effects ; Ophthalmology ; Singapore ; Societies, Medical