Objective: To compare the results of auditory steady-state response (ASSR) and click auditory brainstem response (click ABR) among infants and young children tested at the Ear Unit of a Tertiary General Hospital. Methods: Design: Cross-sectional Study Setting: Tertiary General Hospital Population: Within-subject comparisons of click auditory brainstem response (click ABR) thresholds and auditory steady-state response (ASSR) thresholds among 55 infants and young children, 2 months to 35 months of age referred to the Ear Unit for electrophysiologic hearing assessment. Results: Click ABR showed strong positive correlation to all frequencies and averages of ASSR. Highest correlation was noted with the average of 1-4 kHz ASSR results with Pearson r = 0.89 (Spearman r=0.80), the average of 2-4 kHz had strong positive correlation r = 0.88 (0.79). Correlation was consistently strong through all ASSR frequencies (0.5 kHz at r=0.86 (0.74), 1 kHz at r=0.88 (0.78), 2 kHz at r=0. 87 (0.79), 4 kHz at r=0.85 (0.76)). Average differences of click ABR and ASSR thresholds were 8.2±12.9dB at 0.5 kHz, 8.6±12.6dB at 1 kHz, 5.3±11.8dB at 2 kHz and 7.8±13.4dB at 4 kHz. Among patients with no demonstrable waveforms by click ABR with maximal click stimulus, a large percentage presented with ASSR thresholds. Of these, 80.5% (33 of 41) had measurable results at 0.5 kHz with an average of 107.3±11.1dB, 85.4% (35 of 41) at 1 kHz with an average of 110.5±11.8dB, 73.2% (30 of 41) at 2 kHz with an average of 111.2±11.1dB and 63.4% (26 of 41) at 4 kHz with average of 112.2±8.21dB. Auditory steady-state response results were comparable to auditory brainstem response results in normal to severe hearing loss and provided additional information necessary for complete audiologic assessment especially among patients with severe to profound hearing loss wherein click ABR showed no responses. Up to 85.4% of patients that would have been noted to have no waveforms by click ABR still demonstrated measurable thresholds by ASSR. Conclusion: Our study suggests that ASSR may be the best available tool for assessing children with severe to profound hearing loss, and is a comparably effective tool in overall hearing assessment for patients requiring electrophysiological testing. The advantages of ASSR over click ABR include: 1) detection of frequency-specific thresholds and; 2) the detection of hearing loss thresholds beyond the limits of click ABR.

Ligamentous injuries of the lower limb are a common entity sustained during sports activities and military training. Magnetic resonance (MR) imaging of the knee and ankle is playing an increasingly important role in the detection, diagnosis and prognosis of these injuries and their associated complications. MR imaging with its exquisite soft tissue contrast resolution and multiplanar capability is increasingly seen as the modality of choice for evaluating ligamentous injuries of the knee and ankle. Representative knee and ankle MR studies from a tertiary referral hospital are used to illustrate both the normal appearance and typical radiological features of common ligamentous injuries of the knee and ankle. A thorough understanding of the MR appearances of these injuries is crucial to the radiologist and clinicians involved in the management of these patients.
Ankle Injuries ; diagnosis ; Athletic Injuries ; Humans ; Knee Injuries ; diagnosis ; Ligaments, Articular ; injuries ; physiopathology ; Magnetic Resonance Imaging

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

INTRODUCTIONSevere acute respiratory syndrome (SARS) is a newly emerged atypical pneumonia caused by the SARS-associated coronavirus (SARS-CoV). Chest radiographic appearances have been reported as non-specific, ranging from normal to peribronchial thickening and ill-defined airspace shadowing. This study is a retrospective review of chest radiographic findings in children with suspected and probable SARS during the 2003 outbreak in Singapore.

MATERIALS AND METHODSWe focused on children admitted to the SARS treatment ward from March 2003 to May 2003. Chest radiographs of children admitted with suspected or probable SARS as well as other febrile illness during this period were retrospectively and independently reviewed by 3 radiologists. The radiographs were randomised and anonymised before interpretation. Subsequently, we identified the radiographs of patients who were categorised as suspected or probable SARS. We present our findings in these patients' radiographs.

RESULTSA total of 67 patients' serial chest radiographs were interpreted. Of these, we subsequently selected those patients with suspected or probable SARS for analysis. The radiographic abnormalities in suspected or probable SARS patients consisted of patchy ground glass opacities or patchy airspace consolidation. The abnormalities had a predominantly lower zone distribution on chest radiographs, followed by mid-zone involvement. There was a slight preponderance of peripheral zone involvement. There was equal distribution of abnormalities in both lungs. All the children with radiographic abnormalities made uneventful recoveries and had normal radiographs on follow-up review.

CONCLUSIONSIn children, SARS appears to have a relatively mild and nonspecific pattern of respiratory illness. The radiographic features in children with suspected or probable SARS in our study were comparable to other clusters of paediatric patients during initial presentation. It is difficult to distinguish SARS in children from other viral pneumonias on radiographic features alone. Positive travel history to endemic regions or positive contact history, and laboratory findings of lymphopaenia, leukopaenia and thrombocytopaenia are important clues.

Child ; Child, Preschool ; Diagnosis, Differential ; Female ; Follow-Up Studies ; Humans ; Infant ; Male ; Radiography, Thoracic ; methods ; Retrospective Studies ; Severe Acute Respiratory Syndrome ; diagnostic imaging ; epidemiology

Local back pain and radiculopathy can be debilitating for sufferers of these conditions. There are a multitude of treatment modalities, ranging from conservative approaches such as bed rest, physical therapy and chiropractic manipulation, to more invasive options such as percutaneous spinal intervention (PSI) and surgery. We present here the techniques employed in the use of minimally invasive, image-guided percutaneous techniques under computed tomography fluoroscopy in our institutions. The inherent high spatial and tissue contrast resolution not only allows ease of trajectory planning in avoiding critical structures, but also allows precision needle placement. Cervical, lumbosacral, and sacroiliac pain can therefore be evaluated and treated both safely and effectively.
Administration, Cutaneous ; Fluoroscopy ; methods ; Humans ; Pain, Intractable ; drug therapy ; Spine ; physiopathology ; Tomography, X-Ray Computed ; methods

Purpose: This systematic review and meta-analysis compared the outcomes of the watch-and-wait (WW) approach versus radical surgery (RS) in rectal cancers with clinical complete response (cCR) after neoadjuvant chemoradiotherapy. Methods: This study followed the PRISMA guidelines. Major databases were searched to identify relevant articles. WW and RS were compared through meta-analyses of pooled proportions. Primary outcomes included overall survival (OS), disease-free survival (DFS), local recurrence, and distant metastasis rates. Pooled salvage surgery rates and outcomes were also collected. The Newcastle-Ottawa scale was employed to assess the risk of bias. Results: Eleven studies including 1,112 rectal cancer patients showing cCR after neoadjuvant chemoradiation were included. Of these patients, 378 were treated nonoperatively with WW, 663 underwent RS, and 71 underwent local excision. The 2-year OS (risk ratio [RR], 0.95; P = 0.94), 5-year OS (RR, 2.59; P = 0.25), and distant metastasis rates (RR, 1.05; P = 0.80) showed no significant differences between WW and RS. Local recurrence was more frequent in the WW group (RR, 6.93; P < 0.001), and 78.4% of patients later underwent salvage surgery (R0 resection rate, 97.5%). The 2-year DFS (RR, 1.58; P = 0.05) and 5-year DFS (RR, 2.07; P = 0.02) were higher among RS cases. However, after adjustment for R0 salvage surgery, DFS showed no significant between-group difference (RR, 0.82; P = 0.41). Conclusion Local recurrence rates are higher for WW than RS, but complete salvage surgery is often possible with similar long-term outcomes. WW is a viable strategy for rectal cancer with cCR after neoadjuvant chemoradiation, but further research is required to improve patient selection.

INTRODUCTIONWhile the readmission rate from community hospitals is known, the factors affecting it are not. Our aim was to determine the factors predicting unplanned readmissions from community hospitals (CHs) to acute hospitals (AHs).

MATERIALS AND METHODSThis was an observational prospective cohort study, involving 842 patients requiring post-acute rehabilitation in 2 CHs admitted from 3 AHs in Singapore. We studied the role of the Cumulative Illness Rating Scale (CIRS) organ impairment scores, the Mini-mental State Examination (MMSE) score, the Shah modified Barthel Index (BI) score, and the triceps skin fold thickness (TSFT) in predicting the rate of unplanned readmissions (UR), early unplanned readmissions (EUPR) and late unplanned readmissions (LUPR). We developed a clinical prediction rule to determine the risk of UR and EUPR.

RESULTSThe rates of EUPR and LUPR were 7.6% and 10.3% respectively. The factors that predicted UR were the CIRS-heart score, the CIRS-haemopoietic score, the CIRS-endocrine / metabolic score and the BI on admission. The MMSE was predictive of EUPR. The TSFT and CIRS-liver score were predictive of LUPR. Upon receiver operator characteristics analysis, the clinical prediction rules for the prediction of EUPR and UR had areas under the curve of 0.745 and 0.733 respectively. The likelihood ratios of the clinical prediction rules for EUPR and UR ranged from 0.42 to 5.69 and 0.34 to 3.16 respectively.

CONCLUSIONSPatients who have UR can be identified by the admission BI, the MMSE, the TSFT and CIRS scores in the cardiac, haemopoietic, liver and endocrine/metabolic systems.

Acute Disease ; therapy ; Aged ; Female ; Follow-Up Studies ; Hospitals, Community ; statistics & numerical data ; Hospitals, Special ; statistics & numerical data ; Humans ; Intensive Care Units ; statistics & numerical data ; Male ; Patient Readmission ; trends ; Prospective Studies ; Risk Factors ; Severity of Illness Index ; Singapore

Hepatitis C virus (HCV) infection is a devastating disease that is increasingly being diagnosed among Filipinos, especially in at-risk populations. There are disease-specific nuances in the evaluation and management of this infection. Furthermore, advances in the field brought about by clinical research are rapidly moulding the way we evaluate and manage HCV patients. Evidently, consensus statements formulated by experts in the field are needed in order to serve as a guide to physicians who see HCV patients in the clinic. With this in mind, the Hepatology Society of the Philippines spearheaded the formation of these statements which aimed to address issues in the diagnosis, evaluation, treatment, and follow-up care of patients with HCV infection.
Recommendations on the specific tests to perform in the evaluation of HCV patients before, during and after treatment, and first-line treatment of patients with acute and chronic HCV infection were provided. Treatment algorithms for chronic HCV infection, divided according to viral genotype, were also devised. We acknowledge the limitations brought about by the local inavailability of some drugs/treatment regimens in the local setting at the time of the formulation of these statements. As such, these statements will be revised as soon as new data become locally applicable.

 

Hepatitis C ; Diagnosis ; Infection ; Consensus ; Carcinoma, Hepatocellular ; Liver Cirrhosis

Purpose: Central venous stenosis is a recurring problem affecting dialysis access patency. Increasing evidence suggests that the use of drug-coated balloons (DCBs) improves target lesion primary patency (TLPP) in dialysis access. However, few studies have investigated the use of DCBs specifically in central venous stenosis. Thus, this study presents our initial experience with DCBs in the central vein of a dialysis access circuit. Materials and Methods: This is a retrospective cohort study of all hemodialysis patients who underwent central vein angioplasty with DCB between February 2017 and March 2018 at Singapore General Hospital. We compared the primary patency post DCB angioplasty to the primary patency of the patient’s previous plain old balloon angioplasty (POBA). Results: We observed a 100% anatomic and procedural success rate with no complications. The median follow-up period was 151 days (interquartile range, 85.5- 234 days) and no patients were lost to follow-up. The 30- and 90-day TLPPs after DCB were 93.3% and 75.7%, respectively. The mean primary patency in our study group post-DCB during the follow-up period was 164 days (vs. 140 days in the POBA group). However, no statistically significant difference was detected. Conclusion DCB showed a similar TLPP to that for POBA in treating central venous stenosis with a trend toward a longer re-intervention-free period for DCB. However, there were numerous confounding factors and a well-designed randomized controlled trial is warranted to assess the true utility of DCB in treating central venous stenosis.

INTRODUCTION: Patients with significant comorbidities have high general anaesthetic risks and are often thought to be undesirable candidates for general anaesthesia and, therefore, surgery. External fixation uses local or regional anaesthesia, and allows patients with significant comorbidities to avoid the risks of general anaesthesia. It has been described to be successful in the management of high-risk patients with intertrochanteric fractures. However, published data have been derived from small case series, and no published literature has attempted to analyse them in totality. This review aims to pool together these case series, and to evaluate the outcomes and complications of external fixation when performed in high-risk patients with intertrochanteric fractures. MATERIALS AND METHODS: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) guidelines. All studies that reported the outcomes of external fixation for intertrochanteric fractures of high-risk patients were included. RESULTS: A total of 13 publications, involving 687 patients, were included in the review. All the studies reported postoperative radiological reduction and complete fracture healing with reduction of limb length discrepancy. One study using parallel placement of proximal fixation screws showed shorter operative duration as compared to convergent placement. Another study mentioned that there was no significant difference in mortality rates between patients with stable fractures and those with unstable fractures who underwent external fixation. All the studies reported a decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. CONCLUSION External fixation is promising and useful especially in the management of high-risk patients with intertrochanteric fractures. The procedure can help with radiological reduction of the fracture, reduction of limb length discrepancy, reduction of operative duration, decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. The procedure is versatile and seems to be able to accommodate both stable and unstable fractures. However, unstable fractures may be associated with greater postoperative morbidity, and it may be worthwhile to prognosticate based on the stability of the patients' fracture for better risk-benefit analysis preoperatively. Shorter operative times can also be achieved through parallel proximal pin placement, without impact on mortality or morbidity.