History, 19th Century ; History, 20th Century ; Humans ; Neurosurgery ; history ; Philately ; United States

Strong association between HLA B*1502 and carbamazepine-induced Steven-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) was demonstrated among Han Chinese in 2004. Studies from Europe showed that the HLA B*1502 is not a universal marker for SJS/TEN, but is ethnicity specific for Asians. Reports across Asia has shown that the prevalence of HLA B*1502 is high among Han Chinese (5-15%), Malays (12-15%), and Thais (8-27%), but low among Japan, Korea, Sri Lanka, and most ethnic groups in India. Other than Han Chinese, the association between HLA B*1502 and carbamazepine-induced SJS-TEN is also seen among the Thais and Malay. There is urgent need for further studies to determine the prevalence of SJS/TEN, and HLA B*1502 in the various ethnic groups in Asia, and its association with carbamazepine-induced SJS-TEN in each of these ethnic groups. In view of the significant morbidity and mortality in SJS-TEN, facilities should be developed to allow for screening of HLA B*1502 before carbamazepine is prescribed to the Hans Chinese, Malays and Thais. For those who experience no adverse cutaneous reaction after 3 months use of carbamazepine, the risk of SJS/TEN is low, and the drugs can be continued.

Cancer remains an outstanding cause of global morbidity and mortality, despite intensive research and unprecedented insights into the basic mechanisms of cancer development. A plethora of clinical and experimental evidence suggests that cancers from individual patients are likely to be molecularly heterogeneous in their use of distinct oncogenic pathways and biological programs. Efforts to significantly impact cancer patient outcomes will almost certainly require the development of robust strategies to subdivide such heterogeneous panels of cancers into biologically and clinically homogenous subgroups, for the purposes of personalizing treatment protocols and identifying optimal drug targets. In this review, I describe recent progress in the development of both targeted and genome-wide approaches for the molecular stratification of cancers, drawing examples from both the haematopoietic and solid tumor malignancies.
Animals ; Genomics ; Humans ; Neoplasms/*genetics/*metabolism/pathology

Cancer remains an outstanding cause of global morbidity and mortality, despite intensive research and unprecedented insights into the basic mechanisms of cancer development. A plethora of clinical and experimental evidence suggests that cancers from individual patients are likely to be molecularly heterogeneous in their use of distinct oncogenic pathways and biological programs. Efforts to significantly impact cancer patient outcomes will almost certainly require the development of robust strategies to subdivide such heterogeneous panels of cancers into biologically and clinically homogenous subgroups, for the purposes of personalizing treatment protocols and identifying optimal drug targets. In this review, I describe recent progress in the development of both targeted and genome-wide approaches for the molecular stratification of cancers, drawing examples from both the haematopoietic and solid tumor malignancies.
Animals ; Genomics ; Humans ; Neoplasms/*genetics/*metabolism/pathology

Primary endocrine therapy (PET) is often included as a treatment option in elderly women with operable breast cancer. Elderly women tend to have pre-existing comorbidities and are often reluctant to undergo surgery. The benefit of surgery needs to be weighed against a relatively higher potential for operative morbidity and mortality, and a limited life expectancy. But while PET can provide relatively good locoregional control, it is not curative in nature and the possibility of local complications and metastasis remains. We retrospectively reviewed the outcome of PET in a series of 19 elderly women, older than 70 years of age, who had presented with operable non-metastatic breast cancer. Only about a third of these women were deemed medically unfit for surgery; the rest had declined surgery. Compliance was an issue, with almost half of these patients defaulting treatment and follow-up. Local control was achieved in most patients, but disease progression did occur in 5 patients. Three of these patients received additional treatment; which included surgery in 1 patient. PET should therefore not be considered an equivalent alternative to surgery in elderly women who were fi t to undergo surgery. However, having observed that only 1 of the 6 deaths in our study was related to breast cancer, PET does have a role in women whose life expectancy is more likely to be limited by coexisting morbidities than the breast cancer itself.
Aged ; Aged, 80 and over ; Antineoplastic Agents, Hormonal ; therapeutic use ; Breast Neoplasms ; drug therapy ; Drug Therapy ; utilization ; Female ; Humans ; Retrospective Studies ; Tamoxifen ; therapeutic use

INTRODUCTIONTraditional Chinese Medicine or Traditional Complementary Medicine (TCM) is commonly used in our culture. There are several concerns regarding its use in patients undergoing conventional treatments for breast cancer. In this study, we aimed to evaluate the prevalence and pattern of TCM use among our breast cancer patients, and to identify patients who were most likely to choose TCM.

MATERIALS AND METHODSA total of 300 patients on active follow-up with Breast Service at Tan Tock Seng Hospital were interviewed using a structured questionnaire.

RESULTSA total of 35% (104 of 296) of patients reported using TCM. The majority of the patients were introduced to TCM by family and friends following the diagnosis of breast cancer. All except 3 patients continued with recommended conventional therapy although most did not inform their clinicians of TCM use. None of the patients reported any serious adverse events and 75% of them perceived a benefit from TCM use. Younger patients and those of Chinese ethnicity were more likely to use TCM (P <0.01 and P = 0.03 respectively). There was no significant difference in the dialect group, religious beliefs and educational level between the 2 groups (P >0.05).

CONCLUSIONTCM use is common among our breast cancer patients, particularly the younger women. However, most patients do not inform their clinicians of TCM use while on recommended conventional therapies. It is therefore important for clinicians to initiate discussions regarding TCM use in order to be aware of potential unwanted drug interactions.

Adult ; Aged ; Aged, 80 and over ; Breast Neoplasms ; therapy ; Female ; Humans ; Medical Oncology ; Medicine, Chinese Traditional ; utilization ; Middle Aged

Pediatric-onset multiple sclerosis is underreported because of difficulty in diagnosis and assessment. In Western series, pediatric-onset disease showed significant differences from adult-onset disease with higher female preponderance, polysymptomatic in onset, frequent systemic manifestation in relapses, higher relapse rate, but less disability, and fewer lesions in brain magnetic resonance imaging. Multiple sclerosis manifests differently in Asians, yet there was no large series of pediatric-onset multiple sclerosis reported. We found that pediatric-onset disease in Asians showed greater similarity with adult-onset disease without the reported differences in female preponderance, relapse rate, and magnetic resonance imaging findings. There were also similar proportion and clinical features in optico-spinal form, and long spinal cord lesions were common in both groups. The significant difference was less disability among the pediatric-onset group. Thus, although multiple sclerosis in Asia is different from Western countries, there is greater similarity between the pediatric-onset and adult-onset group in Asia.
Multiple Sclerosis ; Adult ; Asia ; Pediatric ; Cancer Relapse

STUDY DESIGN: A retrospective study of radiographic parameters of patients who underwent lumbar spinal pedicle screw insertion.PURPOSE: The optimal length of pedicle screws is often determined by the lateral radiograph during minimally invasive surgery (MIS). Compared with open techniques, measuring the precise length of screws or assessing the cortical breach is challenging. This study aims to ascertain the optimal pedicle screw lengths on intraoperative lateral radiographs for L1–L5.OVERVIEW OF LITERATURE: Research has revealed that optimal pedicle screw length is essential to optimize fixation, especially in osteoporotic patients; however, it must be balanced against unintentional breach of the anterior cortex, risking injury to adjacent neurovascular structures as demonstrated by case reports.METHODS: We reviewed intra- and postoperative computed tomography scans of 225 patients who underwent lumbar pedicle screw insertion to ascertain which of the inserted screws were ‘optimal screws.’ The corresponding lengths of these screws were analyzed on postoperative lateral radiographs to ascertain the ideal position that a screw should attain (expressed as a percentage of the entire vertebral body length).RESULTS: We reviewed 880 screws of which 771 were optimal screws. We noted a decreasing trend in average optimal percentages of insertion into the vertebral body for pedicle screws going from L1 (average=87.60%) to L5 (average=78.87%). The subgroup analysis revealed that there was an increasing percentage of screws directed in a straight trajectory from L1 to L5, compared to a medially directed trajectory.CONCLUSIONS: During MIS pedicle screw fixation, this study recommends that pedicle screws should not exceed 85% of the vertebral body length on the lateral view for L1, 80% for L2–L4, and 75% for L5; this will minimize the risk of anterior cortical breach yet maximize pedicle screw purchase for fixation stability.
Humans ; Lumbar Vertebrae ; Minimally Invasive Surgical Procedures ; Pedicle Screws ; Radiography ; Retrospective Studies

INTRODUCTION: Airway management outside the operating room can be challenging, with an increased risk of difficult intubation, failed intubation and complications. We aim to examine airway practices, incidence of difficult airway and complications associated with airway code (AC) activation. METHODS: We conducted a prospective audit of AC activations and adverse events in two tertiary hospitals in Singapore. We included all adult patients outside the operating room who underwent emergency intubation by the AC team after AC activation. Adult patients who underwent emergency intubation without AC activation or before the arrival of the AC team were excluded. Data were collected and documented by the attending anaesthetists in a standardised survey form shortly after their responsibilities were completed. RESULTS: The audit was conducted over a 20-month period from July 2016 to March 2018, during which a total of 224 airway activations occurred. Intubation was successful in 218 of 224 AC activations, giving a success rate of 97.3%. Overall, 48 patients (21.4%) suffered an adverse event. Thirteen patients (5.8%) had complications when intubation was carried out by the AC team compared with 35 (21.5%) by the non-AC team. CONCLUSION Dedicated AC team offers better success rate for emergency tracheal intubation. Non-AC team attempted intubation in the majority of the cases before the arrival of the AC team. Increased intubation attempts are associated with increased incidence of adverse events. Equipment and patient factors also contributed to the adverse events. A multidisciplinary programme including the use of supraglottic devices may be helpful to improve the rate of success and minimise complications.

Retrospective review.

To determine the accuracy of thoracolumbar pedicle screw insertion with the routine use of three-dimensional (3D) intraoperative imaging and navigation over a large series of screws in an Asian population.

The use of 3D intraoperative imaging and navigation in spinal surgery is aimed at improving the accuracy of pedicle screw insertion. This study analyzed 2,240 pedicle screws inserted with the routine use of intraoperative navigation. It is one of very few studies done on an Asian population with a large series of screws.

Patients who had undergone thoracolumbar pedicle screws insertion using intraoperative imaging and navigation between 2009 and 2017 were retrospectively analyzed. Computed tomography (CT) images acquired after the insertion of pedicle screws were analyzed for breach of the pedicle wall. The pedicle screw breaches were graded according to the Gertzbein classification. The breach rate and revision rate were subsequently calculated.

A total of 2,240 thoracolumbar pedicle screws inserted under the guidance of intraoperative navigation were analyzed, and the accuracy of the insertion was 97.41%. The overall breach rate was 2.59%, the major breach rate was 0.94%, and the intraoperative screw revision rate was 0.7%. There was no incidence of return to the operating theater for revision of screws.

The routine use of 3D navigation and intraoperative CT imaging resulted in consistently accurate pedicle screw placement. This improved the safety of spinal instrumentation and helped in avoiding revision surgery for malpositioned screws.