The safety of simultaneous bilateral total knee arthroplasty (TKA) remains controversial. The objective of the current study was to investigate perioperative morbidity and mortality rates within 30 days of simultaneous bilateral TKA. A detailed analysis of medical, surgical and anaesthesia records of 183 consecutive patients who underwent total knee arthroplasty between 2002 and 2006 was performed. The mean age of the patients was 67.6 years old. More than 80% had one or more co-morbidities, but none of them had ASA score greater than class 2. The mean hospital stay was 10 days, and the mean surgical time 156 minutes. Less than half of the patients (42.6%) required blood transfusion. The rate of perimorbidity was 15.3 % and there was no mortality in this series. We believe that simultaneous bilateral total knee arthroplasty is a safe and cost effective option for our patients, provided that patients are selected and informed appropriately.

We report here a case of a kidney transplant recipient in whom the ureter was initially implanted into the peritoneum. Excessive ultrafiltration volume and reversal of serum vs dialysate creatinine ratio when the patient was recommenced on continuous ambulatory peritoneal dialysis first suggested the diagnosis which was subsequently confirmed by a plain abdominal x-ray demonstrating placement of ureteric stent in the peritoneum. This rare complication was successfully corrected with surgical re-implantation of ureter into the bladder and 5 years later, the patient remains well with good graft function.
Cadaver ; Kidney Transplantation/*methods ; Postoperative Complications ; Reoperation ; Replantation ; Ureter/*surgery

The study aimed to evaluate the quality of the hybridlayer form by three different adhesive systems. Class Vcavities were prepared on the buccal surface of fourtyextracted human premolars. The prepared teeth wererandomly assigned into four groups according to theadhesive system and application mode. The systemswere: Optibond S (OS, total-etch); Optibond Versa (OV,two-bottles, self-etch); Single Bond Universal (SBU,one-bottle, self-etch) and Single Bond Universal withetchant (SBU + etchant). All cavities were restored withcomposite (Filtek Z350XT). The samples were sectioned,polished and pretreated to remove minerals, proteinand water prior to SEM evaluation. From the images,thickness of the hybrid layers was measured. Present ofresin tags and adaptation failure were also recorded. Thedata obtained were analyzed using ANOVA, Dunnett’sT3, Kruskal-Wallis and Mann-Whitney tests. OS groupshowed the highest average hybrid layer thickness (4.34µm), followed by SBU + etchant (3.06 µm), OV (1.91 µm)and SBU (0.95 µm). Both adhesive and cohesive failureswere observed in SBU group. Present of prominent resintags were seen in both OS and OV groups. In conclusion,all the investigated adhesive systems were able to performdistinguishable actions as shown in micro-morphologicalalteration and hybrid layer thickness. Two-bottles, selfetchadhesive (OV) was proven to produce negligibleadaptation failure compared to other adhesive systems inthe present study. Combined all-in-one adhesive (SBU)was found to render a superior bonding performance intotal-etch mode comparing to self-etch mode.

The present study aimed to determine the factors associated with CKD stage 3b among type 2 diabetics attending primary care follow-up, specifically the role of angiotensin blockade dosage. This was a pilot unmatched case-control study conducted in a teaching primary care centre. Clinical data of 25 cases of diabetic patients with CKD stage 3b (GFR 30-45ml/min/1.73m2) in 2012 were selected for this study, as well as 103 controls who were diabetic patients with GFR more than 45ml/min/1.73m2 in 2012. Systematic random sampling was employed. Data was obtained from patients’ diabetic records, computerised clinical medical information system and medical case notes. Univariate analysis was done using Chi-square, t-test, Fisher’s exact test and Mann-Whitney U-test. Multiple logistic regression was used to determine the associated factors for development of CKD stage 3b. Cases and controls were different in terms of age, duration of diabetes, use and dosage of angiotensin blockade medications, systolic blood pressure and baseline GFR. Multiple logistic regression revealed that systolic blood pressure (Adjusted OR= 1.08, 95% CI= 1.02-1.14, p=0.013) and baseline GFR (Adjusted OR= 0.90, 95% CI= 0.85-0.95, p<0.001) was significantly associated with the development of CKD stage 3b among diabetics. Maximizing the dose of angiotensin blockade had a protective effect (Adjusted OR= 0.14, 95% CI=0.85-0.95, p=0.025). The results of the present study supports the need for good control of systolic blood pressure among diabetic patients to reduce the risk of chronic kidney disease progression. Dose of angiotensin blockade medications should be optimised in these patients.

INTRODUCTIONScalp soft tissue defects are common and result from a variety of causes. Reconstructive methods should maximise cosmetic outcomes by maintaining hair-bearing tissue and aesthetic hairlines. This article outlines an algorithm based on a diverse clinical case series to optimise scalp soft tissue coverage.

MATERIALS AND METHODSA retrospective analysis of scalp soft tissue reconstruction cases performed at the Singapore General Hospital between January 2004 and December 2013 was conducted.

RESULTSForty-one patients were included in this study. The majority of defects <100 cm² were reconstructed with local flaps and were subdivided by location. Methods included rotation, transposition and free flaps. The most common type of reconstruction performed for defects ≥100 cm² was free flap reconstruction. Multistage reconstruction using tissue expanders aided in optimising cosmetic outcomes. There were no major complications or flap failures.

CONCLUSIONBy analysing our experience with scalp soft tissue reconstruction, we have developed an algorithm based on defect size and location, achieving excellent closure and aesthetic outcome while minimising complications and repeat procedures.

Adult ; Aged ; Aged, 80 and over ; Algorithms ; Esthetics ; Female ; Head and Neck Neoplasms ; surgery ; Humans ; Male ; Middle Aged ; Physical Appearance, Body ; Postoperative Complications ; surgery ; Reconstructive Surgical Procedures ; methods ; Retrospective Studies ; Scalp ; surgery ; Singapore ; Skin Neoplasms ; surgery ; Skull ; surgery ; Surgical Flaps ; Tissue Expansion Devices ; Treatment Outcome

INTRODUCTIONAlthough pneumonia is a major complication after acute ischaemic stroke (AIS), pneumonia prediction scores have not been extensively validated. This study aimed to compare the discrimination performance of 5 pneumonia prediction scores in AIS patients.

MATERIALS AND METHODSWe retrospectively reviewed all consecutive adult AIS patients whom presented to our emergency department within 4.5 hours of symptom-onset between January 2012 and February 2015. Diagnosis had to be made by a neurologist and infarcts confirmed by neuroimaging. We excluded patients with pneumonia on presentation. Pneumonia predictors were based on the 5 prediction scoring models: Kwon's score, Chumbler's score, Acute Ischaemic Stroke-Associated Pneumonia Score (AIS-APS), ADSscore and ISAN score. The definition of stroke-associated pneumonia was based on the criteria by the Pneumonia in Stroke Consensus Group. Analysis using area under receiver operating characteristics curve (AUROC) was performed.

RESULTSForty (5.5%) out of 731 patients analysed had stroke-associated pneumonia (SAP). ADSscore had the highest discrimination capacity (AUROC 0.88; 95% CI, 0.84 to 0.92), followed by AIS-APS (AUROC 0.87; 95% CI, 0.83 to 0.91), Kwon's score (AUROC 0.86; 95% CI, 0.82 to 0.92), Prestroke Independence, Sex, Age and National Institutes of Health Stroke Scale (ISAN) score (AUROC 0.85; 95% CI, 0.80 to 0.90) and Chumbler's score (AUROC 0.79; 95% CI, 0.74 to 0.84). However, there was no statistical difference of discrimination capacity among ADSscore, AIS-APS and Kwon's score.

CONCLUSIONADS, AIS-APS and Kwon's scores performed comparably in discriminating SAP in AIS patients.

INTRODUCTION: Uterine rupture is uncommon but has catastrophic implications on the pregnancy. A scarred uterus and abnormal placentation are known contributory factors. The aim of our study was to review the contributing factors, clinical presentation, complications and management of uterine rupture in our population in light of the changing nature of modern obstetric practices. METHODS: A retrospective observational study was conducted at KK Women's and Children's Hospital by studying proven cases of uterine rupture in the period between January 2003 and December 2014. These cases were analysed according to their past history, clinical presentation, complications, management and outcome. RESULTS: A total of 48 cases of proven uterine rupture were identified. The incidence of uterine rupture was 1 in 3,062 deliveries. The ratio of scarred uterus rupture to unscarred uterus rupture was approximately 3:1. The most common factor was previous lower segment caesarean section for the scarred group, followed by a history of laparoscopic myomectomy. Abdominal pain was the common clinical presentation in the antenatal period, while abnormal cardiotocography findings were the most common presentation in intrapartum rupture. CONCLUSION There is a notable shift in the trend of uterine rupture cases given the increasing use of laparoscopic myomectomy and elective caesarean sections. While ruptures from these cases were few, their presentation in the antenatal period calls for diligent monitoring with informed patient involvement in their pregnancy care.

INTRODUCTIONLow birth weight (LBW, <2500 g) is an important risk factor for perinatal mortality and morbidity. We performed the first geospatial study of LBW in Singapore, with focus on the public sector and analysis of the national planning areas.

MATERIALS AND METHODSA dataset of 24,615 singleton deliveries from 2012 to 2014 was obtained from the largest maternity hospital in Singapore. Maternal residences were identified with 28 planning areas according to postal code. Multiple logistic regression was used to examine associations between LBW rates and planning areas. Moran's I statistic was used to test for geospatial clustering of LBW rates among planning areas.

RESULTSThe LBW rate across planning areas ranged from 5.3 to 11.5 per 100 live births (median, 8.4). High LBW rates were associated with: 1) a lower individual socioeconomic status, 2) non-compliance to antenatal visits, and 3) biological factors such as maternal hypertension, low body mass index and Indian race. Moran's statistic indicated no geospatial clustering of LBW rates among the 28 planning areas ( = 0.12). LBW rates were moderately correlated with the Socioeconomic Disadvantage Index (r = 0.58) but uncorrelated with distance travelled to hospital (r = -0.08).

CONCLUSIONThere was no evidence of clustering of LBW rates among planning areas in Singapore that would indicate inequitable distribution of health resources among planning areas. The 2 areas showing the highest rates of LBW infants were Outram and Bukit Merah. We recommend targeted health interventions and outreach programmes to encourage antenatal visits in these areas.

: One of the most feared complications of childhood cancer treatment is second malignant neoplasms (SMNs). This study evaluates the incidence, risk factors and outcomes of SMNs in a tertiary paediatric oncology centre in Singapore.: A retrospective review was conducted on patients diagnosed with childhood cancer under age 21 and treated at the National University Hospital, Singapore, from January 1990 to 15 April 2012. Case records of patients with SMNs were reviewed.: We identified 1124 cases of childhood cancers with a median follow-up of 3.49 (0 to 24.06) years. The most common primary malignancies were leukaemia (47.1%), central nervous system tumours (11.7%) and lymphoma (9.8%). Fifteen cases developed SMNs, most commonly acute myeloid leukaemia/myelodysplastic syndrome (n = 7). Median interval between the first and second malignancy was 3.41 (0.24 to 18.30) years. Overall 20-year cumulative incidence of SMNs was 5.3% (95% CI, 0.2% to 10.4%). The 15-year cumulative incidence of SMNs following acute lymphoblastic leukaemia was 4.4% (95% CI, 0% to 8.9%), significantly lower than the risk after osteosarcoma of 14.2% (95% CI, 0.7% to 27.7%) within 5 years (<0.0005). Overall 5-year survival for SMNs was lower than that of primary malignancies.: This study identified factors explaining the epidemiology of SMNs described, and found topoisomerase II inhibitor use to be a likely risk factor in our cohort. Modifications have already been made to our existing therapeutic protocols in osteosarcoma treatment. We also recognised the importance of other risk management strategies, including regular long-term surveillance and early intervention for detected SMNs, to improve outcomes of high risk patients.
Bone Neoplasms ; therapy ; Cancer Care Facilities ; Central Nervous System Neoplasms ; therapy ; Follow-Up Studies ; Humans ; Incidence ; Leukemia ; therapy ; Leukemia, Myeloid, Acute ; epidemiology ; Lymphoma ; therapy ; Myelodysplastic Syndromes ; epidemiology ; Neoplasms ; therapy ; Neoplasms, Second Primary ; epidemiology ; Osteosarcoma ; therapy ; Pediatrics ; Retrospective Studies ; Risk Factors ; Singapore ; epidemiology ; Survivors ; statistics & numerical data ; Tertiary Care Centers ; Time Factors ; Topoisomerase II Inhibitors ; therapeutic use

INTRODUCTIONWith the global outbreak of Zika virus and its association with microcephaly, an up-to-date fetal head circumference (HC) nomogram is crucial to offer a reference standard in order to make an accurate diagnosis. This study was conducted to revise the local fetal HC nomogram.

MATERIALS AND METHODSIn this retrospective study, ultrasound data was used for construction of the fetal HC nomogram from a total of 6155 pregnancies in the ethnic Chinese population with low risk profile at KK Women's and Children's Hospital over a 10-year period. Regression model was fitted to calculate the mean and standard deviation of HC at each gestational age (GA). Comparison of HC between ethnic groups (no significant differences) and genders were made. The revised chart was compared with another commonly used reference chart (Hadlock). In an independent test population, different reference charts were used to estimate number of cases with microcephaly.

RESULTSA statistically significant difference of HC between the genders was observed across all gestational ages. Gender-specific reference charts and equation were computed. Our revised fetal HC chart showed a different distribution from the Hadlock chart. Compared with the gender-specific charts, the Hadlock HC chart would significantly under-report microcephaly cases in male fetuses, and tend to over-report in female fetuses.

CONCLUSIONThis study provides a new set of gender-specific fetal HC charts in the Singaporean population for antenatal ultrasound surveillance of microcephaly.