We report a case of symptomatic bradycardia caused by consumption of a Chinese herbal medicine which was initially undisclosed to the attending emergency physician. The scientific name of the herb is Panax japonicus. Electrocardiogram revealed sinus bradycardia. Laboratory tests were normal except for the detection of a high serum digoxin level. Further interrogation of the patient eventually disclosed ingestion of the herb which, however, did not contain any digoxin. Other active ingredients in the herb include various types of ginsenoside. These are digoxin-like substances that had caused the observed false-positive detection of digoxin by fluorescence polarization immunoassay due to cross-reactivity. Our case-report provides an important insight about a blind-spot in the field of laboratory medicine (clinical pathology), namely, the false positive detection of digoxin due to crossreactivity in the immunoassay when we come across digoxin-like substances in clinical scenarios, which has barely received attention in the medical literature. It also conveys a clear educational message that with full understanding of the laboratory methodology and its mechanistic rationale there are actually some tricks-of-the-trade that allow us to optimize the specificity of the biochemical tests and the treatment of digoxin-like substances overdose.

Background: Nummular headache is a new category of primary headache disorder characterized by consistent location, size, and shape of painful areas. The pathogenesis is uncertain. Bifocal painful areas are rare manifestations but may expand the clinical diversity of nummular headache. Methods: The clinical characteristics of 5 bifocal nummular headache patients were reported and those of 11 patients in previous studies were reviewed. Bifocal nummular headache was classifi ed into two types. Type I was defi ned as a simultaneous activation of two painful areas while type II was defi ned as two painful areas occurring in different times. Results: All 16 patients were female, with mean age of onset and initial presentation of 54.7 years and 58.2 years, respectively. There were seven type I and nine type II patients. The parietal area, especially the tuber parietale, was the leading site of involvement in both types of patients. The shape and size of painful areas were also similar between these two groups. There was an equal frequency of ipsilateral and contralateral painful areas. The pain intensity was similar in both types of patients but was milder in new painful areas than in previous painful areas in type II patients. Conclusions: Bifocal nummular headache suggests a central role of nummular headache but does not debunk the peripheral theory of nummular headache. The accumulated fi ndings in bifocal NH patients do not support a generalization of pain occurrence or a reproduction of local process of epicranial neuralgia at multiple sites in nummular headache.

COVID-19/therapy* ; COVID-19 Testing ; Communicable Disease Control ; Early Diagnosis ; Housing ; Humans ; Infection Control/organization & administration* ; Patient Isolation ; Primary Health Care/organization & administration* ; Residence Characteristics ; SARS-CoV-2 ; Singapore ; Transients and Migrants

Objective: This study aimed to determine the effect of radiotherapy (RT) on the risk of herpes zoster (HZ) in patients with gynecological cancers via a nationwide population-based study. Methods: Based on patient data obtained from the National Health Insurance Research Database, 1928 gynecological cancer patients were identified with 1:1 matching for RT and non-RT cohorts by age, index date, and cancer type. Another cohort consisting of 964 noncancer individuals matched was used as normal control. The incidence of HZ was compared between cancer patients with and without RT. Age, comorbidities, cancer-related surgery and chemotherapy (CT), and cancer type were adjusted as confounders. Results: The risk of HZ in cancer patients was higher than that of non-cancer individuals (14.23 versus 8.34 per 1,000 person-years [PY], the adjusted hazard ratio [aHR]=1.38, p=0.044). In the cancer population, the incidence of HZ for the RT and non-RT cohorts was 20.55 versus 10.23 per 1,000 PY, respectively (aHR=1.68, p=0.009). Age >50 years was an independent factor for developing HZ. The 5-year actuarial incidence for patients receiving neither RT nor CT, RT alone, CT alone, and combined modalities was 5.4%, 6.9%, 3.7%, and 9.9%, respectively (p<0.001). In the RT cohort, the risk rose rapidly in the first year, becoming steady thereafter. Conclusion This population-based study showed that gynecological cancer patients receiving RT combined with CT had the highest cumulative risk of HZ. Health care professionals should be aware of the potential toxicities.

INTRODUCTIONThe objective of this study was to examine the clinical outcome of single-level lumbar artificial disc replacement (ADR) compared to that of transforaminal lumbar interbody fusion (TLIF) for the treatment of symptomatic degenerative disc disease (DDD) in an Asian population.

METHODSThis was a retrospective review of 74 patients who had surgery performed for discogenic lower backs that involved only the L4/5 and L5/S1 levels. All the patients had lumbar DDD without radiculopathy or spondylolithesis, and concordant pain with discogram at the pathological level. The patients were divided into two groups--those who underwent ADR and those who underwent TLIF.

RESULTSA trend suggesting that the ADR group had better perioperative outcomes (less blood loss, shorter operating time, shorter hospital stay and shorter time to ambulation) than the TLIF group was observed. However, a trend indicating that surgical-approach-related complications occurred more frequently in the ADR group than the TLIF group was also observed. The rate of revision surgery was comparable between the two groups.

CONCLUSIONOur findings suggest that for the treatment of discogenic lower back pain, lumbar ADR has better perioperative outcomes and a similar revision rate when compared with TLIF. However, the use of ADR was associated with a higher incidence of surgical-approach-related complications. More studies with bigger cohort sizes and longer follow-up periods are needed to determine the long-term efficacy and safety of ADR in lumbar DDD.

Adult ; Female ; Follow-Up Studies ; Humans ; Intervertebral Disc Degeneration ; surgery ; Lumbar Vertebrae ; Male ; Middle Aged ; Minimally Invasive Surgical Procedures ; methods ; Retrospective Studies ; Singapore ; epidemiology ; Spinal Fusion ; methods ; Total Disc Replacement ; methods ; Treatment Outcome

INTRODUCTIONThis study investigated the responses of plasma endotoxin and pro- and antiinflammatory cytokines during a 21-km road race in warm and humid conditions. The influence of carbohydrate-electrolyte (CE)-water (WA) drink mix ingested on leukocyte subset responses and the association between plasma lipopolysaccharide (LPS) concentration and fluid balance, exercise intensity, and body core temperature (Tc) were also studied.

MATERIALS AND METHODSThirty runners provided blood samples before and after the half-marathon for leukocyte, LPS and cytokine analyses. Tc was measured by the ingestible telemetric temperature sensor and fluid intake and split-times were recorded at 3 km intervals. Exercise intensity was determined by matching running speed and heart rate during the race with the corresponding speed-oxygen uptake relationship and heart rate measured in the laboratory 2 to 6 weeks before the race.

RESULTSPlasma LPS concentration increased from 1.9 +/- 1.9 pg/mL before, to 2.5 +/- 1.9 pg/mL after running (P <0.05). Peak plasma LPS concentration was 7.5 pg/mL. Plasma IL-1beta and TNF-concentration did not change significantly, whereas significant increases in IL-10 (50%), IL-1ra (23.2%) and IL-6 (65.2%) were observed after the race. No significant correlation between plasma LPS concentration and exercise intensity, hydration and Tc was observed.

CONCLUSIONLeukocyte subset responses were not related to the ratio of CE and water drink mix ingested. Running a half-marathon can induce mild endotoxaemia, which is not related to exercise intensity, fluid balance, and Tc responses. Mixing CE drink with water did not mitigate postexercise leukocytosis and lymphopenia.

Adult ; Beverages ; Cytokines ; immunology ; Endotoxins ; blood ; immunology ; Fluid Therapy ; Hot Temperature ; Humans ; Humidity ; Leukocytes ; immunology ; Lipopolysaccharides ; immunology ; Male ; Physical Exertion ; physiology ; Running ; physiology

INTRODUCTIONThe aim of this study is to report normative data for the Short-Form 36 version 2 (SF-36v2) for assessing health-related quality of life, in the Singapore general population.

MATERIALS AND METHODSData for English and Chinese-speaking participants of the Singapore Prospective Study Programme were analysed. The SF-36v2 scores were norm-based with the English-speaking Singapore general population as reference and reported by age (in decades), gender and ethnicity as well as for the 5 most prevalent chronic medical conditions. Scores were reported separately for the English and Chinese language versions.

RESULTSA total of 6151 English-speaking (61.5% Chinese and 19.2% Malay) and 1194 Chinese-speaking participants provided complete data. Mean (SD) age of all participants was 49.6 (12.58) years with 52.4% being women. In both languages, women reported lower scores than men on all scales. Among the chronic medical conditions, stroke had the largest impact on all English SF-36v2 scales and on 3 Chinese SF-36v2 scales (role-physical, general health and social functioning).

CONCLUSIONWe have provided detailed normative data for the Singapore English and Chinese SF-36v2, which would be valuable in furthering HRQoL research in Singapore and possibly the region.

Adult ; Female ; Health Surveys ; standards ; statistics & numerical data ; Humans ; Language ; Male ; Middle Aged ; Prospective Studies ; Quality of Life ; Singapore ; Young Adult

Introduction: Open disclosure is poorly understood in Malaysia but is an ethical and professional responsibility. The objectives of this study were to determine: (1) the perception of parents regarding the severity of medical error in relation to medication use or diagnosis; (2) the preference of parents for information following the medical error and its relation to severity; and (3) the preference of parents with regards to disciplinary action, reporting, and legal action. Methods: We translated and contextualised a questionnaire developed from a previous study. The questionnaire consisted of four case vignettes that described the following: medication error with a lifelong complication; diagnostic error with a lifelong complication; diagnostic error without lifelong effect; and medication error without lifelong effect. Each case vignette was followed by a series of questions examining the subject’s perception on the above areas. We also determined the content validity of the questionnaire. We invited parents of Malaysian children admitted to the paediatric wards of Tuanku Jaafar Hospital to participate in the study. Results: One hundred and twenty-three parents participated in the study. The majority of parents wanted to be told regarding the event. As the severity of the case vignettes increased, the desire for information, remedial action, acknowledgement of responsibility, compensation, punishment, legal action, and reporting to a higher agency also increased. The findings did not have strong evidence of a relationship with subject’s demographics. Conclusion: This study gives insights into previously unexplored perspectives and preferences of parents in Malaysia regarding open disclosure. It also highlights the opportunity for more research in this area with potentially broad applications.
Disclosure ; Professional-Patient Relations ; Patient Rights

Objective: Anxious depression is a prevalent characteristic observed in Asian psychiatric patients diagnosed with major depressive disorder (MDD). This study aims to investigate the prevalence and clinical presentation of anxious depression in Taiwanese individuals diagnosed with MDD. Methods: We recruited psychiatric outpatients aged over 18 who had been diagnosed with MDD through clinical interviews. This recruitment took place at five hospitals located in northern Taiwan. We gathered baseline clinical and demographic information from the participants. Anxious depression was identified using a threshold of an anxiety/somatization factor score ≥7 on the 21-item Hamilton Rating Scale for Depression (HAM-D). Results: In our study of 399 patients (84.21% female), 64.16% met the criteria for anxious depression. They tended to be older, married, less educated, with more children, and an older age of onset. Anxious depression patients had higher HAM-D and Clinical Global Impression–Severity scale score, more panic disorder (without agoraphobia), and exhibited symptoms like agitation, irritability, concentration difficulties, psychological and somatic anxiety, somatic complaints, hypochondriasis, weight loss, and increased insight. Surprisingly, their suicide rates did not significantly differ from non-anxious depression patients. This highlights the importance of recognizing and addressing these unique characteristics. Conclusion Our study findings unveiled that the prevalence of anxious depression among Taiwanese outpatients diagnosed with MDD was lower compared to inpatients but substantially higher than the reported rates in European countries and the United States. Furthermore, patients with anxious depression exhibited a greater occurrence of somatic symptoms.