INTRODUCTIONThe surgeon uses different methods of surgical hand antisepsis with the aim of reducing surgical site infections. To date, there are no local studies comparing the efficacy of iodine hand scrub against newer alcohol-based hand rubs with active ingredients. Our pilot study compares a traditional aqueous hand scrub using 7.5% Povidone iodine (PVP-I) against a hand rub using Avagard: 61% ethyl alcohol, 1% chlorhexidine gluconate. The outcome measure is the number of Colony Forming Units (CFU) cultured from 10-digit fingertip imprints on agar plates.

MATERIALS AND METHODSTen volunteers underwent 2 hand preparation protocols, with a 30-minute interval in between-Protocol A (3-minute of aqueous scrub using PVP-I) and Protocol B (3-minute of hand rub, until dry, using Avagard). In each protocol, fingertip imprints were obtained immediately after hand preparation (t(0)). The volunteers proceeded to don sterile gloves and performed specific tasks (suturing). At one hour, the gloves were removed and a second set of imprints was obtained (t(1)).

RESULTSFour sets of fingertip imprints were obtained. All 10 participants complied with the supervised hand preparation procedures for each protocol. CFUs of initial fingertip imprints (t(0)): The median CFU counts for initial imprint was significantly higher in the PVP-I treatment (median = 6, Inter Quartile Range (IQR) = 33) compared to the Avagard treatment (median = 0, IQR = 0, P <0.001). CFUs of fingertip imprint at 1 hour (t(1)): The median CFU counts for second imprint (t(1)) was significantly higher in the PVP-I treatment (median = 0.5, IQR = 11) compared to the Avagard treatment (median = 0, IQR = 0, P = 0.009). Our results suggest that the Avagard was more efficacious than aqueous PVP-I scrub at reducing baseline colony counts and sustaining this antisepsis effect.

CONCLUSIONAlcohol hand rub with an active compound, demonstrated superior efficacy in CFU reduction. Based on our results, and those pooled from other authors, we suggest that alcohol-based hand rubs could be included in the operating theatre as an alternative to traditional surgical scrub for surgical hand antisepsis.

Alcohols ; administration & dosage ; Anti-Infective Agents, Local ; administration & dosage ; Antisepsis ; methods ; Chlorhexidine ; administration & dosage ; analogs & derivatives ; Cohort Studies ; Hand ; microbiology ; Hand Disinfection ; methods ; Humans ; Pilot Projects ; Povidone-Iodine ; administration & dosage ; Singapore

Objective: To evaluate the long-term efficacy and safety of three-monthly paliperidone palmitate (PP3M) in Asian patients with stable schizophrenia in a naturalistic setting. Methods: Asian patients recruited between May 2016 and March 2018 from the prospective, single-arm, non-randomized, open-label, multi-national REMISSIO study were analyzed. Patients received PP3M over 12 months following ≥ 4 months of treatment with one-monthly paliperidone palmitate. The primary efficacy endpoint was the proportion of patients who achieved symptomatic remission. Other endpoints were changes in Positive and Negative Syndrome Scale (PANSS) and Personal and Social Performance (PSP) total scores, hospitalization rates, and safety. Results: A total of 71 patients (23.3%) were Asian (South Korea: 33, Malaysia: 21, Taiwan: 17); 95.8% of patients completed the study. At LOCF, 71% of Asian patients achieved symptomatic remission compared to the overall population (n = 172/303, 56.8%). Improvements in mean (standard deviation) PANSS and PSP total scores from baseline to LOCF in Asian patients and overall population were clinically significant. A lower proportion of Asian patients had ≥ 1 psychiatric hospitalization after PP3M treatment (n = 1/70, 1.4%) than during the 12 months before (n = 12/70, 17.1%); compared with patients in the overall population after (n = 8/303, 2.6%) and before PP3M treatment (n = 37/303, 12.2%). The overall incidence of treatment-emergent adverse events across Asian patients was 62.9% compared to 53.1% in the overall population. Safety findings were consistent with the known safety profile of PP3M. Conclusion Our findings confirm existing evidence on the efficacy and tolerability of PP3M in Asian patients with stable schizophrenia over 12 months of treatment.

Background: Venous thromboembolism (VTE) is a serious complication that may occur after total knee arthroplasty (TKA), leading to the recommendation of routine chemoprophylaxis by international guidelines. This study aims to determine if short-duration chemoprophylaxis after TKA reduces the incidence of VTE in an Asian population. Methods: A retrospective study of 316 patients who underwent unilateral primary TKA between 1 January 2011 and 31 December 2013 was conducted. All patients received mechanical prophylaxis. One hundred seventeen patients (37%) received additional chemoprophylaxis, whereas 199 patients (63%) did not. A Doppler ultrasound (DUS) of both lower limbs was conducted for all patients within 6 days after surgery (median = 3 days) to assess for both proximal and distal DVT. Chemoprophylaxis in the form of enoxaparin (low molecular weight heparin; LMWH), aspirin, or heparin was administered until patients had a normal DUS, for a median duration of 4 days. Patients were followed up clinically for a minimum of 6 months to monitor for delayed or recurrent VTE and at least 2 years for patient-reported outcome measures. Results: Overall, 24 patients (7.59%) developed deep vein thrombosis (DVT): three proximal and 21 distal DVTs.Twenty-three of the 24 patients were asymptomatic. Twenty of 199 patients (10.05%) with only mechanical prophylaxis developed DVT, whereas four of 117 patients (3.42%) with additional chemoprophylaxis developed DVT.Multivariate analysis showed that chemoprophylaxis use was associated with reduced incidence of DVT (odds ratio = 0.19, p value = 0.011). Other factors associated with increased DVT incidence include female gender (odds ratio = 5.45, p value = 0.034), positive history of cancer (odds ratio = 5.14, p value = 0.044), and increased length of stay in hospital (odds ratio = 1.19, p value < 0.001). Conclusions Our study has shown that despite the low incidence of DVT in Asian patients undergoing TKA, shortduration chemoprophylaxis might be effective in reducing the incidence of DVT. However, most DVTs observed in our study were distal and may be of limited clinical significance. Further studies are needed to investigate the impact of chemoprophylaxis use on the incidence of PE and overall mortality rates among Asian patients.

Background: Venous thromboembolism (VTE) is a serious complication that may occur after total knee arthroplasty (TKA), leading to the recommendation of routine chemoprophylaxis by international guidelines. This study aims to determine if short-duration chemoprophylaxis after TKA reduces the incidence of VTE in an Asian population. Methods: A retrospective study of 316 patients who underwent unilateral primary TKA between 1 January 2011 and 31 December 2013 was conducted. All patients received mechanical prophylaxis. One hundred seventeen patients (37%) received additional chemoprophylaxis, whereas 199 patients (63%) did not. A Doppler ultrasound (DUS) of both lower limbs was conducted for all patients within 6 days after surgery (median = 3 days) to assess for both proximal and distal DVT. Chemoprophylaxis in the form of enoxaparin (low molecular weight heparin; LMWH), aspirin, or heparin was administered until patients had a normal DUS, for a median duration of 4 days. Patients were followed up clinically for a minimum of 6 months to monitor for delayed or recurrent VTE and at least 2 years for patient-reported outcome measures. Results: Overall, 24 patients (7.59%) developed deep vein thrombosis (DVT): three proximal and 21 distal DVTs.Twenty-three of the 24 patients were asymptomatic. Twenty of 199 patients (10.05%) with only mechanical prophylaxis developed DVT, whereas four of 117 patients (3.42%) with additional chemoprophylaxis developed DVT.Multivariate analysis showed that chemoprophylaxis use was associated with reduced incidence of DVT (odds ratio = 0.19, p value = 0.011). Other factors associated with increased DVT incidence include female gender (odds ratio = 5.45, p value = 0.034), positive history of cancer (odds ratio = 5.14, p value = 0.044), and increased length of stay in hospital (odds ratio = 1.19, p value < 0.001). Conclusions Our study has shown that despite the low incidence of DVT in Asian patients undergoing TKA, shortduration chemoprophylaxis might be effective in reducing the incidence of DVT. However, most DVTs observed in our study were distal and may be of limited clinical significance. Further studies are needed to investigate the impact of chemoprophylaxis use on the incidence of PE and overall mortality rates among Asian patients.

INTRODUCTION

Coronary artery disease (CAD) is one of the leading causes of death globally. Studies have shown association of CAD and its risk factors; however, data on association of these risk factors and severity of CAD as seen in angiography in our local setting are still limited.

OBJECTIVE

The aims of this study were to determine the clinical and angiographic profile of patients who underwent coronary angiography, to correlate cardiovascular risk factors to their angiographic findings, and to compare the trend of risk factors and angiography findings between decades.

METHODS

This is a retrospective observational study of patients aged 18 years or older, of either sex, who underwent coronary angiography at a tertiary hospital from 2001 to 2019. Pertinent risk factors were correlated with angiography findings to determine predictors for significant CAD.

RESULTS

The mean age of the patients was 58.6 years. There were more males (66%) than females. The risk factors for the likelihood of significant CAD are older age (4.98% more for every year increase in age), male sex (2.63 times), and diabetes mellitus (47.64%). The majority of the patients had right dominant circulation, and significant lesions were more commonly seen in the left anterior descending artery. There were statistically significant more patients with hypertension, diabetes, and obesity in the present decade compared with the past.

CONCLUSION

Increased age, male sex, and diabetes are associated with significant CAD in the local setting. Diabetes must be aggressively controlled early to prevent the development of significant CAD.

Coronary Artery Disease ; Risk Factors ; Coronary Angiography

Objective: To evaluate the long-term safety and efficacy of intranasal esketamine in patients with treatment-resistant depression from the Asian subgroup of the SUSTAIN-2 study. Methods: SUSTAIN-2 was a phase 3, open-label, single-arm, multicenter study comprising a 4-week screening, 4-week induction, 48-week optimization/maintenance, and 4-week follow-up (upon esketamine discontinuation) phase. Patients with treatment-resistant depression received esketamine plus an oral antidepressant during the treatment period. Results: The incidence of ≥ 1 serious treatment-emergent adverse event (TEAE) among the 78 subjects from the Asian subgroup (Taiwan: 33, Korea: 26, Malaysia: 19) was 11.5% (n = 9); with no fatal TEAE. 13 Asian patients (16.7%) discontinued esketamine due to TEAEs. The most common TEAEs were dizziness (37.2%), nausea (29.5%), dissociation (28.2%), and headache (21.8%). Most TEAEs were mild to moderate in severity, transient and resolved on the same day. Upon discontinuation of esketamine, no trend in withdrawal symptoms was observed to associate long-term use of esketamine with withdrawal syndrome. There were no reports of drug seeking, abuse, or overdose. Improvements in symptoms, functioning and quality of life, occurred during in the induction phase and were generally maintained through the optimization/maintenance phases of the study. Conclusion The safety and efficacy of esketamine in the Asian subgroup was generally consistent with the total SUSTAIN-2 population. There was no new safety signal and no indication of a high potential for abuse with the long-term (up to one year) use of esketamine in the Asian subgroup. Most of the benefits of esketamine occurred early during the induction phase.

INTRODUCTIONObstructive sleep apnoea (OSA) is associated with increased perioperative morbidity and mortality. Patients at risk of OSA as determined by pre-anaesthesia screening based on the American Society of Anesthesiologists checklist were divided into 2 groups for comparison: (i) those who proceeded to elective surgery under a risk management protocol without undergoing formal polysomnography preoperatively and; (ii) those who underwent polysomnography and any subsequent OSA treatment as required before elective surgery. We hypothesised that it is clinically safe and acceptable for patients identified on screening as OSA at-risk to proceed for elective surgery without delay for polysomnography, with no increase in postoperative complications if managed on a perioperative risk reduction protocol.

MATERIALS AND METHODSA retrospective review of patients presenting to the preanaesthesia clinic over an 18-month period and identified to be OSA at-risk on screening checklist was conducted (n = 463). The incidence of postoperative complications for each category of OSA severity (mild-moderate and severe) in the 2 study groups was compared.

RESULTSThere was no statistically significant difference in the incidence of cardiac (3.3% vs 2.3%), respiratory (14.3% vs 12.5%), and neurologic complications (0.6% vs 0%) between the screening-only and polysomnography-confirmed OSA groups respectively (P >0.05). There was good agreement of the OSA risk that is identified by screening checklist with OSA severity as determined on formal polysomnography (kappa coefficient = 0.953).

CONCLUSIONPreviously undiagnosed OSA is common in the presurgical population. In our study, there was no significant increase in postoperative complications in patients managed on the OSA risk management protocol. With this protocol, it is clinically safe to proceed with elective surgery without delay for formal polysomnography confirmation.

Adult ; Elective Surgical Procedures ; Female ; Humans ; Male ; Middle Aged ; Perioperative Care ; Polysomnography ; Postoperative Complications ; prevention & control ; Preoperative Care ; Risk Reduction Behavior ; Sleep Apnea, Obstructive ; diagnosis

We present five patients with vibrio necrotising fasciitis, a lethal and disabling disease. Two of these patients had a history of exposure to either warm seawater or raw/live seafood, three had underlying chronic liver disease, and four presented with hypotension and fever. There were three deaths and four patients required intensive care unit stays. Among the two survivors, one had high morbidity. Only one patient met the criteria of Laboratory Risk Indicator for Necrotising Fasciitis score > 6. A clinician should suspect possible vibrio necrotising fasciitis if the following are present: contact with fresh seafood/warm seawater, a known history of chronic liver disease and pain that is out of proportion to cutaneous signs. All patients must be managed via intensive care in high dependency units. We recommend a two-step surgical protocol for patient management involving an initial local debridement, followed by a second-stage radical debridement and skin grafting.
Aged ; Aged, 80 and over ; Debridement ; End Stage Liver Disease ; complications ; Fasciitis, Necrotizing ; diagnosis ; microbiology ; surgery ; Female ; Fever ; complications ; Hepatitis B ; complications ; Humans ; Hypotension ; complications ; Male ; Middle Aged ; Retrospective Studies ; Risk Factors ; Seafood ; Seawater ; Severity of Illness Index ; Singapore ; Skin Transplantation ; Vibrio ; Vibrio Infections ; diagnosis ; surgery

Introduction: The rapidly growing number of percutaneous coronary interventions has led to a considerable improvement in the outcome of patients with acute coronary syndromes, yet concurrently exposing patients to enormous volumes of contrast media with the inherent risk of renal function impairment. Objective: To determine the incidence of contrast induced nephropathy of patients admitted at University of Santo Tomas Hospital (USTH) who underwent coronary angiography with or without Percutaneous Transluminal Coronary Angioplasty (PTCA). Methodology: This is a retrospective, descriptive study including patients aged 18 years and above, of any gender, admitted at the USTH from January 1, 2016 to December 31, 2016, who underwent coronary angiography with or without PTCA with baseline and follow up creatinine levels 48-72 hours after the procedure. Data were retrieved by review of medical records of these patients. Results: Three out of 78 patients (3.8%) had elevated creatinine but all three patients also underwent major surgery within 48 hours after coronary angiography which could explain the renal impairment. Conclusion Although contrast induced nephropathy was described as the third most common cause of new Acute Kidney Injury in hospitalized patients, it was accordingly nil among those who underwent coronary angiography at USTH from January to December 2016. Benefi ts and risks of undergoing coronary angiography should always be weighed individually. Risk stratifi cation scores should only serve as a guide in managing patients and proper preventive measures should be applied.
Coronary Angiography ; ErbB Receptors

This clinical pathway for the diagnosis and risk stratification of patients presenting with acute chest pain, including acute coronary syndromes, provides recommendations and algorithms for clinicians to diagnose, risk stratify, and manage acute chest pain in adult patients. The writing committee reviewed existing international and local guidelines. Modifications to the algorithm following face-to-face and virtual meetings resulted in expert decisions written as recommendations and presented in a flow diagram format. The USTH Chest Pain Pathway provides guidance based on current guidelines and recommendations on assessing and evaluating acute chest pain, tailored to local needs and institution-specific facilities. We recommend its use to ensure quality patient care in the hospital.
Acute Coronary Syndrome|critical Pathways