Paracetamol overdose is the most common cause of drug-related poisoning and death worldwide. Although N-acetylcysteine is the widely accepted antidote for paracetamol poisoning, much debate persist regarding the appropriate route and duration of early N-acetylcysteine therapy. There is a paucity of studies comparing the effectiveness of oral and intravenous (IV) acetylcysteine for paracetamol poisoning. Methods: A literature search was performed using the keywords [paracetamol OR acetaminophen] AND [acetylcysteine OR n-acetylcysteine] on the PubMed and Ovid database. The literature search was limited to human exposure studies published in English between 1-Jan-1966 and 1-May-2015. The proportion of patients who developed hepatotoxicity (defined as serum transaminase greater than 1000 IU/L) for each route of administration was determined using multiple regression and the studies were further stratified by early (less than 10 hours from ingestion) and late treatment (longer than 10 hours from ingestion). Results: 3,981 full studies were reviewed for data. Studies with fewer than 20 subjects were excluded. Metaanalysis revealed that the overall proportion of patients who developed hepatotoxicity was 12.3% (95% confidence interval [CI]: 9.6% to 17.2%). The percentages were similar when studies were stratified by route of administration; the proportion for IV treated patients was 12.6% (95% CI: 8.7% to 19.4%) while the proportion for oral treated patients was 12.0% (95% CI: 8.2% to 18.8%). However, there was a marked difference in the percentage of patients who developed hepatotoxicity with early as compared to late N-acetylcysteine treatment. There was a statistically significant effect due to time (p < 0.001) but no significant effect due to route of administration (p = 0.716). Conclusion: Pooled analysis of studies did not find any significant difference in outcome between oral and IV N-acetylcysteine therapy, but these findings require confirmation by randomized controlled trials. However, overall hepatotoxicity was significantly worse if treatment was delayed beyond 8 to 10 hours. ASEAN Journal of Psychiatry, Vol. 17 (2): July – December 2016: XX XX.

Pancreaticopleural fistula is a rare diagnosis requiring a high index of clinical suspicion due to the predominant manifestation of thoracic symptoms. The current literature suggests that confirmation of elevated pleural fluid amylase is the most important diagnostic test. Magnetic resonance cholangiopancreatography is the recommended imaging modality to visualise the fistula, as it is superior to both computed tomography and endoscopic retrograde cholangiopancreatography (ERCP) in delineating the tract within the pancreatic region. It is also less invasive than ERCP. While a trial of medical regimen has traditionally been the first-line treatment, failure would result in higher rates of complications. Hence, it is suggested that management strategies be planned based on pancreatic ductal imaging, with patients having poor chances of spontaneous closure undergoing either endoscopic or surgical intervention. We also briefly describe a case of pancreaticopleural fistula in a patient who was treated using a modified Puestow procedure after failed endoscopic treatment.
Cholangiopancreatography, Endoscopic Retrograde ; adverse effects ; Cholangiopancreatography, Magnetic Resonance ; Endoscopy ; Humans ; Male ; Middle Aged ; Pancreatic Ducts ; physiopathology ; Pancreatic Fistula ; diagnosis ; epidemiology ; therapy ; Pleural Diseases ; diagnosis ; epidemiology ; therapy ; Treatment Outcome

Given the consensus that there is a causal relationship between Zika virus (ZIKV) infection in pregnancy and congenital Zika syndrome (CZS), clinicians must be prepared to manage affected patients despite the numerous gaps in current knowledge. The clinical course in pregnancy appears similar to that in non-pregnant women, although viraemia may be prolonged. ZIKV infection can be diagnosed by serum and urine reverse transcription-polymerase chain reaction, but commercially available serological tests are currently unreliable in dengue-endemic regions. Although vertical transmission can occur at any time during gestation, first- and second-trimester infections have the highest risk of developing central nervous system anomalies. Aberrant fetal growth and pregnancy loss may also occur. Serial ultrasonography should be conducted for infected cases. Without a vaccine, pregnant women should be advised to minimise mosquito bites and reduce sexual transmission risk. Overall, the absolute risk of CZS arising amid a ZIKV outbreak appears relatively low.

No abstract available.
Constipation

This review presents studies that support an inflammation-immunological model for the pathogenesis of post-infectious irritable bowel syndrome (IBS), and highlights recent studies that support a similar disease model in non-post-infectious IBS, in particular, diarrhoea-predominant IBS, as well as in post-infectious functional dyspepsia. These recent studies are highlighted to demonstrate that one line of research in functional gastrointestinal disorders has moved away from the old psychosomatic concepts. It is hoped that this will encourage future students of this field to explore the role of immunological events.
Dyspepsia ; Gastrointestinal Diseases ; Humans ; Inflammation ; Irritable Bowel Syndrome

INTRODUCTIONThis study investigates the knowledge, attitudes and practices of residents in a residential estate in Singapore on the Advance Medical Directive (AMD).

MATERIALS AND METHODSA community-based cross-sectional study was conducted with residents in the residential estate of Toa Payoh Lorong 6, Singapore. A stratifi ed random sampling was conducted to obtain a representative sample of the estate. Only residents aged 21 years and older were included. An interviewer-administered questionnaire was conducted, and only those who understood the AMD suffi ciently were further evaluated on their knowledge, attitudes and practices.

RESULTSA total of 414 residents were enrolled (50.1% response rate). Only 37.9% of the participants knew about the AMD prior to this study. Participants who had a higher knowledge level of AMD, did not wish "for an artifi cially prolonged life", "to be kept alive indefi nitely on a life-support machine", wished to "lessen the fi nancial burden of loved ones", "avoid prolonged suffering" and accepted the "imminence of death" were more willing to sign an AMD. However, "religious beliefs", "personal ethical views", "dissuasion by family members" and "unclear terminology in the AMD" discouraged the participants from signing an AMD. After adjusting for signifi cant factors, participants who did not wish "to be kept alive indefi nitely on a life-support machine" and accepted the "imminence of death" were found to correlate signifi cantly with the willingness to sign an AMD [Prevalence Rate Ratio (PRR) = 2.050 [1.140-3.685], P = 0.016; PRR = 2.669 [1.449-4.917], P = 0.02, respectively].

CONCLUSIONSThere is a need to increase awareness on the AMD. Public education methods can be improved to inform residents on the implications of the AMD.

Adult ; Advance Care Planning ; Aged ; Aged, 80 and over ; Cross-Sectional Studies ; Decision Making ; Female ; Health Knowledge, Attitudes, Practice ; Humans ; Male ; Middle Aged ; Singapore ; Surveys and Questionnaires ; Young Adult

Aerospace Medicine ; Aviation ; Emergencies ; Ethicists ; Humans

Singapore has a sophisticated healthcare system and is an important referral centre for Asia. Like much of the world, methicillin-resistant Staphylococcus aureus (MRSA) is now endemic across its health system. MRSA infection has been associated with considerable attributable mortality, morbidity plus personal and public cost. Nosocomial infections are potentially preventable and need to be considered an unacceptable complication rather than a tolerable byproduct of healthcare. Failure to introduce long-term sustainable infection control initiatives is not an option for responsible clinical leaders and managers. Control of MRSA transmission in Singapore is achievable but we need to accept the challenge and acknowledge that it will take perhaps a decade. It requires implementation of many varied infection control measures to be rolled out sequentially and across all health services. Our ambition, in Singapore, should be for hospitals to achieve an inpatient prevalence of <1% MRSA colonised patients. Identified transmission of MRSA should be regarded as a serious breech. Successful control will require extraordinary collaboration, support, resources, accountability and consistency of effort. Currently, efforts are evolving significantly and today, we have a good opportunity to embark on this difficult journey. Implementing infection control initiatives successfully over the next few years will save lives in the future.
Anti-Bacterial Agents ; therapeutic use ; Disease Outbreaks ; prevention & control ; Hospitals ; Humans ; Infection Control ; methods ; Methicillin Resistance ; Methicillin-Resistant Staphylococcus aureus ; drug effects ; isolation & purification ; Prevalence ; Singapore ; epidemiology ; Staphylococcal Infections ; drug therapy ; epidemiology ; prevention & control

INTRODUCTIONThe National University Hospital (NUH) was the first restructured public hospital in Singapore. As the most recently established hospital in Singapore, it has a unique record of alert organisms including methicillin-resistant Staphylococcus aureus (MRSA).

MATERIALS AND METHODSWe performed a critical review of multiple data sources including surveillance reports, task force reports, published abstracts and manuscripts concerning MRSA in NUH.

RESULTSThree themes emerged: 1) the MRSA rates have remained relatively stable through the life of the hospital despite the increased complexity of patients and intermittent intensified control efforts; 2) the major MRSA task forces were driven by surgeons and 3) a scientific approach to epidemiology has a critical role in understanding and planning interventions.

CONCLUSIONAlthough containment of MRSA can be accomplished to a certain degree through mobilisation of existing resources, higher goals such as eradication would require massive infusions of infrastructural, scientific and human resources to have a chance of success.

History, 20th Century ; History, 21st Century ; Hospitals, University ; history ; Humans ; Incidence ; Infection Control ; history ; methods ; Methicillin-Resistant Staphylococcus aureus ; drug effects ; Population Surveillance ; Singapore ; Staphylococcal Infections ; epidemiology ; microbiology ; prevention & control