INTRODUCTION: There are limited reports on the epidemiology of paediatric intensive care unit (PICU) admissions, deaths and organ donation candidacy. We aimed to describe PICU admission characteristics and outcomes, determine risk factors for mortality, and perform an independent assessment of missed organ donation opportunities. METHOD: We adopted a clinical audit design recruiting consecutive patients admitted to a single-centre multidisciplinary PICU from June 2020 to December 2023. Clinical characteristics and outcomes of survivors and non-survivors were described. Multivariable regression was performed to identify independent risk factors for mortality. Organ donation candidacy was evaluated by an independent team based on the criteria by Singapore's National Organ Transplant Unit. RESULTS: There were 1766 PICU admissions with mean age ± standard deviation of 5.9 ± 6.0 years. Surgical admissions accounted for 707/1766 (40%), while the most common medical admission category was respiratory (416/1766; 23.6%). The majority of 983/1766 (55.7%) had a chronic comorbidity and 312/1766 (17.6%) were dependent on at least 1 medical technology device. Mortality occurred in 99/1766 (5.6%). After adjusting for elective admissions and admission category; comorbidity with adjusted odds ratio (aOR) 95% confidence interval (CI) 3.03 (1.54-5.96); higher Pediatric Index of Mortality 3 (PIM 3) score with aOR 1.06 (95% CI 1.04-1.08); and functional status scale with aOR 1.07 (95% CI 1.00-1.13) were associated with mortality. Among non-survivors, organ donor candidacy was 21/99 (21.2%) but successful organ donation occurred in only 2/99 (2.0%). CONCLUSION In this single-centre audit, comorbidities, PIM 3 score and functional impairment were associated with mortality. Efforts are needed to improve paediatric organ donation rates.
Humans ; Male ; Female ; Tissue and Organ Procurement/statistics & numerical data* ; Intensive Care Units, Pediatric/statistics & numerical data* ; Child, Preschool ; Child ; Infant ; Singapore/epidemiology* ; Risk Factors ; Patient Admission/statistics & numerical data* ; Hospital Mortality ; Adolescent ; Medical Audit ; Comorbidity ; Clinical Audit

Introduction: Many tools have been developed to determine medication appropriateness in older persons including the 2015 American Geriatric Society (AGS) Beers criteria and the Screening Tool of Older People’s Prescriptions (STOPP) criteria. We aimed to determine and compare the prevalence of potentially inappropriate medications (PIMs) based on the Beers criteria 2015 and the STOPP criteria v2 among older persons admitted to a general hospital in Malaysia. Methods: A cross-sectional study comprising of 160 patients aged 65 years old and above admitted to the general medical wards of a tertiary teaching hospital were recruited. Beers criteria 2015 and the STOPP criteria v2 were used to evaluate participants’ medication list on admission, during hospitalisation and on discharge for PIMs. Prevalence of PIMs which was calculated as the total number of patients with one or more PIMs over the total number of patients. Results: The prevalence of PIMs identified by Beers criteria 2015 on admission, during hospitalisation and on discharge were 54.85%, 64.40% and 48.80% respectively. The prevalence of PIM based on STOPP criteria v2 were 33.08%, 47.50% and 42.50% respectively. The most prevalent PIMs according to Beers criteria 2015 and STOPP criteria v2 were diuretics, tramadol, ticlopidine, proton pump inhibitor, benzodiazepines and antipsychotics. Conclusion: The prevalence of PIMs use is high among hospitalised older persons in Malaysia. While it is not possible to avoid all PIMs listed in the Beers and STOPP criteria, clinicians should exercise caution in prescribing drugs such as benzodiazepines, antipsychotics and proton pump inhibitors for older persons weighing the risk versus benefit of the drugs.

Tanshinone IIa is a key ingredient extracted from the traditional Chinese medicine Salvia miltiorrhiza (Danshen), and is widely used to treat various cardiovascular diseases. Vascular calcification is a common pathological change of cardiovascular tissues in patients with chronic kidney disease, diabetes, hypertension and atherosclerosis. However, whether Tanshinone IIa inhibits vascular calcification and the underlying mechanisms remain largely unknown. This study aims to investigate whether Tanshinone IIa can inhibit vascular calcification using high phosphate-induced vascular smooth muscle cell and aortic ring calcification model, and high dose vitamin D₃ (vD₃)-induced mouse models of vascular calcification. Alizarin red staining and calcium quantitative assay showed that Tanshinone IIa significantly inhibited high phosphate-induced vascular smooth muscle cell and aortic ring calcification. qPCR and Western blot showed that Tanshinone IIa attenuated the osteogenic transition of vascular smooth muscle cells. In addition, Tanshinone IIa also significantly inhibited high dose vD₃-induced mouse aortic calcification and aortic osteogenic transition. Mechanistically, Tanshinone IIa inhibited the activation of NF-κB and β-catenin signaling in normal vascular smooth muscle cells. Similar to Tanshinone IIa, inhibition of NF-κB and β-catenin signaling using the chemical inhibitors SC75741 and LF3 attenuated high phosphate-induced vascular smooth muscle cell calcification. These results suggest that Tanshinone IIa attenuates vascular calcification at least in part through inhibition of NF-κB and β-catenin signaling, and Tanshinone IIa may be a potential drug for the treatment of vascular calcification.
Animals ; Mice ; NF-kappa B/metabolism* ; beta Catenin/metabolism* ; Signal Transduction ; Myocytes, Smooth Muscle/metabolism* ; Vascular Calcification/metabolism* ; Phosphates/metabolism*

INTRODUCTION: Chest radiographs (CXRs) are widely used for the screening and management of COVID-19. This article describes the radiographic features of COVID-19 based on an initial national cohort of patients. METHODS: This is a retrospective review of swab-positive patients with COVID-19 who were admitted to four different hospitals in Singapore between 22 January and 9 March 2020. Initial and follow-up CXRs were reviewed by three experienced radiologists to identify the predominant pattern and distribution of lung parenchymal abnormalities. RESULTS: In total, 347 CXRs of 96 patients were reviewed. Initial CXRs were abnormal in 41 (42.7%) out of 96 patients. The mean time from onset of symptoms to CXR abnormality was 5.3 ± 4.7 days. The predominant pattern of lung abnormality was ground-glass opacity on initial CXRs (51.2%) and consolidation on follow-up CXRs (51.0%). Multifocal bilateral abnormalities in mixed central and peripheral distribution were observed in 63.4% and 59.2% of abnormal initial and follow-up CXRs, respectively. The lower zones were involved in 90.2% of initial CXRs and 93.9% of follow-up CXRs. CONCLUSION In a cohort of swab-positive patients, including those identified from contact tracing, we found a lower incidence of CXR abnormalities than was previously reported. The most common pattern was ground-glass opacity or consolidation, but mixed central and peripheral involvement was more common than peripheral involvement alone.
COVID-19 ; Humans ; Lung/diagnostic imaging* ; Radiography, Thoracic ; Retrospective Studies ; SARS-CoV-2 ; Singapore

INTRODUCTION: Fluorescence imaging (FI) with indocyanine green (ICG) is increasingly implemented as an intraoperative navigation tool in hepatobiliary surgery to identify hepatic tumours. This is useful in minimally invasive hepatectomy, where gross inspection and palpation are limited. This study aimed to evaluate the feasibility, safety and optimal timing of using ICG for tumour localisation in patients undergoing hepatic resection. METHODS: From 2015 to 2018, a prospective multicentre study was conducted to evaluate feasibility and safety of ICG in tumour localisation following preoperative administration of ICG either on Day 0-3 or Day 4-7. RESULTS: Among 32 patients, a total of 46 lesions were resected: 23 were hepatocellular carcinomas (HCCs), 12 were colorectal liver metastases (CRLM) and 11 were benign lesions. ICG FI identified 38 (82.6%) lesions prior to resection. The majority of HCCs were homogeneous fluorescing lesions (56.6%), while CLRM were homogeneous (41.7%) or rim-enhancing (33.3%). The majority (75.0%) of the lesions not detected by ICG FI were in cirrhotic livers. Most (84.1%) of ICG-positive lesions detected were < 1 cm deep, and half of the lesions ≥ 1 cm in depth were not detected. In cirrhotic patients with malignant lesions, those given ICG on preoperative Day 0-3 and Day 4-7 had detection rates of 66.7% and 91.7%, respectively. There were no adverse events. CONCLUSION ICG FI is a safe and feasible method to assist tumour localisation in liver surgery. Different tumours appear to display characteristic fluorescent patterns. There may be no disadvantage of administering ICG closer to the operative date if it is more convenient, except in patients with liver cirrhosis.

COVID-19/complications* ; Fracture Fixation ; Fractures, Bone/surgery* ; Humans ; Musculoskeletal Diseases/surgery* ; Time Factors

Objective: To evaluate the effect of adding DPP4 inhibitor (DPP4-i) on glycemic variability (GV) in patients with type 2 diabetes mellitus (T2DM) treated with premixed human insulin (MHI). Methodology: We conducted a prospective study in patients with T2DM on twice-daily MHI with or without metformin therapy. Blinded continuous glucose monitoring was performed at baseline and following 6 weeks of Vildagliptin therapy. Results: Twelve patients with mean (SD) age of 55.8 (13.1) years and duration of disease of 14.0 (6.6) years were recruited. The addition of Vildagliptin significantly reduced GV indices (mmol/L): SD from 2.73 (IQR 2.12-3.66) to 2.11 (1.76-2.55), p=0.015; mean amplitude of glycemic excursions (MAGE) 6.94(2.61) to 5.72 (1.87), p=0.018 and CV 34.05 (8.76) to 28.19 (5.36), p=0.010. In addition, % time in range (3.9-10 mmol/l) improved from 61.17 (20.50) to 79.67 (15.33)%, p=0.001; % time above range reduced from 32.92 (23.99) to 18.50 (15.62)%, p=0.016; with reduction in AUC for hyperglycemia from 1.24 (1.31) to 0.47 (0.71) mmol/day, p=0.015. Hypoglycemic events were infrequent and the reduction in time below range and AUC for hypoglycemia did not reach statistical significance. Conclusion The addition of DPP4-I to commonly prescribed twice-daily MHI in patients with T2DM improves GV and warrants further exploration.
Diabetes Mellitus, Type 2

The coronavirus disease 2019 (COVID-19) is typically diagnosed by specific assays that detect viral nucleic acid from the upper respiratory tract; however, this may miss infections involving only the lower airways. Computed tomography (CT) has been described as a diagnostic modality in the COVID-19 diagnosis and treatment plan. We present a case series with virologically confirmed COVID-19 pneumonia. Variable CT features were observed: consolidation with ground-glass opacities, ground-glass opacities with subpleural reticular bands, and an anterior-posterior gradient of lung abnormalities resembling that of acute respiratory distress syndrome. Evolution of CT findings was observed in one patient, where there was interval resolution of bilateral lung consolidation with development of bronchiolectasis and subpleural fibrotic bands. While sensitive for detecting lung parenchymal abnormalities in COVID-19 pneumonia, the use of CT for initial diagnosis is discouraged and should be reserved for specific clinical indications. Interpretation of chest CT findings should be correlated with duration of symptoms to better determine the disease stage and aid in patient management.
Aged ; Betacoronavirus ; Coronavirus Infections ; diagnosis ; Diagnosis, Differential ; Female ; Humans ; Lung ; diagnostic imaging ; Male ; Middle Aged ; Pandemics ; Pneumonia, Viral ; diagnosis ; Tomography, X-Ray Computed ; methods

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 and was declared a global pandemic by the World Health Organization on 11 March 2020. A definitive diagnosis of COVID-19 is made after a positive result is obtained on reverse transcription-polymerase chain reaction assay. In Singapore, rigorous contact tracing was practised to contain the spread of the virus. Nasal swabs and chest radiographs (CXR) were also taken from individuals who were suspected to be infected by COVID-19 upon their arrival at a centralised screening centre. From our experience, about 40% of patients who tested positive for COVID-19 had initial CXR that appeared "normal". In this case series, we described the temporal evolution of COVID-19 in patients with an initial "normal" CXR. Since CXR has limited sensitivity and specificity in COVID-19, it is not suitable as a first-line diagnostic tool. However, when CXR changes become unequivocally abnormal, close monitoring is recommended to manage potentially severe COVID-19 pneumonia.
Adult ; Betacoronavirus ; Clinical Laboratory Techniques ; Coronavirus Infections ; complications ; diagnosis ; diagnostic imaging ; Female ; Humans ; Lung ; diagnostic imaging ; Male ; Middle Aged ; Pandemics ; Pneumonia, Viral ; complications ; diagnostic imaging ; Radiography ; Sensitivity and Specificity