INTRODUCTION: Creatinine has limitations in identifying and predicting acute kidney injury (AKI). Our study examined the utility of neutrophil gelatinase-associated lipocalin (NGAL) in predicting AKI in patients presenting to the emergency department (ED), and in predicting the need for renal replacement therapy (RRT), occurrence of major adverse cardiac events (MACE) and all-cause mortality at three months post visit. METHODS: This is a single-centre prospective cohort study conducted at Singapore General Hospital (SGH). Patients presenting to SGH ED from July 2011 to August 2012 were recruited. They were aged ≥21 years, with an estimated glomerular filtration rate <60 mL/min/1.73 m², and had congestive cardiac failure, systemic inflammatory response syndrome or required hospital admission. AKI was diagnosed by researchers blinded to experimental measurements. Serum NGAL was measured as a point-of-care test. RESULTS: A total of 784 patients were enrolled, of whom 107 (13.6%) had AKI. Mean serum NGAL levels were raised (P < 0.001) in patients with AKI (670.0 ± 431.9 ng/dL) compared with patients without AKI (490.3 ± 391.6 ng/dL). The sensitivity and specificity of NGAL levels >490 ng/dL for AKI were 59% (95% confidence interval [CI] 49%-68%) and 65% (95% CI 61%-68%), respectively. Need for RRT increased 21% per 100 ng/dL increase in NGAL (P < 0.001), whereas odds of death in three months increased 10% per 100 ng/dL increase in NGAL (P = 0.028). No clear relationship was observed between NGAL levels and MACE. CONCLUSION Serum NGAL identifies AKI and predicts three-month mortality.
Humans ; Lipocalin-2 ; Prospective Studies ; Lipocalins ; Proto-Oncogene Proteins ; Acute-Phase Proteins ; Biomarkers ; Acute Kidney Injury/diagnosis* ; Emergency Service, Hospital ; Predictive Value of Tests

INTRODUCTION: Despite the challenges related to His bundle pacing (HBP), recent data suggest an improved success rate with experience. As a non-university, non-electrophysiology specialised centre in Singapore, we report our experiences in HBP using pacing system analyser alone. METHODS: Data of 28 consecutive patients who underwent HBP from August 2018 to February 2019 was retrospectively obtained. The clinical and technical outcomes of these patients were compared between two timeframes of three months each. Patients were followed up for 12 months. RESULTS: Immediate technical success was achieved in 21 (75.0%) patients (mean age 73.3 ± 10.7 years, 47.6% female). The mean left ventricular ejection fraction was 53.9% ± 12.1%. The indications for HBP were atrioventricular block (n = 13, 61.9%), sinus node dysfunction (n = 7, 33.3%) and upgrade from implantable cardioverter-defibrillator to His-cardiac resynchronisation therapy (n = 1, 4.8%). No significant difference was observed in baseline characteristics between Timeframe 1 and Timeframe 2. Improvements pertaining to mean fluoroscopy time were achieved between the two timeframes. There was one HBP-related complication of lead displacement during Timeframe 1. All patients with successful HBP achieved non-selective His bundle (NSHB) capture, whereas only eight patients had selective His bundle (SHB) capture. NSHB and SHB capture thresholds remained stable at the 12-month follow-up. CONCLUSION Permanent HBP is feasible and safe, even without the use of an electrophysiology recording system. This was successfully achieved in 75% of patients, with no adverse clinical outcomes during the follow-up period.
Humans ; Female ; Middle Aged ; Aged ; Aged, 80 and over ; Male ; Bundle of His ; Follow-Up Studies ; Stroke Volume ; Retrospective Studies ; Treatment Outcome ; Cardiac Pacing, Artificial/adverse effects* ; Electrocardiography ; Ventricular Function, Left/physiology*

INTRODUCTION: Risk stratification in dilated cardiomyopathy (DCM) is imprecise, relying largely on echocardiographic left ventricular ejection fraction (LVEF) and severity of heart failure symptoms. Adverse cardiovascular events are increased by the presence of myocardial scarring. Late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is the gold standard for identifying myocardial scars. We examined the association between LGE on CMR imaging and adverse clinical outcomes during long-term follow-up of Asian patients with DCM. METHODS: Consecutive patients with DCM undergoing CMR imaging at a single Asian academic medical centre between 2005 and 2015 were recruited. Clinical outcomes were tracked using comprehensive electronic medical records and mortality was determined by cross-linkages with national registries. Presence and distribution of LGE on CMR imaging were determined by investigators blinded to patient outcomes. Primary endpoint was a composite of heart failure hospitalisations, appropriate implantable cardioverter-defibrillator shocks and cardiovascular mortality. RESULTS: Of 86 patients, 64.0% had LGE (80.2% male; mean LVEF 30.1% ± 12.7%). Mid-wall fibrosis (71.7%) was the most common pattern of LGE distribution. Over a mean follow-up period of 4.9 ± 3.2 years, 19 (34.5%) patients with LGE reached the composite endpoint compared to 4 (12.9%) patients without LGE (p = 0.01). Presence of LGE, but not echocardiographic LVEF, independently predicted the primary endpoint (hazard ratio 4.15 [95% confidence interval 1.28-13.50]; p = 0.02). CONCLUSION LGE presence independently predicted adverse clinical events in Asian patients with DCM. Routine use of CMR imaging to characterise the myocardial substrate is recommended for enhanced risk stratification and should strongly influence clinical management.

Objective: To examine the wound healing properties of eicosane, pentadecane and palmitic acid by evaluating in term of anti-microbial, anti-inflammatory, proliferation, migration and collagen synthesis. Methods: Anti-microbial activities of Staphylococcus aureus, Bacillus subtilis, Escherichia coli and Pseudomonas aeruginosa were evaluated by carrying out disk diffusion and agar well diffusion methods. Growth rate of tested bacteria was also evaluated for 8 h in conjunction with the sample drugs. Besides, U937 cell lines were used as model study for realtime mRNA genes expression studies of TNF-α and IL-12 under the treatment. Proliferation, migration and collagen content synthesis were carried out on human dermal fibroblast. Results: None of the sample drugs possessed significant inhibition of bacteria tested in this study both in disk diffusion and agar well diffusion methods. In contrary, significantly low expressed mRNA gene expression levels of TNF-α and IL-12 were found under the treatment of respective drugs. Meanwhile in proliferation, migration and hydroxyproline content analysis, all the sample drugs showed no significant positive stimulation. Conclusions: This study therefore explains that apart from their potential in downregulating pro-inflammatory cytokines, these three compounds which were examined individually may not be good candidates in promoting wound healing.

Objective: To evaluate the antimicrobial properties of Kappaphycus alvarezii (K. alvarezii) and Andrographis paniculata (A. paniculata) and to compare the microbial inhibition activities between these two crude extracts. Methods: Both K. alvarezii and A. paniculata were extracted with methanol before the commencement of antimicrobial properties studies. There were a total of eight species of bacteria, including Gram-positive bacteria Bacillus cereus, Bacillus subtilis, Staphylo-coccus aureus and Staphylococcus epidermidis and Gram-negative bacteria, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Salmonella enterica. The antimicrobial activity was tested by disk diffusion method. Results: Crude extract of K. alvarezii was found not effective against both Gram-positive and Gram-negative bacteria. In contrast, A. paniculata showed higher inhibi-tion towards the growth of Gram-positive bacteria compared to Gram-negative bacteria. Results revealed that Bacillus subtilis was susceptible at lower concentration of A. paniculata crude extract however Staphylococcus epidermidis was the most suscep-tible towards A. paniculata at higher concentration. Although the inhibition zones pro-duced by the crude extract were smaller than that of the positive control, streptomycin disc, A. paniculata crude extract still can be considered as potential antimicrobial agents either because it is a natural product or the active compound which is yet identified from its crude extract. Conclusions: Crude extract of K. alvarezii has zero inhibition in bacteria growth whereas A. paniculata exerted higher inhibition towards Gram-positive bacteria. The bioactive compounds contained by A. paniculata can be evaluated in order to yield a better vision towards the mode of action.

Objective To evaluate the antimicrobial properties of Kappaphycus alvarezii (K. alvarezii) and Andrographis paniculata (A. paniculata) and to compare the microbial inhibition activities between these two crude extracts. Methods Both K. alvarezii and A. paniculata were extracted with methanol before the commencement of antimicrobial properties studies. There were a total of eight species of bacteria, including Gram-positive bacteria Bacillus cereus, Bacillus subtilis, Staphylococcus aureus and Staphylococcus epidermidis and Gram-negative bacteria, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Salmonella enterica. The antimicrobial activity was tested by disk diffusion method. Results Crude extract of K. alvarezii was found not effective against both Gram-positive and Gram-negative bacteria. In contrast, A. paniculata showed higher inhibition towards the growth of Gram-positive bacteria compared to Gram-negative bacteria. Results revealed that Bacillus subtilis was susceptible at lower concentration of A. paniculata crude extract however Staphylococcus epidermidis was the most susceptible towards A. paniculata at higher concentration. Although the inhibition zones produced by the crude extract were smaller than that of the positive control, streptomycin disc, A. paniculata crude extract still can be considered as potential antimicrobial agents either because it is a natural product or the active compound which is yet identified from its crude extract. Conclusions Crude extract of K. alvarezii has zero inhibition in bacteria growth whereas A. paniculata exerted higher inhibition towards Gram-positive bacteria. The bioactive compounds contained by A. paniculata can be evaluated in order to yield a better vision towards the mode of action.

INTRODUCTIONDiuretics are the mainstay of therapy for restoring the euvolaemic state in patients with decompensated heart failure. However, diuretic resistance remains a challenge.

METHODSWe conducted a retrospective cohort study to examine the efficacy and safety of ultrafiltration (UF) in 44 hospitalised patients who had decompensated heart failure and diuretic resistance between October 2011 and July 2013.

RESULTSAmong the 44 patients, 18 received UF (i.e. UF group), while 26 received diuretics (i.e. standard care group). After 48 hours, the UF group achieved lower urine output (1,355 mL vs. 3,815 mL, p = 0.0003), greater fluid loss (5,058 mL vs. 1,915 mL, p < 0.0001) and greater weight loss (5.0 kg vs. 1.0 kg, p < 0.0001) than the standard care group. The UF group also had a shorter duration of hospitalisation (5.0 days vs. 9.5 days, p = 0.0010). There were no differences in the incidence of 30-day emergency department visits and rehospitalisations for heart failure between the two groups. At 90 days, the UF group had fewer emergency department visits (0.2 vs. 0.8, p = 0.0500) and fewer rehospitalisations for heart failure (0.3 vs. 1.0, p = 0.0442). Reduction in EQ-5D™ scores was greater in the UF group, both at discharge (2.7 vs. 1.4, p = 0.0283) and 30 days (2.5 vs. 0.3, p = 0.0033). No adverse events were reported with UF.

CONCLUSIONUF is an effective and safe treatment that can improve the health outcomes of Asian patients with decompensated heart failure and diuretic resistance.

Aged ; Diuretics ; therapeutic use ; Drug Resistance ; Emergency Service, Hospital ; Female ; Heart Failure ; therapy ; Hospitalization ; Humans ; Male ; Middle Aged ; Patient Readmission ; Retrospective Studies ; Treatment Outcome ; Ultrafiltration

Angina Pectoris ; diagnosis ; Blood Pressure ; Coronary Angiography ; Coronary Artery Disease ; diagnosis ; Electrocardiography ; Exercise Test ; Female ; Heart Rate ; Humans ; Male ; Middle Aged ; Singapore

Levocardia (left-sided cardiac apex) with abdominal situs inversus is extremely rare. This is also known as isolated levocardia and is almost always associated with severe forms of congenital heart defects with poor prognosis. We report isolated levocardia in a 13-year-old symptomatic male patient. The purpose of this paper is to outline the imaging features of isolated levocardia and to highlight the role of cardiovascular magnetic resonance imaging (CMR) in the diagnosis and management of such cases. Other forms of cardiac malposition, including dextrocardia, mesocardia and criss-cross heart, with chest radiograph and CMR correlation, are also discussed.
Abnormalities, Multiple ; diagnosis ; Adolescent ; Diagnostic Imaging ; Humans ; Levocardia ; diagnosis ; Magnetic Resonance Imaging, Cine ; Male ; Radiography, Thoracic ; Situs Inversus ; diagnosis ; Tomography, X-Ray Computed

Pulmonary embolism (PE) poses a challenge to physicians, as it can be difficult to diagnose but results in significant mortality and morbidity in patients. Diagnosing PE requires an integrated approach using clinical findings, electrocardiography (ECG), blood investigations and imaging modalities. Abnormalities in ECG are common among patients with massive acute PE and can serve as a prognostic indicator. In this article, we describe the ECG presentations of two patients diagnosed with PE, and review the literature on the various types of ECG presentations and their role in predicting the prognosis of PE.
Anticoagulants ; administration & dosage ; Blood Pressure ; Echocardiography ; Electrocardiography ; methods ; Female ; Hemorrhage ; complications ; Humans ; Hypertension ; complications ; Male ; Middle Aged ; Prognosis ; Pulmonary Embolism ; diagnosis ; Stroke ; complications