1
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Fong C, Kueh WL, Lew SJW, Ho BCH, Wong YL, Lau YH, Chia YW, Tan HL, Seet YHC, Siow WT, MacLaren G, Agrawal R, Lim TJ, Lim SL, Lim TW, Ho VK, Soh CR, Sewa DW, Loo CM, Khan FA, Tan CK, Gokhale RS, Siau C, Lim NLSH, Yim CF, Venkatachalam J, Venkatesan K, Chia NCH, Liew MF, Li G, Li L, Myat SM, Zena Z, Zhuo S, Yueh LL, Tan CSF, Ma J, Yeo SL, Chan YH, Phua J. Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study. J Intensive Care 2024; 12:13. [PMID: 38528556 DOI: 10.1186/s40560-024-00725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. METHODS This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. RESULTS There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis. CONCLUSIONS Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.
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Affiliation(s)
- Clare Fong
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore.
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Wern Lunn Kueh
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Sennen Jin Wen Lew
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Benjamin Choon Heng Ho
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yu-Lin Wong
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Hui Ling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Ying Hao Christopher Seet
- Department of Neurology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wen Ting Siow
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Graeme MacLaren
- Cardiothoracic ICU, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Rohit Agrawal
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Tian Jin Lim
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Department of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Pre-Hospital and Emergency Research Center, Duke-NUS Medical School, 8 College Rd, Singapore, 16985, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Vui Kian Ho
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
- Department of Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chai Rick Soh
- Department of Anaesthesiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chian Min Loo
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Roshni Sadashiv Gokhale
- Department of Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chuin Siau
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Noelle Louise Siew Hua Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chik-Foo Yim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Jonathen Venkatachalam
- Department of Respiratory and Critical Care Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Kumaresh Venkatesan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Naville Chi Hock Chia
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
- Yong Loo Lin School of Medicine, 10 Medical Dr, Singapore, 117597, Singapore
- Lee Kong Chian School of Medicine, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Mei Fong Liew
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Guihong Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Li Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Su Mon Myat
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Zena Zena
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Shuling Zhuo
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Ling Ling Yueh
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Caroline Shu Fang Tan
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jing Ma
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Siew Lian Yeo
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
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2
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Puah SH, Cove ME, Phua J, Kansal A, Venkatachalam J, Ho VK, Sewa DW, Gokhale RS, Liew MF, Ho BCH, Ng JJ, Abisheganaden JA, Leo YS, Young BE, Lye DC, Yeo TW. Association between lung compliance phenotypes and mortality in
COVID-19 patients with acute respiratory distress syndrome. Ann Acad Med Singap 2021. [DOI: 10.47102/annals-acadmedsg.2021129] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
ABSTRACT
Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high
mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to
measure lung compliance and examine other factors associated with mortality in COVID-19 patients
with ARDS.
Methods: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8
hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences
between high (<40mL/cm H2O) and low (<40mL/cm H2O) compliance were analysed.
Results: A total of 102 patients with COVID-19 who required invasive mechanical ventilation were
analysed; 15 (14.7%) did not survive. Non-survivors were older (median 70 years, interquartile
range [IQR] 67–75 versus median 61 years, IQR 52–66; P<0.01), and required a longer duration of
ventilation (26 days, IQR 12–27 vs 8 days, IQR 5–15; P<0.01) and intensive care unit support
(26 days, IQR 11–30 vs 11.5 days, IQR 7–17.3; P=0.01), with a higher incidence of acute kidney injury
(15 patients [100%] vs 40 patients [46%]; P<0.01). There were 67 patients who had lung compliance
data; 24 (35.8%) were classified as having high compliance and 43 (64.2%) as having low compliance.
Mortality was higher in patients with high compliance (33.3% vs 11.6%; P=0.03), and was associated
with a drop in compliance at day 7 (-9.3mL/cm H2O (IQR -4.5 to -15.4) vs 0.2mL/cm H2O (4.7 to -5.2)
P=0.04).
Conclusion: COVID-19 ARDS patients with higher compliance on the day of intubation and a
longitudinal decrease over time had a higher risk of death.
Keywords: ARDS, COVID-19-associated respiratory failure, high-flow nasal cannula therapy, HFNC,
post-intubation, ventilation strategies
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tsin Wen Yeo
- Singapore 2019 Novel Coronavirus Outbreak Research Team
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3
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Puah SH, Young BE, Chia PY, Ho VK, Loh J, Gokhale RS, Tan SY, Sewa DW, Kalimuddin S, Tan CK, Pada SKMS, Cove ME, Chai LYA, Parthasarathy P, Ho BCH, Ng JJ, Ling LM, Abisheganaden JA, Lee VJM, Tan CH, Lin RTP, Leo YS, Lye DC, Yeo TW. Clinical features and predictors of severity in COVID-19 patients with critical illness in Singapore. Sci Rep 2021; 11:7477. [PMID: 33820944 PMCID: PMC8021583 DOI: 10.1038/s41598-021-81377-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 12/14/2020] [Indexed: 01/10/2023] Open
Abstract
We aim to describe a case series of critically and non-critically ill COVID-19 patients in Singapore. This was a multicentered prospective study with clinical and laboratory details. Details for fifty uncomplicated COVID-19 patients and ten who required mechanical ventilation were collected. We compared clinical features between the groups, assessed predictors of intubation, and described ventilatory management in ICU patients. Ventilated patients were significantly older, reported more dyspnea, had elevated C-reactive protein and lactate dehydrogenase. A multivariable logistic regression model identified respiratory rate (aOR 2.83, 95% CI 1.24–6.47) and neutrophil count (aOR 2.39, 95% CI 1.34–4.26) on admission as independent predictors of intubation with area under receiver operating characteristic curve of 0.928 (95% CI 0.828–0.979). Median APACHE II score was 19 (IQR 17–22) and PaO2/FiO2 ratio before intubation was 104 (IQR 89–129). Median peak FiO2 was 0.75 (IQR 0.6–1.0), positive end-expiratory pressure 12 (IQR 10–14) and plateau pressure 22 (IQR 18–26) in the first 24 h of ventilation. Median duration of ventilation was 6.5 days (IQR 5.5–13). There were no fatalities. Most COVID-19 patients in Singapore who required mechanical ventilation because of ARDS were extubated with no mortality.
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Affiliation(s)
| | - Barnaby Edward Young
- Tan Tock Seng Hospital, Singapore, Singapore.,National Centre for Infectious Diseases, Singapore, Singapore.,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Po Ying Chia
- Tan Tock Seng Hospital, Singapore, Singapore.,National Centre for Infectious Diseases, Singapore, Singapore.,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Vui Kian Ho
- Sengkang General Hospital, Singapore, Singapore
| | - Jiashen Loh
- Sengkang General Hospital, Singapore, Singapore
| | | | - Seow Yen Tan
- Singapore General Hospital, Singapore, Singapore
| | - Duu Wen Sewa
- Singapore General Hospital, Singapore, Singapore
| | - Shirin Kalimuddin
- Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | | | - Surinder K M S Pada
- Ng Teng Fong General Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Matthew Edward Cove
- National University Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Louis Yi Ann Chai
- National University Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, Singapore, Singapore
| | | | | | | | - Li Min Ling
- Tan Tock Seng Hospital, Singapore, Singapore.,National Centre for Infectious Diseases, Singapore, Singapore.,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - John A Abisheganaden
- Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Vernon J M Lee
- Ministry of Health, Singapore, Singapore.,Saw Swee Hock School of Public Health, Singapore, Singapore
| | - Cher Heng Tan
- Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Raymond T P Lin
- National Centre for Infectious Diseases, Singapore, Singapore.,Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Yee Sin Leo
- Tan Tock Seng Hospital, Singapore, Singapore.,National Centre for Infectious Diseases, Singapore, Singapore.,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore.,Yong Loo Lin School of Medicine, Singapore, Singapore.,Saw Swee Hock School of Public Health, Singapore, Singapore
| | - David C Lye
- Tan Tock Seng Hospital, Singapore, Singapore.,National Centre for Infectious Diseases, Singapore, Singapore.,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore.,Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Tsin Wen Yeo
- Tan Tock Seng Hospital, Singapore, Singapore. .,National Centre for Infectious Diseases, Singapore, Singapore. .,Lee Kong Chian School of Medicine, Novena Campus Clinical Sciences Building, 11 Mandalay Rd, Singapore, 308232, Singapore. .,Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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4
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Ong CWM, Migliori GB, Raviglione M, MacGregor-Skinner G, Sotgiu G, Alffenaar JW, Tiberi S, Adlhoch C, Alonzi T, Archuleta S, Brusin S, Cambau E, Capobianchi MR, Castilletti C, Centis R, Cirillo DM, D'Ambrosio L, Delogu G, Esposito SMR, Figueroa J, Friedland JS, Ho BCH, Ippolito G, Jankovic M, Kim HY, Rosales Klintz S, Ködmön C, Lalle E, Leo YS, Leung CC, Märtson AG, Melazzini MG, Najafi Fard S, Penttinen P, Petrone L, Petruccioli E, Pontali E, Saderi L, Santin M, Spanevello A, van Crevel R, van der Werf MJ, Visca D, Viveiros M, Zellweger JP, Zumla A, Goletti D. Epidemic and pandemic viral infections: impact on tuberculosis and the lung: A consensus by the World Association for Infectious Diseases and Immunological Disorders (WAidid), Global Tuberculosis Network (GTN), and members of the European Society of Clinical Microbiology and Infectious Diseases Study Group for Mycobacterial Infections (ESGMYC). Eur Respir J 2020; 56:2001727. [PMID: 32586885 PMCID: PMC7527651 DOI: 10.1183/13993003.01727-2020] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023]
Abstract
Major epidemics, including some that qualify as pandemics, such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), HIV, influenza A (H1N1)pdm/09 and most recently COVID-19, affect the lung. Tuberculosis (TB) remains the top infectious disease killer, but apart from syndemic TB/HIV little is known regarding the interaction of viral epidemics and pandemics with TB. The aim of this consensus-based document is to describe the effects of viral infections resulting in epidemics and pandemics that affect the lung (MERS, SARS, HIV, influenza A (H1N1)pdm/09 and COVID-19) and their interactions with TB. A search of the scientific literature was performed. A writing committee of international experts including the European Centre for Disease Prevention and Control Public Health Emergency (ECDC PHE) team, the World Association for Infectious Diseases and Immunological Disorders (WAidid), the Global Tuberculosis Network (GTN), and members of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycobacterial Infections (ESGMYC) was established. Consensus was achieved after multiple rounds of revisions between the writing committee and a larger expert group. A Delphi process involving the core group of authors (excluding the ECDC PHE team) identified the areas requiring review/consensus, followed by a second round to refine the definitive consensus elements. The epidemiology and immunology of these viral infections and their interactions with TB are discussed with implications for diagnosis, treatment and prevention of airborne infections (infection control, viral containment and workplace safety). This consensus document represents a rapid and comprehensive summary on what is known on the topic.
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Affiliation(s)
- Catherine Wei Min Ong
- Dept of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
- These authors contributed equally
- Members of ESGMYC
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
- These authors contributed equally
| | - Mario Raviglione
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
- Global Studies Institute, University of Geneva, Geneva, Switzerland
| | | | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, University of Sydney, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
- Members of ESGMYC
| | - Simon Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Division of Infection, Royal London Hospital, Barts Health NHS Trust, London, UK
- Members of ESGMYC
| | - Cornelia Adlhoch
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Tonino Alonzi
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Sophia Archuleta
- Dept of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sergio Brusin
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Emmanuelle Cambau
- AP-HP-Lariboisiere, Bacteriologie, Laboratory Associated to the National Reference Centre for Mycobacteria, IAME UMR1137, INSERM, University of Paris, Paris, France
- Members of ESGMYC
| | - Maria Rosaria Capobianchi
- Laboratory of Virology, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Concetta Castilletti
- Laboratory of Virology, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Daniela M Cirillo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Members of ESGMYC
| | | | - Giovanni Delogu
- Università Cattolica Sacro Cuore, Roma, Italy
- Mater Olbia Hospital, Olbia, Italy
- Members of ESGMYC
| | - Susanna M R Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | | | - Jon S Friedland
- St George's, University of London, London, UK
- Members of ESGMYC
| | - Benjamin Choon Heng Ho
- Tuberculosis Control Unit, Dept of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Giuseppe Ippolito
- Scientific Direction, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Mateja Jankovic
- School of Medicine, University of Zagreb and Clinic for Respiratory Diseases, University Hospital Center Zagreb, Zagreb, Croatia
- Members of ESGMYC
| | - Hannah Yejin Kim
- Sydney Pharmacy School, University of Sydney, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Senia Rosales Klintz
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Csaba Ködmön
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Eleonora Lalle
- Laboratory of Virology, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Yee Sin Leo
- National Centre for Infectious Diseases, Singapore
| | - Chi-Chiu Leung
- Hong Kong Tuberculosis, Chest and Heart Diseases Association, Wanchai, Hong Kong, China
| | - Anne-Grete Märtson
- Dept of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Saeid Najafi Fard
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Pasi Penttinen
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Linda Petrone
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | - Elisa Petruccioli
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
| | | | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Miguel Santin
- Dept of Infectious Diseases, Bellvitge University Hospital-Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Dept of Clinical Science, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
- Members of ESGMYC
| | - Antonio Spanevello
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy
- Dept of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Reinout van Crevel
- Radboudumc Center for Infectious Diseases, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
- Members of ESGMYC
| | - Marieke J van der Werf
- Public Health Emergency Team, European Centre for Disease Prevention and Control, Stockholm, Sweden
- European Centre for Disease Prevention and Control Public Health Emergency team co-authors
| | - Dina Visca
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy
- Dept of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Miguel Viveiros
- Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, NOVA University of Lisbon, Lisbon, Portugal
- Members of ESGMYC
| | | | - Alimuddin Zumla
- Dept of Infection, Division of Infection and Immunity, University College London and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
| | - Delia Goletti
- Translational Research Unit, Epidemiology and Preclinical Research Dept, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy
- Saint Camillus International University of Health and Medical Sciences, Rome, Italy
- Members of ESGMYC
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5
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Lee AJY, Chung CLH, Young BE, Ling LM, Ho BCH, Puah SH, Iqbal SR, Tan GP. Clinical course and physiotherapy intervention in 9 patients with COVID-19. Physiotherapy 2020; 109:1-3. [PMID: 32791333 PMCID: PMC7320677 DOI: 10.1016/j.physio.2020.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Indexed: 02/02/2023]
Abstract
Since the outbreak of the 2019 novel coronavirus (COVID-19), the role of physiotherapy for patients with COVID-19 infection has been highlighted by various international guidelines. Despite that, clinical information regarding the rehabilitation of patients with COVID-19 infection remains limited. In this case series, we provide a novel insight into the physiotherapy management in patients infected with COVID-19 in Singapore. The main findings are: (1) Respiratory physiotherapy interventions were not indicated in the majority of the patients with COVID-19 in this case series; (2) During rehabilitation, exertional or position-related desaturation is a common feature observed in critically ill patients with COVID-19 infection locally. This clinical phenomenon of exertional or positional-related desaturation has significantly slowed down the progression of rehabilitation in our patients. As such, it can potentially result in a significant burden on healthcare resources to provide rehabilitation to these patients. Based on these findings, we have highlighted several recommendations for the provision of rehabilitation in patients who are critically ill with COVID-19.
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Affiliation(s)
- Audrey Jia Yi Lee
- Department of Physiotherapy, Tan Tock Seng Hospital, Singapore, Singapore.
| | - Chloe Lau Ha Chung
- Department of Physiotherapy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Barnaby Edward Young
- Department of Infectious Disease, Tan Tock Seng Hospital, Singapore, Singapore; National Centre for Infectious Diseases, Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Li Min Ling
- Department of Infectious Disease, Tan Tock Seng Hospital, Singapore, Singapore; National Centre for Infectious Diseases, Singapore, Singapore
| | - Benjamin Choon Heng Ho
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ser Hon Puah
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Geak Poh Tan
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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Ng SY, Phua J, Wong YL, Kalyanasundaram G, Mukhopadhyay A, Lim D, Chia N, Ho BCH, Bailey MJ, Shehabi Y, Ti LK. Singapore SPICE: sedation practices in intensive care evaluation in Singapore - a prospective cohort study of the public healthcare system. Singapore Med J 2019; 61:19-23. [PMID: 31197381 DOI: 10.11622/smedj.2019055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION A study was conducted to describe the sedation practices of intensive care units (ICUs) in Singapore in terms of drug use, sedation depth and the incidence of delirium in both early (< 48 hours) and late (> 48 hours) periods of ICU admission. METHODS A prospective multicentre cohort study was conducted on patients who were expected to be sedated and ventilated for over 24 hours in seven ICUs (surgical ICU, n = 4; medical ICU, n = 3) of four major public hospitals in Singapore. Patients were followed up to 28 days or until ICU discharge, with four-hourly sedation monitoring and daily delirium assessment by trained nurses. The Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were used. RESULTS We enrolled 198 patients over a five-month period. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 25.3 ± 9.2, and 90.9% were emergency hospital admissions. Patients were followed up for 1,417 ICU patient days, of which 396 days were in the early period and 1,021 days were in the late period. 7,354 RASS assessments were performed. Propofol and fentanyl were the sedative agents of choice in the early and late periods, respectively. Patients were mostly in the light sedation range, especially in the late period. At least one episode of delirium was seen in 23.7% of patients. CONCLUSION Sedation practices in Singapore ICUs are characterised by light sedation depth and low incidence of delirium, possibly due to the drugs used.
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Affiliation(s)
- Shin Yi Ng
- Department of Surgical Intensive Care, Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, National University Hospital, National University Health System, Singapore
| | - Yu Lin Wong
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Amartya Mukhopadhyay
- FAST and Chronic Programmes, Alexandra Hospital, National University Hospital, National University Health System, Singapore
| | - Danny Lim
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore
| | - Naville Chia
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore
| | | | - Michael J Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Yahya Shehabi
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Lian Kah Ti
- Department of Anaesthesia, NUS Yong Loo Lin School of Medicine, National University Health System, Singapore
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Leong SHB, Chan E, Ho BCH, Yeo C, Lew S, Sewa DW, Lim SL, Lee CW, Chia PL, Lim TSE, Lee EK, Ong MEH. Therapeutic temperature management (TTM): post-resuscitation care for adult cardiac arrest, with recommendations from the National TTM Workgroup. Singapore Med J 2018; 58:408-410. [PMID: 28740998 DOI: 10.11622/smedj.2017067] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Therapeutic temperature management (TTM) was strongly recommended by the 2015 International Liaison Committee on Resuscitation as a component of post-resuscitation care. It has been known to be effective in improving the survival rate and neurologic functional outcome of patients after cardiac arrest. In an effort to increase local adoption of TTM as a standard of post-resuscitation care, this paper discusses and makes recommendations on the treatment for local providers.
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Affiliation(s)
| | - Enoch Chan
- Unit for Prehospital Emergency Care, Singapore General Hospital, Singapore
| | | | - Colin Yeo
- Cardiology Department, Changi General Hospital, Singapore
| | - Sennen Lew
- Medical Intensive Care Unit, Khoo Teck Puat Hospital, Singapore
| | - Duu Wen Sewa
- Medical Intensive Care Unit, Singapore General Hospital, Singapore
| | - Shir Lynn Lim
- Medical Intensive Care Unit, Singapore General Hospital, Singapore
| | - Chee Wan Lee
- Cardiology Department, Khoo Teck Puat Hospital, Singapore
| | - Pow Li Chia
- Cardiology Department, Tan Tock Seng Hospital, Singapore
| | | | - Eng Kiang Lee
- Medical Intensive Care Unit, Ng Teng Fong General Hospital, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Sun YJ, Lim TK, Ong AKY, Ho BCH, Seah GT, Paton NI. Tuberculosis associated with Mycobacterium tuberculosis Beijing and non-Beijing genotypes: a clinical and immunological comparison. BMC Infect Dis 2006; 6:105. [PMID: 16820066 PMCID: PMC1552074 DOI: 10.1186/1471-2334-6-105] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 07/05/2006] [Indexed: 11/11/2022] Open
Abstract
Background The Mycobacterium tuberculosis Beijing genotype is biologically different from other genotypes. We aimed to clinically and immunologically compare human tuberculosis caused by Beijing and non-Beijing strains. Methods Pulmonary tuberculosis patients were prospectively enrolled and grouped by their M. tuberculosis genotypes. The clinical features, plasma cytokine levels, and cytokine gene expression levels in peripheral blood mononuclear cells (PBMC) were compared between the patients in Beijing and non-Beijing groups. Results Patients in the Beijing group were characterized by significantly lower frequency of fever (odds ratio, 0.12, p = 0.008) and pulmonary cavitation (odds ratio, 0.2, p = 0.049). Night sweats were also significantly less frequent by univariate analysis, and the duration of cough prior to diagnosis was longer in Beijing compared to non-Beijing groups (medians, 60 versus 30 days, p = 0.048). The plasma and gene expression levels of interferon (IFN) γ and interleukin (IL)-18 were similar in the two groups. However, patients in the non-Beijing group had significantly increased IL-4 gene expression (p = 0.018) and lower IFN-γ : IL-4 cDNA copy number ratios (p = 0.01). Conclusion Patients with tuberculosis caused by Beijing strains appear to be less symptomatic than those who have disease caused by other strains. Th1 immune responses are similar in patients infected with Beijing and non-Beijing strains, but non-Beijing strains activate more Th2 immune responses compared with Beijing strains, as evidenced by increased IL-4 expression.
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Affiliation(s)
- Yong-Jiang Sun
- Department of Infectious Diseases, Tan Tock Seng Hospital, Republic of Singapore
| | - TK Lim
- Department of Medicine, National University of Singapore, Republic of Singapore
| | | | | | - Geok Teng Seah
- Department of Microbiology, National University of Singapore, Republic of Singapore
| | - Nicholas I Paton
- Department of Infectious Diseases, Tan Tock Seng Hospital, Republic of Singapore
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Ho BCH, Tai DYH. Severe adult chickenpox infection requiring intensive care. Ann Acad Med Singap 2004; 33:84-8. [PMID: 15008570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Chickenpox (varicella) in adults can be severe with increased mortality. This study investigated the clinical presentation and outcome of 12 adult chickenpox patients requiring intensive care. MATERIALS AND METHODS A retrospective, observational study was performed in an adult medical intensive care unit of a university-affiliated hospital involving consecutive patients with varicella admitted over 4 years (1997-2000). RESULTS The 12 patients had a mean +/- SD age of 40 +/- 20 (range, 15 to 86) years. Two patients were above 65 years old (aged 73 and 86 years). All but 1 were male. None had previous varicella vaccination. Six patients had direct exposure to persons with chickenpox infection. Four patients had underlying pulmonary pathology: past pulmonary tuberculosis (2), emphysema (1) and recurrent right pleural effusion from autoimmune serositis (1). The mean APACHE II score was 14.2 (range, 6 to 26). Ten patients had varicella pneumonia (of whom 2 had acute respiratory distress syndrome and 5 had acute lung injury), 1 had chickenpox encephalitis and 1 patient presented concomitantly with diabetic ketoacidosis. The median duration of stay in the intensive care unit (ICU) was 11 days (range, less than 1 day to 76 days). Nine patients (75%) required mechanical ventilation (median duration, 14 days; range, less than 1 day to 79 days). All patients were treated with acyclovir. There were 3 deaths (25%); 2 were above 65 years old and 1 was 37 years old with acute myeloid leukaemia on chemotherapy. CONCLUSION Patients with varicella infection requiring intensive care carry significant mortality. In our series, old age appears to be associated with increased mortality (P = 0.045).
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Affiliation(s)
- B C H Ho
- Department of General Medicine, Tan Tock Seng Hospital, Singapore.
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