Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

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 Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn.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.

The effect of spent coffee ground (SCG) loading, matrix ratio and biological treatment of SCG on poly(hydroxybutyrate) (PHB)/poly(lactic acid) (PLA) polymer blend

This study investigates the effects of SCG embedded into biodegradable polymer blends and aimed to formulate and characterise biomass-reinforced biocomposites using spent coffee ground (SCG) as reinforcement in PHB/PLA polymer blend. The effect of SCG filler loading and varying PHB/PLA ratios on the tensile properties and morphological characteristics of the biocomposites were examined. The results indicated that tensile properties reduction could be due to its incompatibility with the PHB/PLA matrixSCG aggregation at 40 wt% content resulted in higher void formation compared to lower content at 10 wt%. A PHB/PLA ratio of 50/50 with SCG loading 20 wt% was chosen for biocomposites with treated SCG. Biological treatment of SCG using Phanerochaete chrysosporium CK01 and Aspergillus niger DWA8 indicated P. chrysosporium CK01 necessitated a higher moisture content for optimum growth and enzyme production, whereas the optimal conditions for enzyme production (50-55 %, w/w) differed from those promoting A. niger DWA8 growth (40 %, w/w). SEM micrographs highlighted uniform distribution and effective wetting of treated SCG, resulting in improvements of tensile strength and modulus of biocomposites, respectively. The study demonstrated the effectiveness of sustainable fungal treatment in enhancing the interfacial adhesion between treated SCG and the PHB/PLA matrix.

Efficacy of octenidine- and chlorhexidine-based wash-mitts against Candida albicans and Candida auris - a comparative study

BACKGROUND

Management of outbreaks of the newly emerging pathogen Candida auris may include use of antimicrobial wash-mitts for decolonization. However, currently there is little clinical evidence to support the wide adoption of 'whole-body decolonization' as part of the protocol to effectively manage C. auris outbreaks. The aim of this study was to investigate the chemical tolerance of C. auris compared with the surrogate test organism Candida albicans as established in the European Standards (EN).

METHODS

Two commercially available antiseptic-impregnated wash-mitts based on either chlorhexidine digluconate (CHG) or octenidine dihydrochloride (OCT) were studied. Comparison of susceptibility of C. auris and C. albicans was investigated based on the standardized test protocol EN 13624. Experiments were conducted using the impregnation liquid squeezed from the wash-mitts at a contact time of 30 s at different concentrations between 0.5% and 97% in the presence of low organic soiling.

FINDINGS

Yeasticidal efficacy according to EN 13624 was found for the OCT wash-mitts at 30 s at ≥10% concentration with C. albicans. In comparison, reduction ≥4 log10 was found at a much lower concentration of ≥1% for both C. auris strains. For the CHG wash-mitts, efficacy against C. albicans was below 2 log10 reduction at 97% concentration within 30 s. Efficacy against the two C. auris strains was around 3 log10 reduction.

CONCLUSION

Both C. auris strains were found to be significantly more susceptible when compared with C. albicans. Data also demonstrate that not all antiseptic-impregnated wash-mitts are equally effective against C. auris with OCT having a higher efficacy compared with CHG.

Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study

AIM

To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation.

BACKGROUND

There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns.

DESIGN

A mixed-methods study.

METHODS

Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies.

RESULTS

Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors.

CONCLUSIONS

Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration.

RELEVANCE TO CLINICAL PRACTICE

Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, care-givers or members of the public were involved in the study.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with metastatic colorectal cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with metastatic colorectal cancer (mCRC), published in late 2022, were adapted in December 2022, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with mCRC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with mCRC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian countries. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with mCRC across the different countries of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation, coupled with a disparity in the drug approvals and reimbursement strategies, between the different countries.

Measurement of renal congestion and compliance following intravenous fluid administration using shear wave elastography

Objective

Ultrasound shear wave elastography (SWE) is a novel technique that may provide non-invasive measurements of renal compliance. We aimed to investigate the relationship between intravenous (IV) fluid administration and change in SWE measurements. We hypothesised that following IV fluid administration in healthy volunteers, global kidney stiffness would increase and that this increase in stiffness could be quantified using SWE. Our second hypothesis was that graduated doses of IV fluids would result in a dose-dependent increase in global kidney stiffness measured by SWE.

Design

Randomised prospective study.

Setting

Intensive Care Unit.

Participants

Healthy volunteers aged 18-40 years.

Interventions

Participants were randomised to receive 20 ml/kg, 30 ml/kg, or 40 ml/kg of normal saline. The volume of fluid infused was based on the actual body weight recorded.

Main outcome measures

We recorded average SWE stiffness (kPa with standard deviation of the mean), median SWE stiffness (kPa), and the interquartile range.

Results

Ninety-eight percent of participants (44/45) demonstrated an increase in global kidney stiffness following administration of IV fluids. The average SWE pre fluid administration was 7.572 kPa ± 2.38 versus 14.9 kPa ± 4.81 post fluid administration (p < 0.001). In subgroup analysis, there were significant changes in global kidney stiffness pre and post fluid administration with each volume (ml/kg) of fluid administered. Average percentage change in global kidney stiffness from baseline was compared between the three groups. There was no significant difference when comparing groups 1 and 2 (197.1% increase ± 49.5 vs 216.1% ± 72.0, p ¼ 0.398), groups 2 and 3 (216.1% increase ± 72.0 vs 197.8% ± 59.9, p ¼ 0.455), or groups 1 and 3 (197.1% increase ± 49.5 vs 197.8% ± 59.9, p ¼ 0.972).

Conclusions

Fluid administration results in immediately visible and quantifiable changes in global kidney stiffness across all infused volumes of fluid.

Use of the pour plate technique in tuberculocidal efficacy testing according to EN 14348 - a comparative study

Effective disinfection strategies are essential to prevent the spread of Mycobacterium tuberculosis. Tuberculocidal efficacy of disinfectants can be demonstrated by testing disinfectants in in-vitro tests, such as the well-established quantitative suspension test EN 14348 using Mycobacterium terrae as a surrogate organism in European disinfectant testing. In other European standard tests, such as EN 13727 and EN 13624, use of the pour plate technique is well established; however, in EN 14348, the spread plate technique alone is considered. Comparative experiments according to EN 14348 with M. terrae were conducted using a peracetic-acid-based disinfectant. Either the pour plate technique or the spread plate technique was used for cultivation. Differences in colony size and morphology were observed when comparing the growth of M. terrae on pour plates compared with spread plates. However, no significant differences in biocidal efficacy data were obtained when applying either spread plates or pour plates in the quantitative suspension test described in EN 14348 under both clean and dirty conditions.

Clinical Outcomes of Routine Awake Prone Positioning in COVID-19 Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Before coronavirus disease 2019 (COVID-19) emerged, proning had been demonstrated to improve oxygenation in those with acute hypoxic respiratory failure and be performed in non-intensive care settings. This benefit was further exemplified by the COVID-19 pandemic, leading to awake prone positioning (APP). We assessed the efficacy of routine APP versus standard care in preventing death and invasive mechanical ventilation (IMV) in non-intubated hypoxic COVID-19 patients. PubMed, Cochrane Library, Scopus, and medRxiv databases were used from January 1st, 2020, to January 15th, 2022, to identify randomized controlled trials (RCTs). Routine APP group were encouraged to be self-prone, whereas the standard care group received care according to local clinical practice and allowed APP crossover as rescue therapy. We included eight COVID-19 RCTs assessing 809 APP vs. 822 standard care patients. APP group had less IMV requirement (26.5% vs. 30.9%; OR - odds ratio 0.77; P=0.03) than the standard care group, with subgroup analysis showing greater benefit (32.5% vs. 39.1%; OR 0.75; P=0.02) for those mainly requiring oxygen support of non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC). The time to IMV initiation was similar (mean 8.3 vs. 10.0 days; P=0.66) for patients requiring NIMV and HFNC. Patients mainly receiving supplemental oxygen and non-rebreather masks had improved oxygenation parameters, although not statistically significant. Other outcomes involving all-cause hospital mortality, hospital and ICU (intensive care unit) length of stay, and adverse events were comparable. APP appeared to be an important modality for reducing IMV requirements, especially in those requiring NIMV and HFNC.

Comparison of ROX index (SpO2/FIO2 ratio/respiratory rate) with a modified dynamic index incorporating PaO2/FIO2 ratio and heart rate to predict high flow nasal cannula outcomes among patients with acute respiratory failure: a single centre retrospective study

Background

High flow nasal cannula (HFNC) is increasingly being used to support patients with acute respiratory failure (ARF) and to avoid need for intubation. However, almost one third of the patients do not respond and require escalation of respiratory support. Previously, ROX index (SpO₂/FIO₂ [SF] ratio/respiratory rate) has been validated among pneumonia patients to facilitate early recognition of patients likely to fail HFNC and therefore, benefit from timely interventions. However, it has been postulated that incorporation of PaO₂/FIO₂ (PF) ratio from arterial blood gas (ABG) analysis may better predict the outcome of HFNC compared to indices that utilizes SF ratio. Similarly, heart rate increase after HFNC therapy initiation has been found to be associated with HFNC failure. Therefore, we aimed to compare ROX index with a new modified index to predict HFNC outcomes among ARF patients.

Materials and methods

This single centre 2-year retrospective study included ARF patients of varying etiologies treated with HFNC. The modified index incorporated heart rate and substituted PF ratio for SF ratio in addition to respiratory rate. We named the index POX-HR and calculated Delta POX-HR index as the difference pre- and post-HFNC initiation POX-HR. We also recorded ROX index at the time when post-HFNC initiation ABG was done (‘post-HFNC initiation ROX’) and calculated Delta ROX. HFNC success was defined as no need of escalation of respiratory support or discharged to ward within 48 h of HFNC initiation, or successful wean off HFNC for at least 12 h. Evaluation was performed using area under the receiver operating characteristic curve (AUROC) and cut-offs assessed for prediction of HFNC outcomes.

Results

One hundred eleven patients were initiated on HFNC for ARF, of whom 72 patients (64.9%) had HFNC success. Patients with HFNC failure had significantly lower values for all the indices. At median of 3.33 h (IQR 1.48–7.24 h), Delta POX-HR demonstrated the best prediction accuracy (AUROC 0.813, 95% CI 0.726–0.900). A Delta POX-HR > 0.1 was significantly associated with a lower risk of HFNC failure.

Conclusions

Our proposed modified dynamic index (Delta POX-HR) may facilitate early and accurate prediction of HFNC outcomes compared to ROX index among ARF patients of varied etiologies.

Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis

BACKGROUND

A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated.

OBJECTIVES

To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients.

METHODS

Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021.

RESULTS

Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups.

CONCLUSIONS

Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.

Effective design of barrier enclosure to contain aerosol emissions from COVID-19 patients

Facing shortages of personal protective equipment, some clinicians have advocated the use of barrier enclosures (typically mounted over the head, with and without suction) to contain aerosol emissions from coronavirus disease 2019 (COVID-19) patients. There is, however, little evidence for its usefulness. To test the effectiveness of such a device, we built a manikin that can expire micron-sized aerosols at flow rates close to physiological conditions. We then placed the manikin inside the enclosure and used a laser sheet to visualize the aerosol leaking out. We show that with sufficient suction, it is possible to effectively contain aerosol from the manikin, reducing aerosol exposure outside the enclosure by 99%. In contrast, a passive barrier without suction only reduces aerosol exposure by 60%.

In-hospital cardiac arrest incidence and outcomes in the era of COVID-19: an observational study in a Singapore hospital

Background

COVID-19 pandemic has resulted in significant strain on healthcare resources and this requires diligent resource re-allocation. We aim to describe the incidence and outcomes of in-hospital cardiac arrest (IHCA) during this period as compared to non-pandemic period.

Methods

We conducted a retrospective study in a tertiary care hospital in Singapore. The study compared the incidence and outcomes of code blue activations over a 3-month period from March to May 2020 (COVID-19 period) with the same months in 2019 (pre-COVID-19 period). The primary outcome of the study was the rate of survival to hospital discharge for IHCA. The secondary outcomes included incidence of all code blue activation per 1000 hospital admissions, incidence of IHCA per 1000 hospital admissions.

Outcomes

The rate of survival to hospital discharge for IHCA was 5.88% in the COVID-19 period as compared to 10.0% in the pre-COVID-19 period [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.26-1.95]. Compared to pre-COVID-19 period, there were more IHCA incidences per 1000 hospital admissions in the COVID-19 period (1.86 vs 1.03; OR, 1.81; 95% CI, 0.78-4.41).

Conclusions

The study observed a trend towards higher incidence of IHCA and lower rate of survival to hospital discharge during COVID-19 pandemic compared to pre-COVID-19 period.

Clinical features and predictors of severity in COVID-19 patients with critical illness in Singapore

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.

Impact of implementing novel automated code blue activation system on in-hospital cardiac arrest: A single center study

BACKGROUND

Prompt identification and management of patients having clinical deterioration on wards is one of the key steps to reduce in-hospital cardiac arrests (IHCA). Our organization implemented a novel Automated Code Blue Alert and Activation (ACBAA) system since 1st March 2018.

METHODS

We conducted a retrospective before-and-after ACBAA system implementation study in JurongHealth Campus (JHC) of National University Health system (NUHS), Singapore. In JHC, code blue can be activated by both manual activation and ACBAA system activation from 1st March 2018. The ACBAA system will be activated when any of the pre-defined peri-arrest criteria is met. The primary outcome of the study was the incidence of IHCA. The secondary outcome included return of spontaneous circulation (ROSC) of IHCA and in-hospital survival to home discharge of code blue activation.

OUTCOMES

The incidence of IHCA per 1000 hospital admissions after-ACBAA system implementation was 14.6% lower than before-ACBAA system though not statistically significant [relative risk (RR): 0.86, 95% confidence interval (CI) 0.55-1.34, P > 0.05]. Compared to the before-ACBAA system period, the after-ACBAA system period had a trend for higher rate of survival to home discharge after IHCA (RR: 2.13, 95% CI 0.65-6.93, P > 0.05) with good neurological outcome.

CONCLUSIONS

Implementation of a novel ACBAA system has shown a trend in reducing IHCA incidence. In the era of digitalised healthcare system, the ACBAA system is practical and advisable to implement in order to reduce IHCA. Further studies are required to validate the criteria for peri-arrest code blue activation.

Point-of-Care Ultrasound Training Among Intensivists in Singapore: A Multicentre Survey

INTRODUCTION

Point of care ultrasound (POCUS) has become essential in the management of critically ill patients. Multiple POCUS training courses exist, but are not widely adopted in Singapore. Given the discordance between training supply and demand, we aimed to uncover the learning needs and barriers among intensive care medicine (ICM) doctors locally.

MATERIALS AND METHODS

An anonymous online survey was carried out from January to April 2019 among ICM doctors from 6 major teaching hospitals in Singapore.

RESULTS

66 out of 160 ICM specialists and trainees responded (41.3%). Although only 6% of respondents had current formal POCUS accreditation, the majority were already using critical care echocardiography (CCE) and pleural/ lung ultrasound. 93% supported having a local training programme. More than 50% of trainees wanted training in CCE, diaphragm/muscle ultrasound, airway ultrasound and ultrasound for neurological disease. More than 50% of specialists wanted training in diaphragm/muscle ultrasound, with mixed interests in other topics. The top 2 obstacles hindering POCUS training were lack of supervisors and locally based programmes.

CONCLUSIONS

ICM doctors who responded were supportive of a local POCUS training programme. The programme's curriculum should address the learning needs of the majority of learners, with diaphragm/muscle ultrasound being the top unmet need. The programme would need to develop supervisors and be as affordable as possible.

Characteristics and Outcomes of COVID-19 Patients with Respiratory Failure Admitted to a “Pandemic Ready” Intensive Care Unit – Lessons from Singapore

Introduction: Singapore was one of the first countries affected by the coronavirus disease 2019 (COVID-19) pandemic but has been able to prevent its healthcare system and intensive care units (ICU) from being overwhelmed. We describe the clinical features, management and outcomes of COVID-19 patients with respiratory failure admitted to our ICU. Materials and Methods: A case series of COVID-19 patients admitted to our ICU for respiratory failure from 7 February, with data censoring at 30 June 2020, was performed from a review of medical records. Results: Twenty-two COVID-19 patients were admitted to our ICU for respiratory failure. The median age was 54.5 years (IQR 30–45.5), 72.7% were male and had at least one comorbidity. The Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 2.5 (IQR 1.25–7) and 10 (8.25–12) respectively. Thirteen patients required invasive mechanical ventilation (IMV) and had a median PaO2/FiO2 ratio of 194 mmHg (IQR 173–213) after intubation. The 28-day survival was 100%, with 2 patients demising subsequently. The overall ICU mortality rate was 9.1% at the time of data censoring. In IMV survivors, length of IMV and ICU stay were 11 days (IQR 9–17.75) and 16 days (IQR 12–32) respectively. Conclusion: Low COVID-19 ICU mortality was observed in our “pandemic-ready” ICU. This was achieved by having adequate surge capacity to facilitate early ICU admission and IMV, lung protective ventilation, and slow weaning. Being able to maintain clinical standards and evidence-based practices without having to resort to rationing contributed to better outcomes. Keywords: Acute respiratory distress syndrome, Coronavirus, Critical care, Pandemic, Pneumonia

Characteristics and Outcomes of COVID-19 Patients with Respiratory Failure Admitted to a "Pandemic Ready" Intensive Care Unit - Lessons from Singapore

INTRODUCTION

Singapore was one of the first countries affected by the coronavirus disease 2019 (COVID-19) pandemic but has been able to prevent its healthcare system and intensive care units (ICU) from being overwhelmed. We describe the clinical features, management and outcomes of COVID-19 patients with respiratory failure admitted to our ICU.

MATERIALS AND METHODS

A case series of COVID-19 patients admitted to our ICU for respiratory failure from 7 February, with data censoring at 30 June 2020, was performed from a review of medical records.

RESULTS

Twenty-two COVID-19 patients were admitted to our ICU for respiratory failure. The median age was 54.5 years (IQR 30-45.5), 72.7% were male and had at least one comorbidity. The Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 2.5 (IQR 1.25-7) and 10 (8.25-12) respectively. Thirteen patients required invasive mechanical ventilation (IMV) and had a median PaO2/FiO2 ratio of 194 mmHg (IQR 173-213) after intubation. The 28-day survival was 100%, with 2 patients demising subsequently. The overall ICU mortality rate was 9.1% at the time of data censoring. In IMV survivors, length of IMV and ICU stay were 11 days (IQR 9-17.75) and 16 days (IQR 12-32) respectively.

CONCLUSION

Low COVID-19 ICU mortality was observed in our "pandemic-ready" ICU. This was achieved by having adequate surge capacity to facilitate early ICU admission and IMV, lung protective ventilation, and slow weaning. Being able to maintain clinical standards and evidence-based practices without having to resort to rationing contributed to better outcomes.

Investigation of the susceptibility of Candida auris and Candida albicans to chemical disinfectants using European Standards EN 13624 and EN 16615

BACKGROUND

Since the first appearance of Candida auris in 2009, this yeast has become a relevant pathogen in the clinical field. C. auris has been detected on various surfaces in health facilities, and is therefore a target for appropriate disinfection procedures. Preventive measures have to be implemented based on disinfectants with proven efficacy against C. auris.

AIM

The chemical tolerance of C. auris was compared with the surrogate test organism Candida albicans as established in the European standards (EN). In this way, conclusions will be drawn as to whether the disinfectants tested according to EN 13624 and EN 16615 are at least equally effective against C. auris.

METHODS

The chemical susceptibility of C. auris and C. albicans was investigated using standardized EN test protocols. EN 13624 and EN 16615 were used in this study to examine two commercially available surface disinfectants based on alcohol and quaternary ammonium compounds (QACs), respectively. In addition, the survival rates of the two yeast species were studied on a defined test surface simulating practical conditions.

FINDINGS

In comparison with C. albicans, C. auris was found to be significantly more susceptible to the alcohol- and QAC-based disinfectants used in this study. C. albicans was found to be more tolerant to drying on the test surface in EN 16615, yielding higher recovery rates.

CONCLUSION

C. albicans is a suitable surrogate test organism when targeting yeasticidal efficacy, which, based on EN 13624 and EN 16615, includes efficacy against the human pathogen C. auris.

Performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) in the prediction of hospital mortality in a mixed ICU in Singapore

Background:

The Acute Physiology and Chronic Health Evaluation II (APACHE II) is used to quantify disease severity and hospital mortality risk in critically ill patients. It is widely used in intensive care units (ICUs) in Singapore, but its prognostic validity remains questionable as it has not been thoroughly assessed by established statistical methods.

Objectives:

This study aimed to: (a) evaluate the discrimination and calibration accuracy of the APACHE II in the prediction of hospital mortality in a mixed ICU, and (b) customise the APACHE II in an effort to maximise its prognostic performance.

Methods:

A prospective cohort study was conducted and all adult patients with >24 h of ICU admission in a tertiary care institution in Singapore were included. The outcome measure was hospital mortality, and all patients were followed-up until hospital discharge or death for up to one year after ICU admission.

Results:

There were 503 patients, and their mean (SD) age and APACHE II score were 61.2 (15.8) years and 24.5 (8.2), respectively. Hospital mortality was 31%, and no patients were lost to follow-up. The APACHE II has good discrimination (receiver operating characteristic: 0.76) but poor calibration (Hosmer–Lemeshow C test: <0.001). Customisation did not significantly improve calibration accuracy.

Conclusions:

The APACHE II and its customised version should not be used in the local setting as they both have poor calibration. There is an urgent need for larger studies to perform second-level customisation or to develop a new prognostic model tailored to the Singapore critical care setting.

Liver Transplant Waitlist Outcomes and the Allocation of Hepatocellular Carcinoma Model for End-Stage Liver Disease Exception Points at a Low-Volume Center

BACKGROUND

Organ scarcity continues to be the main problem limiting the number of liver transplants performed. Outcomes of patients waitlisted for an organ in an Asian country with low organ donation rate have not been well evaluated. Our current policy of allocating 15 exception points to patients with hepatocellular carcinoma (HCC) to render them competitive for a transplant also requires review.

METHODS

The waiting list registry and the organ transplant registry of a single institution in Asia were reviewed from December 2005 to June 2016 for all patients who underwent liver transplantation. Patient characteristics and outcomes of waitlist dropouts were evaluated. Statistical analyses were performed using SPSS version 20.0.

RESULTS

One hundred seventy-three patients were waitlisted for a deceased donor liver-only transplant. The most common etiology of liver disease was hepatitis B, followed by cholestatic diseases. Approximately half of the patients had HCC (45.6%). Priority listing for transplant comprised 15.6% of cases. Median Model for End-Stage Liver Disease (MELD) at listing was 15, and median waiting time to transplant was 17 weeks (interquartile range = 6.5-43.5). Overall, 89 (51.4%) patients underwent liver transplantation and 68 (39.3%) dropped out. For patients with HCC, the most common cause of dropout was progression beyond University of California San Francisco transplant criteria (62.5%). The cumulative incidence of dropout at 3 months among patients with HCC who received exception MELD scores was 11%. This was higher than those listed with physiologic MELD of 14-16 points (7%) but lower than those with 17-19 points (16%).

CONCLUSIONS

Hepatitis B-related liver disease and HCC comprise the majority of patients listed for liver transplant. Dropout rates are high and this is due to the lack of donor organs. The current policy of allocating 15 exception MELD points to patients with HCC within transplant criteria may underestimate the dropout risk of patients with HCC in our population.

Donor-Derived Candida dubliniensis Resulting in Perigraft Abscesses in a Liver Transplant Recipient Proven by Whole Genome Sequencing: A Case Report

BACKGROUND

The transmission of fungi via transplant, although well-known, has not often been molecularly proven. We describe a case of donor-derived candidiasis verified by whole genome sequencing.

CASE DESCRIPTION

The multiorgan donor was a 42-year-old woman with subdural hemorrhage. Procurement of the thoracic organs was performed followed by the abdominal organs. Tissue from the left bronchus grew Candida dubliniensis. The liver recipient was a 63-year-old woman with cryptogenic liver cirrhosis. She was noted to have worsening leukocytosis on postoperative day (POD) 9. Computed tomography of the abdomen and pelvis showed multiple rim-enhancing collections around the graft. Percutaneous drainage was performed. Fluid cultures grew C dubliniensis. C dubliniensis isolated from the donor's left bronchus and the liver recipient's abscesses were verified to be related by whole genome sequencing. We postulate that C dubliniensis colonizing the donor's transected trachea could have contaminated the inferior vena cava when the former was left open after explant of the donor's lungs. A portion of the donor's contaminated inferior vena cava was transplanted along with the liver graft, resulting in the infected collections in the recipient.

CONCLUSIONS

Our case report highlights the importance of maintaining a sterile field during organ procurement, especially in a multiorgan donor whose organs are explanted in succession.

Cervical and lumbar paraspinal calcinosis in systemic sclerosis

Calcinosis is a well-recognized manifestation of systemic sclerosis. Paraspinal or intraspinal calcinosis is rare, with reports of calcinosis involving the cervical, thoracic and lumbar separately, but not together. We now report a case of limited cutaneous scleroderma with extensive paraspinal calcinosis of the cervical and lumbar spine.

An unusual localised reaction associated with vancomycin therapy

Vancomycin has been documented to cause various adverse cutaneous reactions. We present a case report of a man, who developed a large localized erythematous plaque in his forearm following parenteral vancomycin therapy. We believe this to be the first reported case of such cutaneous reaction associated with parenteral vancomycin therapy.

Seasonal variability of chlorophyll-a and oceanographic conditions in Sabah waters in relation to Asian monsoon--a remote sensing study

A study was conducted to investigate the influence of Asian monsoon on chlorophyll-a (Chl-a) content in Sabah waters and to identify the related oceanographic conditions that caused phytoplankton blooms at the eastern and western coasts of Sabah, Malaysia. A series of remote sensing measurements including surface Chl-a, sea surface temperature, sea surface height anomaly, wind speed, wind stress curl, and Ekman pumping were analyzed to study the oceanographic conditions that lead to large-scale nutrients enrichment in the surface layer. The results showed that the Chl-a content increased at the northwest coast from December to April due to strong northeasterly wind and coastal upwelling in Kota Kinabalu water. The southwest coast (Labuan water) maintained high concentrations throughout the year due to the effect of Padas River discharge during the rainy season and the changing direction of Baram River plume during the northeast monsoon (NEM). However, with the continuous supply of nutrients from the upwelling area, the high Chl-a batches were maintained at the offshore water off Labuan for a longer time during NEM. On the other side, the northeast coast illustrated a high Chl-a in Sandakan water during NEM, whereas the northern tip off Kudat did not show a pronounced change throughout the year. The southeast coast (Tawau water) was highly influenced by the direction of the surface water transport between the Sulu and Sulawesi Seas and the prevailing surface currents. The study demonstrates the presence of seasonal phytoplankton blooms in Sabah waters which will aid in forecasting the possible biological response and could further assist in marine resource managements.

Getting 'Smad' about obesity and diabetes

Recent findings on the role of transforming growth factor (TGF)-β/Smad3 signaling in the pathogenesis of obesity and type 2 diabetes have underscored its importance in metabolism and adiposity. Indeed, elevated TGF-β has been previously reported in human adipose tissue during morbid obesity and diabetic neuropathy. In this review, we discuss the pleiotropic effects of TGF-β/Smad3 signaling on metabolism and energy homeostasis, all of which has an important part in the etiology and progression of obesity-linked diabetes; these include adipocyte differentiation, white to brown fat phenotypic transition, glucose and lipid metabolism, pancreatic function, insulin signaling, adipocytokine secretion, inflammation and reactive oxygen species production. We summarize the recent in vivo findings on the role of TGF-β/Smad3 signaling in metabolism based on the studies using Smad3^−/− mice. Based on the presence of a dual regulatory effect of Smad3 on peroxisome proliferator-activated receptor (PPAR)β/δ and PPARγ2 promoters, we propose a unifying mechanism by which this signaling pathway contributes to obesity and its associated diabetes. We also discuss how the inhibition of this signaling pathway has been implicated in the amelioration of many facets of metabolic syndromes, thereby offering novel therapeutic avenues for these metabolic conditions.

Infections caused by Gordonia species at a medical centre in Taiwan, 1997 to 2008

The inability of conventional identification systems to accurately identify Gordonia spp. often results in the misdiagnosis of infections by these rare pathogens, which require genomic sequencing for precise identification. In the present study, we describe nine cases of the various types of infection caused by Gordonia spp. From 1997 to 2008, 66 isolates (from 30 patients) initially identified as Rhodoccus spp. by conventional biochemical methods, by the Bacteriology Laboratory of National Taiwan University Hospital, were retrospectively analysed to assess the accuracy of species identification. Fifteen of these isolates (from nine patients) were later found to be Gordonia spp. by two molecular methods: PCR-restriction fragment length polymorphism for heat shock protein gene (hsp65) and the 16S rRNA gene sequencing analysis. Gordonia sputi (n = 8) was the most common species, followed by Gordonia terrae (n = 7). Most of the isolates were isolated from blood (n = 11), followed by soft tissue (n = 2) and eye (n = 2). Five patients presented with bacteraemia and two of these had catheter-related bloodstream infection. Two patients had soft tissue infections and another two patients had infective keratitis and conjunctivitis. The random amplified polymorphic DNA patterns for isolates from different patients were different, indicating that they were genetically unrelated. Accurate identification with molecular methods is required if the role of Gordonia spp. in causing infection is to be recognized.

A patient with thyroid storm presenting with apathetic thyrotoxicosis and features of meningoencephalitis

BACKGROUND

Apathetic thyrotoxicosis is distinctly unusual in thyroid storm and features of meningoencephalitis are very rare. Here we present such a patient.

PATIENT FINDINGS

The patient was a 67-year-old Chinese woman who presented with acute generalized weakness, decreased mentation, fever, and rapid deterioration to coma, accompanied by meningism, initially mimicking meningoencephalitis. Further investigations excluded intracranial lesions. Laboratory findings were consistent with Graves' thyrotoxicosis. She was treated for thyroid storm with antithyroid drugs, Lugol's iodine solution, and other supportive management. Subsequently, her level of consciousness returned to normal and neurological signs resolved.

SUMMARY

We report a patient with thyroid storm with an apathetic presentation, manifesting as coma with meningism, that mimicked meningoencephalitis. These resolved after treatment for thyroid storm was instituted.

CONCLUSIONS

Apathetic thyrotoxicosis is a rare presentation of thyroid storm. Early recognition and treatment is essential for reducing its morbidity and mortality.

Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients

BACKGROUND

Treatment with corticosteroids can reduce the incidence of postextubation stridor (PES) and reintubation in critically ill adult patients, but the mechanisms remain unknown.

METHODS

A randomized, controlled clinical trial was conducted in an adult medical and surgical Intensive Care Unit (ICU) of a teaching hospital. Seventy-one patients who had a cuff leak percentage <24% of tidal volume received either a bolus injection of methylprednisolone at 40 mg (treated group, n=38) or normal saline (placebo group, n=33) 4 h prior to a planned extubation. The cuff leak percentage was re-assessed 1 h and 4 h post-injection. Eighty patients who had a cuff leak percentage ≥ 24% served as a control group. Plasma concentrations of multiple cytokines and C-reactive protein (CRP) were measured at baseline, 4 h and 24 h after the intervention.

RESULTS

The incidences of PES (15.8% vs. 39.4%, P<0.05) and reintubation rate (7.9% vs. 30.3%, P<0.05) were lower in the treated group compared to the placebo group. The plasma concentrations of IL-4 and IL-10 increased while the levels of IL-6 and IL-8 decreased at 24 h in the treated group compared to the placebo group. No difference in CRP levels was observed between the treated and placebo groups.

CONCLUSION

A single injection of methylprednisolone at the dose used 4 h prior to planned extubation effectively reduced the incidence of PES and the reintubation rate. These beneficial effects were associated with the up-regulation of IL-4 and IL-10 and the down-regulation of IL-6 and IL-8 in the critically ill adult patients.

Combined heart-liver transplantation with extended cardiopulmonary bypass

We report a case of combined heart and liver transplantation for familial amyloid polyneuropathy. This is the first such combined transplant performed in Asia, and differs from previously described cases, in that cardiopulmonary bypass was continued at partial flow during liver transplantation in our case. This was done in order to provide haemodynamic support to the cardiac graft and to protect it from the impending reperfusion insult that frequently accompanies liver transplantation. The utility of this management course is discussed, along with its actual and potential complications. We also describe the impact of a lung-protective ventilation strategy employed during cardiac transplantation.

Clinical significance of nontuberculous mycobacteria isolates in elderly Taiwanese patients

The aim of this study was to investigate the clinical significance of nontuberculous mycobacteria (NTM) isolates in elderly Taiwanese patients. From 2004 through 2008, patients >65 years old with NTM isolation were identified. The definitions of NTM disease followed the American Thoracic Society and Infectious Disease Society of America (ATS/IDSA) criteria. Among the 3,175 NTM isolates, Mycobacterium avium complex (MAC; n = 1,118, 35.2%) was the most prevalent species, followed by M. abscessus (n = 545, 17.2%). Among the 1,633 elderly patients with NTM isolates, the most prevalent NTM species were MAC (n = 592, 36.3%) and M. fortuitum complex (n = 311, 19.0%). NTM colonization was found in 1,339 (80.4%) patients and only 326 (19.6%) patients had NTM diseases. During the study period, the annual incidence rates (per 100,000 inpatients and outpatients) of NTM colonization and disease both increased significantly (p < 0.0001) from 10.5 to 15.8 and from 2.1 to 4.3, respectively. Isolated pulmonary NTM infections compromised 294 (90.2%) of the 326 elderly cases of NTM disease. In conclusion, this study found an increasing trend in the incidence of both NTM isolates and NTM diseases among elderly Taiwanese patients. MAC and M. abscessus were the most frequent species causing various types of NTM disease.

Diagnostic performance of an enzyme-linked immunospot assay for interferon-gamma in extrapulmonary tuberculosis varies between different sites of disease

OBJECTIVES

To evaluate diagnostic performance of an enzyme-linked immunospot assay for interferon-gamma (T SPOT-TB) in patients with suspected extrapulmonary tuberculosis (TB).

METHODS

From January 2007 to December 2008, patients with suspected extrapulmonary TB were prospectively enrolled from 2 tertiary care hospitals.

RESULTS

A total of 138 patients with suspected extrapulmonary TB were enrolled; 50 patients had positive culture for Mycobacterium tuberculosis and 39 patients had probable TB. The sites of infection were lymph node (n = 20), pleura (n = 19), bone/joint (n = 15), urinary tract (n = 7), peritoneum (n = 7), meninges (n = 6), disseminated (n = 5), intestine (n = 3), pericardium (n = 2), skin (n = 2), throat (n = 1), neck (n = 1), and genitalia (n = 1). The overall sensitivity and specificity were 79.8% (71/89) and 81.6% (40/49). The sensitivity ranged from 100% for tuberculous meningitis, tuberculous pericarditis, and intestinal TB, 95% for lymphadenitis, to 42.9% for tuberculous peritonitis. The sensitivity of the T SPOT-TB assay was 70.6% in immunocompromised patients and 85.5% in immunocompetent patients (p = 0.09).

CONCLUSIONS

The T SPOT-TB assay can be a useful tool for diagnosing extra-pulmonary TB in immunocompetent and immunocompromised patients, particularly for tuberculous meningitis, pericarditis, lymphadenitis, and intestinal TB.

Thermoresponsive core-shell magnetic nanoparticles for combined modalities of cancer therapy

Thermoresponsive polymer-coated magnetic nanoparticles loaded with anti-cancer drugs are of considerable interest for novel multi-modal cancer therapies. Such nanoparticles can be used for magnetic drug targeting followed by simultaneous hyperthermia and drug release. Gamma-Fe(2)O(3) iron oxide magnetic nanoparticles (MNP) with average sizes of 14, 19 and 43 nm were synthesized by high temperature decomposition. Composite magnetic nanoparticles (CNP) of 43 nm MNP coated with the thermoresponsive polymer poly-n-isopropylacrylamide (PNIPAM) were prepared by dispersion polymerization of n-isopropylacrylamide monomer in the presence of the MNP. In vitro drug release of doxorubicin-(dox) loaded dehydrated CNP at temperatures below and above the lower critical solution temperature of PNIPAM (34 degrees C) revealed a weak dependence of drug release on swelling behavior. The particles displayed Fickian diffusion release kinetics; the maximum dox release at 42 degrees C after 101 h was 41%. In vitro simultaneous hyperthermia and drug release of therapeutically relevant quantities of dox was achieved, 14.7% of loaded dox was released in 47 min at hyperthermia temperatures. In vivo magnetic targeting of dox-loaded CNP to hepatocellular carcinoma (HCC) in a buffalo rat model was studied by magnetic resonance imaging (MRI) and histology. In summary, the good in vitro and in vivo performance of the doxorubicin-loaded thermoresponsive polymer-coated magnetic nanoparticles suggests considerable promise for applications in multi-modal treatment of cancer.

Significant non-alcoholic fatty liver disease is found in non-diabetic, pre-obese Chinese in Singapore

INTRODUCTION

To characterise the anthropometrical and metabolic parameters of a group of non-diabetic and non-obese patients who had histologically-proven nonalcoholic steatohepatitis (NASH).

METHODS

During September 1997 to November 1999, consent for liver biopsies were sought from a consecutive series of patients, whose body mass index (BMI) were equal to or less than 30 kg per square metres, and who had persistently elevated serum alanine transaminase (more than 2.5 times upper limit of normal for more than six months), with no associated viral hepatitis, alcohol or drug-induced liver disease, hereditary liver disease and diabetes mellitus. Patients who were found to have steatohepatitis histologically were further studied. Their body weight, height, waist and hip circumferences were taken, and fasting serum lipid and glucose measured. Serum insulin was measured in six patients and insulin resistance (IR) was calculated by homeostasis model assessment. Oral glucose tolerance tests were done if fasting glucose levels were greater than 6 mmol/L. All liver biopsies were reviewed by a single histopathologist. Three age- and sex-matched controls were randomly selected for each patient.

RESULTS

11 of 12 patients who underwent liver biopsies were found to have NASH. All 11 were Chinese: eight males and three females. 73 percent of them had hepatic fibrosis. Overall, compared to controls, they had significantly higher body weight, BMI, IR and triglyceridaemia. The female patients also had a higher waist-hip ratio than controls. None had diabetes mellitus, and one had impaired glucose tolerance/fasting glycaemia. Nine out of 11 had BMI between 25 and 30 kg per square metres.

CONCLUSION

Significant histological changes of NASH with hepatic fibrosis were found in Singaporean Chinese non-diabetic patients with BMI of less than 30 kg per square metres.

Recurrent abdominal pain in a woman with a wandering spleen

A 28-year-old Malay woman presented with recurrent abdominal pain for five years. She had delivered her child seven months earlier. She was found to have bicytopenia, with a haemoglobin level of 7.9 g/dL and a platelet count of 85 x 10(9)/L. Computed tomography revealed a wandering spleen. Complications of a wandering spleen, for which splenectomy is advocated, include functional asplenia (due to torsion of the splenic pedicle), splenic infarction or splenic vessel thrombosis. A splenectomy was performed and at operation, splenomegaly with a long mesentery was found. Splenic histology was negative for malignancy. The bicytopenia resolved postoperatively, and she remains well.

Visual disturbances in dengue fever: an answer at last?

Visual disturbances in dengue infection are uncommon but may result in permanent visual impairment. We report a 32-year-old Chinese woman with dengue infection and she developed retinal haemorrhage, retinal vasculitis and macular detachment. Autoimmune screen revealed a low C4 complement level, possibly due to partial C4 complement deficiency. The patient was treated with steroids and there was significant improvement in her vision. Partial C4 deficiency predisposes to autoimmune disease, and patients with pre-existing low C4 levels may be susceptible to ocular complications in dengue infection. Interestingly, previous case reports of ophthalmic complications of dengue infection occurred in young female patients, who are likewise predisposed to autoimmune disease. In conclusion, in individuals predisposed to autoimmune disease (females and patients with partial C4 deficiency), dengue infection may provide the antigenic trigger for immune complex deposition and retinal vasculitis. Steroids may have an important role in the treatment of this condition.

Referral patterns and waiting times for liver transplantation in Singapore

INTRODUCTION

Referral patterns, waiting times, waiting list, and mortality provide information on how effectively a transplant programme deals with referred patients. This paper aims to review these parameters in the Singapore National Liver Transplant Programme.

METHODS

Data of all patients referred to the Singapore National Liver Transplant Programme since its inception were captured and outcomes were retrieved and described.

RESULTS

562 patients were referred for liver transplant evaluation from 1990-2004, consisting of 457 adults and 105 children. The main indications for referral were hepatitis B liver disease and hepatocellular carcinoma in adults, and biliary atresia in children. Most patients were of United Network of Organ Sharing (UNOS) status 3 or 4 at the time of referral. 114 (20.28 percent) patients had transplants, consisting of 66 adults (14.44 percent) and 48 (45.71 percent) children. 138 adults and ten children were rejected for transplant, mainly for the reason of being "too early". The median waiting time for adults who had transplants was 3.3 months while adults still on the waiting list had been waiting for 16.2 months. The overall waiting list mortality was 44.3 percent, being 52.5 percent in adults and 23.2 percent in children.

CONCLUSION

The overall transplantation rate is low and the waiting list mortality is high as a result of low availability of organs, particularly in adults. Paediatric liver transplant appears to have been better at dealing with referred patients but this is probably due to availability of living-related liver transplant. Improvement in these may result from the Human Organ Transplant Act.

Liver transplantation in Singapore 1990-2004

INTRODUCTION

Liver transplantation is the accepted standard of care for patients with hepatocellular carcinoma, decompensated liver cirrhosis, and acute liver failure. Since the first liver transplant done in Singapore in 1990, results have been improving. We review the overall results of liver transplantation over the last 15 years.

METHODS

All transplant cases from 1990 to 2004 were reviewed retrospectively.

RESULTS

100 liver transplants were performed over the last 15 years; four in the first five years and 96 in the subsequent ten years. Overall one- and five-year survival rates were 80 percent and 78 percent, respectively. 44 were paediatric transplants, of which biliary atresia was the commonest indication for paediatric transplant. 56 were adult transplants of which hepatocellular carcinoma and decompensated hepatitis B cirrhosis were the commonest indications for adult transplant. Infection remained the commonest cause of mortality.

CONCLUSION

The number of transplants carried out per year was small due to the low cadaveric donation rate, but the survival of liver transplant patients was comparable to well-established liver transplant centres.

Computed tomography features of spontaneously perforated pyometra: a case report

Spontaneous perforation of pyometra is an extremely rare emergent gynecologic disease. We report a 73-year-old woman with a spontaneously perforated pyometra presenting with acute abdomen in the emergency department. A dedicated computed tomography examination of the abdominal and pelvic regions revealed the diagnosis. The patient recovered well after surgical intervention and antibiotic treatment.

Endovascular repair of abdominal aortic aneurysms with aortocaval fistula

OBJECTIVES

To examine the risk of high-flow type II endoleak following endovascular repair of abdominal aortic aneurysm with aortocaval fistula.

DESIGN

Case reports.

SUBJECTS

Two patients with abdominal aortic aneurysms with aortocaval fistula.

METHODS

Both patients had an endovascular repair of their aortic aneurysms.

RESULTS

The aneurysms were successfully treated in both patients, without any endoleak on completion angiography. Apart from a transient type II lumbar endoleak in one of the patients, no endoleak was found after 3 and 12 month follow-up. Seven other cases have been published, reporting one type II and one type Ic endoleak.

CONCLUSION

We found no evidence that endovascular repair of abdominal aortic aneurysm with aortocaval fistula is associated with a higher incidence of persistent endoleak.

MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report

BACKGROUND/METHODS

Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died.

RESULTS

Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation.

CONCLUSIONS

MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.

Dexamethasone induces dendritic alteration but not apoptosis in the neurons of the hippocampus in postnatal rats

One day old rats received daily injections of dexamethasone and were sacrificed 24 h after the 1st and 7th injections. Neuronal death by apoptosis in the hippocampus was investigated by immunohistochemistry using bcl2, bax and caspase3 antibodies. The immunoreactivity expressed by the pyramidal neurons and the dentate granule cells with these antibodies was comparable in the dexamethasone treated and control rats injected with saline. At the ultrastructural level, the dendrites showed vacuolation indicative of degeneration in the dexamethasone administered rats. Results of reverse transcriptase-polymerase chain reaction analysis showed that bcl2 and bax mRNA was constitutively expressed in the hippocampus of control rats and showed no significant change in the dexamethasone treated rats. The results of this study indicate that dexamethasone induces degeneration of the dendrites but does not induce neuronal apoptosis in the hippocampus of postnatal rats.

Prevalence of hepatitis G virus infection in patients with liver diseases in Singapore

The prevalence of hepatitis G virus (HGV) infection in patients with liver diseases in Singapore and its pathogenic role in these patients was studied. One hundred and forty-eight patients who had chronic hepatitis or acute non A-E hepatitis were studied. Presence of HGV RNA was determined by nested polymerase chain reaction of the 5'non-coding region of the virus in all the patients. Hepatitis G IgG antibody to the envelope (E2) antigen was tested with an enzyme immunoassay (Boehringer Mannheim, Singapore) in 76 of them. Most patients (93%) were ethnically Chinese, predominantly males (74%) and chronic hepatitis B (72%) patients. Others had chronic hepatitis C (19%) or cryptogenic cirrhosis (6%). Four patients had acute non A-E hepatitis. HGV RNA and anti-HGenv were present in 3.5% and 8.3% of those with chronic liver disease. HGV infection did not account for any of the acute non A-E hepatitis and most of the cryptogenic cirrhosis.

A tumor necrosis factor alpha- and interleukin 6-inducible protein that interacts with the small subunit of DNA polymerase delta and proliferating cell nuclear antigen

A cDNA encoding a protein of 36 kDa, polymerase delta-interacting protein 1 (PDIP1), that interacts with the small subunit (p50) of DNA polymerase delta (pol delta) was identified in a two-hybrid screen of a HepG2 cDNA library by using p50 as bait. The interaction of PDIP1 with p50 was confirmed by pull-down assays, and a similar assay was used to demonstrate that PDIP1 interacts directly with the proliferating cell nuclear antigen (PCNA). PCNA and p50 bound to PDIP1 simultaneously, and PDIP1 stimulated pol delta activity in vitro in the presence, but not the absence, of PCNA, suggesting that PDIP1 also interacts functionally with both p50 and PCNA. Subcellular localization studies demonstrated that PDIP1 is a nuclear protein that colocalizes with PCNA at replication foci. A putative PCNA-binding motif was identified within the C terminus of PDIP1, and a synthetic peptide containing this PCNA-binding motif was shown to bind PCNA by far-Western analysis. Northern analysis demonstrated that PDIP1 mRNA is present in a wide variety of human tissues. PDIP1 was found to be highly homologous to a previously identified protein, B12 [Wolf, F. W., Marks, R. M., Sarma. V., Byers, M. G., Katz, R. W., Shows, T. B. & Dixit, V. M. (1992) J. Biol. Chem. 267, 1317-1326], one of the early response genes induced by tumor necrosis factor alpha. PDIP1 synthesis can also be induced by tumor necrosis factor alpha and by IL-6, cytokines essential for liver regeneration after loss of hepatic tissue. It is suggested that PDIP1 provides a link between cytokine activation and DNA replication in liver as well as in other tissues.

Hyperglycemia and its related factors in Taiwanese middle-aged adults

Our study used data collected in Chung-Hsing Village to evaluate the relationship between hyperglycemia and its related factors in Taiwanese middle-aged adults in May 1998. All government employees at the Taiwan Provincial Government in Chung-Hsing Village aged 40-64 years were candidates for this study. Only 708 volunteers completed a structured questionnaire and underwent venous blood tests. To study the significant related factors of hyperglycemia, the t-test, chi(2) analysis and multivariate logistic regression were used. Our results showed that 40% of the 708 subjects were men and 60% were women. The mean age was 50.5 plus minus 6.8 years. The mean values of fasting glucose were 4.68 plus minus 1.92 mmol/L in men and 4.70 plus minus 1.70 mmol/L in women (P > 0.05). The proportions of hyperglycemia were 6.4% in men and 5.7% in women (P > 0.05). After controlling for other covariates, the multivariate logistic regression analysis showed that the significant related factors for hyperglycemia were older age (odds ratio=2.86, 95%; confidence interval=1.36-6.05; P < 0.01) and hypertriglyceridemia (odds ratio=3.34, 95%; confidence interval=1.68-6.64; P < 0.001).

Concurrent de novo autoimmune hepatitis and recurrence of primary biliary cirrhosis post-liver transplantation

Primary biliary cirrhosis (PBC) is well known to recur after liver transplantation (LT). The recurrence is usually subclinical and evident only on histological examination. Recently, a new entity of de novo autoimmune hepatitis (AIH) has emerged that occurs after LT in patients who underwent transplantation for diseases other than AIH. This new condition occurs more often in children; however, there was a recent report of the first 2 cases in adults who originally underwent LT for PBC. We report the first case of concurrent de novo AIH and recurrence of PBC documented on the liver biopsy of an adult patient who underwent LT for end-stage PBC. Unlike the earlier report of 2 adults, our patient manifested an antinuclear antibody titer of more than 1/800 from a previously negative titer pre-LT, as well as fulfilled the International AIH Group criteria for a definite diagnosis of AIH. PBC recurrence was evidenced by typical florid duct lesion, antimitochondrial antibody titer increasing from 1/40 to greater than 1/800, and an elevated serum immunoglobulin M level. After the addition of azathioprine to baseline immunosuppression of tacrolimus and prednisolone, the patient responded rapidly, with complete normalization of liver test results.

Epidemiology of serum aminotransferase activities in the elderly

BACKGROUND

Our study used data collected in Chung-Hsing Village in May 1998 to explore the distribution of serum aminotransferase activities and the relationship between aminotransferase and its related factors in the elderly.

METHODS

All individuals aged 65 and over were recruited as study subjects. A total of 1093 persons, out of 1774 registered residents, were contacted by face-to-face interview. The response rate was 61.6 percent. However, only 586 subjects had blood tests and completed questionnaires. Analysis in this study was based on these 586 subjects. In order to study the significant related factors of abnormal aminotransferase activities, the t-test, ANOVA, chi-square analysis, and multivariate logistic regression were used.

RESULTS

There were 66 percent men and 34 percent women. The mean age was 73.1 +/- 5.3 years. The mean values of aspartate aminotransferase (AST) were 29.3 +/- 14.5 u/l in men and 27.8 +/- 10.7 u/l in women (p > .05). The mean values of alanine aminotransferase (ALT) were 30.9 +/- 25.2 u/l in men and 26.3 +/- 12.6 u/l in women (p < .01). The abnormality rates of AST (> or = 40 u/l) were 10.5 percent in men and 12.2 percent in women (p > .05). The abnormality rates of ALT (> or = 40 u/l) were 16.7 percent in men and 12.6 percent in women (p > .05). After controlling for the other covariates, the multivariate logistic regression analysis showed that the significant related factor of abnormal AST was retirement status (odds ratio 4.4; 95 percent confidence interval = 1.5-13.3; p < .01). The significant related factors of abnormal ALT were obesity (odds ratio = 2.2; 95 percent confidence interval = 1.1-4.2; p < .05) and hypertriglyceridemia (odds ratio = 2.7; 95 percent confidence interval = 1.5-4.9; p < .01).

CONCLUSIONS

We raise the hypothesis that evidence of liver disease with abnormal ALT may co-vary with other indicators of chronic diseases. A large-scale investigation will be suggested in the future to demonstrate the causal-effect issue between abnormal ALT and obesity or hypertriglyceridemia.

A case of alpha-fetoprotein-producing gastric cancer

INTRODUCTION

A case of alpha-fetoprotein (AFP)-producing gastric cancer is described in a 57-year-old Chinese woman.

CLINICAL PICTURE

She presented with bleeding tendency and bone pain, and was found to have haematological evidence of disseminated intravascular coagulation and spinal metastasis. Her tumour markers, including AFP, Ca 19-9 and carcinoembryonic antigen (CEA) were elevated. In view of the elevated tumour markers, there was an exhaustive search for a primary lesion in the gastrointestinal tract, liver and ovaries. There was no radiological evidence to suggest any lesion in the chest, liver or pelvis. Lectin affinity electrophoresis of the AFP showed AFP-L2 and AFP-L3 bands, which are suggestive of a non-hepatoma malignancy.

MANAGEMENT

Gastroscopy showed a gastric ulcer and she developed bleeding after the gastric biopsy which required urgent surgery. Intraoperatively she was found to have carcinomatous peritone and a malignant ulcer in the greater curve of the stomach. Histology confirmed a linitis plastica like adenocarcinoma which stains for AFP.

OUTCOME

She died from multi-organ failure 3 days after surgery.

CONCLUSION

AFP-producing adenocarcinoma of the stomach is not uncommon. Lectin affinity electrophoresis of AFP is helpful in the differentiation between hepatoma and non-hepatoma malignancies.