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Koh HK, Fook-Chong SMC, Lee HY. Improvement of Mortality Prognostication in Patients With Epidermal Necrolysis: The Role of Novel Inflammatory Markers and Proposed Revision of SCORTEN (Re-SCORTEN). JAMA Dermatol 2022; 158:160-166. [PMID: 34935871 PMCID: PMC8696686 DOI: 10.1001/jamadermatol.2021.5119] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Epidermal necrolysis is a severe cutaneous adverse reaction in which severe systemic inflammation results in extensive epithelial keratinocyte necrosis. The most commonly used prognostic score in epidermal necrolysis, the Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN), was recently found to overestimate mortality in contemporary cohorts. Identification of independent prognostic markers may help to stratify risk more accurately. OBJECTIVE This study evaluates the association between novel inflammatory markers and in-hospital mortality in patients with epidermal necrolysis to study the incremental prognostic value of these markers in combination with SCORTEN. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted over a 17-year period from 2003 to 2019. Patients were enrolled from Singapore General Hospital, the national referral center for epidermal necrolysis. A total of 196 patients with epidermal necrolysis were recruited, 4 (2%) of whom were excluded owing to incomplete data. MAIN OUTCOMES AND MEASURES The main outcome assessed was the in-hospital mortality rate. Discrimination and calibration of risk scores were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plot, respectively. Evaluation of the incremental prognostic value of these markers was done by comparing the AUC between the old and new risk score, and the use of net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS Among 192 total patients (median [IQR] age 56 [42-70] years; 114 [59.4%] women), there were 43 (22.4%) who did not survive to discharge. Of the novel inflammatory markers, only red cell distribution width to hemoglobin ratio was significant in predicting in-hospital mortality (odds ratio [OR] 3.55; 95% CI, 1.76-7.16; P < .001) after adjusting for SCORTEN. The RDW/Hb as applied in 4 risk groups showed similar discrimination to SCORTEN (AUC [95% CI]: RDW/Hb in 4 groups, 0.76 [0.69-0.84], vs SCORTEN, 0.78 [0.70-0.85], P = .89). When RDW/Hb was added to SCORTEN, the composite score Re-SCORTEN showed significantly better discrimination than SCORTEN alone (AUC [95% CI]: Re-SCORTEN, 0.83 [0.77-0.89], vs SCORTEN, 0.78 [0.70-0.85], P = .02). The overall NRI was 0.94 (95% CI, 0.68-1.20), P < .001. The IDI was 0.06 (95% CI 0.03-0.08), P < .001. Re-SCORTEN showed good calibration based on the calibration plot. CONCLUSIONS AND RELEVANCE In this cohort of patients, RDW/Hb, an inexpensive and readily available marker, showed similar predictive accuracy with SCORTEN. Furthermore, when used in combination with SCORTEN, it also helped augment prognostic ability.
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Affiliation(s)
- Hui Kai Koh
- Department of Internal Medicine, Singapore General Hospital, Singapore
| | | | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Singapore,Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore,Allergy Center, Singapore General Hospital
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Upadhyaya VS, Lim GH, Chan EYK, Fook-Chong SMC, Leong LCH. Evaluating the preoperative breast cancer characteristics affecting the accuracy of axillary ultrasound staging. Breast J 2019; 26:162-167. [PMID: 31562691 DOI: 10.1111/tbj.13635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 04/23/2019] [Revised: 08/31/2019] [Accepted: 09/06/2019] [Indexed: 11/30/2022]
Abstract
We evaluate the preoperative breast cancer (BC) characteristics that affect the diagnostic accuracy of axillary ultrasound (US) and determine the reliability of US in the different subgroups of BC patients. Axillary US assessments in women with invasive BC diagnosed between 2009 and 2016 in a single institution were retrospectively reviewed. The diagnostic accuracy of axillary US was obtained using surgical nodal histology as the gold standard. Preoperative breast tumor sonographic and histological factors affecting axillary US diagnostic accuracy were examined. Of the 605 newly diagnosed invasive BC cases reviewed, 251 (41.5%) had nodal metastases. Axillary US sensitivity was 75.7%, specificity 92.9%, positive predictive value 88.4%, negative predictive value 84.4%, and false-negative rate 24.3%. Lower US sensitivity was seen with invasive lobular cancer (ILC) (P = .043), grade I/II, (P = .021), unifocal (P = .039), and smaller tumors (P < .001). US specificity was lower in grade III (P < .001), estrogen receptor (ER)-negative (P < .001), progesterone receptor (PR)-negative (P = .004), HER2-positive (P = .015), triple-negative (P = .001), and larger breast tumors (P < .001). US has moderate sensitivity and good specificity in detecting metastatic axillary lymph nodes. Based on preoperative cancer characteristics, US was less sensitive for nodal metastases from ILC, unifocal, lower grade, and smaller breast tumors. It was also less specific in grade III, ER-negative, PR-negative, HER2-positive, triple-negative, and larger breast tumors. Caution is suggested in interpreting the US axillary findings of patients with these preoperative tumor features.
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Affiliation(s)
| | - Geok Hoon Lim
- Breast Department, KK Women's and Children's Hospital, Singapore
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Poon WB, Fook-Chong SMC, Ler GYL, Loh ZW, Yeo CL. Creation and validation of the Singapore birth nomograms for birth weight, length and head circumference based on a 12-year birth cohort. Ann Acad Med Singap 2014; 43:296-304. [PMID: 25028138] [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: 06/03/2023]
Abstract
INTRODUCTION Both gestation and birth weight have significant impact on mortality and morbidity in newborn infants. Nomograms at birth allow classification of infants into small for gestational age (SGA) and large for gestational age (LGA) categories, for risk stratification and more intensive monitoring. To date, the growth charts for preterm newborn infants in Singapore are based on the Fenton growth charts, which are constructed based on combining data from various Western growth cohorts. Hence, we aim to create Singapore nomograms for birth weight, length and head circumference at birth, which would reflect the norms and challenges faced by local infants. MATERIALS AND METHODS Growth parameters of all babies born or admitted to our unit from 2001 to 2012 were retrieved. Following exclusion of outliers, nomograms for 3 percentiles of 10th, 50th, and 90th were generated for the gestational age (GA) ranges of 25 to 42 weeks using quantile regression (QR) combined with the use of restricted cubic splines. Various polynomial models (second to third degrees) were investigated for suitability of fit. The optimum QR model was found to be a third degree polynomial with a single knotted cubic spline in the mid-point of the GA range, at 33.5 weeks. Check for goodness of fit was done by visual inspection first. Next, check was performed to ensure the correct proportion: 10% of all cases fall above the upper 90th percentile and 10% fall below the lower 10th percentile. Furthermore, an alternative formula-based method of nomogram construction, using mean, standard deviation (SD) and assumption of normality at each gestational age, was used for counterchecking. RESULTS A total of 13,403 newborns were included in the analysis. The new infant-foetal growth charts with respect to birth weight, heel-crown length and occipitofrontal circumference from 25 to 42 weeks gestations with the 10th, 50th and 90th were presented. CONCLUSION Nomograms for birth weight, length and head circumference at birth had significant impact on neonatal practice and validation of the Singapore birth nomograms against Fenton growth charts showed better sensitivity and comparable specificity, positive and negative predictive values.
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Affiliation(s)
- Woei Bing Poon
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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Peeraully T, Hameed S, Cheong PT, Pavanni R, Hussein K, Fook-Chong SMC, Tan EK. Complementary therapies in hemifacial spasm and comparison with other movement disorders. Int J Clin Pract 2013; 67:801-6. [PMID: 23869681 DOI: 10.1111/ijcp.12151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 02/06/2013] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES We determined the prevalence, range and factors influencing the use of complementary therapy among hemifacial spasm patients and compared the patterns of use of complementary therapies across different movement disorders in a systematic pooled analysis of published literature. METHODS A structured questionnaire was administered to 96 hemifacial spasm patients evaluating frequency of complementary therapy use, and factors influencing patients' decision to seek these therapies. We also performed a PubMed search of epidemiology studies on use of complementary therapies in movement disorders. RESULTS Fifty-one per cent of patients had tried complementary therapies, of which 47% reported some perceived benefit and 4.1% informed their doctor. Acupuncture (71.4%) and facial massage (17.6%) were most commonly used. Complementary therapy use was associated with greater HFS severity. The mean cost of treatment was about $78 per month. We identified eight articles on use of complementary therapies in movement disorders; Parkinson's disease (5), Tourette syndrome (2) and dystonia (1). Twenty-five to 88% of patient had tried complementary therapies, of which 32-70% reported some benefit. Trials of acupuncture (2-63%) and massage (7-38%) were reported across the spectrum of movement disorders studied. Mean cost of complementary therapies varied from 43 to 102 USD per month. CONCLUSION Complementary therapies are used by over 50% of HFS patients, and the use is correlated with severity of disease. Despite differences in race, culture and population demographics, acupuncture and massage are used by patients across the spectrum of movement disorders.
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Affiliation(s)
- T Peeraully
- Department of Neurology, Singapore General Hospital, Singapore
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Lee AYJ, Tan J, Koh J, Fook-Chong SMC, Lo NN, Howe TS. Five-year outcome of individuals with hip fracture admitted to a Singapore hospital: quality of life and survival rates after treatment. J Am Geriatr Soc 2012; 60:994-6. [PMID: 22587868 DOI: 10.1111/j.1532-5415.2012.03936.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
PURPOSE To determine whether continuous infiltration of local anaesthetic can reduce the pain score and morphine use over 48 hours after total knee arthroplasty (TKA). METHODS 11 men and 43 women aged 50 to 82 years who underwent unilateral TKA for osteoarthritis were recruited. They were randomised into 3 groups. In group 1, 17 patients who acted as controls received patient-controlled analgesia (PCA) with intravenous morphine for 48 hours. In group 2, 16 patients received continuous infiltration of bupivacaine to the subcutaneous tissue and intra-articular space for 48 hours, in addition to PCA. In group 3, 21 patients received an intra-articular injection of local anaesthetic, followed by continuous infiltration of bupivacaine to the subcutaneous tissue and intraarticular space for 48 hours, in addition to PCA. For each patient, a visual analogue score (VAS) for pain was recorded postoperatively at 2, 4, 6, 12, 24, 36, and 48 hours. The total amount of morphine used was recorded at 24 and 48 hours. RESULTS Over 48 hours, the VAS for pain and morphine use was significantly higher in controls than patients in groups 2 and 3. CONCLUSION Continuous infiltration of local anaesthetic into the intra-articular space and subcutaneous tissues, in addition to PCA with intravenous morphine, provides significantly more pain relief and reduces morphine use.
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Affiliation(s)
- Johnny C A Ong
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
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Tan KBL, Fook-Chong SMC, Lee SL, Tan LK. Foetal peak systolic velocity in the middle cerebral artery: an Asian reference range. Singapore Med J 2009; 50:584-586. [PMID: 19551310] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION The aim of this study was to establish reference values of peak systolic blood flow velocity measurement in the foetal middle cerebral artery (MCA-PSV) in the local Asian obstetric population and to compare our reference ranges with those of previously-published studies. METHODS 329 normal pregnant women attending the outpatient antenatal clinics of the Department of Obstetrics and Gynaecology in the Singapore General Hospital underwent Doppler ultrasonography at least once between 16 and 40 weeks' gestation. The blood flow velocity recordings from the foetal middle cerebral artery were obtained. New reference ranges were constructed by regressing each parameter on gestational age. RESULTS New reference ranges for foetal middle cerebral artery with gestation were constructed for an Asian population. Our reference curves were compared with that of a previously-constructed one. CONCLUSION MCA-PSV increases with advancing gestational age. There appear to be differences between Asian and non-Asian reference ranges for MCA-PSV.
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Affiliation(s)
- K B L Tan
- Clinical Research Centre, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, #02-02, 10 Medical Drive, Singapore.
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Lim LL, Tham KW, Fook-Chong SMC. Obstructive sleep apnoea in Singapore: polysomnography data from a tertiary sleep disorders unit. Ann Acad Med Singap 2008; 37:629-636. [PMID: 18797554] [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: 05/26/2023]
Abstract
INTRODUCTION Comprehensive sleep architecture and respiratory event data in local patients with suspected obstructive sleep apnoea (OSA) from overnight polysomnography (PSG), the gold standard for the evaluation of sleep-related breathing disorders, are not widely available. We present 1 year retrospective PSG data with the objective of describing PSG characteristics of patients evaluated for OSA in Singapore. MATERIALS AND METHODS PSG data of patients evaluated for OSA in 1 year (January through December 2005) in the Sleep Laboratory of a public tertiary hospital were retrospectively reviewed. RESULTS Five hundred and eighty-four diagnostic PSG studies were performed in patients with symptoms suggestive of sleep-disordered breathing, including snoring, excessive daytime sleepiness, unrefreshing sleep, or recurrent unexplained awakenings. There were 449 male patients (76.9%) and 135 female patients (23.1%), with a mean age of 47.5 years (SD 12.7). Men were on average younger than women, 46.1 years versus 52.0 years (P <0.0005). The mean body mass index (BMI) was 27.9 (SD 6.7), with no significant difference between genders. An association was shown between apnoea-hypopnoea index (AHI) and BMI (Pearson correlation index r = 0.362). Men had overall significantly higher AHI (16.5 vs 9), shorter mean sleep onset latency (11 vs 16.5 minutes), more light sleep (65.5% vs 58.9%), less deep sleep (17.7% vs 23%), and more respiratory event related arousals per hour of sleep (11.6 vs 5.1) (P <0.0005). Severity was classified: AHI <5 ("Normal Overall AHI") (28.3%), AHI 5-15 ("Mild") (22.3%), AHI >15-30 ("Moderate") (18.3%), AHI >30 ("Severe") (31.2%). There was no significant age difference among the 4 groups. More severe OSA patients were significantly heavier, and had more light sleep, less deep sleep, less REM sleep, more respiratory event related arousals and lower levels of oxygen desaturation. CONCLUSION OSA is predominant in middle-aged, overweight Singapore males and much less common in females who tend to be older. A majority of patients have moderate to severe OSA, which significantly disturbs normal sleep architecture. The relatively lower BMI compared to Caucasian OSA populations may be related to local craniofacial characteristics and/or higher percentage of body fat for BMI which has been described in Singaporeans.
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Affiliation(s)
- Li Ling Lim
- Singapore Neurology & Sleep Centre, Gleneagles Medical Centre, Singapore.
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9
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Katory M, Tang CL, Koh WL, Fook-Chong SMC, Loi TT, Ooi BS, Ho KS, Eu KW. A 6-year review of surgical morbidity and oncological outcome after high anterior resection for colorectal malignancy with and without splenic flexure mobilization. Colorectal Dis 2008; 10:165-9. [PMID: 17506796 DOI: 10.1111/j.1463-1318.2007.01265.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE High anterior resection (HAR) for colorectal cancer is traditionally performed with routine mobilization of the splenic flexure. This is a retrospective review of mortality and morbidity following HAR in which the splenic flexure has been preserved. METHOD From a prospective database, all patients who had undergone elective HAR for colorectal cancer between 1999 and 2005 were identified. Morbidity, mortality, pathology and survival data for patients having HAR with and without splenic flexure mobilization were analysed. RESULTS A total of 707 patients were identified. Five hundred and thirty-one had HAR with preservation of the splenic flexure. In these patients outcome was: anastomotic leak (0.4%), wound infection (3.6%), anastomotic stricture (0.4%) and 30-day mortality (0.9%). No statistical significant difference was found for postoperative morbidity (P = 0.1926), 30-day mortality (P =0.3285), lymph node harvest (P = 0.2127) or survival (P = 0.1457) compared with patients in whom the splenic flexure was mobilized. Longitudinal resection margins were greater following HAR with splenic flexure mobilization (P < 0.0001). CONCLUSION No morbidity, oncological or survival disadvantage in performing splenic flexure preserving HAR was found.
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Affiliation(s)
- M Katory
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Tan EK, Lu ZY, Fook-Chong SMC, Tan E, Shen H, Chua E, Yih Y, Teo YY, Zhao Y. Exploring an interaction of adenosine A2A receptor variability with coffee and tea intake in Parkinson's disease. Am J Med Genet B Neuropsychiatr Genet 2006; 141B:634-6. [PMID: 16823803 DOI: 10.1002/ajmg.b.30359] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Caffeine is an adenosine receptor A1 and A2A receptor antagonist and a putative functional genetic variant of the A2A receptor (2592C > Tins) mediates caffeine-induced anxiety. Here we investigated the potential interaction of this A2A genetic variant with the quantity of coffee and tea intake and their relationship with the risk of PD. A total of 441 subjects consisting of 222 PD and 219 race, gender and age matched controls were included. A multivariate analysis of the variables including the 2592C > Tins A2A genotypes, age of onset, gender, and the quantity of tea and coffee intake, interaction of the A2A genotypes with coffee intake, interaction of A2A genotypes with tea intake demonstrated the quantity of coffee intake to be significantly associated with PD (P < 0.0005, OR = 0.922, 95% CI: 0.881, 0.964). However, there was no significant interaction of the A2A genotypes with the quantity of coffee and tea intake in modulating the risk of PD. The dose dependent protective effect of coffee intake in PD was independent of the 2592C > Tins A2A genotype suggesting that the pharmacogenetic action of caffeine in PD may be mediated differently from other caffeine-induced neurologic syndromes.
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Affiliation(s)
- E K Tan
- Department of Neurology, Singapore General Hospital, Singapore
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Prakash KM, Fook-Chong SMC, Leoh TH, Dan YF, Nurjannah S, Tan YE, Lo YL. The lower subscapular nerve conduction studies and utilisation in brachial plexopathy evaluation. J Neurol Sci 2006; 247:77-80. [PMID: 16647087 DOI: 10.1016/j.jns.2006.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Revised: 03/16/2006] [Accepted: 03/16/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To define the optimal nerve conduction study (NCS) method of lower subscapular nerve and evaluate its clinical utility. METHODS Thirty healthy adults (8 males) with a mean age of 45.2+/-16.5 (range, 21-75) years were recruited in this study. A total of sixty nerves were studied using the Dantec Counterpoint EMG machine (Dantec, Skovlunde, Denmark). 6 patients with clinical and electrodiagnostic evidence of brachial plexopathy were also evaluated. RESULTS The mean+/-2 standard deviation values of the distal latencies, base-to-peak amplitudes and inter-side amplitude ratio were 2.38+/-0.52 (range, 1.80-2.90) ms, 13.10+/-5.10 (range, 8.70-21.10) mV and 0.93+/-0.12 (range, 0.67-1.00), respectively. There was a significant correlation between the subject age and the base-to-peak amplitudes. All 6 patients with brachial plexopathy had reduced base-to-peak amplitudes as well as inter-side amplitude ratio of less than 0.67 (the normal limits for control). CONCLUSION The lower subscapular NCS were satisfactorily recordable and well tolerated. It was useful in evaluation of patients with brachial plexopathy.
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Affiliation(s)
- Kumar M Prakash
- Department of Neurology, National Neuroscience Institute (SGH campus), Singapore General Hospital, Singapore 169608, Singapore.
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Low WK, Toh ST, Wee J, Fook-Chong SMC, Wang DY. Sensorineural hearing loss after radiotherapy and chemoradiotherapy: a single, blinded, randomized study. J Clin Oncol 2006; 24:1904-9. [PMID: 16622266 DOI: 10.1200/jco.2005.05.0096] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The synergistic ototoxicity of radiation and cisplatin (CDDP) has not been adequately studied. This study investigated whether the use of concurrent and postradiotherapy CDDP in patients with nasopharyngeal carcinoma (NPC) resulted in a difference in postradiotherapy sensorineural hearing when compared with the use of radiotherapy alone. PATIENTS AND METHODS Newly diagnosed patients were randomly assigned to the radiotherapy or chemoradiotherapy groups. Bone conduction hearing thresholds were performed before treatment and at 1 week, 6 months, 1 year, and 2 years after completion of radiotherapy. Statistical analysis was performed using the Mann-Whitney U test. RESULTS Hearing thresholds averaged over 0.5, 1, and 2 kHz were found to be poorer in the chemoradiotherapy group (58 patients) compared with the radiotherapy group (57 patients) at 1 year (P = .001) and 2 years (P = .03) after radiotherapy. Hearing thresholds at 4 kHz were significantly worse for patients in the chemoradiotherapy arm at all of the postradiotherapy time points studied and were more severely affected than the thresholds at lower speech frequencies. In the radiotherapy group, deterioration of median hearing thresholds, which occurred in the immediate post-treatment period, improved within the first year but deteriorated again at 2 years. In the chemoradiotherapy group, median hearing threshold deterioration, which started immediately after radiotherapy, stabilized by 1 year. CONCLUSION Patients with NPC who received radiotherapy and concurrent/adjuvant chemotherapy using CDDP experienced greater sensorineural hearing loss compared with patients treated with radiotherapy alone, especially to high-frequency sounds in the speech range. Normal inner ear tissue tolerance, which was once defined only for radiotherapy patients alone, should be redefined in chemoradiotherapy patients.
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Affiliation(s)
- Wong Kein Low
- Department of Otolaryngology, Singapore General Hospital, Singapore, Singapore.
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Abstract
STUDY OBJECTIVE To describe the clinical characteristics and outcome of patients with severe melioidosis requiring intensive care. DESIGN Retrospective chart review. SETTING Two ICUs from a tertiary-care teaching hospital. PATIENTS Twenty-seven adult ICU patients with microbiologically documented melioidosis. INTERVENTIONS None. MEASUREMENTS AND RESULTS The median age was 59 years with a male preponderance (26:1). Twenty patients (74%) had medical comorbidities, with diabetes mellitus being the most common (59.3%). Almost all patients (96.3%) were bacteremic. Twenty patients (74.1%) presented with pneumonia. Twenty patients (74.1%) were in septic shock, and 16 patients (59.3%) had ARDS. Twelve patients (44.4%) required hemodialysis. The patients had a median of three organ dysfunctions, and the median APACHE (acute physiology and chronic health evaluation) II score was 27. The overall mortality was 48.1%. Mortality among patients with septic shock was 60%. The median ICU length of stay for survivors and nonsurvivors was 11 days and 2 days, respectively. Multivariate analysis revealed that the number of organ dysfunctions is an independent predictor of mortality (odds ratio, 8.2; 95% confidence interval, 1.3 to 51.4). CONCLUSIONS The outcome of severe melioidosis requiring intensive care is poor, with death being predicted by the number of organ dysfunctions.
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Affiliation(s)
- Kenneth P W Chan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital.
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Sim LSJ, Hendriks JHCL, Bult P, Fook-Chong SMC. US correlation for MRI-detected breast lesions in women with familial risk of breast cancer. Clin Radiol 2005; 60:801-6. [PMID: 15978891 DOI: 10.1016/j.crad.2004.12.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Revised: 11/24/2004] [Accepted: 12/02/2004] [Indexed: 11/17/2022]
Abstract
AIM To examine the value of US correlation for MRI-detected breast lesions in women with familial risk of breast cancer. METHODS From an initial dataset of 245 women with positive family history who had breast cancer surveillance involving mammography or MRI between November 1994 and February 2001, 179 subjects with follow-up data were selected. A total of 43 women with 48 MRI-detected lesions underwent further assessment with US. Histopathological correlation was available from 38 breast biopsies performed for 33 women. RESULTS Sonographic correlates were identified in 32 (66.7%) of the 48 MRI-detected lesions, with cancer present in 11 (34.4%) of these. This compares with 1 (6.3%) cancer found in the 16 lesions without sonographic correlates. Of the 12 malignant lesions, 11 (91.7%) had sonographic correlates whereas 21 (58.3%) of the 36 benign lesions had sonographic correlates. In all 74% of breast biopsies were performed under US guidance compared with 8% under MRI guidance. The proportion of MRI- and US-correlated benign and malignant lesions undergoing US-guided biopsy were 85.7% and 90.9%, respectively. CONCLUSION The probability of cancer was significantly higher in MRI-detected breast lesions with sonographic correlates compared with those without such correlation. The advantage of convenient biopsy under US guidance as opposed to MRI guidance highlights the value of sonographic assessment of MRI-detected breast lesions.
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Affiliation(s)
- L S J Sim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
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Sim LSJ, Hendriks JHCL, Fook-Chong SMC. Breast ultrasound in women with familial risk of breast cancer. Ann Acad Med Singap 2004; 33:600-6. [PMID: 15531956] [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: 05/01/2023]
Abstract
INTRODUCTION The aim of this study was to assess the performance and value of breast ultrasound in women with familial risk of breast cancer. MATERIALS AND METHODS From an initial dataset of 245 women with positive family history who had breast cancer surveillance utilising mammography or magnetic resonance imaging (MRI) between November 1994 and February 2001, 179 subjects with follow-up data were selected. Eighty-four women had breast ultrasound done with histopathological correlation available from 48 breast biopsies performed in 42 women. RESULTS The sensitivity of ultrasound, mammography and MRI was 83.3%, 53.9% and 93.3%, respectively. The specificity of ultrasound, mammography and MRI was 65.5%, 85.7% and 63.6%, respectively. Ultrasound was the imaging modality with intermediate sensitivity, specificity, negative predictive value (NPV) and cancer detection rate. The sensitivity, specificity, positive predictive value (PPV), NPV and accuracy of combined mammography and ultrasound were 92.9%, 62.5%, 52.0%, 95.2% and 71.7%, respectively. These results did not differ significantly from MRI. Almost two-thirds of the breast biopsies were performed under ultrasound guidance. CONCLUSIONS Although breast ultrasound screening per se was not assessed in this study, extrapolation of these results to sonographic screening of high familial risk women would come at a better specificity to MRI, albeit with a 10% decrease in sensitivity but at a fraction of the cost of MRI. Ultrasound also provides the advantage of convenient imaging guidance for biopsy. Employing ultrasound following mammography would match MRI in sensitivity, specificity, PPV, NPV and accuracy, and should not be ignored in these women.
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Affiliation(s)
- L S J Sim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
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Koh LP, Hwang WYK, Tan CH, Linn YC, Goh YT, Chuah CTH, Ng HJ, Fook-Chong SMC, Tan PHC. Long term follow-up of Asian patients with chronic myeloid leukemia (CML) receiving allogeneic hematopoietic stem cell transplantation (HSCT) from HLA-identical sibling-evaluation of risks and benefits. Ann Hematol 2003; 83:286-94. [PMID: 15060748 DOI: 10.1007/s00277-003-0810-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2003] [Accepted: 10/09/2003] [Indexed: 10/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is the only known curative therapy for patients with chronic myeloid leukemia (CML), but is associated with significant morbidity and mortality. The recent introduction of imatinib mesylate (STI-571) and reduced intensity transplant regimens has made the choice of primary treatment for patients with CML increasingly difficult. We have evaluated the outcome of 53 patients who have received allogeneic HSCT from human leukocyte antigen (HLA)-identical sibling donors between October 1985 and March 2002, determined the variables affecting the outcome, and tried to define indications for this aggressive approach. Successful engraftment occurred in 49 (98%) of evaluable patients. Acute graft-versus-host disease (GVHD) of grade II to IV severity was observed in 63% of the evaluable patients whereas the incidence of chronic GVHD was 57.5%. The Kaplan-Meier estimate of survival at 10 years was 54% [95% confidence interval (CI): 38-70%] and 31% (95% CI: 6-56%) for patients with first chronic phase and more advanced diseases, respectively. Multivariate analysis showed that younger age, absence of grade III-IV GVHD, the use of busulphan and cyclophosphamide (BuCy) as preparative regimen, and transplantation performed after January 1992 were factors associated with improved survival. Patients who were 30 years of age or younger who had transplantation done within 1 year after diagnosis during their first chronic phase of disease had a particularly good prognosis, with a probability of surviving 10 years of 72% (95% CI: 52-92%). We conclude that allogeneic HSCT remains a feasible option for Asian patients with CML. The most favorable outcome is observed in younger patients with early phase of the disease.
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Affiliation(s)
- L P Koh
- Bone Marrow Transplantation Program, Department of Haematology, Singapore General Hospital, Outram Road, 169608, Singapore.
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Tan EK, Tan C, Fook-Chong SMC, Lum SY, Chai A, Chung H, Shen H, Zhao Y, Teoh ML, Yih Y, Pavanni R, Chandran VR, Wong MC. Dose-dependent protective effect of coffee, tea, and smoking in Parkinson's disease: a study in ethnic Chinese. J Neurol Sci 2003; 216:163-7. [PMID: 14607318 DOI: 10.1016/j.jns.2003.07.006] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Few studies have examined the relationship of coffee and tea in Parkinson's disease (PD). The potential protective effect of coffee intake and risk of PD has not been studied in a Chinese population. There is a high prevalence of caffeine takers among Chinese in our population. OBJECTIVE We undertook a case control study to examine the relationship between coffee and tea drinking, cigarette smoking, and other enviromental factors and risk of PD among ethnic Chinese in our population. METHODS AND RESULTS 300 PD and 500 population controls were initially screened. Two hundred case control pairs matched for age, gender, and race were finally included in the analysis. Univariate analysis revealed significant association of PD with coffee drinking (p<0.0005), tea drinking (p=0.019), alcohol drinking (p=0.001), cigarette smoking (p<0.0005), and exposure to heavy metals (p=0.006). Conditional logistic regression analysis demonstrated that amount of coffee drunk (OR 0.787, 95%CI 0.664-0.932, p=0.006), amount of tea drunk (OR 0.724, 95%CI 0.559-0.937, p=0.014), number of cigarettes smoked (OR 0.384, 95%CI 0.204-0.722, p=0.003), history of heavy metal and toxin exposure (OR 11.837, 95%CI 1.075-130.366, p=0.044), and heart disease (OR 5.518, 95%CI 1.377-22.116, p=0.016) to be significant factors associated with PD. One unit of coffee and tea (3 cups/day for 10 years) would lead to a 22% and 28% risk reduction of PD. One unit of cigarette smoke (3 packs/day for 10 years) reduced the risk of PD by 62%. CONCLUSIONS We demonstrated a dose-dependent protective effect of PD in coffee and tea drinkers and smokers in an ethnic Chinese population. A history of exposure to heavy metals increased the risk of PD, supporting the multifactorial etiologies of the disease.
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Affiliation(s)
- E-K Tan
- Department of Neurology, Singapore General Hospital, Singapore.
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Abstract
OBJECTIVES (1) To study the developmental changes of sphenoid sinus in Asian children and (2) to test the hypothesis that the sphenoid sinus may be developing slower in Asian, by comparing the growth patterns between Asian and Caucasian children. MATERIALS AND METHODS Review of MR imaging of the skull of 220 Asian children less than 15 years of age in a tertiary hospital. The results were compared to a representative Caucasian study by Szolar et al. [Surg. Radiol. Anat., 16 (1994) 193]. RESULTS Grade 1 sphenoid was present in all children less than 6 months old. Conversion from marrow to fat of the sphenoid sinus (Grade 2) began at 7 months and was present in patients up to 6 years old. Signs of pneumatization (Grade 3) of the sphenoid sinus were first noted in patients at 10 months old. Almost 100% pneumatization was seen in all the children after 6 years old except for one child with Grade 1 sphenoid at 11 years old. Compared to Caucasian children, there was a significantly higher proportion of Grade 3 cases in Asian children from 0 to 4 years of age (P = 0.05). No difference in the distribution of cases was noted from 4 to 8 years (P = 0.466) and 8-15 years (P = 1.00). CONCLUSION The developmental changes of the sphenoid sinus in Asian children were determined and found to be similar when compared to Caucasian children. The findings did not support the hypothesis that the Asian sphenoid sinus is developing slower compared to that of the Caucasians.
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Affiliation(s)
- Henry K K Tan
- Division of Pediatric Surgery, Otolaryngology Service, KK Women and Children Hospital, Singapore 229899.
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Affiliation(s)
- E K Tan
- Department of Neurology, Diagnostic Radiology, Singapore General Hospital, Singapore 169608, Republic of Singapore.
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Koh LP, Kurup A, Goh YT, Fook-Chong SMC, Tan PHC. Randomized trial of fluconazole versus low-dose amphotericin B in prophylaxis against fungal infections in patients undergoing hematopoietic stem cell transplantation. Am J Hematol 2002; 71:260-7. [PMID: 12447954 DOI: 10.1002/ajh.10234] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Over the past decade, invasive fungal infections have become an increasingly important problem in patients undergoing hematopoietic stem cell transplantation (HSCT). The optimal approach for prophylactic antifungal therapy has yet to be determined. To resolve this issue, we performed a prospective randomized study to compare the efficacy of fluconazole (FL) versus low-dose amphotericin B (AmB) in preventing fungal infections during the first 100 days after HSCT. Patients undergoing allogenic or autologous HSCT were randomized to receive fluconazole 200 mg/day PO or amphotericin B 0.2 mg/kg/day IV beginning 1 day prior to commencement of conditioning regimen and continuing until engraftment, drug-associated toxicity was suspected, or systemic fungal infection was suspected or proven. High-dose amphotericin B (0.5-1.0 mg/kg/day) was started for patients with suspected or proven fungal infections. From January 1993 to December 1998, a total of 186 patients were enrolled into the trial, with 100 receiving FL and 86 receiving AmB. Eighty (43%) patients were removed from prophylaxis for persistent fever despite broad-spectrum antibacterial therapy or suspected fungal infections (FL 46 vs. AmB 34, P > 0.05). The incidence of proven fungal infections (FL 12% vs. AmB 12.8%), suspected fungal infections (FL 4% vs. AmB 2.3%), superficial fungal infections (FL 1% vs. AmB 4.6%) did not show any significant difference. The survival at 100 days post transplant was similar between the 2 groups (FL 78% vs. AmB 70%, P = 0.254). Death attributable to fungal infections was similar in both groups (6% vs. 7%, P > 0.05). We conclude that fluconazole is as effective as low-dose amphotericin B in prophylaxis against fungal infections in patients undergoing hematopoietic cell transplantation.
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Affiliation(s)
- L P Koh
- Department of Hematology, Singapore General Hospital, Outram Road, Singapore 169608.
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Tan EK, Chai A, Zhao Y, Lum SY, Fook-Chong SMC, Teoh ML, Yih Y, Pavanni R, Wong MC. Mitochondrial complex I polymorphism and cigarette smoking in Parkinson's disease. Neurology 2002; 59:1288-9. [PMID: 12391372 DOI: 10.1212/01.wnl.0000031809.71668.a1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- E K Tan
- Department of Neurology, Singapore General Hospital, Singapore.
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Tan EK, Lum SY, Fook-Chong SMC, Teoh ML, Yih Y, Tan L, Tan A, Wong MC. Evaluation of somnolence in Parkinson's disease: comparison with age- and sex-matched controls. Neurology 2002; 58:465-8. [PMID: 11839852 DOI: 10.1212/wnl.58.3.465] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors found a significantly higher prevalence of daytime somnolence in 201 patients with PD compared with 214 age- and sex-matched healthy control subjects (Epworth Sleepiness Scale score 5.6 vs 4.6). The prevalence of "sleep attacks" (SA) was about seven times higher in patients with PD than in control subjects (13.9% vs 1.9%; p < 0.0005). Multivariate analysis demonstrated that a higher dose of levodopa and longer duration of disease significantly predicted for SA in patients with PD. Epworth Sleepiness Scale scores of > or =10 had 71.4% sensitivity and 88.4% specificity for SA.
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Affiliation(s)
- E K Tan
- Department of Neurology, Singapore General Hospital, Outram Road, Singapore 169608, Republic of Singapore.
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