Long term survival and disease burden from out-of-hospital cardiac arrest: a population-based cohort study

Background

Long-term outcomes of out-of-hospital cardiac arrest (OHCA) are important to evaluate the overall health burden of OHCA on society. The concept of disability-adjusted life years (DALY) have recently been utilised to measure disease burden in OHCA, but data in an Asian cohort remains limited. We aimed to quantify and identify predictors of long-term survival (up to 10 years follow up) in patients with OHCA, as well as to quantify the annual disease burden of OHCA estimated using DALY in a national multi-ethnic Asian cohort.

Methods

We conducted an open cohort study through the linkage of the Pan-Asian Resuscitation Outcomes Study and the Singapore Registry of Births and Deaths from 2010 to 2020 in Singapore [1]. We quantified long-term survival using the standardised mortality ratio (SMR) for each year of follow up and the annual disease burden using DALY. Predictors of long-term survival were identified using cox-proportional hazards models. Kaplan-Meier survival curves were constructed for the overall population, and by key characteristics. The proportion surviving (and 95% CI) was calculated for up to eight years post-OHCA.

Results

We included 802 cases in the analysis. The mean age was 56.0 (SD 17.8), 631 cases (78.7%) were male, and the majority (552 cases, 68.8%) were of Chinese ethnicity (Table 1). The proportion surviving at one year of follow up was 0.84 (95% CI: 0.81–0.87), at five years of follow up was 0.68 (95% CI 0.65–0.72), and at ten years of follow up was 0.62 (95% CI 0.57–0.67) (Figure 1). Age at arrest (HR 1.03, 95% CI: 1.02–1.04, p<0.001), shockable first arrest rhythm (HR 0.75, 95% CI: 0.52–0.93, p=0.015) and Cerebral Performance Category (CPC) (HR 4.62, 95% CI: 3.17–6.75, p<0.001) were independently associated with mortality (Figure 2, 3). At one year, the SMR was 14.9 (95% CI: 12.5–17.8), and this decreased to 1.2 (95% CI: 0.7–1.8) at three years, and 0.4 (95% CI: 0.2–0.8) at five years (Figure 4). The top three causes of death after OHCA based on ICD10 categories were pneumonia, chronic ischemic heart disease, and acute myocardial infarction. The total DALY increased from 304.1 in 2010 to 849.7 in 2015, followed by decreasing to 547.1 in 2018. The mean DALY decreased from 12.162 in 2010 to 3.599 in 2018.

Conclusions

Age at arrest and CPC category was independently associated with higher risk of mortality, while a shockable first arrest rhythm was independently associated with a lower risk of mortality in long-term OHCA survivors. Initial survivors of OHCA have an increased mortality rate compared to the general population for the first three years, but normalises to that of the general population subsequently, while the annual disease burden of OHCA quantified using DALY showed decreasing trends from 2010 to 2018. Further improvements in the surveillance and management of OHCA may be warranted to improve the long-term survivorship and decrease the burden of disease of OHCA globally.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council, Clinician Scientist Award, Singapore (NMRC/CSA/024/2010 and NMRC/CSA/0049/2013), Ministry of Health, Health Services Research Grant, Singapore (HSRG/0021/2012)

The association of smoking status with glycemic control, metabolic profile and diabetic complications- Results of the Australian National Diabetes Audit (ANDA)

BACKGROUND

Tobacco smoking and diabetes mellitus contribute significantly to the overall health burden and mortality of Australians. We aimed to assess the relationship of smoking with glycemic control, metabolic profile and complications in Australian patients living with diabetes.

METHODS

We analysed the 2011-2017 biennial Australian National Diabetes Audit cross-sectional data. Patients were classified as current, past or never smokers. Linear (or quantile) and logistic regression models were used to assess for associations.

RESULTS

Data from 15,352 patients were analysed, including 72.2% with type 2 diabetes. Current smokers comprised 13.5% of the study population. Current and past smokers had a median HbA_1c that was 0.49% and 0.14% higher than never smokers, respectively, as well as higher triglyceride and lower HDL levels (all p values < .0001). Compared to never smokers, current smokers had higher odds of severe hypoglycemia and current and past smokers had higher odds of myocardial infarction, stroke, peripheral vascular disease, lower limb amputation, erectile dysfunction and peripheral neuropathy (all p values ≤.001), with no significant change over time.

CONCLUSION

When compared to never smokers, current and past smokers had poorer glycemic and lipid control and higher odds of macrovascular and microvascular complications. Despite this, current smoking remains prevalent among Australians with diabetes.

Impact of different glycaemic treatment targets on pregnancy outcomes in gestational diabetes

AIM

With no current randomized trials, we explored the impact of tight compared with standard treatment targets on pregnancy outcomes in gestational diabetes mellitus (GDM).

METHODS

This cohort study of singleton births ≥ 28 weeks' gestation was conducted at two major Australian maternity services (2009-2013). Standardized maternal, neonatal and birth outcomes were examined using routine healthcare data and compared for women with GDM at Service One (n = 2885) and Service Two (n = 1887). Services applied different treatment targets: Service One (standard targets, reference group) fasting < 5.5 mmol/l, 2-h postprandial < 7.0 mmol/l; Service Two (tight targets) fasting < 5.0 mmol/l, 2-h postprandial < 6.7 mmol/l. Multivariable regression with propensity score adjustment was used to examine associations between targets and outcomes.

RESULTS

GDM prevalence and insulin use were 7.9% and 31% at Service One, and 5.7% and 46% at Service Two. There were no differences in primary outcomes: birthweight > 90th centile [adjusted odds ratio (OR) 1.06, 95% confidence interval (CI) 0.87-1.30] and < 10th centile (OR 0.84, 95% CI 0.70-1.01), or secondary outcomes gestational hypertension, pre-eclampsia, shoulder dystocia or a perinatal composite. Service Two with tight targets had increased induction of labour (OR 3.63, 95% CI 3.17-4.16), elective Caesarean section (OR 1.75, 95% CI 1.37-2.23) and Apgar scores < 7 at 5 min (OR 1.54, 95% CI 1.05-2.25), decreased hypoglycaemia (OR 0.76, 95% CI 0.61-0.94]), jaundice (OR 0.47, 95% CI 0.35-0.63) and respiratory distress (OR 0.68, 95% CI 0.47-0.98).

CONCLUSIONS

Tight GDM treatment targets were associated with greater insulin use and no difference in primary birthweight outcomes. The service with tight targets had higher obstetric intervention, lower rates of reported hypoglycaemia, jaundice, respiratory distress and lower Apgar scores. High-quality interventional data are required before tight treatment targets can be implemented.

Weight loss after laparoscopic adjustable gastric band and resolution of the metabolic syndrome and its components

BACKGROUND

Substantial weight loss in the setting of obesity has considerable metabolic benefits. Yet some studies have shown improvements in obesity-related metabolic comorbidities with more modest weight loss. By closely monitoring patients undergoing bariatric surgery, we aimed to determine the effects of weight loss on the metabolic syndrome and its components and determine the weight loss required for their resolution.

METHODS

We performed a prospective observational study of obese participants with metabolic syndrome (Adult Treatment Panel III criteria) who underwent laparoscopic adjustable gastric banding. Participants were assessed for all criteria of the metabolic syndrome monthly for the first 9 months, then 3-monthly until 24 months.

RESULTS

There were 89 participants with adequate longitudinal data. Baseline body mass index was 42.4±6.2 kg m^-2 with an average age was 48.2±10.7 years. There were 56 (63%) women. Resolution of the metabolic syndrome occurred in 60 of the 89 participants (67%) at 12 months and 60 of the 75 participants (80%) at 24 months. The mean weight loss when metabolic syndrome resolved was 10.9±7.7% total body weight loss (TBWL). The median weight loss at which prevalence of disease halved was 7.0% TBWL (17.5% excess weight loss (EWL)) for hypertriglyceridaemia; 11% TBWL (26.1-28% EWL) for high-density lipoprotein cholesterol and hyperglycaemia; 20% TBWL (59.5% EWL) for hypertension and 29% TBWL (73.3% EWL) for waist circumference. The odds ratio for resolution of the metabolic syndrome with 10-12.5% TBWL was 2.09 (P=0.025), with increasing probability of resolution with more substantial weight loss.

CONCLUSIONS

In obese participants with metabolic syndrome, a weight loss target of 10-12.5% TBWL (25-30% EWL) is a reasonable initial goal associated with significant odds of having metabolic benefits. If minimal improvements are seen with this initial target, additional weight loss substantially increases the probability of resolution.

Latent tuberculosis in patients with diabetes mellitus: prevalence, progression and public health implications

BACKGROUND

Diabetes mellitus (DM) confers a higher risk for tuberculosis (TB). Yet, TB screening and chemoprophylaxis for latent TB infection (LTBI) in DM remains controversial. We conducted a cross-sectional study to elucidate LTBI prevalence and longitudinal follow-up to ascertain LTBI to active TB progression rate in DM.

METHODS

220 DM patients without previous TB from the outpatient diabetes clinic of the hospital were enrolled. T-Spot TB, tuberculin-skin-test (TST) and chest radiography (CXR) were performed. LTBI was defined by negative CXR with reactive T-Spot TB. Progression to active TB was confirmed by cross-checking against the TB registry.

RESULTS

The prevalence of LTBI was 28.2% (62/220) by reactive T-Spot. None progressed to active TB from 2007-2013. Multivariate analysis revealed that any co-morbidity (p=0.016) was positively associated while metformin (p=0.008) was negatively associated with LTBI.

CONCLUSIONS

Over a quarter of DM patients harbor LTBI. While the lack of demonstrable progression to active TB within the follow-up time frame up to this point does not unequivocally support a routine TB screening policy or anti-TB chemoprophylaxis for LTBI in a diabetic population for now, this preliminary evidence needs re-evaluation with longer follow-up of this enrolled cohort over the next decade.

The effect of comorbidity on hospital mortality in patients with SLE from an Asian tertiary hospital

Objectives

The objective of the study was to assess the disease burden of systemic lupus erythematosus (SLE) and the usefulness of the Charlson Comorbidity Index (CCI) as risk-adjusted hospital mortality predictors in patients with SLE using a hospital administrative database.

Methods

A historical cohort study of a hospital discharge database from 2004 to 2011 was used to identify cases with SLE and comorbidity using the International Statistical Classification of Diseases and Related Health Problems, ninth revision, Australian modification (ICD-9-AM) codes.

Results

Over the eight years, 841 patients met the criteria of SLE with a hospital mortality rate of 9.2%. The hospital mortality rates (2.4%, 15.7%, 25.0%, and 30.4%, respectively, p < 0.001) and hospital length of stay (geometric mean, 3.5, 5.6, 8.8, and 7.5 days, respectively, p < 0.001) were consistently increased for patients with CCI ranging from none, low, moderate to high grade, respectively. Cox proportional hazards model analysis showed that CCI (hazard ratio (HR) 7.8 high vs. none, p < 0.001) and infectious disease (HR 2.0, p = 0.016) were significant and independent predictors of hospital mortality. Similar results were also seen with hospital length of stay by zero-truncated negative binomial regression model analysis.

Conclusion

The SLE burden is high in this population. Comorbidities and infectious disease were some of the most important contributors to hospital mortality and resource utilization.

Impact of partial sleep deprivation on immune markers

BACKGROUND

Sleep quality is considered to be an important predictor of immunity. Lack of sleep therefore may reduce immunity, thereby increasing the susceptibility to respiratory pathogens. A previous study showed that reduced sleep duration was associated with an increased likelihood of the common cold. It is important to understand the role of sleep in altering immune responses to understand how sleep deprivation leads to an increased susceptibility to the common cold or other respiratory infections.

OBJECTIVE

We sought to examine the impact of partial sleep deprivation on various immune markers.

PATIENTS AND METHODS

Fifty-two healthy volunteers were partially sleep deprived for one night. We took blood samples before the sleep deprivation, immediately after, and 4 and 7 days after sleep deprivation. We measured various immune markers and used a generalized estimating equation (GEE) to examine the differences in the repeated measures.

RESULTS

CD4, CD8, CD14, and CD16 all showed significant time-dependent changes, but CD3 did not. The most striking time-dependent change was observed for the mitogen proliferation assay and for HLA-DR. There was a significant decrease in the mitogen proliferation values and HLA-DR immediately after the sleep deprivation experiment, which started to rise again on day 4 and normalized by day 7.

CONCLUSIONS

The transiently impaired mitogen proliferation, the decreased HLA-DR, the upregulated CD14, and the variations in CD4 and CD8 that we observed in temporal relationship with partial sleep deprivation could be one possible explanation for the increased susceptibility to respiratory infections reported after reduced sleep duration.

Prospective audit and feedback on antibiotic prescription in an adult hematology-oncology unit in Singapore

We evaluated the impact of a prospective audit and feedback antimicrobial stewardship program (ASP) on antibiotic prescription and resistance trends in a hematology-oncology unit in a university hospital (National University Cancer Institute, Singapore [NCIS]). A prospective interrupted time-series study comprising 11-month pre-intervention (PIP) and intervention evaluation phases (IEP) flanking a one-month implementation phase was carried out. Outcome measures included defined daily dose per 100 (DDD/100) inpatient-days of ASP-audited and all antibiotics (encompassing audited and non-audited antibiotics), and the incidence-density of antibiotic-resistant microorganisms at the NCIS. Internal and external controls were DDD/100 inpatient-days of paracetamol at the NCIS and DDD/100 inpatient-days of antibiotics prescribed in the rest of the hospital. There were 580 ASP recommendations from 1,276 audits, with a mean monthly compliance of 86.9%. Significant reversal of prescription trends towards reduced prescription of audited (coefficient = -2.621; 95% confidence interval [CI]: -4.923, -0.319; p = 0.026) and all evaluated antibiotics (coefficient = -4.069; 95% CI: -8.075, -0.063; p = 0.046) was observed. No changes were seen for both internal and external controls, except for the reversal of prescription trends for cephalosporins hospital-wide. Antimicrobial resistance did not change over the time period of the study. Adverse outcomes-the majority unavoidable-occurred following 5.5% of accepted ASP recommendations. Safe and effective ASPs can be implemented in the complex setting of hematology-oncology inpatients.

Cognitive screening in Asia: recognizing the role of the patient-family unit

BACKGROUND/AIMS

Cognitive screening programmes may improve awareness and help at-risk subjects receive earlier medical attention. Cognitive profiles of subjects who attend cognitive screening by personal choice (self-referred) compared to those where the referral was initiated by family members (family-referred) were compared.

METHODS

A cross-sectional survey of community subjects attending a cognitive screening initiative. Performance on the MMSE, Frontal Assessment Battery (FAB), Elderly Cognitive Assessment Questionnaire (ECAQ) and Even Briefer Assessment Scale for Depression was evaluated.

RESULTS

A total of 342 subjects with a mean age of 59.2 +/- 9.0 years were screened. Overrepresentation of Chinese and Indian subjects and underrepresentation of Malay subjects was noted. The prevalence of cognitive impairment ranged from 7.0 to 9.6% depending on the screening instrument used. Of the 342 subjects, 267 were self-referred, while 75 subjects were family-referred. Family-referred subjects had lower MMSE (p < 0.001), lower ECAQ (p < 0.001) and lower FAB (p < 0.001) scores but were not more depressed compared to self-referred subjects (p = 0.904). Only the difference in ECAQ scores remained significant after adjustment for baseline differences in age and education. The prevalence of hypertension, diabetes mellitus and hypercholesterolaemia was not statistically different between the 2 groups.

CONCLUSIONS

Family members play a crucial role in the diagnosis of cognitive impairment, especially in older subjects with fewer years of education.

Deep vein thrombosis in stroke patients admitted to a rehabilitation unit in Singapore

BACKGROUND

Studies have shown that deep vein thrombosis (DVT) is common after an acute stroke. Less common are studies documenting DVT in stroke patients admitted to rehabilitation. The purpose of this study was to determine the frequency and risk factors of DVT in stroke patients admitted to a rehabilitation unit in Singapore.

METHODS

A prospective observational single-center study of patients with ischemic and hemorrhagic stroke with lower limb paresis admitted to a rehabilitation center in Singapore. The screening protocol consisted of quantitative D-dimer assay (DDA) within 24-48 h of rehabilitation admission followed by duplex ultrasound scan of the paretic lower extremity if DDA level was elevated (equal or greater than 0.34 microg/ml).

RESULTS

Altogether, 341 patients were screened at a mean of 23 days poststroke. One hundred and ninety-eight (58.1%) patients had an elevated DDA and all underwent ultrasound scans. The frequency of lower limb DVT was 9% (18) - seven proximal and 11 distal. DVT was significantly related to higher D-dimer levels (P=0.029) and cortical strokes (P=0.004), but not to age, gender, race, nature of stroke, atrial fibrillation, severity of lower limb weakness, and ambulatory and functional status. No patients had clinical pulmonary embolism during rehabilitation.

CONCLUSIONS

Lower limb DVT is uncommon in stroke patients admitted to rehabilitation in Singapore. Future research should include evaluation of the cost-effectiveness of such a screening protocol.

Exclusion of acute pulmonary embolism: computed tomography pulmonary angiogram or D-dimer?

INTRODUCTION

The aim of our study was to determine the accuracy of the D-dimer test in the exclusion of pulmonary embolism.

METHODS

In 2006, 446 patients at our hospital underwent computed tomography pulmonary angiogram (CTPA) for the exclusion of pulmonary embolism. We selected patients with a clinical suspicion of pulmonary embolism, and who underwent both a CTPA examination and a D-dimer test performed within a period of five days. Pregnant women, patients with an allergy to intravenous contrast and those who were on anticoagulant therapy were excluded. Based on our criteria, 219 cases were selected. D-dimer test was performed using an immunoturbidimetric assay. A cut-off value of 500 ng/ml was selected as the upper limit to exclude thrombosis.

RESULTS

There were 42 patients positive for pulmonary embolism on CTPA and all had elevated D-dimer values. There were 177 patients negative for pulmonary embolism on CTPA and 49 of them had normal D-dimer values. The sensitivity and specificity of the D-dimer test was 100.0 percent (95 percent confidence interval [CI] 91.6-100.0) and 27.7 percent (95 percent CI 21.2-34.9), respectively. The likelihood ratio for a positive test and negative test was 1.38 and 0, respectively.

CONCLUSION

The D-dimer test is suitable for screening patients with a clinical suspicion of pulmonary embolism. The indiscriminate use of CTPA results in unnecessary testing and elevates healthcare costs. Clinicians are urged to give due consideration to a D-dimer test result prior to requesting a CTPA examination.

Striving for a better operative outcome: 101 pancreaticoduodenectomies

Pancreaticoduodenectomy (PD), once carried high morbidity and mortality, is now a routine operation performed for lesions arising from the pancreatico-duodenal complex. This study reviews the outcome of 101 pancreaticoduodenectomies performed after formalization of HepatoPancreatoBiliary (HPB) unit in the Department of Surgery. A prospective database comprising of patients who underwent PD was set up in 1999. Retrospective data for patients operated between 1996 and 1999 was included. One hundred and one cases accrued over 10 years from 1996 to 2006 were analysed using SPSS (Version 12.0). The mean age of our cohort of patients was 61+/-12 years with male to female ratio of 2:1. The commonest clinical presentations were obstructive jaundice (64%) and abdominal pain (47%). Majority had malignant lesions (86%) with invasive adenocarcinoma of the head of pancreas being the predominant histopathology (41%). Median operative time was 315 (180-945) minutes. Two-third of our patients had pancreaticojejunostomy (PJ) while the rest had pancreaticogastrostomy (PG). There were five patients with pancreatico-enteric anastomotic leak (5%), three of whom (3%) were from PJ anastomosis. Overall, in-hospital and 30-day mortality were both 3%. The median post-operative length of stay (LOS) was 15 days. Using logistic regressions, the post-operative morbidity predicts LOS following operation (p<0.005). The strategy in improving the morbidity and mortality rates of pancreaticoduodenectomies lies in the subspecialization of surgical services with regionalization of such complex surgeries to high volume centers. The key success lies in the dedication of staffs who continues to refine the clinical care pathway and standardize management protocol.

The impact of malnutrition on survival and the CD4 count response in HIV-infected patients starting antiretroviral therapy

BACKGROUND

The impact that malnutrition at the time of starting antiretroviral therapy (ART) has on survival and the CD4 count response is not known.

METHODS

A retrospective cohort study of patients attending the national HIV referral centre in Singapore who had a CD4 count less than 250 cells/microL and a measurement of body weight performed at the time of starting ART was carried out. Demographic and clinical variables were extracted from an existing database. Body mass index (BMI) was calculated from the weight in kilograms divided by the square of the height in metres. Moderate to severe malnutrition was defined as BMI less than 17 kg/m(2). Intent-to-treat Cox models were used to determine the predictors of survival.

RESULTS

A total of 394 patients were included in the analysis, of whom 79 died during a median study follow-up of 2.4 years. Moderate to severe malnutrition was present in 16% of patients at the time of starting ART, and was found to be a significant independent predictor of death [hazard ratio (HR) 2.19, 95% confidence interval (CI) 1.29-3.73, P=0.004 for those with BMI<17 compared with those with BMI>18.5] as were stage of disease (HR 2.47, 95% CI 1.20-5.07, P=0.014 for those who were at stage C compared with those at stage A) and the type of ART [HR 0.50, 95% CI 0.27-0.93, P=0.03 for highly active antiretroviral therapy (HAART) compared with non-HAART treatment]. Malnutrition did not impair the magnitude of the increase in CD4 count at 6 or 12 months.

CONCLUSIONS

Malnutrition at the time of starting ART was significantly associated with decreased survival, but the effect appeared not to be mediated by impaired immune reconstitution. Given the increasing access to ART in developing countries and the high frequency of HIV-associated wasting, studies of nutritional therapy as an adjunct to the initiation of HAART are urgently needed.

Haematological parameters in severe acute respiratory syndrome

Clinical presentation of severe acute respiratory syndrome (SARS) is non‐specific and isolation of all suspected patients is difficult because of the limited availability of isolation facilities. We studied changes in haematological parameters in SARS patients using median values analysed according to the day of symptom onset. White cell (WCC), absolute neutrophil, absolute lymphocyte (ALC) and platelet counts followed a v‐shaped trend with the nadir at day 6 or 7 after symptom onset except for ALC in the ICU group that had not reached the nadir by day 12. None of our patients had a platelet count < 80 × 10⁹/l and WCC < 2 × 10⁹/l in the first 5 days of symptoms and these parameters may allow early stratification of febrile patients into likely and unlikely SARS cases to allow effective utilization of isolation facilities. On multivariate analysis, age is the only independent predictor for ICU admission.

Predictors of success in smoking cessation among hospitalized patients

OBJECTIVE

To determine the predictors of continued smoking abstinence in patients receiving smoking cessation intervention during and following hospital admission.

METHODOLOGY

A prospective cohort study was conducted in a university-affiliated hospital. A total of 248 smokers admitted with primary cardiac and respiratory conditions received verbal advice (lasting about 1 h) and standard booklets on smoking cessation from a dedicated nurse counsellor. After discharge, participants received follow-up telephone counselling calls every 2 weeks from the same smoking counsellor. The main outcome measure was continued abstinence at 2 months after hospital discharge, as determined by self-reporting and carbon monoxide breath testing. The following groups of covariates were analysed to determine the possible factors associated with smoking abstinence: demographics, smoking history, readiness to quit, and medical history.

RESULTS

At 2 months post-discharge, 108 (43.5%) patients remained abstinent. Low nicotine dependence score (odds ratio, 2.30; 95% CI, 1.25-4.26; P = 0.008), decision to quit by sudden cessation as compared to reduction of smoking (odds ratio, 7.19; 95% CI, 1.56-33.06; P = 0.011), and initial hospitalization for their medical condition (odds ratio, 6.37; 95% CI, 1.33-30.44; P = 0.020) were the main independent predictors for positive outcome.

CONCLUSION

Among this cohort of hospitalized patients receiving smoking cessation intervention, low dependence on tobacco, motivation to quit by sudden cessation, and initial hospitalization were the main independent predictors of smoking abstinence after discharge from hospital.

Why generic and disease-specific quality-of-life instruments should be used together for the evaluation of patients with persistent allergic rhinitis

BACKGROUND

The importance of assessing health-related quality of life (HRQL) of patients with allergic rhinitis (AR) has been well established, but the specific roles of rhinitis-specific or general health instruments have not been delineated.

OBJECTIVE

We analysed the psychometric properties of a disease-specific instrument, the Rhinoconjunctivitis Quality-of-Life Questionnaire (RQLQ) and the general health instrument, the Medical Outcome Short-Form 36 (SF-36) as they are employed in combination in patients with persistent AR in clinical practice.

METHOD

We analysed the data collected from a prospective study of 43 newly diagnosed patients with persistent AR and 44 controls. We interviewed the patients four times, at baseline, weeks 4, 8 and 10.

RESULTS

The RQLQ and SF-36 have good discriminative property, internal consistency, and test-retest reliability. The RQLQ is superior to the SF-36 as an evaluative instrument because more of its domains respond to change, the magnitude of change was greater, and the response was faster. The SF-36 is more susceptible to floor and ceiling effects. Both instruments are unsuitable for mildly symptomatic patients based on Rasch model analysis. Each questionnaire assesses a distinct and significant portion of the total HRQL of persistent AR.

CONCLUSION

The SF-36 and RQLQ are good for discriminating rhinitis patients from controls, but the former is poor for detecting changes in QOL. Both are inappropriate for mildly symptomatic patients. Each instrument measures non-overlapping halves of the measurable HRQL. For an assessment of the HRQL in persistent AR that is complete and responsive both instruments should be employed together.

Pulmonary function and exercise capacity in survivors of severe acute respiratory syndrome

The aim of this study was to investigate pulmonary function and exercise capacity in a group of survivors of the severe acute respiratory syndrome (SARS). At 3 months after hospital discharge, 46 survivors of SARS underwent the following evaluation: spirometry, static lung volumes and carbon monoxide transfer factor (TL,CO). In total, 44 of these patients underwent cardiopulmonary exercise testing. No abnormalities were detected in the pulmonary function tests in 23 (50%) of the patients. Abnormalities of forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC and TL,CO were detected in seven (15%), 12 (26%), one (2%) and 18 (39%) patients, respectively. All of these abnormalities were mild except in one case. In 18 patients (41%), the maximum aerobic capacity was below the lower limit of the normal range. Breathing reserve was low in four patients and significant oxygen desaturation was detected in a further four patients. Comparison of the measured exercise capacity with resting pulmonary function tests showed many cases of discordance in impairment. In conclusion, pulmonary function defects were detected in half of the recovered severe acute respiratory syndrome patients 3 months after hospital discharge, but the impairment was mild in almost all cases. Many patients had reduced exercise capacity that cannot be accounted for by impairment of pulmonary function.

Improving the diagnosis related grouping model's ability to explain length of stay of elderly medical inpatients by incorporating function-linked variables

INTRODUCTION

This study first aimed to determine the adequacy of the Diagnosis Related Grouping (DRG) model's ability to explain (1) the variance in the actual length of stay (LOS) of elderly medical inpatients and (2) the LOS difference in the same cohort between the departments of Geriatric Medicine (GRM) and General Medicine (GM). We then looked at how these explanatory abilities of the DRG changed when patients' function-linked variables (ignored by DRG) were incorporated into the model.

MATERIALS AND METHODS

Basic demographic data of a consecutively hospitalised cohort of elderly medical inpatients from GRM and GM, as well as their actual LOS, discharge DRG codes [with their corresponding trimmed average length of stay (ALOS)] and selected function-linked variables (including premorbid functional status, change in functional profile during hospitalisation and number of therapists seen) were recorded. Beginning with ALOS, function-linked variables that were significantly associated with LOS were then added into two multiple liner regression models so as to quantify how the functional dimension improved the DRGs' abilities to explain LOS variances and interdepartmental LOS differences. Forward selection procedure was employed to determine the final models. For the interdepartmental analysis, the study sample was restricted to patients who shared common DRG codes.

RESULTS

114 GRM and 118 GM patients were studied. Trimmed ALOS alone explained 8% of the actual LOS variance. With the addition of function-linked variables, the adjusted R2 of the final model increased to 28%. Due to common code restrictions, the data of 79 GRM and 78 GM patients were available for the analysis of interdepartmental LOS differences. At the unadjusted stage, the median stay of GRM patients was 4.3 days longer than GM's and with adjustments made for the DRGs, this difference was reduced to 3.9 days. Additionally adjusting for the patients' functional features diminished the interdepartmental LOS discrepancy even further, to 2.1 days.

CONCLUSION

This study demonstrates that for elderly medical inpatients, the incorporation of patients' functional status significantly improves the DRG model's ability to predict the patients' actual LOS as well as to explain interdepartmental LOS differences between GRM and GM.

Prevalence of and risk factors for nasal colonization with Staphylococcus aureus among human immunodeficiency virus-positive outpatients in Singapore

We studied the prevalence of and risk factors for Staphylococcus aureus nasal colonization in HIV-positive outpatients in Singapore. Overall prevalence was 23% (45 of 195), with 3% (6 of 195) being MRSA. Recent antibiotic use and hospitalization were independent predictors of MRSA colonization. Isolates were genotypically identical to our hospital's inpatient circulating strain.

Clinical predictors of acute respiratory acidosis during exacerbation of asthma and chronic obstructive pulmonary disease

Mechanical ventilation (MV) during exacerbation of asthma or chronic obstructive pulmonary disease (COPD) is unequivocally needed when apnoea, cardiorespiratory arrest, coma, hypoxia or treatment failure is present. The need is less clear when the patient can respond, has intact airway reflexes and spontaneous respiration. In this situation, acidosis is an important factor in the decision to institute MV. This study aimed to provide a clinical means of identifying patients with acute respiratory acidosis (ARA) in a setting where blood gas analysis is unavailable. We undertook a prospective, observational study of consecutive patients who presented to two emergency departments with severe and life-threatening exacerbation of asthma or COPD. Each underwent clinical assessment, treatment and blood gas analysis. The outcome measure was ARA or mixed ARA and metabolic acidosis. A total of 127 episodes in patients aged 15-90 years (65.3% males and 34.7% females) were included in the study. Of these, 62.2% had asthma and 37.8% had COPD; 71.7% had life-threatening and 28.3% had severe attacks. Overall, the adjusted odds ratio (and 95% confidence intervals) for predictors of ARA were 7.09 (1.79-28.06) for drowsiness, 4.11 (1.31-12.88) for flushing, 3.34 (1.01-11.02) for having COPD and 2.86 (1.01-8.07) for intercostal retractions. In conclusion, with drowsiness, the likelihood of ARA is about seven times higher. The presence of flushing, COPD and intercostal retractions also increase the risk of ARA.

Hepatotoxicity of tuberculosis chemotherapy under general programme conditions in Singapore

SETTING

The Singapore Tuberculosis (TB) Control Unit, a high volume national referral centre.

OBJECTIVES

To determine the incidence, clinical course and outcome of TB drug-induced hepatitis (DH) and the risk factors associated with DH under general programme conditions.

DESIGN

A retrospective review of adult patients started on TB treatment in 1998.

RESULTS

There were 55 cases of DH in the cohort of 1036 patients treated in 1998. The median time to diagnosis of DH was 38 days. Factors significantly associated with DH were abnormal baseline transaminases/ bilirubin (OR 2.1, 95%CI 1.1-4.3, P = 0.02), age >60 years (OR 1.97, 95%CI 1.14-3.34, P = 0.01) and female sex (OR 1.9, 95%CI 1.07-3.4, P = 0.02). Ethnicity, self-reported alcohol consumption and body weight were not associated with development of DH. All three patients with fatal DH had received pyrazinamide-containing regimens. Treatment was re-introduced in 48 patients and successfully completed in 45 patients. The median time to reinstitution of TB treatment was 23 days.

CONCLUSION

The incidence of TB drug-induced hepatitis was 5.3%. Age >60 years, abnormal baseline transaminase/bilirubin levels and female sex were risk factors associated with the development of TB drug-induced hepatitis.

Impact of an asthma carepath on the management of acute asthma exacerbations

INTRODUCTION

Clinical pathways are being developed to standardise the management of acute asthma with the aim of improving asthma care. We evaluated the impact of an asthma carepath (CP), developed and instituted at a large community-based teaching hospital.

MATERIALS AND METHODS

Case records of consecutive asthma cases were reviewed after the implementation of a new asthma CP (November 1999 to March 2000). Data from July to October 1998 were used as historical control data [pre-carepath (pre-CP)]. Data collected included patient demographics, investigations performed, treatment prescribed, use of peak expiratory flow rate (PEFR) monitoring, length of stay (LOS) and asthma relapse rates.

RESULTS

One hundred and eighteen consecutive cases treated according to CP were compared with 67 pre-CP controls. There was no significant difference between the two groups with regard to LOS, use of PEFR monitoring, use of systemic steroids in hospital or asthma relapse after discharge (P > 0.05). A significant decrease in sputum tests (34.3% pre-CP versus 18.6% CP, P = 0.017) and use of antibiotics (62.7% pre-CP versus 30.4% CP, P < 0.001) was observed for patients on CP. The proportion of patients who had their salbutamol reviewed (49.3% pre-CP versus 73.7% CP, P = 0.001) and oxygen reviewed (25.8% pre-CP versus 73.8% CP, P = 0.004) was also significantly higher for cases on CP.

CONCLUSION

Although the asthma CP did not significantly reduce LOS or early relapse, it was associated with a significant reduction of the use of sputum tests and antibiotics. Review of salbutamol and oxygen as treatment was also more likely.

Tracheoesophageal puncture outcomes and predictors of success in laryngectomised patients

INTRODUCTION

Prosthetic voice restoration has been widely used for vocal rehabilitation in laryngectomised patients. The objectives of this study were to examine success rates, predictors of success and complications for our patients who had undergone tracheoesophageal punctures (TEPs) and voice prosthesis placement after laryngectomy. To our knowledge, this is the first analysis of the use and complications of TEPs in Singapore.

PATIENTS AND METHODS

Thirty-eight patients seen in our centre were analysed in this retrospective case review. Factors analysed included voice quality with age, timing of insertion, type of closure, use of radiotherapy, regular maintenance and attendance at our clinic. Twenty-eight had undergone primary TEP surgery and 10 had undergone secondary TEP surgery for voice restoration after laryngectomy for cancer. Thirty-five patients had primary closure of the pharynx with 13 vertical, 19 horizontal and 3 T-shaped closures. The other 3 patients required reconstructive surgery. Thirty-five patients had radiotherapy. A numerical assessment of voice production was made of patients immediately and at 6 months post-insertion. A review of the complications was also done.

RESULTS

TEPs provided a fair to good voice in 74% of our laryngectomees. Patients who attended the voice restoration clinics and who regularly cleaned their prostheses were found to have statistically better voices (P = 0.044 and P = 0.002, respectively). Patients less than 60 years old had better results, as did patients with horizontal or T-shaped closures; however, these were not statistically significant. Secondary TEPs provided fair/good voices in 90% of cases compared to 68% of primary TEPs. Voice quality during radiotherapy was diminished but recovered at 6 months postradiotherapy. The commonest complications noted included crusting (seen in 40% of cohort), candida infections and leaks which were seen in 16% of our patients. There was no mortality attributable to the use of TEPs in our study.

Social comparison and affiliation under threat: going beyond the affiliate-choice paradigm

This study examined the emotional similarity hypothesis--a derivation from social comparison theory, which predicts that increasing fear should lead to greater affiliation with someone who is awaiting the same threat (and who therefore is of relatively similar emotional status) relative to someone who has already experienced the threat (and who therefore is of relatively dissimilar emotional status). The results failed to support the emotional similarity hypothesis and in so doing challenged the importance of emotional comparison as a determinant of verbal affiliation under threat. Cognitive clarity concerns instead seemed to account better for the observed effects on verbal affiliation. Supplementary analyses of nonverbal affiliation (facial glances) likewise ran counter to an emotional similarity prediction. Effects of affiliation on anxiety were also examined. Previous conclusions regarding the pattern and causes of affiliation under threat that have relied on the affiliate-choice paradigm are considered.