Ministry of Health Clinical Practice Guidelines: Diabetes Mellitus

The Ministry of Health (MOH) have updated the clinical practice guidelines on Diabetes Mellitus to provide doctors and patients in Singapore with evidence-based treatment for diabetes mellitus. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Diabetes Mellitus, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Paraganglioma with acute hyperamylasaemia masquerading as acute pancreatitis

Phaeochromocytomas are rare catecholamine-producing tumours. Although classically described to present with headache, diaphoresis and palpitations, they also present in unusual ways; hyperamylasaemia is one such rare presentation. We describe a man with an extra-adrenal phaeochromocytoma (paraganglioma) presenting with diaphoresis, abdominal pain and multi-organ failure. He had hyperamylasaemia of 1,087 (normal range [NR] 44-161) U/L, which mimicked acute severe pancreatitis. Serum lipase and radiographic imaging of the pancreas appeared normal, and the serial amylase levels normalised over six days upon stabilisation of his condition. 24-hour urinary metanephrines of 10,406 (NR 400-1,500) nmol/day suggested a catecholamine-secreting tumour, and metaiodobenzylguanine scintigraphy confirmed this. We postulate that amylase (of the salivary isotype) is released by hypoxic tissues when high catecholamine levels cause vasoconstriction and that fluctuating hypotension decreases organ perfusion. This case highlights the need for awareness of rare presentations of phaeochromocytomas and encourages physicians to rethink the diagnosis when investigations are inconsistent.

Coagulation and cytokine profile after major hepatobiliary surgery in Chinese patients

BACKGROUND/AIMS

Hypercoagulability and increased circulating cytokine levels have been separately reported after surgical operations. We investigated whether the cytokine level and postoperative coagulation profile would change similarly in Chinese patients undergoing major hepatobiliary surgery.

METHODOLOGY

Serial serum levels of IL-6, IL-1 beta and TNF-alpha were measured by colorimetric ELISA. Serial coagulation profile was measured by thrombelastography. Hemoglobin and white cell counts were also measured serially.

RESULTS

Only mild hypercoagulability was found at the 12th and 144th hours, evidenced by shortening of r-time and k-time on thrombelastography (P < 0.05). IL-6 and IL-1 beta levels were significantly raised from the 12th hour (P < 0.01) while TNF-alpha level was unchanged. From the 3rd hour to the 48th hour, there was negative correlation between IL-6 levels and various thrombelastographic parameters such as coagulation index (r = -0.777, P < 0.001); k-time (r = 0.478, P < 0.05); maximum amplitude (r = -0.688, P < 0.01) and angle (r = -0.665, P < 0.01).

CONCLUSIONS

We observed a much milder degree of hypercoagulability in Chinese patients after major hepatobiliary surgery as compared to those reported in other operations in non-Chinese patients. Unlike in sepsis where a close link between increased cytokine levels and hypercoagulability has been reported, increase in IL-6 was associated with less hypercoagulability in Chinese patients after major hepatobiliary surgery.

Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine

Thirty-eight ASA I-III patients undergoing lower abdominal operations were randomly allocated to receive either morphine (group M, patient-controlled analgesia bolus = 1 mg of morphine) or tramadol (group T, patient-controlled analgesia bolus = 10 mg of tramadol) for post-operative patient-controlled analgesia (PCA) after receiving morphine intraoperatively. There were no between-group differences in the pain, sedation or vomit scores. The nausea scores were significantly higher in group T in the initial 20 h and between 32 and 36 h (P < 0.01, 0-4 and 8-12 h; P < 0.05, 4-8, 12-16, 16-20 and 32-36 h). The incidence of dizziness was also significantly higher in group T (68.4% vs. 31.6%, group T vs. group M, P < 0.05). There was no difference in the overall satisfaction. We conclude that the use of tramadol, compared with morphine, for post-operative PCA after intraoperative loading with morphine is associated with more nausea and dizziness, but with similar sedation, quality of analgesia and patient satisfaction.

The haematuria clinic--referral patterns in Northern Ireland

One hundred consecutive patients with haematuria were seen over a three month period at the haematuria clinic, Belfast City Hospital. 14% of patients were found to have transitional cell carcinoma of the urinary bladder; all of these presented with frank haematuria and were over 50 years of age. No malignancy was detected in the microscopic haematuria group. 14% of patients with macroscopic haematuria held back for longer than one month before seeking advice from their general practitioner. 23% with macroscopic and 30% with microscopic haematuria had their symptoms noted by the general practitioner for more than a month before they were referred for investigation. The waiting time for initial investigation at the haematuria clinic took longer than six weeks in 52% with macroscopic and 39% with microscopic haematuria. Our study has identified a high-risk group who need immediate referral and investigation. The importance of patient education, rapid referral by general practitioners and also the need to increase the capacity of the haematuria clinic are emphasized.

Clinical features and rapid viral diagnosis of human disease associated with avian influenza A H5N1 virus

BACKGROUND

Human infection with an avian influenza A virus (subtype H5N1) was reported recently in Hong Kong. We describe the clinical presentation of the first 12 patients and options for rapid viral diagnosis.

METHODS

Case notes of 12 patients with virus-culture-confirmed influenza A H5N1 infection were analysed. The clinical presentation and risk factors associated with severe disease were defined and the results of methods for rapid virus diagnosis were compared.

FINDINGS

Patients ranged from 1 to 60 years of age. Clinical presentation was that of an influenza-like illness with evidence of pneumonia in seven patients. All seven patients older than 13 years had severe disease (four deaths), whereas children 5 years or younger had mild symptoms with the exception of one who died with Reye's syndrome associated with intake of aspirin. Gastrointestinal manifestations, raised liver enzymes, renal failure unrelated to rhabdomyolysis, and pancytopenia were unusually prominent. Factors associated with severe disease included older age, delay in hospitalisation, lower-respiratory-tract involvement, and a low total peripheral white blood cell count or lymphopenia at admission. An H5-specific reverse-transcription PCR assay (RT-PCR) was useful for rapid detection of virus directly in respiratory specimens. A commercially available enzyme immunoassay was more sensitive than direct immunofluorescence for rapid viral diagnosis. Direct immunofluorescence with an H5-specific monoclonal antibody pool was useful for rapid exclusion of H5-subtype infection.

INTERPRETATION

Avian Influenza A H5N1 virus causes human influenza-like illness with a high rate of complications in adults admitted to hospital. Rapid H5-subtype-specific laboratory diagnosis can be made by RT-PCR applied directly to clinical specimens.

Emerging applications of the single cell gel electrophoresis (Comet) assay. I. Management of invasive transitional cell human bladder carcinoma. II. Fluorescent in situ hybridization Comets for the identification of damaged and repaired DNA sequences in individual cells

ABSTRACT I: Management of invasive transitional cell human bladder carcinoma. The two main treatment options for invasive transitional cell bladder carcinoma are radiotherapy or primary cystectomy with urinary diversion or bladder substitution. Approximately 50% of patients fail to respond to radiotherapy and such patients so treated are disadvantaged by the absence of predictive information regarding their radiosensitivity, since the tumour gains additional time for metastatic spread before cystectomy is performed. The SF2 clonogenic assay, which measures the surviving fraction of tumour cells after 2 Gy X-ray irradiation, is regarded as a good measure of radiosensitivity. However, the assay is time consuming and provides results for only approximately 70% of human tumours. In this paper three bladder transitional cell carcinoma cell lines (HT1376, UMUC-3 and RT112) were exposed to X-irradiation (0-10 Gy). We have compared the responses obtained using a clonogenic assay and a more clinically feasible alkaline single cell gel electrophoresis (Comet) assay. A very good inverse correlation was obtained between cell survival (clonogenic assay) and mean tail moment (Comet assay) for the three cell lines, indicating that the Comet assay can be used to predict the radio-responsiveness of individual cell lines. The clinical usefulness of the assay for predicting response to radiotherapy in bladder cancer patients is currently being investigated. ABSTRACT II: Fluorescent in situ hybridization (FISH) Comets for the identification of damaged and repaired DNA sequences in individual cells. In mammalian cells the extent of DNA damage is partly and the rate of DNA repair very considerably dependent on DNA position and transcription. This has been established by biochemical techniques which are labour intensive and require large numbers of cells. The Comet assay for overall DNA damage and repair is relatively simple and allows individual cells to be examined. Here we present a protocol for combination of the Comet assay with fluorescent in situ hybridization (FISH) using a p53 gene probe which allows specific observation of p53 sequences within DNA comets. Chromosome-specific probes can also be used. Optimization of the FISH/Comet protocol to include automation of the analysis is currently underway to facilitate future application of the technique to study selective DNA damage and repair in defined sequences in single mammalian cells.

Comparison of tramadol and tramadol/droperidol mixture for patient-controlled analgesia

PURPOSE

To compare the analgesic efficacy and side effects of tramadol vs tramadol and droperidol for post-operative patient-controlled analgesia (PCA).

METHODS

Randomised, double-blind study. Thirty-four patients undergoing elective colorectal or head and neck surgery were allocated to Group 1 (n = 18, PCA bolus 10 mg tramadol) or Group 2 (n = 16, PCA bolus 10 mg tramadol + 0.1 mg droperidol). Anaesthesia was induced with fentanyl and thiopentone and maintained with O2, N2O plus enflurane or isoflurane with iv morphine at doses decided by the attending anaesthetists. Muscle relaxation was achieved with atracurium or vecuronium. Patients were observed four-hourly for pain using an 11-point verbal rating scale (VRS). Nausea and vomiting, and sedation were assessed using four-point scales post-operatively. Vital signs, request for rescue anti-emetic and analgesic, and overall satisfaction were recorded.

RESULTS

The mean nausea scores were lower in Group 2 (1.00 +/- 1.33 vs 0.06 +/- 0.25 at 0-8 hr, 1.22 +/- 1.93 vs 0.06 +/- 0.25 at 8-16 hr, P < 0.01; 0.81 +/- 1.68 vs 0 at 32-40 hr, P < 0.05; Group 1 vs Group 2). The vomiting scores were also lower (0.50 +/- 1.04 vs 0 at 0-8 hr, 0.67 +/- 1.50 vs 0, at 8-16 hr, P < 0.05; Group 1 vs Group 2). Seven (39%) patients in Group 1, but none in Group 2 requested rescue anti-emetic (P < 0.01). There were no differences in VRS, sedation score, overall satisfaction or vital signs.

CONCLUSION

Tramadol and droperidol combination is superior to tramadol alone for post-operative PCA. It provides a similar quality of analgesia with less nausea and vomiting and without an increase in sedation.

Clinics in diagnostic imaging (19). Acute respiratory distress syndrome (ARDS) secondary to intra-abdominal sepsis

A 47-year-old Chinese woman developed acute shortness of breath 12 days after a major abdominal surgery. Abdominal CT demonstrated a large intra-peritoneal fluid collection, subsequently proved to be due to an anastomosis breakdown. Chest radiograph showed bilateral diffuse air space shadowing. clinical and radiological findings were compatible with the diagnosis of acute respiratory distress syndrome (ARDS) secondary to intra-abdominal sepsis. The aetiology and management of ARDS, and the role of the radiologist in the diagnosis and treatment of intra-abdominal fluid collections are discussed.

Effect of i.v. metoclopramide on gastric emptying after opioid premedication

Metoclopramide was given i.m. or i.v. to patients who had been given an opioid premedication, and the effects on gastric emptying assessed. Forty patients were allocated randomly to one of four treatment groups: group 1, oral diazepam 10 mg; group 2, i.m. morphine 10 mg; group 3, i.m. morphine 10 mg and i.v. metoclopramide 10 mg; group 4, i.m. morphine 10 mg and i.m. metoclopramide 10 mg. Gastric emptying was estimated from the absorption of oral paracetamol. I.v. metoclopramide antagonized the reduction in paracetamol absorption caused by morphine, whereas i.m. metoclopramide did not. This finding may be of importance in anaesthesia for emergencies.

Memory function after i.v. midazolam or inhalation of isoflurane for sedation during dental surgery

Memory function was assessed with a recognition memory test in 40 dental patients before and after sedation with i.v. midazolam or inhalation of isoflurane. The two groups were comparable, but there was a significant impairment of memory (P less than 0.001) at the time of discharge for both words and faces after midazolam, but not after isoflurane.