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Feng L.,National University of Singapore | Yap K.B.,Alexandra Hospital | Ng T.P.,National University of Singapore
American Journal of Geriatric Psychiatry | Year: 2013

Objective: Among patients with chronic kidney disease (CKD), we investigated the prevalence of depressive symptoms, their impact on mortality and quality of life, and correlates of depressive symptoms. Design: Prospective cohort study, followed up to 4 years. Setting: General community. Participants: A total of 362 older adults with CKD (Stages 3 and 4 assessed from estimated glomerular filtration rate [eGFR]) drawn from the Singapore Longitudinal Aging Study cohort. Measurements: Scores on the Geriatric Depression Scale (GDS) and the prevalence of depressive symptoms (GDS -5) and other variables were assessed at baseline, and SF-12 quality of life (QOL) (at 2 years) and mortality determined from 4 years of follow-up. Results: Depressive symptoms were present in 13% of the participants at baseline, and were associated with poorer SF-12 QOL scores (up to 30 percentage point differences). There was a significant association between depressive symptoms and increased mortality risk (odds ratio: 3.17; 95% confidence interval: 1.17-8.61; c2 = 5.11; df = 1; p = 0.023), which was statistically significant in unadjusted analysis, but not in multivariate analysis that accounted for covariates (odds ratio: 2.62; 95% confidence interval: 0.77-8.89; c2 = 2.37; df = 1; p = 0.13). Baseline cognitive impairment, functional disability, and other chronic illness were significantly associated with both increasing GDS scores and depressive symptoms. No relationship between eGFR and depressive symptoms was observed. Conclusion: Depression among individuals with CKD was significantly associated with poorer quality of life, but not with increased mortality in predialysis CKD patients. More prospective studies are needed to establish the effects of depression on adverse CKD outcomes in predialysis CKD patients. © 2013 American Association for Geriatric Psychiatry.


Feng L.,National University of Singapore | Nyunt M.S.Z.,National University of Singapore | Yap K.B.,Alexandra Hospital | Ng T.P.,National University of Singapore
Journal of the American Medical Directors Association | Year: 2014

Objective: This study aimed to examine the cross-sectional and longitudinal relationships between physical frailty at baseline and depressive symptoms at baseline and at follow-up. Design: Four-year prospective study. Setting: Communities in the South East Region of Singapore. Participants: We analyzed data of 1827 older Chinese adults aged 55 and above in the Singapore Longitudinal Aging Study-I. Measurements: The frailty phenotype (based on Fried criteria) was determined at baseline, depressive symptoms (Geriatric Depression Scale ≥5) at baseline and follow-ups at 2 and 4years. Results: The mean age of the population was 65.9 (standard deviation 7.26). At baseline, 11.4% (n=209) had depressive symptoms, 32.4% (n=591) were prefrail and 2.5% (n=46) were frail. In cross-sectional analysis of baseline data, the adjusted odds ratios (OR)s and 95% confidence intervals controlling for demographic, comorbidities, and other confounders were 1.69 (1.23-2.33) for prefrailty and 2.36 (1.08-5.15) for frailty, (P for linear trend <.001). In longitudinal data analyses, prospective associations among all participants were: prefrail: OR=1.86 (1.08-3.20); frail: OR=3.09 (1.12-8.50); (P for linear trend=009). Among participants free of depressive symptoms at baseline, similar prospective associations were found: prefrail OR=2.26 (1.12-4.57); frail: OR=3.75 (1.07-13.16); (P for linear trend=009). Conclusion: These data support a significant role of frailty as a predictor of depression in a relatively younger old Chinese population. Further observational and interventional studies should explore short-term dynamic and bidirectional associations and the effects of frailty reversal on depression risk. © 2014 American Medical Directors Association, Inc.


Chrousos G.P.,National and Kapodistrian University of Athens | Zapanti E.D.,Alexandra Hospital
Endocrinology and Metabolism Clinics of North America | Year: 2014

HIV infection induces hypothalamic-pituitary-adrenal (HPA) axis derangements. Partial glucocorticoid resistance has been observed in a subset of AIDS patients, possibly owing to HIV-induced altered cytokine secretion and action. Because glucocorticoids have immunomodulatory effects, the severity of the HPA axis disorder could play a central role in disease progression. The characteristic phenotype of AIDS patients (visceral obesity, lipodystrophy) may be owing to effects of HIV proteins on the HPA axis, including changes in glucocorticoid and insulin sensitivity of target tissues, as well as altered cytokine production and interaction with the HPA axis, genetic causes, comorbidities, and, possibly, use of antiretroviral agents. © 2014 Elsevier Inc.


Modi C.S.,Coventry University | Morris G.,Alexandra Hospital | Mukherjee R.,Alexandra Hospital
Arthroscopy - Journal of Arthroscopic and Related Surgery | Year: 2010

Purpose: The aim of this systematic review was to identify the evidence as to whether computer simulators are able to teach and assess arthroscopic skills in a valid and reliable manner and whether these skills can be transferred to the operating theater. Methods: Multiple databases were searched by use of strict eligibility criteria to obtain the best evidence available. The studies were critically appraised by independent reviewers with narrative data synthesis. Results: The systematic literature search found 83 studies, of which 9 were included within this review. All of the studies were performed to validate the use of computer simulation, with only 1 study showing the effect on surgical performance within the operating theater. Five studies investigated knee arthroscopy and four investigated shoulder arthroscopy, with all showing high levels of internal validity and consistency for computer simulation. Outcome measures that appear to be able to discriminate skill level and experience include time to completion for tasks, the distance and path traveled by the probe, and the number of probe collisions. Conclusions: Knee and shoulder arthroscopy computer simulators with force feedback, haptic technology, and computer-generated outcome data showed high levels of internal consistency and reliability. The studies also showed improvement of skill levels for inexperienced participants. The evidence suggests that knee arthroscopy simulator training may result in improved performance within the operating theater. Further studies are required to show the transfer and predictive validity of computer simulation within the operating theater to enable it to become established as a valid training tool. Level of Evidence: Level III, systematic review. © 2010 Arthroscopy Association of North America.


Marsh S.,Alexandra Hospital
Journal of perioperative practice | Year: 2012

Surgical smoke is a regular hazard that the majority of perioperative personnel are exposed to. Many staff are unaware of the risks of surgical smoke and many more may take it for granted that a surgical facemask provides enough protection. This article provides detail on the composition of surgical smoke and highlights the potential dangers that theatre staff face and what could be done to protect them. It will demonstrate the potential harm for the patient with particular reference to laparoscopic procedures as these are becoming more favourable in general and gynaecological specialities and are of particular interest to the author.


Guo S.,Alexandra Hospital
Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand | Year: 2011

Skin complications have been reported to be associated with tourniquet use. The UK Medical Devices Agency (MDA) recommends the use of a limb drape to act as underpadding to reduce these complications. Our hospital had traditionally used Velbands as an underpadding, but changed to limb drapes on the advice of the MDA. The purpose of this study is to establish whether Velbands are still a safe and cost-effective tourniquet underpadding. A prospective clinical study was performed on consecutive patients undergoing hand surgery over a four-month period. Patients were randomly allocated into one of two treatment groups. Group 1 using Velband as tourniquet underpadding and Group 2 using limb drapes as underpadding. All patients had identical tourniquets, tourniquet pressure and skin preparation agents. After surgery, the tourniquet was removed and the skin beneath the tourniquet was inspected for any skin reaction or damage. Each group included 50 patients. Skin was normal after tourniquet use in all cases and there was no difference between the two groups. Velband is still a safe and cost-effective tourniquet underpadding in hand surgery.


Jewell D.P.,Alexandra Hospital
Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand | Year: 2011

Trapezio-metacarpal joint arthritis is common, affecting 7% of men and 15% of women. Numerous surgical techniques are described for this condition but it is not clear which is best. Eighty-six silicone trapezium replacements were assessed at an average of 46 months (six to 156 months) postoperatively for patient satisfaction, pain, key and power grip strength, range of motion, complications and disability with DASH score. Patient satisfaction was 92%. There was excellent pain reduction from 4.2 to 0.6 on a scale of 0 to 5. Strength was 72% and 84% of age-sex-matched normal data for key and power grips, respectively. The complication rate was low, with two cases of persistent pain. One resolved spontaneously, the other resolved following revision of the silicone implant. The average DASH score was 30. Silicone trapezium replacement is an effective operation that offers the patient good pain relief, strength and good function with few complications.


Tsagalis G.,Alexandra Hospital
Hippokratia | Year: 2011

Anemia is a common finding in patients with CKD, with a prevalence that increases gradually as eGFR declines. The prevalence of renal anemia depends on the size of the study and the selection of participants. Diabetic status increases the prevalence of anemia in patients with CKD. Anemia in CKD is due primarily to reduced production of erythropoietin in the kidney and secondarily to shortened red cell survival. Erythropoeitin (EPO) is produced by peritubular cells in the kidneys of the adult and in hepatocytes in the fetus. These cells are sensitive to hypoxia that once sensed leads to an increase in EPO production. EPO circulates in the plasma and induces redcell production in the bone marrow after successful binding to erythroid progenitor cells. Apart from EPO, folate, B 12 and iron are needed to assure effective erythropoiesis. Factors that can dysregulate this process include inflammation, uremic toxins, hypothyroidism, hypersplenism and ongoing infection. The investigation of renal anemia requires the assessment of a variety of biological indices. Among them, the complete blood count, the reticulocyte index, B 12, folate, ferritin levels and the saturation of transferrin are the most valuable tools in revealing the cause of renal anemia.


Leonidou A.,Alexandra Hospital
Journal of orthopaedic surgery (Hong Kong) | Year: 2013

PURPOSE. To compare the effects of different warfarin reversal protocols on surgical delay and complication rate in hip fracture patients. METHODS. Records of 7 men and 17 women aged 68 to 93 (mean, 82) years who were on warfarin and underwent surgery for femoral neck fractures were reviewed. The time to surgery, complication rate, and mortality were recorded, as were the International Normalised Ratio (INR) on admission and the day of operation, as well as the dose, route, and time of administration of vitamin K for reversing the anticoagulation effect of warfarin. Patients were divided into 4 groups based on the warfarin reversal treatment. Group 1 (n=4) included patients who did not receive reversal treatment, as their admission INR was 1.5 or less. Group 2 (n=6) included patients who did not receive reversal treatment even though their INR was >1.6. Group 3 (n=5) included patients who received inappropriate reversal treatment (late or low-dose oral administration). Group 4 (n=9) included patients who received appropriate reversal treatment in terms of dose, route, and time of administration. RESULTS. Among the 4 groups, the mean INR was 2.2 (range, 1.3-4.6) on admission and 1.4 (range, 1.0-1.6) on the day of surgery. Group 1 was excluded from further analysis. Respectively in groups 2, 3, and 4, the mean times to surgery were 2.3, 2.6, and 1.2 days, and the complication rates were 67%, 20%, and 11%. CONCLUSION. Early administration of intravenous vitamin K for hip fracture patients on warfarin is recommended to ensure early operative management and avoid postoperative complications.


Fischer B.,Alexandra Hospital
Regional Anesthesia and Pain Medicine | Year: 2010

For more than 25 years, Regional Anesthesia has challenged anesthesiologists to determine whether it offers real benefits in terms of patient outcome from major surgery, compared with general anesthesia. Although there is good evidence that regional analgesia offers superior pain relief to systemic opioid analgesia, evidence to support improved outcome from surgery remains elusive. Although many publications appear to support the hypothesis, others show no benefit, and the lack of properly conducted, large studies makes it difficult to draw any evidence-based conclusions in favor of regional anesthesia. Given that all major regional techniques have the potential to cause significant risks to patient outcome, it is incumbent on all anesthesiologists to balance the intended benefits against the significant adverse events associated with regional techniques.We are beginning to develop an evidence base for both the benefits and risks of regional anesthesia, when used for specific patient groups and for specific surgical procedures. This presentation looks at some of the evidence and examines how it can be used to develop guidelines for best practice. Copyright © 2010 by American Society of Regional Anesthesia and Pain Medicine.

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