Ngiam K.Y.,Khoo Teck Puat Hospital |
Lee W.-J.,Min Sheng General Hospital |
Lee Y.-C.,Chien Hsin University of Science and Technology |
Cheng A.,Khoo Teck Puat Hospital
Obesity Surgery | Year: 2014
High glycated hemoglobin A1c (HbA1c) is strongly correlated with developing type 2 diabetes mellitus (T2DM) complications; this study reviews the efficacy of various types of metabolic surgeries in reducing HbA1c levels in type 2 diabetics with BMI <35 kg/m2. An electronic search of MEDLINE databases using terms 'metabolic surgery', type 2 diabetes mellitus, BMI <35 kg/m2, and related keywords for studies published between 1987 and 2013. Data from 53 articles with 2,258 patients were selected for this review. The weighted mean change in HbA1c was -2.8 % (95 % CI -2.8 to -2.7, p < 0.01) and weighted mean BMI change was -5.5 kg/m2 (95 % CI -5.6 to -5.4, p < 0.01). There was a strong correlation between weighted percentage mean change in HbA1c and BMI. Adjustable gastric banding and duodenal jejunal bypass were inferior to other surgeries in reducing BMI and HbA1c in BMI <35 kg/m2. Metabolic surgery significantly decreases HbA1c in T2DM patients with BMI <35 kg/m2 and that the magnitude of HbA1c change may be a useful surrogate of DM control. © 2013 Springer Science+Business Media New York.
Siddiqui S.,Khoo Teck Puat Hospital
International Archives of Medicine | Year: 2013
Readmission to the surgical intensive care unit of a tertiary care hospital has traditionally been tracked as a quality indicator and many studies have suggested various figures as to the acceptable rate of such. ICU beds being a precious resource readmitting a patient could imply hasty discharge or inadequate care. Patients readmitted generally have a higher mortality and length of stay due to the worsening of their illness. The definition of 'ICU readmission' varies from either in the first 24 hours, to over the next 2 days or even whether the patient comes back during the entire period of admission. The association between increasing severity of illness and the risk of readmission to ICU has not been systematically summarized and one can speculate as to the various predictive signs of possible readmission. We looked at our data over the past 5 months of all adult surgical ICU patients who were readmitted during the same admission after ICU discharge. Fourteen patients were readmitted with the monthly rate varying from 3-11% per month. The age ranged from 33 to 90 years and the gender was mostly male. The patients' initial admission diagnosis varied as they belonged to General surgery, ENT, Neurosurgery and Orthopedic disciplines and the time from initial discharge to readmission ranged from 40 to 4 days. The majority of the readmission causes were respiratory and these included desaturation, PE, pneumonia and mucus plugging. Other causes included hypotension, sepsis, dysrhythmias, recurrent drop in GCS and GI re-bleed. When compared to the first admission most patients had a longer length of stay during the readmission. The outcomes were mostly good with only one patient expiring after readmission. © 2013 Siddiqui; licensee BioMed Central Ltd.
Tham A.C.,Khoo Teck Puat Hospital
Clinical & experimental ophthalmology | Year: 2012
The purpose of this paper was to analyse the causes, pathogenesis, diagnostic modalities and treatment outcomes of microsporidial keratoconjunctivitis (MKC). Microsporidia are increasingly recognized as opportunistic infectious pathogens in immunocompromized patients causing keratoconjunctivitis. In the recent years, there has been a surge in reports of MKC in immunocompetent individuals presenting with stromal keratitis. A detailed literature search was done using Medline, OVID, Cochrane Library, UptoDate and Google Scholar databases with the terms microsporidia, keratitis, conjunctivitis, immunocompromized and immunocompetent. The articles were reviewed to determine the spectrum of clinical presentation, disease course, investigations, treatment modalities and outcome. Thirty-six publications were reviewed, and 151 cases of MKC were included for this review. The main presenting features included pain, redness, photophobia, epiphora and blurring of vision. Duration of the symptoms lasted between 4 days and 18 months. Light microscopy with modified trichrome stain was most commonly used to diagnose MKC. Resolution of symptoms was most commonly achieved with oral albendazole and/or topical fumidil B. Topical fluoroquinolones are also effective as a monotherapy as suggested by recent studies. Clinical outcome was good (visual acuity ≤ 6/12) for the patients who presented earlier (≤1 month) (75% of cases with documented final best-corrected visual acuity). MKC occurs more commonly in immunocompetent individuals than expected and can be diagnosed in earlier stages. From our review, we conclude that the patients, who were diagnosed early and treated, had complete resolution of symptoms with a better clinical outcome. © 2011 The Authors. Clinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists.
Sim H.-L.,Khoo Teck Puat Hospital |
Tan K.-Y.,Khoo Teck Puat Hospital
Colorectal Disease | Year: 2014
Background: Open haemorrhoidectomy has been associated with considerable postoperative pain and discomfort. Perianal intradermal injection of methylene blue has been shown to ablate perianal nerve endings and may bring about temporary pain relief after haemorrhoidectomy. We hypothesized that the administration of intradermal methylene blue would reduce postoperative pain during the initial period after surgery. Method: A randomized, prospective, single-blind placebo-controlled trial was conducted. Patients were randomized to intradermal injection at haemorrhoidectomy of either 4 ml 1% methylene blue and 16 ml 0.5% marcaine or of 16 ml 0.5% marcaine and 4 ml saline prior to surgical dissection. Patients were asked to fill in a pain diary with a visual analogue scale. The primary outcome measure was pain score and analgesic use. Secondary outcomes were complications. Results: There were 37 patients in the methylene blue arm and 30 patients in the placebo arm. There were no statistically significant differences in the sex, type of haemorrhoid, number of haemorrhoids excised, duration of surgery or hospital stay. The mean pain scores were significantly lower and the use of paracetamol was also significantly less in the methylene blue group during the first three postoperative days. The risk ratio of acute urinary retention occurring when methylene blue was not used was 2.320 (95% CI 1.754-3.067). Other complication rates were not significantly different. Conclusion: Perianal intradermal injection of methylene blue was useful in reducing the initial postoperative pain of open haemorrhoidectomy. © 2014 The Association of Coloproctology of Great Britain and Ireland.
Lee F.,Khoo Teck Puat Hospital
Singapore Medical Journal | Year: 2011
Defibrillation may be needed in witnessed and unwitnessed cardiac arrests. Cardiopulmonary resuscitation (CPR) must be initiated and defibrillation administered without delay. Every shock cycle includes 1-2 minutes of CPR followed by rhythm analysis. The energy level for biphasic defibrillation of ventricular fibrillation is 150 J with possible step-wise escalation to 360 J. All healthcare workers need to learn and be authorised to use an automated external defibrillator (AED). In addition, all ambulances must be equipped with AEDs when transporting patients. Self-adhesive pads /paddles must be applied firmly to the skin for best effect. Monitoring electrodes and pacemaker locations should be considered during paddle/pad placement. AED skills should be imparted to a wide variety of community groups. More efforts will be made to increase the availability of AEDs in public, residential, commercial and industrial facilities.
Ramalingam G.,Khoo Teck Puat Hospital |
Anton C.K.S.,Khoo Teck Puat Hospital
Obesity Surgery | Year: 2011
Sleeve gastrectomy was conceived in 1988 both as a first step to the duodenal switch procedure and as an extension of anti-reflux surgery where patients lost significant weight. It is now a stand-alone laparoscopic bariatric procedure worldwide with two international consensus summits identifying it as a safe and feasible restrictive and appetite-suppressing procedure. In our centre, it is a key component in the surgical armamentarium and used as a first-line and revisional procedure for morbid obesity. The procedure is performed using standard five port technique. One year results are reviewed for its feasibility in our Asian patients. Twenty of 48 laparoscopic sleeve gastrectomies have a 1-year follow-up with four of them a revisional procedure for bands with complications. There were 11 males and 9 females (average age 43.6) and a representation of all four major ethnic groups. Average weight and BMI improved from 116.3 to 90.2 kg and 42.5 to 33.1 kg m -2 after 1 year, respectively. Average weight loss was 26.1 kg and excess weight loss (in percent) was 49.6%. There was an improvement in diabetes mellitus, hypertension, obstructive sleep apnoea and asthma and three complications including two leaks and a gastro-oesophageal spasm/stricture. Laparoscopic sleeve gastrectomy is safe and feasible as first-line surgery for morbid obesity and revisional procedures for band-related complications in the short term. Further studies are required to elucidate the exact mechanisms of weight loss in the sleeve gastrectomy to answer the appropriateness of the variations in the technique and long-term weight loss and morbidity. © 2011 Springer Science + Business Media, LLC.
Yeo D.,Khoo Teck Puat Hospital |
Tan K.-Y.,Khoo Teck Puat Hospital
World Journal of Gastroenterology | Year: 2014
While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology. © 2014 Baishideng Publishing Group Inc. All rights reserved.
Wee E.,Khoo Teck Puat Hospital
Journal of Postgraduate Medicine | Year: 2011
Nonvariceal upper gastrointestinal bleeding is unique from variceal bleeding in terms of patient characteristics, management, rebleeding rates, and prognosis, and should be managed differently. The majority of nonvariceal upper gastrointestinal bleeds will not rebleed once treated successfully. The incidence is 80 to 90% of all upper gastrointestinal bleeds and the mortality is between 5 to 10%. The causes include nonacid-related ulceration from tumors, infections, inflammatory disease, Mallory-Weiss tears, erosions, esophagitis, dieulafoy lesions, angiodysplasias, gastric antral vascular ectasia, and portal hypertensive gastropathy. Rarer causes include hemobilia, hemosuccus pancreaticus, and aortoenteric fistulas. Hematemesis and melena are the key features of bleeding from the upper gastrointestinal tract, but fresh per rectal bleeding may be present in a rapidly bleeding lesion. Resuscitation and stabilization before endoscopy leads to improved outcomes. Fluid resuscitation is essential to avoid hypotension. Though widely practiced, there is currently insufficient evidence to show that routine red cell transfusion is beneficial. Coagulopathy requires correction, but the optimal international normalized ratio has not been determined yet. Risk stratification scores such as the Rockall and Glasgow-Blatchford scores are useful to predict rebleeding, mortality, and to determine the urgency of endoscopy. Evidence suggests that high-dose proton pump inhibitors (PPI) should be given as an infusion before endoscopy. If patients are intolerant of PPIs, histamine-2 receptor antagonists can be given, although their acid suppression is inferior. Endoscopic therapy includes thermal methods such as coaptive coagulation, argon plasma coagulation, and hemostatic clips. Four quadrant epinephrine injections combined with either thermal therapy or clipping reduces mortality. In hypoxic patients, endoscopy masks allow high-flow oxygen during upper gastrointestinal endoscopy. The risk of rebleeding reduces after 72 hours. In rebleeding, repeat endoscopy is useful and persistent failure of endoscopic therapy mandates either embolization or surgery. In this review, we analyze the management of nonvariceal upper gastrointestinal bleeding with evidence from the currently published clinical trials.
Khoo S.A.,Khoo Teck Puat Hospital
International psychogeriatrics / IPA | Year: 2013
This study aims to determine the prevalence, profile, and severity of neuropsychiatric symptoms (NPS) across the dementia continuum and their relative impact on caregiver distress and quality of life (QoL) in persons with dementia (PWD). Six hundred and sixty-seven PWD and their family caregivers presented to a memory clinic in a tertiary hospital across a 60-month period. Clinicians determined the dementia diagnosis and severity using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition and the Clinical Dementia Rating scale, respectively. The Neuropsychiatric Inventory Questionnaire was administered to assess NPS in PWD and the corresponding distress experienced by the caregiver. QoL for PWD (PWD-QoL) was assessed by the Quality of Life-Alzheimer's Disease scale. Ninety-six percent of PWD presented with at least one NPS, 18% experiencing mild, 31% moderate, and 47% severe symptoms, respectively. While agitation (63.1%), apathy (61.8%), depression (55.5%), and irritability (55.5%) were the most common NPS; disinhibition (35.2%), hallucination (25.5%), and elation (14.2%) were the least common. NPS increased generally but differentially as dementia progressed and significantly predicted caregiver distress (ηp 2 = 0.732, p < 0.0001) and PWD-QoL (ηp 2 = 0.066, p < 0.0001). Factor analysis revealed two NPS clusters, disruptive and affective; the former exerting greater impact on caregiver distress and the latter on PWD-QoL. The results show a high prevalence of NPS which increase caregiver distress and negatively impact PWD-QoL. The differential profile of NPS across the dementia stages warrants stage-specific interventions and due consideration in resource planning and service design for PWD and their caregivers.
Wee E.W.,Khoo Teck Puat Hospital
Postgraduate medicine | Year: 2013
Patients with dyspepsia may present with associated complaints of abdominal pain, bloating, fullness, acid reflux, and epigastric tenderness on examination. The evaluation of patients with dyspepsia includes taking a comprehensive history and performing a physical examination. Although taking a patient history has its limitations in making an accurate diagnosis, it is useful in guiding the selection of subsequent diagnostic tests. Differential diagnoses of dyspepsia are best addressed using an anatomical approach. Patients with chronic dyspepsia lasting > 1 month should be evaluated for the presence of alarm features. Alarm features mandate an upper gastrointestinal endoscopy examination, as these may be suggestive of a malignancy. In patients without alarm features, a Helicobacter pylori test-and-treat strategy is cost-effective if the prevalence of H. pylori infection is high. Tests for H. pylori infection can be divided into non-invasive and minimally invasive tests. Many different antibiotic combination therapies (eg, triple therapy, quadruple therapy, levofloxacin-based therapy, sequential therapy, concomitant therapy, and probiotics with eradication therapy) are now available for the eradication of H. pylori infection. In patients who are symptomatic without an organic pathology, functional dyspepsia and other causes of abdominal pain need to be considered. Functional dyspepsia is best managed using a multifaceted approach by establishing a good physician-patient relationship, dietary and lifestyle interventions, medical therapy, psychotherapy, and the use of psychotropic medications. This review rationalizes the current-day recommendations for the evaluation and management of patients with dyspepsia in a clinical setting.