The use of midazolam and haloperidol in cancer patients at the end of life.

INTRODUCTION: This study aimed to describe the patterns of sedative use among terminally ill cancer patients who were referred to a hospital-based specialist palliative care service for symptom management. It also aimed to examine whether sedative use among terminally ill cancer patients during the last two days of life had any impact on their survival. METHODS: A retrospective review of case notes was carried out for patients with a diagnosis of terminal cancer, who died in a 95-bedded oncology ward between September 2006 and September 2007. Data was collected on patient characteristics, duration of palliative care, indications and doses of sedatives used at 48 hours and 24 hours before death. RESULTS: A total of 238 patients died while receiving specialist palliative care, 132 of whom (55.5%) were female. At 48 hours and 24 hours before death, 22.6% and 24.8% of patients, respectively, were on sedatives like midazolam, haloperidol or both. The median dose of midazolam was 5 mg/day while the haloperidol dose at 48 hours and 24 hours before death was 3 mg/day and 4 mg/day, respectively. The indications for midazolam were anxiety, breathlessness and stiffness, while those for haloperidol were confusion agitation and nausea. Survival analysis showed no significant difference in survival between patients who were on sedatives and those who were not. The p-value for log-rank test was 0.78. CONCLUSION: The results showed that the doses and overall frequency of sedative use in this patient population tended to be low and that usage of sedatives had no deleterious influence on survival.

Prolonged cough presenting with diagnostic difficulty: a study of aetiological and clinical outcomes.

INTRODUCTION: Prolonged cough is a common reason for referral to a respiratory physician. Some cases of prolonged cough can be a diagnostic challenge, especially when it is not accompanied by features that suggest common aetiologies. The current study examined this group of patients so as to ascertain the final aetiological and clinical outcomes. METHODS: We performed a chart review of cases that had been prospectively identified. The inclusion criteria were cough lasting more than three weeks, normal chest radiograph, non-smoking status, no history of angiotensin-converting enzyme inhibitor use, normal physical examination and absence of suggestive features of asthma, gastroesophageal reflux disease and postnasal drip syndrome. We classified the final diagnoses into three categories: likely diagnosis; possible diagnosis; and no diagnosis established, and traced the clinical outcomes. RESULTS: A total of 54 patients met the study criteria. The median duration of cough was 16 weeks (range four weeks to five years), while the median age of the patients was 38 (range 18-73) years. A likely diagnosis was reached in 23 patients and a possible diagnosis, in 12 patients. Gastroesophageal reflux disease and postnasal drip syndrome were the commonest diagnoses. There were no cases of asthma. The cough improved completely in 44 patients. Three cases were lost to follow-up before an outcome could be documented. CONCLUSION: In most of these cases, a diagnosis could be achieved. The cough improved in the majority of patients, including those in whom a diagnosis could not be made.

Severe refractory hypoxaemia in H1N1 (2009) intensive care patients: initial experience in an Asian regional hospital.

INTRODUCTION: The management of Influenza A (H1N1) patients with acute respiratory distress syndrome (ARDS) is an emerging challenge, especially during the 2009 pandemic. These patients frequently require advanced mechanical ventilation (MV) and on occasion, rescue therapy. We describe the demographics, presentation, course and outcomes of the first 12 H1N1 patients with ARDS who were admitted to our institution. METHODS: This was a retrospective chart review of H1N1 patients with ARDS who were admitted to our intensive care unit (ICU) between July and September 2009. RESULTS: Seven of the 12 patients were female. The median age was 46 (range 27-66) years. 25 percent of the patients had good health prior to the infection. The presenting symptoms were mainly cough (100 percent), fever (92 percent) and dyspnoea (64 percent). The median times from symptom onset to both hospitalisation and ICU admission were five (range 2-9) days. Ten (83 percent) patients required invasive MV within 24 hours of presentation. The mean PaO2/ FiO2 ratio was 87.9 +/- 37.3 mmHg, with a mean positive end expiratory pressure at 16.1 +/- 7.3 cm H2O. Three patients required either unconventional MV and/or prone positioning, inhaled nitric oxide or nebulised prostacyclin. The mean Acute Physiology and Chronic Health Evaluation II score was 12.7 +/- 9.1. Among survivors, the median number of ventilator days was 7.5 (range 5-11), with a median length of ICU stay of ten (range 6-14) days. The median length of hospitalisation was 13.5 (range 9-31) days. The mortality rate in our case series was 50 percent. CONCLUSION: Unlike patients of seasonal influenza, our severe H1N1 patients were of a younger age. A significant proportion had no underlying risk factors. Despite high ventilatory requirements, unconventional MV and adjunct therapy, the mortality rate remained high.

Acute naphthalene poisoning following the non-accidental ingestion of mothballs.

Ingestional naphthalene mothball poisoning leading to prolonged haemolysis and methaemoglobinaemia can present with diagnostic and therapeutic challenges. A 19-year-old woman ingested 12 mothballs, and presented two days later with haemolysis and methaemoglobinaemia. She was treated with red blood cell transfusions, intravenous methylene blue, N-acetylcysteine and ascorbic acid. Continuous venovenous haemofiltration was conducted for 45 hours. Haemolysis with anaemia and methaemoglobinaemia persisted even after five days post-ingestion. Clinical and biochemical parameters improved. We describe a case of ingestional naphthalene poisoning with a good outcome after treatment.

Severe community-acquired pneumonia requiring intensive care: a study of 80 cases from Singapore.

INTRODUCTION: Severe community-acquired pneumonia is a major cause of mortality and morbidity worldwide. This study looked at the clinical characteristics of these patients admitted to a Singaporean community hospital and the prognostic impact of age, bacteraemia and logistic organ dysfunction score (LODS) on intensive care unit mortality. METHODS: Retrospective analysis of 80 severe community-acquired pneumonia patients admitted to the intensive care unit over a 20-month period was conducted. The Mann-Whitney U and chi-square tests were used for statistical analysis and a p-value of less than 0.5 was considered as significant. RESULTS: There were 55 male and 25 female patients, with a median age of 62 years. The median LODS was 5. The intensive care unit mortality was 30 percent. The median LODS of intensive care unit survivors was 5 and of non-survivors, 8. The overall hospital mortality was 37.5 percent. A microbiological aetiology was identified in 38 percent of patients. Three of four patients with melioidosis died. Between intensive care unit survivors and non-survivors, there was a significant difference in the LODS, but no significant difference in the age and incidence of bacteraemia. CONCLUSION: Severe community-acquired pneumonia is a highly fatal disease which requires early initiation of appropriate empirical antibiotic therapy, which should include coverage for melioidosis in the local context. The microbiological workup should include testing for tuberculosis. The LODS system may be an appropriate tool in estimating the severity of illness.

Kikuchi's disease: a Singapore case series.

INTRODUCTION: Kikuchi's disease is a benign form of cervical lymphadenopathy that commonly affects young adults. We report a case series from our hospital. METHODS: The clinical features of 23 cases of Kikuchi's disease diagnosed at Changi General Hospital over a seven year period are presented. The cases were identified from pathology records using the search term histiocytic necrotising lymphadenitis. RESULTS: Most of our patients (78 percent) were young women who presented with cervical lymphadenopathy. The median age was 31 years. In the 18 cases who completed follow-up at the hospital, there was spontaneous resolution of symptoms within a six-month period. One patient demonstrated seropositivity for systemic lupus erythematosus (SLE) and was initially started on steroids. However, the treatment was discontinued shortly afterwards since she did not meet the diagnostic criteria for SLE. Excision biopsy of the affected lymph node was the diagnostic method of choice. CONCLUSION: Kikuchi's disease is not uncommon in the Singaporean population. Establishing an early diagnosis is crucial since the clinical presentation can mimic tuberculous lymphadenitis or malignant lymphoma. The diagnostic method of choice is excision biopsy.

Gemella empyema cured without antibiotics: a case report.

INTRODUCTION: Gemella are gram-positive bacteria that are commensals of the upper respiratory tract in humans and infrequently known to cause infections. CLINICAL PICTURE: We report a case of thoracic empyema due to Gemella morbillorum in an elderly Chinese male who had been having symptoms for 3 months and no response to multiple courses of antibiotics. INTERVENTION: The collection was drained with ultrasound guidance. OUTCOME: Drainage of the empyema produced rapid resolution of symptoms and no antibiotics were started. CONCLUSIONS: Gemella is a very rare cause of empyema which usually responds well to treatment.

An unusual case of metformin associated lactic acidosis.

Metformin Associated Lactic Acidosis (MALA) is a rare, but serious complications of Type 2 diabetes mellitus treatment with a mortality rate of around 50%. It most commonly occurs in the setting of hepatic, cardiac or renal insufficiency. We report the case of an elderly female with MALA and concomitant starvation ketosis in the absence of any known risk factor, who went undiagnosed for a period of at least a month and made a complete recovery in the hospital.