The Effect of Building-Level Socioeconomic Status on Bystander Cardiopulmonary Resuscitation: A Retrospective Cohort Study.

OBJECTIVE: Understanding the social determinants of bystander cardiopulmonary resuscitation (CPR) receipt can inform the design of public health interventions to increase bystander CPR. The association of socioeconomic status with bystander CPR is generally poorly understood. We evaluated the relationship between socioeconomic status and bystander CPR in cases of out-of-hospital cardiac arrest (OHCA). METHODS: This was a retrospective cohort study based on the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study registry between 2010 and 2018. We categorized patients into low, medium, and high Singapore Housing Index (SHI) levels-a building-level index of socioeconomic status. The primary outcome was receipt of bystander CPR. The secondary outcomes were prehospital return of spontaneous circulation and survival to discharge. RESULTS: A total of 12,730 OHCA cases were included, the median age was 71 years, and 58.9% were male. The bystander CPR rate was 56.7%. Compared to patients in the low SHI category, those in the medium and high SHI categories were more likely to receive bystander CPR (medium SHI: adjusted odds ratio [aOR] 1.48, 95% CI 1.30-1.69; high SHI: aOR 1.93, 95% CI 1.67-2.24). High SHI patients had higher survival compared to low SHI patients on unadjusted analysis (OR 1.79, 95% CI 1.08-2.96), but not adjusted analysis (adjusted for age, sex, race, witness status, arrest time, past medical history of cancer, and first arrest rhythm). When comparing high with low SHI, females had larger increases in bystander CPR rates than males. CONCLUSIONS: Lower building-level socioeconomic status was independently associated with lower rate of bystander CPR, and females were more susceptible to the effect of low socioeconomic status on lower rate of bystander CPR.

Characteristics and Outcomes of Traumatic Cardiac Arrests in the Pan-Asian Resuscitation Outcomes Study.

OBJECTIVE: Little is known about survival outcomes after traumatic cardiac arrest in Asia, or the association of Utstein factors with survival after traumatic cardiac arrests. This study aimed to describe the epidemiology and outcomes of traumatic cardiac arrests in Asia, and analyze Utstein factors associated with survival. METHODS: Traumatic cardiac arrest patients from 13 countries in the Pan-Asian Resuscitation Outcomes Study registry from 2009 to 2018 were analyzed. Multilevel logistic regression was performed to identify factors associated with the primary outcomes of survival to hospital discharge and favorable neurological outcome (Cerebral Performance Category (CPC) 1-2), and the secondary outcome of return of spontaneous circulation (ROSC). RESULTS: There were 207,455 out-of-hospital cardiac arrest cases, of which 13,631 (6.6%) were trauma patients aged 18 years and above with resuscitation attempted and who had survival outcomes reported. The median age was 57 years (interquartile range 39-73), 23.0% received bystander cardiopulmonary resuscitation (CPR), 1750 (12.8%) had ROSC, 461 (3.4%) survived to discharge, and 131 (1.0%) had CPC 1-2. Factors associated with higher rates of survival to discharge and favorable neurological outcome were arrests witnessed by emergency medical services or private ambulances (survival to discharge adjusted odds ratio (aOR) = 2.95, 95% confidence interval (CI) = 1.99-4.38; CPC 1-2 aOR = 2.57, 95% CI = 1.25-5.27), bystander CPR (survival to discharge aOR = 2.16; 95% CI 1.71-2.72; CPC 1-2 aOR = 4.98, 95% CI = 3.27-7.57), and initial shockable rhythm (survival to discharge aOR = 12.00; 95% CI = 6.80-21.17; CPC 1-2 aOR = 33.28, 95% CI = 11.39-97.23) or initial pulseless electrical activity (survival to discharge aOR = 3.98; 95% CI = 2.99-5.30; CPC 1-2 aOR = 5.67, 95% CI = 3.05-10.53) relative to asystole. CONCLUSIONS: In traumatic cardiac arrest, early aggressive resuscitation may not be futile and bystander CPR may improve outcomes.

Endoscopic sleeve gastroplasty (ESG) for morbid obesity: how effective is it?

INTRODUCTION: ESG is an effective treatment for classes I and II obesity. However, the benefit of ESG in patients with morbid obesity (BMI ≥ 40 kg/m2) who decline surgery is not known. The study aims to compare the effectiveness and safety of ESG in all three obesity classes at 1 year. METHODS: We reviewed 484 patient records and identified 435 patients (class I: 105, class II: 169, class III: 161) who underwent ESG at our unit between May 2013 and March 2020. We compared their total body weight loss (%TBWL) and safety over 1 year. We used a linear mixed model (LMM) to analyse repeated measures of weight loss outcomes at 3, 6, 9, and 12 months for comparison between the three BMI groups. RESULTS: Among the 435 patients, 396 patients (class I: 99, class II: 151, class III: 146) completed 6 months, and 211 patients reached 1 year (class I: 50, class II: 77, class III: 84). There was no difference in age between the groups. In LMM analysis, adjusting for age and sex, we found ESG had a significantly higher TBWL, %TBWL, and BMI decline in class III compared to classes I and -II obesity at all time points (p < 0.001). The adjusted mean %TBWL at 1 year with classes I, -II, and -III obesity was 16.5%, 18.2%, and 20.5%, respectively. The overall complication rate and the hospital stay was identical in the three groups. CONCLUSION: ESG induced significant weight loss in all classes of obesity. In class III obesity, the weight loss achieved was significantly higher at 1 year. In patients declining or unsuitable for surgery, ESG could be considered as an alternative treatment option.

Comparison of postpartum incontinence outcomes after vacuum-assisted and forceps-assisted deliveries in a tertiary maternity unit.

INTRODUCTION AND HYPOTHESIS: Forceps-assisted deliveries are an established risk factor for pelvic organ prolapse and pelvic floor injury. However, specific comparison of incontinence outcomes between vacuum-assisted and forceps-assisted deliveries are scarce in the literature. We aimed to compare the initial impact of vacuum and forceps deliveries on new-onset urinary and faecal incontinence as well as pelvic floor muscle strength, with the hypothesis that incontinence outcomes were poorer after forceps- than after vacuum-assisted delivery. METHODS: This is a retrospective cohort study of incontinence outcomes in patients who had primary vacuum- or forceps-assisted delivery. The study population included 108 postpartum patients who had undergone operative vaginal delivery (63 vacuum-assisted, 45 forceps-assisted), met the inclusion criteria and attended the postpartum assessment service. Outcomes studied were the presence and severity of symptoms manifesting beyond 1 month postpartum - faecal incontinence and stress, urgency and mixed urinary incontinence - as well as pelvic floor muscle strength scores based on the modified Oxford scale. RESULTS: Prevalence of new-onset urinary and faecal incontinence was 35.6% in the forceps group and 30.2% in the vacuum group. The data suggest that there is no significant difference in the prevalence of new-onset incontinence symptoms (p = 0.70, difference in prevalence [forceps - vacuum]: 5.4%, 95% CI -0.25, +0.15), frequency (p = 0.40) and amount (p = 0.48) of urine leakage or mean muscle strength scores (p = 0.89). CONCLUSION: In our maternity unit, we observed that type of operative vaginal delivery was not associated with significant differences in urinary incontinence and pelvic floor muscle strength outcomes.

Healing outcomes and predictors among patients with venous leg ulcers treated with compression therapy.

OBJECTIVE: This study aimed to compare the healing outcomes between three types of compression therapy-two-layer bandage (2LB), four-layer bandage (4LB), and compression stockings, and to identify the predictors of venous leg ulcer (VLU) healing. METHOD: A retrospective review of the medical records of patients diagnosed with VLU between 2011 and 2016 in Singapore was conducted. Univariate and multivariate analyses were done between healed and unhealed VLU patients at three and six months, based on potential factors, ranging from demographic profile to comorbidities and treatment-related variables. RESULTS: Data from 377 patients' medical records were analysed. The healing rates with the three types of compression system, 4LB, 2LB and compression stockings, were 22.3%, 34.9% and 8.7% respectively at three months; at six months they were 44.2%, 41.9% and 34.8% respectively. Patients on 2LB reported a significantly higher proportion of healed ulcers at three months (p=0.003) but at six months there was no difference in healing rates between the three types of therapy. At three and six months, the duration of compression therapy was found to be an independent predictor of healing (p<0.001). CONCLUSION: In this study, the 2LB appeared to show the most favourable healing outcome in the short-term but as VLUs persisted beyond the months, the type of compression system used did not make a difference in the healing outcome. Our findings suggested that, as the duration became more prolonged, VLUs became more resistant to healing despite compression therapy. Therefore, it may be necessary for clinicians to consider adjuvant therapies for hard-to-heal ulcers at an earlier stage.

Poor Outcomes of Cirrhosis due to Nonalcoholic Steatohepatitis Compared With Hepatitis B After Decompensation With Ascites.

INTRODUCTION: Decompensation with ascites portends a poor prognosis in cirrhosis. The aim of this study was to compare the outcomes of patients with nonalcoholic steatohepatitis (NASH) with hepatitis B virus (HBV) cirrhosis after decompensation with ascites. METHODS: We conducted a retrospective study to evaluate the outcomes of patients with NASH and HBV cirrhosis who were admitted to hospital for first-onset ascites from January 1, 2004, to June 30, 2015. They were followed up until death, liver transplantation, or loss to follow up. RESULTS: Patients with NASH had lower median (interquartile range) Model for End-Stage Liver Disease score (11 [9-14] vs 14 [11-17], P < 0.001). Over 60 months, patients with NASH cirrhosis had higher cumulative incidence of dilutional hyponatremia (P < 0.001) and refractory ascites (P = 0.028). They also had higher cumulative incidence of cirrhosis-related deaths and liver transplantation compared with HBV cirrhosis (65.7%; [95% confidence interval (CI) 53.6-75.4] vs 42.5% [95% CI 32.4-55.2], P = 0.008). Multivariable competing risk analysis showed that NASH (subdistribution hazard ratio [sHR] 1.88 [95% CI 1.14-3.11], P = 0.014), non-Chinese ethnicity (sHR 1.63 [95% CI 1.06-2.50], P = 0.027), history of hepatocellular carcinoma (sHR 1.76 [95% CI 1.05-2.95], P = 0.033), estimated glomerular filtration rate <60 mL/min/1.73 m2 (sHR 1.70 [95% CI 1.09-2.65], P = 0.020), and Model for End-Stage Liver Disease score ≥15 (sHR 3.26 [95% CI 2.11-5.05], P < 0.001) were independent predictors of poor transplant-free survival. DISCUSSION: Patients with decompensated cirrhosis due to NASH had much poorer prognosis compared with HBV with more complications and greater healthcare resource utilization. Greater awareness is necessary for early diagnosis of NASH before decompensation.

Primary obesity surgery endoluminal (POSE-2) procedure for treatment of obesity in clinical practice.

BACKGROUND: The POSE-2 procedure shortens and narrows the stomach using multiple full-thickness plications in the gastric body. We studied the efficacy and safety of POSE-2 for obesity at 1 year in a real-world setting. METHODS: We reviewed the records of 75 patients who underwent POSE-2 at our unit. The primary outcome was percentage total body weight loss (%TBWL) at 1 year. Secondary outcomes were safety and durability. We used linear mixed model analysis. RESULTS: 46 patients completed 1 year. Mean age and body mass index (BMI) were 49.3 years (standard deviation [SD] 10.2) and 38.2 kg/m2 (SD 6.6), respectively. Technical success rate was 98.7 % (n = 74). Mean TBWL, %TBWL, and BMI decline at 1 year were 20 kg (SD 12.7), 17.8 % (SD 9.5), 7 kg/m2 (SD 4.3). Adverse events occurred in four patients. The median length of stay was 1 day. Endoscopy at 1 year in 15 patients showed intact sutures and a reduction in gastric length compared with baseline (26.9 cm [SD 5.3] vs. 35.7 cm [SD 3.5]; P < 0.001). CONCLUSION: POSE-2 induced significant weight loss at 1 year. It appears to be safe, durable, and required only a short hospital stay.

Endoscopic sleeve gastroplasty, laparoscopic sleeve gastrectomy, and laparoscopic greater curve plication: do they differ at 2 years?

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) is an effective treatment option for obesity. However, data comparing its efficacy to bariatric surgery are scarce. We aimed to compare the effectiveness and safety of ESG with laparoscopic sleeve gastrectomy (LSG) and laparoscopic greater curve plication (LGCP) at 2 years. METHODS : We reviewed 353 patient records and identified 296 patients who underwent ESG (n = 199), LSG (n = 61), and LGCP (n = 36) at four centers in Spain between 2014 and 2016. We compared their total body weight loss (%TBWL) and safety over 2 years. A linear mixed model (LMM) was used to analyze repeated measures of weight loss outcomes at 6, 12, 18, and 24 months to compare the three procedures. RESULTS : Among the 296 patients, 210 (ESG 135, LSG 43, LGCP 32) completed 1 year of follow-up and 102 (ESG 46, LSG 34, LGCP 22) reached 2 years. Their mean (standard deviation [SD]) body mass index (BMI) was 39.6 (4.8) kg/m2. There were no differences in age, sex, or BMI between the groups. In LMM analysis, adjusting for age, sex, and initial BMI, we found ESG had a significantly lower TBWL, %TBWL, and BMI decline compared with LSG and LGCP at all time points (P = 0.001). The adjusted mean %TBWL at 2 years for ESG, LSG, and LGCP were 18.5 %, 28.3 %, and 26.9 %, respectively. However, ESG, when compared with LSG and LGCP, had a shorter inpatient stay (1 vs. 3 vs. 3 days; P < 0.001) and lower complication rate (0.5 % vs. 4.9 % vs. 8.3 %; P = 0.006). CONCLUSION : All three procedures induced significant weight loss in obese patients. Although the weight loss was lower with ESG compared with other techniques, it displayed a better safety profile and shorter hospital stay.

Defining prostate cancer size and treatment margin for focal therapy: does intralesional heterogeneity impact the performance of multiparametric MRI?

OBJECTIVES: To evaluate the impact of intralesional heterogeneity on the performance of multiparametric magnetic resonance imaging (mpMRI) in determining cancer extent and treatment margins for focal therapy (FT) of prostate cancer. PATIENTS AND METHODS: We identified men who underwent primary radical prostatectomy for organ- confined prostate cancer over a 3-year period. Cancer foci on whole-mount histology were marked out, coding low-grade (LG; Gleason 3) and high-grade (HG; Gleason 4-5) components separately. Measurements of entire tumours were grouped according to intralesional proportion of HG cancer: 0%, <50% and ≥50%; the readings were corrected for specimen shrinkage and correlated with matching lesions on mpMRI. Separate measurements were also taken of HG cancer components only, and correlated against entire lesions on mpMRI. Size discrepancies were used to derive the optimal tumour size and treatment margins for FT. RESULTS: There were 122 MRI-detected cancer lesions in 70 men. The mean linear specimen shrinkage was 8.4%. The overall correlation between histology and MRI dimensions was r = 0.79 (P < 0.001). Size correlation was superior for tumours with high burden (≥50%) compared to low burden (<50%) of HG cancer (r = 0.84 vs r = 0.63; P = 0.007). Size underestimation by mpMRI was more likely for larger tumours (51% for >12 mm vs 26% for ≤12 mm) and those containing HG cancer (44%, vs 20% for LG only). Size discrepancy analysis suggests an optimal tumour size of ≤12 mm and treatment margins of 5-6 mm for FT. For tumours ≤12 mm in diameter, applying 5- and 6-mm treatment margins would achieve 98.6% and 100% complete tumour ablation, respectively. For tumours of all sizes, using the same margins would ablate >95% of the HG cancer components. CONCLUSIONS: Multiparametric MRI performance in estimating prostate cancer size, and consequently the treatment margin for FT, is impacted by tumour size and the intralesional heterogeneity of cancer grades.

Evaluating the preoperative breast cancer characteristics affecting the accuracy of axillary ultrasound staging.

We evaluate the preoperative breast cancer (BC) characteristics that affect the diagnostic accuracy of axillary ultrasound (US) and determine the reliability of US in the different subgroups of BC patients. Axillary US assessments in women with invasive BC diagnosed between 2009 and 2016 in a single institution were retrospectively reviewed. The diagnostic accuracy of axillary US was obtained using surgical nodal histology as the gold standard. Preoperative breast tumor sonographic and histological factors affecting axillary US diagnostic accuracy were examined. Of the 605 newly diagnosed invasive BC cases reviewed, 251 (41.5%) had nodal metastases. Axillary US sensitivity was 75.7%, specificity 92.9%, positive predictive value 88.4%, negative predictive value 84.4%, and false-negative rate 24.3%. Lower US sensitivity was seen with invasive lobular cancer (ILC) (P = .043), grade I/II, (P = .021), unifocal (P = .039), and smaller tumors (P < .001). US specificity was lower in grade III (P < .001), estrogen receptor (ER)-negative (P < .001), progesterone receptor (PR)-negative (P = .004), HER2-positive (P = .015), triple-negative (P = .001), and larger breast tumors (P < .001). US has moderate sensitivity and good specificity in detecting metastatic axillary lymph nodes. Based on preoperative cancer characteristics, US was less sensitive for nodal metastases from ILC, unifocal, lower grade, and smaller breast tumors. It was also less specific in grade III, ER-negative, PR-negative, HER2-positive, triple-negative, and larger breast tumors. Caution is suggested in interpreting the US axillary findings of patients with these preoperative tumor features.

The impact of healthcare worker influenza vaccination on nosocomial influenza in a tertiary hospital: an ecological study.

BACKGROUND: To protect hospitalized patients, who are more susceptible to complications of influenza, seasonal influenza vaccination of healthcare workers (HCW) has been recommended internationally. However, its effectiveness is still being debated. To assess the effectiveness of HCW influenza vaccination, we performed an ecological study to evaluate the association between healthcare worker influenza vaccination and the incidence of nosocomial influenza in a tertiary hospital within Singapore between 2013 and 2018. METHODS: Nosocomial influenza was defined as influenza among inpatients diagnosed 7 days or more after admission by laboratory testing, while healthcare worker influenza vaccination rate was defined as the proportion of healthcare workers that was vaccinated at the end of each annual seasonal vaccination exercise. A modified Poisson regression was performed to assess the association between the HCW vaccination rates and monthly nosocomial influenza incidence rates. RESULTS: Nosocomial influenza incidence rates followed the trend of non-nosocomial influenza, showing a predominant mid-year peak. Across 2,480,010 patient-days, there were 256 nosocomial influenza cases (1.03 per 10,000 patient-days). Controlling for background influenza activity and the number of influenza tests performed, no statistically significant association was observed between vaccination coverage and nosocomial influenza incidence rate although a protective effect was suggested (IRR 0.89, 95%CI:0.69-1.15, p = 0.37). CONCLUSION: No significant association was observed between influenza vaccination rates and nosocomial influenza incidence rates, although a protective effect was suggested. Aligning local HCW vaccine timing and formulation to that of the Southern Hemisphere may improve effectiveness. HCW vaccination remains important but demonstrating its effectiveness in preventing nosocomial influenza is challenging.

Risk factors and diagnostic markers of bacteremia in Stevens-Johnson syndrome and toxic epidermal necrolysis: A cohort study of 176 patients.

BACKGROUND: Sepsis is the main cause of death in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). OBJECTIVES: Our aim was to identify admission risk factors predictive of bacteremia and the accompanying clinical or biochemical markers associated with positive blood cultures. METHODS: A retrospective cohort study over a 14-year period (2003-2016) was performed. RESULTS: The study included 176 patients with SJS (n = 59), SJS-TEN overlap (n = 51), and TEN (n = 66). During hospitalization, bacteremia developed in 52 patients (29.5%), who experienced poorer outcomes, including higher intensive care unit admission (P < .0005), longer length of stay (P < .0005), and higher mortality (P < .0005). There were 112 episodes of bacteremia, and isolates included Acinetobacter baumannii (27.7%, n = 31) and Staphylococcus aureus (21.4%, n = 24). On multivariate analysis, clinical factors present at admission that were predictive of bacteremia included hemoglobin ≤10 g/dL (odds ratio [OR] 2.4, confidence interval [CI] 2.2-2.6), existing cardiovascular disease (OR 2.10, CI 2.0-2.3), and body surface area involvement ≥10% (OR 14.3, CI 13.4-15.2). The Bacteremia Risk Score was constructed with good calibration. Hypothermia (P = .03) and procalcitonin ≥1 µg/L (P = .02) concurrent with blood culture sampling were predictive of blood culture positivity. LIMITATIONS: This is a retrospective study performed in a reference center. CONCLUSION: Hemoglobin ≤10 g/dL, cardiovascular disease, and body surface area involvement ≥10% on admission were risk factors for bacteremia. Hypothermia and elevated procalcitonin are useful markers for the timely detection of bacteremia.

Changes in primary glomerulonephritis in Singapore over four decades
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This review of 3,289 native kidney biopsies over the past four decades in Singapore documents the changing pattern of biopsy-proven glomerulonephritis (GN)from that of a third world country to that of a developed nation. In the 1st decade, mesangial proliferative GN was the most common form of primary GN, similar to the Asian region. In the 2nd decade, the percentage of mesangial proliferative GN decreased, but membranous GN became more common, as was seen in China and Thailand. In the 3rd decade, focal segmental glomerulosclerosis (FSGS) and membranous nephropathy continued to rise, but it was only recently, in the 4th decade, that FSGS prevalence increased dramatically, although membranous nephropathy continues to increase in some Asian countries. In the last decade in Singapore, Malaysia, and Japan, prevalence of IgA nephritis has decreased but remains the most common GN. The percentage of FSGS continues to increase in many countries like in Italy, United States of America, United Kingdom, China, and Malaysia. We surmise that socioeconomic factors play significant roles in the evolution of the renal biopsy pattern.
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Comparative Study of Pattern-Based Versus Size Ratio Ultrasound Strain Elastographic Techniques on Breast Masses.

OBJECTIVES: The aim of this study was to compare the diagnostic performance of strain elastographic techniques involving pattern-based elastography versus size ratio elastography on breast masses. METHODS: Female patients presenting to the radiology department for ultrasound (US)-guided biopsies, fine-needle aspirations, or localizations of breast masses were invited to undergo US elastographic assessments of the lesions before the breast procedures. The masses were evaluated for color score and color map size ratio elastographic assessments with one US machine and size ratio and grayscale strain pattern elastographic assessments with another machine. With the histopathologic diagnosis as the reference standard, the sensitivity, specificity, and area under the receiver operating characteristic curve were compared among the 4 groups. RESULTS: A total of 154 breast masses from 139 women were assessed. The sensitivity and specificity were 0.615 (95% confidence interval, 0.470-0.747) and 0.824 (0.736-0.892), respectively for the color score, 0.962 (0.868-0.995) and 0.765 (0.670-0.843) for the size ratio, 0.904 (0.790-0.968) and 0.745 (0.649-0.826) for the color map size ratio, and 0.635 (0.490-0.764) and 0.422 (0.324-0.523) for the grayscale strain pattern. The areas under the receiver operating characteristic curve were 0.729 for the color score, 0.874 for the size ratio (P = .001 with the color score as a reference), 0.836 for the color map size ratio (P = .002), and 0.556 for the grayscale strain pattern (P < .001). CONCLUSIONS: Size ratio elastography had higher sensitivity and better diagnostic accuracy compared to color score elastography. This superiority was demonstrated on two different US systems, and size ratio elastography should thus be considered over color score elastography in the adjunctive US assessment of breast lesions.

The types of caregiving reactions experienced by the older spouse caregivers.

AIMS: To examine factors associated with the four types of caregiver reactions according to the modified Caregiver Reaction Assessment (mCRA) and assess the differences in the narrative assessment from spouse caregivers between the high-positive and high-negative caregiver reactions. BACKGROUND: There is a limited understanding of the factors contributing to positive and negative reactions among older spouse caregivers with chronic illnesses. Narrative assessment from spouse caregivers has not been studied before. DESIGN: The study design was a paired-sample, mixed-method survey design. Data were collected from spouse caregivers (≥55 years old) and care-recipients in one medical institute from February 2017-December 2017. This manuscript used STROBE checklist to ensure complete reporting. METHODS: Demographic, socioeconomic, Frailty Index, perceived stress, and quality of life data were gathered from caregiver dyads. mCRA, relationship, and life satisfaction data were collected from caregivers. mCRA identified the four types of caregiver reactions: (a) high-positive, low-negative; (b) high-positive, high-negative; (c) low-positive, high-negative; and (d) low-positive, low-negative. A qualitative interview was conducted to understand the differences in the narrative and choice of words used to describe caregiving experience. RESULTS: Seventy-five caregiver dyads were recruited. Total perceived stress was found to be negatively associated with high-positive, low-negative caregiver reaction (baseline category: low-positive, high-negative) by multinomial logistic regression. Content analyses showed that low-positive and high-negative caregivers used words that implied a lack of volition. Caregivers with positive experience viewed caregiving as a responsibility; the opposite viewed it as having 'no choice'. CONCLUSIONS: Perceived stress is an important indicator of caregiver reactions. Words used when describing caregiving experiences can potentially depict the spouse caregivers' current state of being as a caregiver. RELEVANCE TO CLINICAL PRACTICE: Spouse caregiver's narrative of their caregiving experience may provide easy and quick insights if interventions are needed. Early identification of negative reactions will allow for prompt interventions in mitigating caregivers' stress.

A prediction tool for hospital-acquired pressure ulcers among surgical patients: Surgical pressure ulcer risk score.

Surgical patients are prone to developing hospital-acquired pressure ulcers (HAPU). Therefore, a better prediction tool is needed to predict risk using preoperative data. This study aimed to determine, from previously published HAPU risk factors, which factors are significant among our surgical population and to develop a prediction tool that identifies pressure ulcer risk before the operation. A literature review was first performed to elicit all the published HAPU risk factors before conducting a retrospective case-control study using medical records. The known HAPU risks were compared between patients with HAPU and without HAPU who underwent operations during the same period (July 2015-December 2016). A total of 80 HAPU cases and 189 controls were analysed. Multivariate logistic regression analyses identified eight significant risk factors: age ≥ 75 years, female gender, American Society of Anaesthesiologists ≥ 3, body mass index < 23, preoperative Braden score ≤ 14, anaemia, respiratory disease, and hypertension. The model had bootstrap-corrected c-statistic 0.78 indicating good discrimination. A cut-off score of ≥6 is strongly predictive, with a positive predictive value of 73.2% (confidence interval [CI]: 59.7%-84.2%) and a negative predictive value of 80.7% (CI: 74.3%-86.1%). SPURS contributes to the preoperative identification of pressure ulcer risk that could help nurses implement preventive measures earlier.

Five-year long-term clinical outcome after bariatric metabolic surgery: A multi-ethnic Asian population in Singapore.

Bariatric surgery is an effective treatment for morbid obesity and its metabolic related comorbidities; type 2 diabetes, hypertension and hyperlipidaemia.1 However, the literature is scarce regarding the long-term outcome after bariatric surgery, especially among multi-ethnic Asian populations. Considering the growing number of bariatric metabolic surgeries in Asia, we have attempted to provide a regional perspective on 5-year long-term clinical outcomes post bariatric surgery in Singapore. Between 2010 and 2016, all bariatric operative cases were included, and these comprised: laparoscopic sleeve gastrectomy (LSG), 393; laparoscopic Roux-En-Y gastric bypass (RYGB), 125; laparoscopic mini-gastric bypass (MGB), 43. The primary outcome measure was the percentage of excess weight loss (% EWL) at 6 months, 1, 2, 3, 4 and 5 years, with % remission of type 2 diabetes mellitus (T2DM) at 1 year following LSG (49.7%, 61.2%, 56.1%, 47.8%, 40.8% and 47.3%; 82.2%), RYGB (60.2%, 62.1%, 57.6%, 50.1%, 48.7% and 47.7%; 86.9%) and MGB (58%, 68.1%, 62.7%, 66.2%, 64.0%, 65.2%; 71.9%). In conclusion, MGB and RYGB showed the greatest % EWL at 5 years and are recommended for moderate T2DM. LSG is an effective bariatric operation with a high % EWL up to 2 years, and a high remission rate of mild T2DM. The remission rate of T2DM was equally high in all 3 surgical groups, independent of ethnic differences.

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review.

BACKGROUND: End stage renal disease (ESRD)/ end stage renal failure (ESRF) is on the rise globally and especially in Singapore. Varicella or chickenpox is not uncommon among adults especially ESRD/ESRF patients. It has been reported to cause complications and even death among immunocompetent adults. METHODS: A retrospective data collection on patients with varicella infection and ESRD in Singapore General Hospital (SGH) from the year 2005 to 2016 was performed. Continuous data and categorical data were summarized as median (range) and count (%) respectively. The association of health care utilization (total length of hospital stay, readmission related to varicella, intensive care unit admission) and mortality with complication due to varicella were tested using chi-square and Mann-Whitney test for categorical and continuous outcomes respectively. RESULTS: Sixty-six patients with ESRD developed varicella during the study period (2005-2016). The case incidence rates for varicella among ESRD ranges from 97 to 267 per 100,000 populations with ESRD yearly. There were 9 deaths (13.6%). Mortality was higher among the ESRD patients with one or more varicella complications compared to patients without complications ((25% vs 7.1%, 95% CI for difference: - 1.1%, 36.9%, p = .063). Likewise, utilisation of intensive or high dependency units were higher among patients with complications compared to those without (20.8% vs 2.4%, 95% CI for difference: 1.6%, 35.3%, p = .012). Length of stay was twice as long in the group with complications compared to patients without (median (IQR) days: 14 (8, 21) vs 7 (5, 14), p = .065), although it did not reach statistical significance. CONCLUSIONS: Varicella is associated with high morbidity and significant mortality rate in ESRD patients. Varicella vaccination is recommended for seronegative ESRD patients.

Utility of a Medical Alert Protection System compared to telephone follow-up only for home-alone elderly presenting to the ED - A randomized controlled trial.

OBJECTIVE: Medical Alert Protection Systems (MAPS) are a form of assistive technology designed to support independent living in the care of elderly patients in the community. We aimed to investigate the utility of using such a device (eAlert! System) in elderly patients presenting to an Emergency Department (ED). METHODS: Elderly patients presenting to an ED were randomized to receive MAPS or telephone follow-up only (control arm). All patients were followed up at one-week, one-month and six-month post-intervention. A confidence scale (at 1week, 1month and 6months) and EQ-5D score (at 6months) were also administered. RESULTS: 106 and 91 participants enrolled in the MAPS and control arms respectively. Within both individual arms, there were significant reductions in the median number of ED visits and median number of admissions in the six month periods before, compared to after intervention (p<0.01 for both). However, the reductions were not significantly different between the two arms. Among participants who have had one or more admissions during the six months period post intervention, the MAPS arm had significantly lower median total length of stay (8days, Interquartile Range [IQR]=(4, 14)) compared to the control arm (15days, IQR=(3, 25), p=0.045). The median health state score for health state was significantly higher in the MAPS arm (70 IQR=(60,80) versus 60 IQR=(50,70), p=0.008). CONCLUSION: In this population of elderly ED patients, the use of a MAPS decreased length of stay for admissions and improved quality of life measures.

Cyclosporine treatment for Stevens-Johnson syndrome/toxic epidermal necrolysis: Retrospective analysis of a cohort treated in a specialized referral center.

BACKGROUND: Treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) remains controversial. OBJECTIVE: We sought to evaluate the impact of cyclosporine on hospital mortality in patients with SJS/TEN. METHODS: All patients with SJS and TEN admitted to our center from 2011 to 2014 were treated under a standardized protocol that allowed for cyclosporine therapy if the inclusion and exclusion criteria were met. Clinical data were reviewed retrospectively. Comparative analysis was made on mortality outcomes with patients treated with cyclosporine versus what was expected based on SCORTEN. RESULTS: In all, 44 patients were admitted during the study period. A total of 24 patients received cyclosporine and the remaining 20 patients were treated supportively. SCORTEN predicted 7.2 deaths and 3 were observed in the group treated with cyclosporine. In the group treated supportively, SCORTEN predicted 5.9 deaths and 6 deaths were observed. The standardized mortality ratio of SJS/TEN treated with cyclosporine was 0.42 (95% confidence interval 0.09-1.22). LIMITATION: Small sample size, retrospective design, and referral bias are limitations. CONCLUSION: The use of cyclosporine may improve mortality in SJS/TEN and needs to be validated in controlled studies.