Granulomatous Mastitis and Factors Associated with Recurrence: An 11-Year Single-Centre Study of 113 Patients in Singapore.

BACKGROUND: Granulomatous mastitis (GM) is an inflammatory breast disease of unknown aetiology. It poses diagnostic and therapeutic challenges with myriad forms of clinical presentation, varying results to treatments and propensity to recur. This study aims to look at clinical and treatment factors that predispose to recurrence of GM. METHODS: We performed a retrospective review of 113 patients in our unit with histologically proven GM from 2006 to 2016. Demographic, clinical, treatment and outcomes data were collected and analysed. RESULTS: Eighty-nine patients were treated with antibiotics (78.8%), 79 (69.9%) with steroids and 23 (20.4%) patients underwent surgery. Twenty (17.7%) patients had recurrence. Patients who presented with inflammatory signs and symptoms had increased odds of having subsequent recurrence: skin changes (1.50), pain (2.00), fistula (4.39) and antibiotic treatment (6.65). Four patients (20%) with recurrence had positive bacterial cultures. All 4 grew Corynebacterium. Patients with Corynebacterium infection had a 2.64 times higher risk of recurrence. Surgery did not preclude recurrence. There was a 70% (7/10) penicillin resistance rate in our patients with positive cultures for Corynebacterium. CONCLUSION: Initial presentation with inflammatory signs and symptoms may confer increased risk of recurrence, warranting closer monitoring. Corynebacterium infection may play a part as a causative factor and risk factor for recurrence. Non-penicillin antibiotics should be considered as first-line antibiotics for patients presenting with inflammatory changes. Further prospective studies with larger patient populations might reveal information on the aetiology of GM and result in the development of a more standardized and effective treatment regimen.

Utility of bronchoalveolar lavage in the management of immunocompromised patients presenting with lung infiltrates.

BACKGROUND: Bronchoalveolar lavage (BAL) is utilized for diagnosing lung infiltrates in immunocompromised. There is heterogeneity in the data and reported diagnostic yields range from 26 to 69%. Therefore, selection criteria for BAL to maximize yield and minimize complications are unclear. Objectives of this study were to determine the diagnostic yield and complication rate of BAL in immunocompromised patients presenting with lung infiltrates, and identify factors impacting these outcomes. Exploratory aims included characterization of pathogens, rate of treatment modification and mortality. METHODS: Retrospective study from January 2012 to December 2016. Patients on mechanical ventilation were excluded. Positive diagnostic yield was defined as confirmed microbiological or cytological diagnosis. RESULTS: A total of 217 patients were recruited (70.1% male and mean age: 51.7 ± 14.6 years). Diagnostic yield was 60.8% and complication rate 14.7%. Complications (hypoxemia and endobronchial bleeding) were all sell-limiting. Treatment modification based on BAL results was 63.3%. In 97.0% an infectious aetiology was identified. HIV infection (OR 5.304, 95% CI 1.611-17.458, p = 0.006) and severe neutropenia (OR 4.253, 95% CI 1.288-14.045, p = 0.018) were associated with positive yield. Leukemia (OR 0.317, 95% CI 0.102-0.982, p = 0.047) was associated with lower yield. No factors impacted complication rate. Overall mortality (90-day) was 17.5% and in those with hematologic malignancy, it was 28.3%. CONCLUSION: BAL retains utility in diagnosis of immunocompromised patients with lung infiltrates. However, patients with hematologic malignancy have a high mortality and alternative sampling should be considered because of poor results with BAL. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01374542 . Registered June 16, 2011.

Frailty and functional decline after emergency abdominal surgery in the elderly: a prospective cohort study.

Background: Frailty has been associated with an increased risk of adverse postoperative outcomes in elderly patients. We examined the impact of preoperative frailty on loss of functional independence following emergency abdominal surgery in the elderly. Methods: This prospective cohort study was performed at a tertiary hospital, enrolling patients 65 years of age and above who underwent emergency abdominal surgery from June 2016 to February 2018. Premorbid variables, perioperative characteristics and outcomes were collected. Two frailty measures were compared in this study-the Modified Fried's Frailty Criteria (mFFC) and Modified Frailty Index-11 (mFI-11). Patients were followed-up for 1 year. Results: A total of 109 patients were prospectively recruited. At baseline, 101 (92.7%) were functionally independent, of whom seven (6.9%) had loss of independence at 1 year; 28 (25.7%) and 81 (74.3%) patients were frail and non-frail (by mFFC) respectively. On univariate analysis, age, Charlson Comorbidity Index and frailty (mFFC) (univariate OR 13.00, 95% CI 2.21-76.63, p < 0.01) were significantly associated with loss of functional independence at 1 year. However, frailty, as assessed by mFI-11, showed a weaker correlation than mFFC (univariate OR 4.42, 95% CI 0.84-23.12, p = 0.06). On multivariable analysis, only premorbid frailty (by mFFC) remained statistically significant (OR 15.63, 95% CI 2.12-111.11, p < 0.01). Conclusions: The mFFC is useful for frailty screening amongst elderly patients undergoing emergency abdominal surgery and is a predictor for loss of functional independence at 1 year. Including the risk of loss of functional independence in perioperative discussions with patients and caregivers is important for patient-centric emergency surgical care. Early recognition of this at-risk group could help with discharge planning and priority for post-discharge support should be considered.

Diagnostic performance of ATA, BTA and TIRADS sonographic patterns in the prediction of malignancy in histologically proven thyroid nodules.

INTRODUCTION: We aimed to compare the malignancy risk stratification of histologically proven thyroid nodules using the 2015 American Thyroid Association (ATA) Management Guidelines, 2014 British Thyroid Association (BTA) Guidelines for the Management of Thyroid Cancer and the Thyroid Imaging Reporting and Data System (TIRADS). METHODS: Thyroid nodules measuring > 1 cm resected over 5.5 years were retrospectively studied. Demographic information as well as cytology and histopathology results were collected. Static ultrasonography (US) images and radiologists' reports of each resected nodules were reviewed and classified based on the above risk classification systems. RESULTS: A total of 167 thyroid nodules from 150 patients were examined. More malignant nodules were solid (78.4% vs. 62.5%; p = 0.049) or hypoechoic (70.6% vs. 28.6%; p < 0.001), and had irregular margins (35.3% vs. 8.0%; p < 0.001), taller-than-wide morphology (9.8% vs. 2.7%; p = 0.031), microcalcifications (33.3% vs. 8.0%; p < 0.001), disrupted rim calcifications (9.8% vs. 0.9%; p = 0.012) or associated abnormal cervical lymphadenopathy (13.7% vs. 0.9%; p = 0.001) compared with benign nodules. The guidelines' diagnostic performance was: ATA - sensitivity 98.0%, specificity 17.3%, positive predictive value (PPV) 35.0%, negative predictive value (NPV) 95.0%; BTA - sensitivity 90%, specificity 50.9%, PPV 45.5%, NPV 91.8%; and TIRADS - sensitivity 94.0%, specificity 28.2%, PPV 37.3%%, NPV 91.2%. CONCLUSION: Sonographic patterns outlined by the three guidelines displayed high sensitivity and NPV. Although isolated suspicious US features cannot predict malignancy risk, they should be considered when risk stratifying nodules that do not fit into particular sonographic patterns based on current guidelines.

One-year and three-year mortality prediction in adult major blunt trauma survivors: a National Retrospective Cohort Analysis.

BACKGROUND: Survivors of trauma are at increased risk of dying after discharge. Studies have found that age, head injury, injury severity, falls and co-morbidities predict long-term mortality. The objective of our study was to build a nomogram predictor of 1-year and 3-year mortality for major blunt trauma adult survivors of the index hospitalization. METHODS: Using data from the Singapore National Trauma Registry, 2011-2013, we analyzed adults aged 18 and over, admitted after blunt injury, with an injury severity score (ISS) of 12 or more, who survived the index hospitalization, linked to death registry data. The study population was randomly divided 60/40 into separate construction and validation datasets, with the model built in the construction dataset, then tested in the validation dataset. Multivariable logistic regression was used to analyze 1-year and 3-year mortality. RESULTS: Of the 3414 blunt trauma survivors, 247 (7.2%) died within 1 year, and 551 (16.1%) died within 3 years of injury. Age (OR 1.06, 95% CI 1.05-1.07, p < 0.001), male gender (OR 1.53, 95% CI 1.12-2.10, p < 0.01), low fall from 0.5 m or less (OR 3.48, 95% CI 2.06-5.87, p < 0.001), Charlson comorbidity index of 2 or more (OR 2.26, 95% CI 1.38-3.70, p < 0.01), diabetes (OR 1.31, 95% CI 1.68-2.52, p = 0.04), cancer (OR 1.76, 95% CI 0.94-3.32, p = 0.08), head and neck AIS 3 or more (OR 1.79, 95% CI 1.13-2.84, p = 0.01), length of hospitalization of 30 days or more (OR 1.99, 95% CI 1.02-3.86, p = 0.04) were predictors of 1-year mortality. This model had a c-statistic of 0.85. Similar factors were found significant for the model predictor of 3-year mortality, which had a c-statistic of 0.83. Both models were validated on the second dataset, with an overall accuracy of 0.94 and 0.84 for 1-year and 3-year mortality respectively. CONCLUSIONS: Adult survivors of major blunt trauma can be risk-stratified at discharge for long-term support.