Outcome of childhood epistaxis with treatment of allergic rhinitis: a randomized controlled study.

The purpose of this study is to (1) to determine if treatment of underlying allergic rhinitis (AR) in children will affect epistaxis outcome, (2) to compare efficacy of three outpatient AR treatment regimens in epistaxis outcomes, and (3) to investigate potential factors in the pathogenesis of epistaxis with underlying AR. A single-blind randomized-controlled study was conducted in the Otolaryngology clinic in KK Women's and Children's Hospital. Sixty children aged below 18 years with underlying untreated AR, with first presentation of epistaxis, were randomized to three different AR treatments: treatment 1, antihistamine (20 patients); treatment 2, nasal steroid spray (20 patients); and treatment 3, both antihistamine and nasal steroid spray (20 patients). Epistaxis severity and frequency were assessed. Pre-treatment, 95% of patients within each of the three treatment groups described epistaxis symptoms. Post-treatment, there was improvement in epistaxis outcome (resolution of epistaxis) with 20% (4/20), 40% (8/20), and 60% (12/20) of patients in treatment groups 1 (antihistamine), 2 (nasal steroid spray), and 3 (combined therapy) respectively, who reported resolution of epistaxis. Treatment regimens containing nasal steroid spray resulted in greater improvement of epistaxis severity and frequency. Combined therapy (treatment 3) resulted in the best epistaxis outcome at 1-month follow-up. Majority (90%) reported nose-picking/rubbing behavior. CONCLUSIONS: Intranasal corticosteroids are superior to oral antihistamines in relieving itch or rhinorrhea in AR. Intranasal corticosteroids may be important in treating epistaxis with underlying AR, because digital trauma from itch/rhinorrhea-related nose-picking/rubbing frequently leads to epistaxis. Results from this study will be important to primary and emergency physicians, community pediatricians, and pediatric allergists and otolaryngologists. WHAT IS KNOWN: • Childhood epistaxis commonly co-exists with allergic rhinitis (AR), causing significant symptoms and distress to patients. • There are currently no studies reporti ng on epistaxis outcome aft er treatment of underlying AR. WHAT IS NEW: • This is a single-blind randomized-controlled study of 60 children aged below 18 years with underlying untreated AR, with first presentation of epistaxis to a children's hospital in Singapore Patients were randomized to three different regimens to treat AR: treatment 1, antihistamine; treatment 2, nasal steroid spray; and treatment 3, both antihistamine and nasal steroid spray. • Treatment regimens containing nasal steroid spray improved epistaxis outcomes, with combined therapy of antihistamine and nasal steroid spray resulting in the best outcome for resolution of epistaxis among the three treatment regimens.

Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial.

AIM: This article is a report of a randomized controlled trial to examine the effectiveness of a targeted multiple intervention strategy in reducing the number of patient falls in an acute care hospital. BACKGROUND: Prevention of patient falls remains a challenge that has eluded healthcare institutions. The effectiveness of targeted multiple fall prevention interventions in reducing the incidences of falling has not been established. METHODS: Patients who scored 5 and above on the Hendrich II Fall Risk Model, a fall assessment tool, were recruited in 2006. Patients who were randomized to the intervention group received targeted multiple interventions. Both the research groups received the standard fall prevention interventions from the ward nurses. The rates of fall incidences for both groups were reported with 95% CI, calculated using Wilson method and compared using the Chi-square test. The relative risk was estimated and 95% CI was calculated using the methods described by Armitage and Berry. The times to first fall events were constructed using the Kaplan-Meier method. The hazard ratio was reported at 95% CI and the comparison was made using the log-rank test. RESULTS: There were 912 and 910 participants in the control and intervention groups, respectively. The fall incidence rates were 1·5% (95% CI: 0·9-2·6) and 0·4% (95% CI: 0·2-1·1) in the control and intervention groups, respectively. The relative risk estimate of 0·29 (95% CI: 0·1-0·87) favours the intervention group. CONCLUSION: This study showed that targeted multiple interventions were effective in reducing the incidences of falls in patients in the acute care setting.

The effect of body mass on health-related quality of life among Singaporean adolescents: results from the SCORM study.

PURPOSE: To investigate the relationship between body mass and health-related quality of life (HRQOL) among Singaporean adolescents. Variation in this relationship by age, gender and ethnicity, and association of HRQOL with change in body mass over time and with demographic, socioeconomic and health variables were also assessed. METHODS: HRQOL was assessed for Singaporean adolescents aged 11-18 from their own (N=1,249) and their parent's (N=948) perspective using PedsQLTM 4.0 generic core scales. Body mass, measured as body mass index z-score based on the WHO Reference 2007, was categorized as thin, healthy weight, overweight and obese. Multiple linear regression models assessed the relationship between current body mass and HRQOL, adjusting for demographic, socioeconomic and health variables. Differences between adolescent and parent-proxy reported HRQOL were also investigated. RESULTS: Obese adolescents (and their parents) reported significantly lower HRQOL, overall and in most domains, compared to healthy weight adolescents. Parents tended to report lower HRQOL for their adolescents than the adolescents did themselves; however, this difference was much larger and statistically significant for obese adolescents. CONCLUSIONS: Obesity is associated with reduced HRQOL among adolescents. The effect in these Singaporean adolescents is similar to that in populations with higher rates of obesity. Awareness of this relationship can make it easier for health professionals, teachers, parents and peers to be supportive of obese adolescents.

Building a Longitudinal National Integrated Cardiovascular Database　- Lessons Learnt From SingCLOUD.

Background: Real world data on clinical outcomes and quality of care for patients with coronary artery disease (CAD) are fragmented. We describe the rationale and design of the Singapore Cardiovascular Longitudinal Outcomes Database (SingCLOUD). Methods and Results: We designed a health data grid to integrate clinical, administrative, laboratory, procedural, prescription and financial data from all public-funded hospitals and primary care clinics, which provide 80% of health care in Singapore. Here, we explain our approach to harmonize real-world data from diverse electronic medical and non-medical platforms to develop a robust and longitudinal dataset. We present pilot data on patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) between 2012 and 2014. The initial data set had 53,395 patients. Of these, 35,203 had CAD confirmed on coronary angiography, of whom 21,521 had PCI. Eventually, limiting to 2012-2014, 3,819 patients had MI with PCI, while 5,989 had MI. Compared with the quality improvement registry, Singapore Cardiac Data Bank, which had 189 fields for analysis, the SingCLOUD platform generated an additional 313 additional data fields, and was able to identify an additional 250 heart failure events, 664 major adverse cardiovascular events at 2 years, and low-density lipoprotein levels to 1 year for 3,747 patients. Conclusions: By integrating multiple incongruent data sources, SINGCLOUD enables in-depth analysis of real-world cardiovascular "big data".

Can external and subjective information ever be used to reduce the size of randomised controlled trials?

In the design of randomised trials in rare cancers, a Bayesian approach has been advocated, which allows for external and subjective information to be formally incorporated. We explore whether this can be extended more generally to allow for smaller trials to be conducted using a case study involving a trial of nasopharyngeal carcinoma. The external information available at various points during the trial is first summarised in the form of 'prior distributions'. Each of these is then combined with the accumulated data from the trial at that point in time to form 'posterior distributions', from which conclusions are drawn. We have argued that such a framework for the design, analysis and interpretation of a randomised trial in the light of external evidence is particularly useful in situations such as trials in rare cancers. But more generally, it may potentially also allow for smaller trials to be conducted. Although, at this point in time, we are hesitant to recommend the full implementation of the Bayesian methodology to modify the (conventionally) planned trial size we submit that a formal synthesis of the external evidence bearing on the question of concern is a valuable exercise in itself.

Prognostic value of left atrial size in chronic kidney disease.

AIMS: Patients with chronic kidney disease (CKD) have high cardiovascular risk. Although stress imaging provides accurate risk estimation in this population, it is unknown if combinatorial cardiac imaging adds incremental value. METHODS AND RESULTS: We performed transthoracic echocardiography and stress single photon emission computed tomography (SPECT) to assess their value in predicting late cardiovascular disease (CVD) mortality in 200 patients with creatinine clearance <60 mL/min without a history of coronary heart disease. During a median follow-up duration of 3.7 (3.5-4.0) years, there were 25 deaths because of CVD. Older age, abnormal SPECT, and increased indexed left atrial (LA) diameter were associated with CVD mortality on univariate analysis with P = 0.007, 0.01, and 0.004, respectively. In multivariable analysis, indexed LA diameter >24 mm/m(2) was independently predictive of CVD mortality [hazard ratio (HR) 2.75, confidence interval (CI) 1.14-6.59], but abnormal SPECT was not. Each mm/m(2) increase in indexed atrial diameter was associated with an HR 1.20 (95% CI 1.06-1.37). CONCLUSIONS: In patients with CKD, the indexed LA diameter predicts CVD mortality independent of an abnormal SPECT result. Consideration should be given to this simple measurement as a prognostic tool in this population.

Subjective evaluation of the accuracy of video imaging prediction following orthognathic surgery in Chinese patients.

PURPOSE: The aims of this retrospective study were to assess the subjective accuracy of predictions generated by a computer imaging software in Chinese patients who had undergone orthognathic surgery and to determine the influence of initial dysgnathia and complexity of the surgical procedure on prediction accuracy. PATIENTS AND METHODS: The sample consisted of 40 Chinese patients who had completed treatment involving orthodontics and orthognathic surgery. All the patients had lateral cephalometric radiographs and profile photographs taken within 3 months before surgery and at least 6 months after surgery. The computer-generated predicted images and the actual post-treatment images were displayed simultaneously to a panel of orthodontists, oral maxillofacial surgeons and laypersons to allow side-by-side comparison. The panel was asked to determine which image was more esthetic and to rate the likeness between the actual and predicted images using a 10 cm visual analog scale. RESULTS: The results showed that the actual image was judged to be more esthetic in 82% of the cases, with the orthodontists more likely to select the actual profile compared to laypersons (P = .005). Orthodontists and surgeons rated the likeness of the images similarly while laypersons rated the likeness significantly lower than the clinicians (P = .012 and P = .015, respectively). Skeletal III cases were judged to be less accurately predicted than skeletal II cases by laypersons (P = .006) and orthodontists (P = .036). Cases treated by single-jaw osteotomy were given better ratings compared to cases with bimaxillary osteotomy by all panel groups but the differences did not reach significant level. CONCLUSIONS: Skeletal III cases managed by bimaxillary osteotomy were least accurately predicted by the computer program. As there exists a possibility that the predicted image may be judged to be more esthetic than the actual image, clinicians must make extra effort to manage patient expectations when using computer simulations for patient education.

Evaluation of the linearity of soft- to hard-tissue movement after orthognathic surgery.

INTRODUCTION: Our aim in this study was to investigate whether a linear relationship exists between soft- to hard-tissue changes for both maxillary and mandibular landmarks over a wide range of skeletal changes. METHODS: The sample consisted of 30 Chinese patients with Class III malocclusion treated with bilateral sagittal split osteotomy and LeFort I advancement. Lateral cephalograms were taken within 2 months before surgery and at least 6 months after surgery. Soft- and hard-tissue changes were recorded by computer-supported measurements of presurgical and postsurgical lateral cephalograms. To evaluate the linear association between soft- and hard-tissue movement, a quadratic function of hard-tissue movement adjusted for sex was initially fitted to the data. The residual plots were used to examine the appropriateness of the fitted quadratic function, and the lack of fit was examined by the F test. A linear function was fitted to the data when the quadratic term was not significant. RESULTS: Visual inspection of the scatter plots of the 5 pairs of corresponding soft- and hard-tissue landmarks showed that relationships between the soft and hard tissues were reasonably linear for both male and female subjects, except for the Sn-ANS pair that showed a curvilinear relationship. Statistical tests confirmed that the association for the Sn-ANS pair was quadratic. CONCLUSIONS: The results of this study provide evidence of a linear relationship between soft- to hard-tissue changes for mandibular landmarks over a wide range of skeletal changes. The nonlinear response of maxillary soft tissues to underlying hard-tissue change in the Sn-ANS pair supports the use of nonlinear ratios for selected maxillary soft- to hard-tissue movements in simulation software.

Low-molecular-weight heparin compared with aspirin for the treatment of acute ischaemic stroke in Asian patients with large artery occlusive disease: a randomised study.

BACKGROUND: Acute stroke patients with large artery occlusive disease (LAOD) have a distinct pathophysiology and may respond differently to anticoagulation treatments. We compared the efficacy of a low-molecular-weight heparin (LMWH), nadroparin calcium, with aspirin in Asian acute stroke patients with LAOD. METHODS: Acute ischaemic stroke patients with onset of symptoms less than 48 h and LAOD (diagnosed by transcranial doppler imaging, carotid duplex scan, or magnetic resonance angiography) were recruited. Patients were randomly assigned to receive either subcutaneous nadroparin calcium 3800 anti-factor Xa IU/0.4 mL twice daily or oral aspirin 160 mg daily for 10 days, and then all received aspirin 80-300 mg once daily for 6 months. This study is registered at www.strokecenter.org/trials (number 493). FINDINGS: Among 603 patients recruited, 353 (180 LMWH, 173 aspirin) had LAOD (300 had intracranial LAOD only, 42 had both intracranial and extracranial disease, and 11 had extracranial disease only). The proportion of patients with good outcomes at 6 months (Barthel index >or=85) was 73% in the LMWH group and 69% in the aspirin group (absolute risk reduction 4%; 95% CI -5 to 13). Analysis of prespecified secondary outcome measures showed a benefit in outcome for LMWH versus aspirin on the modified Rankin scale dichotomised at 0-1 (odds ratio 1.55, 95% CI 1.02-2.35). Haemorrhagic transformation of infarct and severe adverse events were similar in both groups. Post-hoc analyses of patients without LAOD, and all treated patients, showed similar proportions with a good outcome in aspirin and LMWH groups (78%vs 79% and 73%vs 75%, respectively). INTERPRETATION: Overall, the results do not support a significant benefit of LMWH over aspirin in patients with LAOD. The benefits indicated in most outcome measures warrant further investigation into the use of anticoagulation for acute stroke in patients with large artery atherosclerosis, particularly in intracranial atherosclerosis.

Incidence, predictors, and outcomes of device failure of X-sizer thrombectomy: real-world experience of 200 cases in 5 years.

BACKGROUND: Clinical studies have evaluated the safety and efficacy of adjunctive X-sizer (EndiCOR Inc, San Clemente, CA) in percutaneous coronary intervention (PCI). However, patient and lesion subsets were highly selected, and extrapolation of the results to daily practice is problematic. METHODS: X-sizer thrombectomy was performed in 200 procedures from August 2000 to July 2005. The indications for the procedures were primary PCI in 71%. Device failure was defined as the occurrence of 1 or more of the following conditions: (a) failure of the X-sizer to reach the target segment, (b) failure to achieve final thrombolysis in myocardial infarction 3 flow, (c) slow flow or no-reflow, (d) distal embolization, and (e) coronary perforation. RESULTS: Device failure occurred in 48 procedures, giving a device failure rate of 24%. Logistic regression analysis showed that ostial lesion was the only independent predictor of device failure (OR 4.89, 95% CI 1.23-19.51, P = .024). A total of 19 patients had developed 22 adverse events, giving a 30-day adverse event rate of 9.5%. Among these, there were 13 deaths, 4 strokes, 2 reinfarctions, 2 repeat PCIs, and 1 coronary artery bypass grafting. Logistic regression analysis showed that X-sizer device failure was independently associated with 30-day adverse events (OR 3.42, 95% CI 1.04-11.25, P = .043). CONCLUSIONS: The incidence of device failure of X-sizer thrombectomy was 24%. Ostial lesion was an independent predictor of device failure. Notably, X-sizer device failure was independently associated with 30-day adverse event. These highlight the importance of case selection and the problem with its use in ostial lesions.

An Asian community's perspective on facial profile attractiveness.

AIM: To assess the facial profile preferences of laypersons in an Asian community and the influence of age, ethnic and gender on profile selection. METHODS: A sample of 149 laypersons (65.1% Chinese, 21.5% Malays and 13.4% Indians), comprising of 112 females (75.2%) participated in the study. The mean age was 24.6 years (SD 4.4). A facial profile photograph and a lateral cephalometric radiograph of a Chinese male and female adult with a normal profile and a class I incisor and skeletal relationship were digitized to create a baseline template. Computerized digital photographic image modification was carried out on the template to obtain seven facial profiles [bimaxillary protrusion, protrusive mandible, retrusive mandible, normal profile (incisor and skeletal class I pattern), retrusive maxilla, protrusive maxilla and bimaxillary retrusion] for each gender. The laypersons were asked to rank the profiles of each gender on a scale of 1 (very attractive) to 7 (least attractive). RESULTS: Orthognathic Chinese male and female profiles were perceived to be the most attractive. A male orthognathic profile with normative Chinese cephalometric values was perceived to be more attractive than a 'flatter' bimaxillary retrusive profile. Bimaxillary retrusion and normal Chinese female profiles were perceived to be the most attractive. A male or female profile with a protrusive mandible was judged to be the least attractive. Age, gender and ethnicity were nonsignificant predictors for the most attractive female profile. CONCLUSIONS: Orthognathic Chinese male and female profiles were judged to be the most attractive by Asian adult laypersons. Male and female profiles with mandibular protrusion were judged to be the least attractive.

Outcome of orthognathic surgery in Chinese patients. A subjective and objective evaluation.

OBJECTIVE: To evaluate the outcome of orthognathic surgery by objective cephalometric measurement of posttreatment soft-tissue profile and by subjective evaluation of profile esthetics by laypersons and clinicians. MATERIALS AND METHODS: The sample consisted of 30 Chinese patients who had completed combined orthodontic and orthognathic surgical treatment. The posttreatment cephalograms of these patients were analyzed with respect to profile convexity, facial height, and lip contours and these were compared to the previously established esthetic norms. Line drawings of the soft-tissue profile were displayed to a panel comprising six laypersons and six clinicians who scored the esthetics of each profile using a 7-point scale. RESULTS: Complete normalization of cephalometric soft-tissue variables was not achieved with orthognathic surgery in most patients, with four of the six soft-tissue cephalometric measurements showing significant differences compared to the esthetic norms. There were good correlations in the esthetic scores between laypersons and clinicians, even though clinicians tend to rate the profiles more favorably. Facial convexity and facial height did not significantly influence the subjective scores of both the laypersons and clinicians. Lower lip protrusion was the only cephalometric variable that significantly influenced clinicians' assessment of profile esthetics (P<.01). CONCLUSIONS: Profile convexity and lower facial height proportion had little influence on both lay and professional perception of profile esthetics. Lower lip position is the only cephalometric variable that significantly influenced clinicians' assessment of profile esthetics.

Randomized trial of radiotherapy versus concurrent chemoradiotherapy followed by adjuvant chemotherapy in patients with American Joint Committee on Cancer/International Union against cancer stage III and IV nasopharyngeal cancer of the endemic variety.

PURPOSE: The Intergroup 00-99 Trial for nasopharyngeal cancer (NPC) showed a benefit of adding chemotherapy to radiotherapy. However, there were controversies regarding the applicability of the results to patients in endemic regions. This study aims to confirm the findings of the 00-99 Trial and its applicability to patients with endemic NPC. PATIENTS AND METHODS: Between September 1997 and May 2003, 221 patients were randomly assigned to receive radiotherapy (RT) alone (n = 110) or chemoradiotherapy (CRT; n = 111). Patients in both arms received 70 Gy in 7 weeks using standard RT portals and techniques. Patients on CRT received concurrent cisplatin (25 mg/m2 on days 1 to 4) on weeks 1, 4, and 7 of RT and adjuvant cisplatin (20 mg/m2 on days 1 to 4) and fluorouracil (1,000 mg/m2 on days 1 to 4) every 4 weeks (weeks 11, 15, and 19) for three cycles after completion of RT. All patients were analyzed by intent-to-treat analysis. The median follow-up time was 3.2 years. RESULTS: Distant metastasis occurred in 38 patients on RT alone and 18 patients on CRT. The difference in 2-year cumulative incidence was 17% (95% CI, 14% to 20%; P = .0029). The hazard ratio (HR) for disease-free survival was 0.57 (95% CI, 0.38 to 0.87; P = .0093). The 2- and 3-year overall survival (OS) rates were 78% and 85% and 65% and 80% for RT alone and CRT, respectively. The HR for OS was 0.51 (95% CI, 0.31 to 0.81; P = .0061). CONCLUSION: This report confirms the findings of the Intergroup 00-99 Trial and demonstrates its applicability to endemic NPC. This study also confirms that chemotherapy improves the distant metastasis control rate in NPC.

Measurement of macular pigment: Raman spectroscopy versus heterochromatic flicker photometry.

PURPOSE: There are several techniques for measuring macular pigment (MP) in vivo, of which Raman spectroscopy (RS) is a recently developed objective METHOD: This study reports the reproducibility, test-retest variability, and validity of RS MP readings, by comparing them with heterochromatic flicker photometry (HFP). METHODS: MP was measured with HFP and RS in 120 healthy subjects, and the latter technique was also used on two separate occasions in a sample of 20 subjects to investigate the intersessional variability of readings. Intrasessional reproducibility of RS MP measurements was also calculated. In addition, serum concentrations of lutein (L) and zeaxanthin (Z) were measured and correlated with both RS and HFP MP readings. RESULTS: Mean (+/-SD) MP in the right eye was 0.279 +/- 0.145 and 0.319 +/- 0.155 with RS and HFP, respectively. The differences between corresponding MP readings taken on RS and HFP lay within the Bland-Altman 95% limits of agreement for the two instruments in 93.6% and 94.4% of cases in the right and left eyes, respectively. Intrasessional reproducibility of RS readings, expressed as the coefficient of variation, was 8.42% +/- 7.12%. Ninety-five percent of MP readings taken with RS on two separate occasions lay within the 95% limits of agreement for the two sessions. A positive, but insignificant, relationship was observed between RS and HFP MP readings and serum concentrations of L and Z (RS, P = 0.356; HFP, P = 0.540). CONCLUSIONS: RS, an objective method of measuring MP levels in vivo, exhibits acceptable reproducibility and test-retest variability. The results demonstrated good correlation between RS and HFP measurements of MP, thus authenticating RS against a validated psychophysical technique of measuring MP. However, investigators should use only one of these instruments for the duration of any given study because of differences in the scientific rationale, and the factors that influence RS and HFP measurements of MP.

An outbreak of primary dengue infection among migrant Chinese workers in Singapore characterized by prominent gastrointestinal symptoms and a high proportion of symptomatic cases.

BACKGROUND: An outbreak of dengue occurred among Chinese migrant workers at a construction site in Singapore that was characterized by a number of unusual features. METHODS: Clinical and laboratory data were prospectively collected from workers who were hospitalized with fever. We compared the frequency of disease manifestations in these patients with historical data from other cases of dengue admitted to the same centre. A serological survey was performed at the construction site one month after the onset of the outbreak. RESULTS: Thirty-nine patients were admitted from the affected construction site with confirmed acute dengue infection in March and April 2002. Fever, headache and rash were common and occurred at similar frequency in outbreak patients and historical controls. Gastrointestinal manifestations were significantly more common in the outbreak patients compared with controls (nausea 68%, diarrhea 41%, hyponatremia 47% and elevated urea 20%). Of the 274 studied in the serological survey, 27 had serological evidence of acute dengue, of whom 24 (89%) had experienced a febrile illness in the previous month. The virus was cultured and identified as Dengue-2. Few patients had a positive IgG for dengue indicating that this was likely a primary infection. CONCLUSION: This outbreak of primary dengue infection was characterized by unusually prominent gastrointestinal symptoms and a high proportion of symptomatic transmission. Manifestations of dengue may be altered when outbreaks involve immunologically naïve adults who have migrated to dengue endemic areas.

Impact of glycemic control on occurrence of no-reflow and 30-day outcomes in diabetic patients undergoing primary angioplasty for myocardial infarction.

Diabetes mellitus is associated with endothelial dysfunction and platelet activation that may contribute to the occurrence of no-reflow. We postulate that optimal glycemic control is associated with the lower risk of no-reflow and better outcomes. Diabetic patients who underwent primary angioplasty for myocardial infarction from January 2001 to June 2004 were analyzed. No-reflow was defined as TIMI flow < 3 in the absence of mechanical obstruction. Patients were divided into 2 glycemic control groups according to the HbA1c value: optimal (less than or equal to 7%), and suboptimal (> 7%). A total of 183 diabetic patients (93% noninsulin-requiring) were included for analysis. The median HbA1c of the optimal (n = 37) and suboptimal (n = 146) glycemic control groups were 6.5% and 8.5%, respectively. Compared to the suboptimal glycemic control group, the optimal glycemic control group was older, likely to have hypertension, previously suffered a stroke, have renal failure and a higher baseline creatinine. No-reflow occurred in 16% of the optimal and 18% of the suboptimal glycemic control groups. Multivariate analysis showed that optimal glycemic control was not associated with a lesser occurrence of no-reflow (OR 1.27, 95% CI 0.19-8.29; p = 0.807). The optimal glycemic control group had 30-day survival (90% versus 93%; p = 0.698) and 30-day event-free survival (84% versus 86%; p = 0.695) rates similar to the suboptimal glycemic control group. Among diabetic patients undergoing primary angioplasty, optimal glycemic control was not associated with a lesser occurrence of no-reflow or better 30-day outcomes.

Effects of head posture on cerebral hemodynamics: its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation.

OBJECTIVE: Severely head-injured patients have traditionally been maintained in the head-up position to ameliorate the effects of increased intracranial pressure (ICP). However, it has been reported that the supine position may improve cerebral perfusion pressure (CPP) and outcome. We sought to determine the impact of supine and 30 degrees semirecumbent postures on cerebrovascular dynamics and global as well as regional cerebral oxygenation within 24 hours of trauma. METHODS: Patients with a closed head injury and a Glasgow Coma Scale score of 8 or less were included in the study. On admission to the neurocritical care unit, a standardized protocol aimed at minimizing secondary insults was instituted, and the influences of head posture were evaluated after all acute necessary interventions had been performed. ICP, CPP, mean arterial pressure, global cerebral oxygenation, and regional cerebral oxygenation were noted at 0 and 30 degrees of head elevation. RESULTS: We studied 38 patients with severe closed head injury. The median Glasgow Coma Scale score was 7.0, and the mean age was 34.05 +/- 16.02 years. ICP was significantly lower at 30 degrees than at 0 degrees of head elevation (P = 0.0005). Mean arterial pressure remained relatively unchanged. CPP was slightly but not significantly higher at 30 degrees than at 0 degrees (P = 0.412). However, global venous cerebral oxygenation and regional cerebral oxygenation were not affected significantly by head elevation. All global venous cerebral oxygenation values were above the critical threshold for ischemia at 0 and 30 degrees. CONCLUSION: Routine nursing of patients with severe head injury at 30 degrees of head elevation within 24 hours after trauma leads to a consistent reduction of ICP (statistically significant) and an improvement in CPP (although not statistically significant) without concomitant deleterious changes in cerebral oxygenation.

A randomized controlled trial to compare calcipotriol with betamethasone valerate for the treatment of cutaneous lichen planus.

BACKGROUND: Topical calcipotriol is a vitamin D3 analogue which influences keratinocyte proliferation and differentiation. Its efficacy in cutaneous lichen planus has not been well evaluated. METHODS: This is a randomized open-label trial comparing the effectiveness of calcipotriol 50 microg/g versus betamethasone 0.1% ointments twice daily for 12 weeks in patients with cutaneous lichen planus, with respect to thickness, pigmentation, clearance and pruritus. Patient self-assessment was made at 0, 4, 8 and 12 weeks post randomization using visual analogue scales (VAS). Clinical assessment was made at week 12 and adverse events noted. Clinical response was defined as 75% or more for lesion flattening and absent or minimal pigmentation, and 50% or more for clearance. RESULTS: A total of 31 patients were randomized: 15 to calcipotriol and 16 to betamethasone. Clinically assessed lesion flattening occurred in approximately half the patients. With calcipotriol, there were two responses for pigmentation and one for clearance but none with betamethasone. Patient VAS indicated a gradual improvement in all measures but with little difference between the treatments. The largest difference indicated a 12-point disadvantage to calcipotriol for thickness but this was not statistically significant (p=0.09). Side effects reported were erythema (one patient) and increased pruritus (two patients), all with calcipotriol. CONCLUSION: Calcipotriol appears no more effective than betamethasone. The course of the disease appears to be affected in the same way by both treatments.

A population-based survey of mental disorders in Singapore.

INTRODUCTION: Mental illnesses are not only a growing public health concern but also a major social and economic issue affecting individuals and families throughout the world. The prevalence of mental disorders, the extent of disability caused by these disorders, and services utilisation of these patients has been well studied in developed countries. The aim of this study was to establish the prevalence of select mental disorders and their associated sociodemographic correlates in the adult Singapore resident population. MATERIALS AND METHODS: This was a cross-sectional, populationbased, epidemiological study of adult Singapore residents aged 18 years and above. The subjects were randomly selected using a disproportionate stratified sampling method. The diagnoses of selected mental disorders including major depressive disorder (MDD), dysthymia, bipolar (bipolar I & II) disorders, generalised anxiety disorder (GAD), obsessive compulsive disorder (OCD), alcohol abuse and alcohol dependence were established using the Composite International Diagnostic Interview, which is a fully structured diagnostic instrument that assesses lifetime and 12-month prevalence of mental disorders. RESULTS: Among the 6616 respondents (response rate of 75.9%), 12.0% had at least one lifetime affective, anxiety, or alcohol use disorders. The lifetime prevalence of MDD was 5.8% and that of bipolar disorder was 1.2%. The combined lifetime prevalence of the 2 anxiety disorders, GAD and OCD was 3.6%, with the latter being more common than GAD (0.9% and 3.0% respectively). The lifetime prevalence of alcohol abuse and dependence were found to be 3.1% and 0.5% respectively. Age, gender, ethnicity, marital status and chronic physical illnesses were all significant correlates of mental disorders. CONCLUSION: The identified associated factors would help guide resource allocation, policy formulation and programme development in Singapore.

Severe obstructive sleep apnea and outcomes following myocardial infarction.

STUDY OBJECTIVE: We sought to determine the effect of severe obstructive sleep apnea (OSA) on long-term outcomes after myocardial infarction. We hypothesized that severe OSA was associated with lower event-free survival rate after ST-segment elevation myocardial infarction (STEMI). METHODS: A total of 120 patients underwent an overnight sleep study during index admission for STEMI. Severe OSA was defined as apnea hypopnea index (AHI) ≥ 30, and non-severe OSA defined as AHI < 30. RESULTS: Among the 105 patients who completed the study, 44 (42%) had severe OSA and 61 (58%) non-severe OSA. The median creatine kinase level and mean left ventricular systolic function were similar between the 2 groups. None of the 105 study patients had received treatments for OSA. Between 1- and 18-month follow-up, the severe OSA group incurred 1 death, 2 reinfarctions, 1 stroke, 6 unplanned target vessel revascularizations, and 1 heart failure hospitalization. In contrast, there were only 2 unplanned target vessel revascularizations in the non-severe OSA group. The incidence of major adverse events was significantly higher in the severe OSA group (15.9% versus 3.3%, adjusted hazard ratios: 5.36, 95% CI: 1.01 to 28.53, p = 0.049). Kaplan-Meier event-free survival curves showed the event-free survival rates in the severe OSA group was significantly worse than that in the non-severe OSA group (p = 0.021, log-rank test). CONCLUSION: 42% of the patients admitted with STEMI have undiagnosed severe OSA. Severe OSA carries a negative prognostic impact for this group of patients. It is associated with a lower event-free survival rate at 18-month follow-up.