Detection of Atrial Fibrillation After Ischemic Stroke with an Insertable Cardiac Monitor: A Systematic Review and Individual Patient Data Meta-Analysis of Randomised Clinical Trials.

OBJECTIVE: In ischemic stroke patients, we compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring on the incidence of atrial fibrillation (AF) detection and other clinical outcomes. BACKGROUND: Current guidelines recommend the routine use of 12-lead electrocardiography or Holter monitoring for AF detection after ischemic stroke. Recent randomised controlled trials have investigated the impact of ICM versus non-ICM methods of cardiac monitoring for AF detection in this population. However, precise recommendations for monitoring post-stroke AF are lacking; including the optimal timing, duration, and method of electrocardiography monitoring. METHODS: A systematic search was conducted on Embase and PubMed from database inception until 27 October 2022 to include randomised controlled trials that compared ICM with non-ICM methods of cardiac monitoring for post-stroke AF detection. This yielded 3 randomised controlled trials with a combined cohort of 1231 patients with a recent ischemic stroke. Individual patient data (IPD) was then reconstructed from Kaplan-Meier curves and analysed using the shared-frailty Cox model. An aggregate data meta-analysis was conducted for 1231 patients across all 3 studies for outcomes that could not be reconstructed using IPD. RESULTS: One-stage meta-analysis demonstrated an increase in the hazard ratio (HR 6.01, 95% CI 3.40-10.60; p<0.001) of AF detection in patients undergoing monitoring via ICM compared to standard care. Aggregate data meta analysis revealed a significant increase in initiation of anticoagulation (OR 3.09, 95% CI 2.05 - 4.66; p<0.00001) in the ICM group. However, no significant differences in the incidence of recurrent ischemic stroke, transient ischemic attack or death were found. CONCLUSIONS: In this meta-analysis, we found that the use of ICM increased the detection rate of post-stroke AF and the rate of anticoagulation initiation. However, this did not translate into a reduced incidence of recurrent ischemic stroke.

A musculoskeletal ultrasound program as an intervention to improve disease modifying anti-rheumatic drugs adherence in rheumatoid arthritis: a randomized controlled trial.

Objectives: To evaluate the effect of a musculoskeletal ultrasound programme (MUSP) applying real-time ultrasonography with reinforcement of findings by a rheumatologist on improving disease-modifying anti-rheumatic drugs (DMARDs) adherence in rheumatoid arthritis (RA).Method: Eligible RA patients with low adherence score (< 6) on the 8-item Morisky Medication Adherence Scale (MMAS-8) were randomized to either an intervention group (receiving MUSP at baseline) or a control group (no MUSP), and followed up for 6 months. Adherence measures (patient-reported and pharmacy dispensing records) and clinical efficacy data were collected. The MUSP's feasibility and acceptability were assessed.Results: Among 132 recruited RA patients, six without baseline visits were excluded; therefore, 126 patients were analysed (62 intervention and 64 control). The primary outcome (proportion of patients with 1 month MMAS-8 score < 6) was significantly smaller (p = 0.019) in the intervention (35.48%) than the control group (56.25%). However, 3 and 6 month adherence and clinical efficacy outcomes were not significantly different between the two groups (all p > 0.05). All 62 patients completed the MUSP (mean time taken, 9.2 min), with the majority reporting moderately/very much improved understanding of their joint condition (71%) and the importance of regularly taking their RA medication(s) (79%). Most patients (90.3%) would recommend the MUSP to another RA patient.Conclusions: The MUSP improved RA patients' DMARDs adherence in the short term and was feasible and well accepted by patients. Future studies could evaluate whether repeated feedback using MUSP could help to sustain the improvement in DMARD adherence in RA patients, and whether this may be clinically impactful and cost-effective.

Thermography in rheumatoid arthritis: a comparison with ultrasonography and clinical joint assessment.

AIM: To compare thermography with ultrasonography and clinical joint assessment in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS: Thermography and ultrasonography (power Doppler (PD) and grey-scale (GS) joint inflammation scored semi-quantitatively 0-3) were performed sequentially on both hands of 37 RA patients. Using generalised estimating equations analysis, (a) thermographic parameters (TP) were compared between joints based on their PD and GS joint inflammation positivity/negativity status, while (b) TP and ultrasound-detected joint inflammation were compared between joints categorised by their clinical swelling/tenderness status. RESULTS: Comparing PD positive versus negative joints, the differences in mean values (95% CI) for TP including maximum (Tmax), minimum (Tmin), average (Tavg), and Tmax minus Tmin (Tmax-min) temperatures (in °C) were 1.37 (0.86, 1.87), 0.91 (0.46, 1.36), 1.16 (0.67, 1.64), and 0.46 (0.28, 0.64), respectively. Comparing GS positive versus negative joints, the corresponding results for thermography were 1.09 (0.67, 1.52), 0.66 (0.32, 1.00), 0.86 (0.47, 1.26), and 0.45 (0.28, 0.62), respectively. p-Values were all <0.001. The differences in mean values (95% CI) for ultrasound scores, but not for TP, were statistically significant for (a) swollen tender joints (PD: 0.67 [0.39, 0.96], p<0.001; GS: 0.86 [0.54, 1.18], p<0.001) and (b) swollen non-tender joints (PD: 0.46 [0.07, 0.84], p=0.021; GS: 0.83 [0.37, 1.29], p<0.001) when compared to non-swollen non-tender joints. CONCLUSION: Joints in RA patients have significantly higher temperature readings when ultrasound-detected joint inflammation is present. Swollen tender/non-tender joints exhibited a greater degree of ultrasound-detected joint inflammation than non-swollen non-tender joints, although their temperature readings were not significantly higher.

Pulse electroplating of copper film: a study of process and microstructure.

Copper films with high density of twin boundaries are known for high mechanical strength with little tradeoff in electrical conductivity. To achieve such a high density, twin lamellae and spacing will be on the nanoscale. In the current study, 10 microm copper films were prepared by pulse electrodeposition with different applied pulse peak current densities and pulse on-times. It was found that the deposits microstructure was dependent on the parameters of pulse plating. Higher energy pulses caused stronger self-annealing effect on grain recrystallization and growth, thus leading to enhanced fiber textures, while lower energy pulses gave rise to more random microstructure in the deposits and rougher surface topography. However in the extremes of pulse currents we applied, the twin densities were not as high as those resulted from the medium or relatively high pulse currents. The highest amount of nanoscale twinning was found to form from a proper degree of self-annealing induced grain structure evolution. The driving force behind the self-annealing is discussed.

The open retrograde approach as an alternative for failed percutaneous access for difficult below the knee chronic total occlusions-A case series.

UNLABELLED: Retrograde puncture via patent pedal vessels can be attempted in failed antegrade approach for infrapopliteal long chronic total occlusion. However in cases where the pedal vessels are unable to be visualized via duplex ultrasonography or fluoroscopy an open approach offers an additional option to a vascular surgeon for successful recanalization. Our case report highlights 3 cases where successful hybrid open retrograde approach was able to achieve recanalization of long chronic total occlusion. PRESENTATION OF CASES: The three cases in our series presented with critical limb ischaemia. All three cases had undergone duplex imaging of the affected arterial system. As the antegrade approach to cross the lesion failed a retrograde approach was attempted in all 3 cases. However when the usual modality of retrograde puncture via the use of ultrasound or fluoroscopy failed we proceeded with an open approach. DISCUSSION: Retrograde approach usually offers a better chance of successfully crossing a chronic total occlusion lesion. However puncturing a distal vessel successfully and traversing a catheter or guidewire across proves to be a challenge. An open approach offers an additional pathway for puncturing the target vessel when duplex imaging or fluoroscopic guidance fails. CONCLUSION: Open approach is usually attempted as a last resort by many endovascular surgeons. However procedural time, contrast and radiation usage could have been cut short in cases where the distal target vessels pose a technical challenge for approach via a percutaneous method.

Nebulized albuterol in acute childhood asthma: comparison of two doses.

Thirty-three children and adolescents from 5 to 17 years of age with moderate to severe acute asthma were given nebulized albuterol therapy in either a high (0.30 mg/kg body weight) or standard (0.15 mg/kg) dose administered at three hourly intervals in a randomized double-blind study. The high-dose hourly regimen resulted in significantly greater improvement in the forced expiratory volume in 1 second (FEV1). Furthermore, patients receiving the high dose showed a steady improvement in the FEV1 from the start to the end of the study, whereas FEV1 plateaued after the second dose in the standard-dose group. Although a rise in heart rate and a fall in serum potassium level occurred, neither of these changes nor other side effects were different in the two groups. The high-dose therapy resulted in much higher serum albuterol levels than the standard dose. There was no correlation between the drug levels and side effects or initial and subsequent FEV1. It is concluded that occasional hourly high-dose albuterol therapy should be considered for some pediatric patients with acute asthma of moderate severity, especially those who relapse between doses.

High-versus low-dose, frequently administered, nebulized albuterol in children with severe, acute asthma.

Thirty-two 5- to 17-year-old children who had severe, acute asthma were randomly assigned to receive either high doses (0.15 mg/kg of body weight per dose) or low doses (0.05 mg/kg of body weight per dose) of nebulized albuterol every 20 minutes for six doses. Compared with the low-dose regimen, the high-dose regimen resulted in significantly greater improvement in forced expiratory volume in 1 second, forced vital capacity, and wheeze score and a lower hospitalization rate. The changes in heart rate, respiratory rate, blood pressure, white blood cell count, and serum potassium concentration did not differ significantly between the groups. The incidence of side effects, which included tremor, hyperactivity, and vomiting, was not significantly different in the two populations. Serum albuterol levels varied widely, but there was no correlation between the levels and the increase in heart rate or other side effects. high-dose, frequently administered, nebulized albuterol appears both safe and effective in treating severe, acute asthma in children.

Survival among Chinese women with lung cancer in Singapore: a comparison by stage, histology and smoking status.

Lung cancer generally carries a poor prognosis and the determinants of survival have been of interest. However, survival estimates in Asian populations are scarce. This study describes survival rates and their determinants in Singapore Chinese women, a primarily non-smoking population. Three hundred and twenty-six Chinese women, diagnosed with primary lung carcinoma in three major hospitals in Singapore between April 1996 and December 1998, were followed up till 31 December 2000. The Kaplan-Meier method was used for survival analysis. Two hundred and eighty (85.7%) died from the disease during follow-up. The median survival time was 0.7 years and the three-year survival was 15.8%. These survival rates are similar to those of Western populations, and they provide a basis for examining trends over time. Age at diagnosis was an independent prognostic factor [adjusted hazard ratio (relative risk) 1.4, 95% confidence intervals (CI) 1.1-1.9 for women above 65 years relative to younger women]. Most (70.5%) tumours were stage III/IV at diagnosis. Three-year survival ranged from 72% among patients with stage I tumours to 7% for stage IV tumours. Overall, there was no survival difference among different histological types in all stages combined. When limited to stages I and II cancers, adenocarcinomas were associated with a better outcome relative to other histological subtypes combined (adjusted relative risk 0.4, 95% CI 0.1-1.0). Smoking was an independent risk factor (adjusted relative risk 1.3, 95% CI 1.0-1.8). Nevertheless, non-smokers comprised 57.4% of this series, highlighting the importance of increased awareness among health professionals and the public that lung cancer is not only a disease of smokers. The high proportion of late-stage tumours in this study and the impact of disease stage on outcome underline the importance of early detection in improving survival of lung cancer.

Recording compliance of dental splint use in obstructive sleep apnoea patients by force and temperature modelling.

Fibre-optic sensors are used to monitor the force and temperature of dental splints worn by patients suffering from sleep apnoea. Owing to the small size of the sensors, they can be easily embedded within the splint in a way that does not affect the effectiveness of the splint, and, at the same time, are able to indicate whether the splint has been properly worn by the patient. The overall dimensions of the sensor are approximately 0.375 mm thickness, 1 cm length and 3 mm width. The force and temperature sensors are calibrated and found to have sensitivities of better than 0.5 N and 0.1 degrees C, respectively. Trials performed on patients show that the measurement of pressure and temperature is an effective way of monitoring the proper usage of the dental splint by the patients.

Building a generic architecture for medical information exchange among healthcare providers.

Due to the inability to exchange clinical information among hospitals, continuity of care cannot be maintained and a tremendous amount of medical resource has been wasted. This paper describes an architecture that would facilitate exchange of clinical information among heterogeneous hospital information systems. It is dubbed 'Medical Information Exchange Center' or MIEC as part of a six-year Health Information Network Project hosted by the Department of Health. MIEC was designed so that it is innovative yet technically feasible today. It is convenient for authorized users yet secure enough so people can trust and has minimal impact to participated hospitals. Authorized users will be able to access information through two web-based interfaces directed to physician and non-physician users respectively. Hospitals are connected through a virtual private network to exchange patient information and users need to obtain a private key from the certificate authority in order to securely connect to MIEC. A pilot project was conducted to demonstrate the feasibility of this architecture and the problems encountered were discussed.

Talk your way round--a speech interface to a virtual museum.

PURPOSE: To explore the development of a speech interface to a virtual world and to consider its relevance for disabled users. METHOD: The system was developed using mainly software that is available at minimal cost. How well the system functioned was assessed by measuring the number of times a group of users with a range of voices had to repeat commands in order for them to be successfully recognized. During an initial session, these users were asked to use the system with no instruction to see how easy this was. RESULTS: Most of the spoken commands had to be repeated less than twice on average for successful recognition. For a set of 'teleportation' commands this figure was higher (2.4), but it was clear why this was so and could easily be rectified. The system was easy to use without instruction. Comments on the system were generally positive. CONCLUSIONS: While the system has some limitations, a virtual world with a reasonably reliable speech interface has been developed almost entirely from software which is available at minimal cost. Improvements and further testing are considered. Such a system would clearly improve access to virtual reality (VR) technologies for those without the skills or physical ability to use a standard keyboard and mouse. It is an example of both assistive technology (AT) and universal design.

Endobronchial mass in a patient with Burkholderia pseudomallei infection.

INTRODUCTION: Burkholderia pseudomallei infection, the great mimicker of infectious diseases, has protean clinical manifestations. CLINICAL PICTURE: A 37-year-old man who presented with community-acquired pneumonia affecting the right upper lobe had unremitting fever. Bronchoscopy showed an endobronchial mass in the right upper lobe bronchus. TREATMENT: Intravenous ceftriaxone and oral erythromycin, with empiric antituberculous treatment added later. This was subsequently switched to intravenous ceftazidime and oral doxycycline after the diagnosis was made. OUTCOME: There was resolution of the endobronchial mass. CONCLUSION: This case illustrates a unique and unreported presentation of melioidosis.

Two cases of lower respiratory tract infection due to Chlamydia pneumonia in Singapore.

Chlamydia pneumoniae, previously known as Chlamydia psittaci strain TWAR, causes both upper and lower respiratory tract infection. We report the first two cases of culture-positive Chlamydia pneumoniae lower respiratory infection in Singapore. Both patients had underlying fibrosing alveolitis and presented with a history of prolonged productive cough and fever. Chlamydia pneumoniae was isolated from the bronchoalveolar lavage fluid in the absence of other pathogens. The patients responded clinically to three weeks of oral doxycycline therapy. Infection due to Chlamydia pneumoniae should be considered when a patient with community-acquired pneumonia fails to respond to the usual standard antimicrobial therapy.

Four cases of developmental foregut cysts.

Four patients with developmental foregut cysts were seen in the Singapore General Hospital between 1991 and 1994. Three had bronchogenic cysts while one had features consistent with both enteric and bronchogenic origin. Among those patients with bronchogenic cysts, only one was symptomatic, having presented with cough and dysphagia. Two other patients presented incidentally on chest radiographs done for pre-National Service enlistment while one patient was picked up when a repeat chest radiograph was done following a course of antibiotics. The diagnosis of our first patient with the symptomatic bronchogenic cyst was based on barium swallow and a computerised tomographic scan of the thorax. Two patients were diagnosed on histology following open thoracotomy and surgical resection of the cysts to have a bronchogenic and a cyst of mixed origin as described above respectively. The last patient who underwent video-assisted thoracoscopic surgery with resection of the cyst was confirmed histologically to have a bronchogenic cyst.

Rapid mycobacterial tuberculosis detection in bronchoalveolar lavage samples by polymerase chain reaction in patients with upper lobe infiltrates and bronchiectasis.

In areas where tuberculosis is endemic, a positive sputum acid-fast bacilli (AFB) smear is frequently regarded as almost diagnostic of pulmonary tuberculosis (PTB). The main problem arises when the AFB smear is negative. The main aim of this study was to determine the clinical utility of rapid mycobacterial tuberculosis (MTB) detection in bronchoalveolar lavage (BAL) samples by polymerase chain reaction (PCR) in 52 patients who underwent diagnostic bronchoscopy for suspected PTB. These patients had either upper lobe infiltrates (n = 31) or bronchiectasis (n = 21). Mycobacterial culture is usually used as the gold standard of diagnosis. We chose to define active PTB based on positive mycobacterial cultures and/or histological evidence of caseous necrosis and AFB, and/or when there was clinical plus radiological improvement following therapy. We compared AFB smear, respiratory mycobacterial culture, BAL PCR for MTB and clinical active PTB. Four patients who were smear and culture negative had clinical and radiological clearance following anti-tuberculous therapy showing that using mycobacterial culture as a gold standard may have its limitations. When Kappa (a chance-corrected measure of agreement) was calculated for acid-fast bacilli smear and BAL PCR against our definition of active PTB, it was 0.28 (fair agreement) and 0.73 (substantial agreement), respectively. BAL PCR gave a sensitivity, specificity, positive and negative predictive values of 66.7%, 100%, 100% and 88%, respectively, for the group with upper lobe infiltrates. We also demonstrated that BAL for PCR has a good concordance with the final diagnosis of active tuberculosis.

Ethnicity, obstructive sleep apnoea and ischaemic heart disease.

We studied the relationship between different ethnic groups, obstructive sleep apnoea (OSA) and ischaemic heart disease. Four hundred and thirty-two inpatients from the medical wards were interviewed. Limited overnight sleep studies were done in 129 of those who had habitual snoring, daytime sleepiness based on an Epworth sleepiness scale of 8 or more, or a large neck size of 40 cm or more. There were 315 Chinese (72.9%), 67 Malays (15.5%), 43 Indians (10%) and 3 from other races (1.4%). The prevalence of OSA was 19.7%, 30% and 12% among the Chinese, Malays and Indians, respectively. The prevalence ratio for OSA was 1.52 in Malays using Chinese patients as the baseline (P = 0.07). The median neck circumference was 37 cm in both racial groups. The median body mass index was 22.7 kg/m2 in Chinese compared to 23.6 kg/m2 in Malays. The median apnoea-hypopnoea index was 22.7, 19.0 and 26.9 events/hour among the Chinese, Malays and Indians, respectively. OSA was independently associated with the prevalence of IHD (adjusted prevalence ratio 1.68; 95% CI: 1.15, 2.46; P = 0.009). The prevalence of ischaemic heart disease (IHD) was 31%, 24% and 28% in Chinese, Malays and Indians, respectively. The prevalence ratio for IHD in Malays compared to Chinese was 0.77. After adjusting for OSA, there was an even greater reduction in the risk of IHD (adjusted prevalence ratio 0.70). This suggests that OSA is a confounder in the relationship between race and ischaemic heart disease.

A primary health care project in Sarawak.

PIP: A joint pilot project between the Ministry of Health and the Dept. of Social and Preventive Medicine, University of Malaya, to test the value of village aides in extending the health care system into isolated Iban communities was begun in May 1979 in the Entabai District of Sarawak. A group of 15 village aides consisting of 11 traditional Iban manangs (medicine men) and 4 youths were trained to provide primary health care including simple curative care, preventive care, and to assist in the detection of malaria. Evaluation carreid out 2 years later showed the following. With regard to curative care, the village aides were each, on the average, treating 70.6 patients/month, the most common complaint being headache (30.4%), which along with abdominal pain, constipation, bodyache, diarrhea, vomiting, fever, worm infections, cough, and sore throat, accounted for 89% of all illnesses seen by them. Subsequent to the introduction of village aides in the project area, the number of seriously ill patients requiring admission to the rest beds of the klinik desa dropped by 43.8% and the number of emergency referrals to the backup divisional hospitals fell by 46.1% showing that patients were coming to the klink desa for treatment at an earlier stage. The 11 traditional Iban manangs, who had recently received training had, on their own accord, drastically reduced the use of traditional Iban modes of therapy in preference for modern medicine. During the 24 months immediately after the introduction of village aides into Entabai, 9 gravity feed water supply systems together with related health packages advocating general cleanliness, the use of latrines, and fences were affected, whereas only 6 such systems were installed in the previous 24 months, indicating that it is likely that the village aides were of some assistance in mobilizing the community with respect to self-help efforts. During the same period, the majority of longhouses in the area successfully established a number of vegetable gardens growing foods for home consumption, and continue to vigorously advocate breastfeeding of infants in opposition to bottlefeeding. During the 23 months after village aides were introduced, a total of 1093 blood films were collected by the 15 village aides, the average number of blood films/village aide being 3.2 blood slides/month. Village aides are socially accepted by the Iban community who utilize their curative skills when mild illness disturb them, but who proceed directly to the klinik desa when more serious illness such as fever strike. The project has established clear lines of communication between the health team and the community, and has stimulated the community to organize itself to achieve an increasingly high level of health through community participation and self-reliance. Plans have been approved in principle to train a further 2000 village aides in primary health care for the state of Sarawak.^ieng

Use of radiosynovectomy in recurrent warfarin-related haemarthrosis in degenerative arthritis.

Radiosynovectomy is a local and minimally invasive radiotherapy for treating various chronic inflammatory arthritis such as rheumatoid arthritis, osteoarthritis and haemophilic arthropathy. In haemophilic arthropathy, it reduces the frequency of haemarthrosis and delays the development of severe joint destruction, which ultimately requires surgical intervention. Its role in warfarin-related haemarthrosis is less clear. Haemarthrosis is an uncommon complication of warfarin use, and anticoagulation may need to be discontinued. We describe yttrium-90 radiosynovectomy use in a 74-year-old man with underlying ischaemic heart disease, atrial fibrillation, previous embolic stroke and recurrent haemarthrosis of an osteoarthritic right knee. Anticoagulation was vital and could not be permanently stopped. Due to continuing anticoagulation, he had multiple hospitalisations with recurrent right knee haemarthrosis. Intraarticular right knee yttrium-90 citrate colloid injection led to a cessation of haemarthrosis for eight months. We examined the available literature for the role of radiosynovectomy in such circumstances.