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.
We aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30th day. Our ...secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation.
All OHCAs from 2012 to 2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30th day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval.
12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function– aOR 0.98 (95%CI: 0.97–0.98); survival to discharge– aOR 0.98 (95%CI: 0.98–0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests.
We demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (>7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional ‘down-times’, which could aid clinical decisions in TOR or OHCA management.
Background:
Evidence shows that early initiation of a continuous chain of rehabilitation is associated with better functional outcomes in traumatic brain injured patients. The Department of ...Rehabilitation Medicine initiated early screening and review of patients with all traumatic brain injury (TBI) severity within 72 hours of acute admission, followed by direct transfer of suitable patients to acute inpatient rehabilitation (AIR).
Objectives:
This study aim to document the demographics and clinical characteristics of all TBI patients admitted to the local acute hospital; determine the characteristics of patients with TBI who are directly transferred to AIR following early screening and review; and determine clinical predictors affecting functional outcomes of patients of all TBI severity.
Methods:
A total of 491 patients were screened and reviewed; 116 patients were directly transferred to AIR.
Results:
The median age of the screened cohort was 67.0 years (interquartile range 50.0–77.0 years). Falls were the leading mechanism of TBI. Infection (odds ratio (OR)=2.95, 95% confidence interval (CI) 1.59–5.49) and neurosurgical intervention (OR=2.18, 95% CI 1.24–3.81) increased the odds of transfer to AIR. The Functional Independence Measure (FIM) gain after receiving AIR was significant (p<0.001). Increased age, complications, high motor admission FIM (AFIM) and long rehabilitation length of stay (RLOS) were negatively associated with FIM gain and FIM efficiency.
Conclusions:
Our study demonstrated that falls were the leading mechanism of TBI, with the majority of patients being older. Infection and neurosurgical intervention increased the likelihood of transfer to AIR. There was functional improvement after AIR. Age, complications, motor AFIM and RLOS were negatively associated with FIM gain and FIM efficiency. Further local research is warranted to confirm these findings.
The aim of this study was to compare the body temperature measurements at tympanic, forehead and temporal sites using infrared thermometers. A total of 1576 consecutive visitors to Singapore General ...Hospital at two entry locations were included in this study. Pearson correlation and Bland–Altman mean difference between sites (95% confidence interval for limits of agreement) were calculated for the relationship between the three different sites of temperatures recorded (i.e. temporal, forehead and tympanic). Of all the visitors, 27 (1.7%) had fever. Moderate positive correlation was found between temporal and forehead temperature readings (r=0.602, mean difference (temporal – forehead), (95% limits of agreement) = 0.1 (−0.8, 0.7)), and there was very weak positive correlation between tympanic and temporal temperature readings (r=0.177, mean difference (temporal – tympanic), (95% limits of agreement) = −0.3 (−1.7, 1.1)). Sensitivity for temporal temperature readings (⩾37.5°C) to detect febrile visitors was 3.7%, specificity was 99.6%, positive predictive value was 14.3% and negative predictive value was 98.3%. Our results demonstrate that tympanic temperature readings should be used for fever screening instead of temporal or forehead readings.
Background:
Although growing evidence suggests that fructose intake contributes to the development of non-alcoholic fatty liver disease (NAFLD), fructose intake in NAFLD patients has not been ...documented locally.
Objectives:
The objectives of this study were to compare fructose intake between NAFLD patients and controls with chronic hepatitis B, and to ascertain whether fructose intake was associated with the presence of NAFLD.
Methods:
This was a cross-sectional, case–control study. Thirty-four patients diagnosed with NAFLD and 34 controls with chronic hepatitis B participated in this study between 2012 and 2014 in the Singapore General Hospital outpatient setting. Fructose, energy and nutrient intake were assessed by using food frequency questionnaires.
Results:
NAFLD patients had higher body mass index (28.6±4.0 vs. 22.5±3.9 kg/m2, p<0.001) and waist circumference (100.0±7.9 vs. 80.2±11.7 cm, p<0.001) than controls. Cases reported higher intakes of energy (2378±708 vs. 1796±398 kcal, p<0.001), protein (109±37 vs. 84±25 g, p<0.01), fat (87±33 vs. 62±19 g, p<0.001), total carbohydrate (294±83 vs. 232±63 g, p<0.001) and fructose (42±17 vs. 31±15 g, p<0.05). Logistic regression analysis showed waist circumference (odds ratio: 1.25; 95% confidence interval: 1.11–1.41; p<0.001) and energy intake (odds ratio: 1.002; 95% confidence interval: 1.001–1.004; p<0.05) were significant risk factors for NAFLD.
Conclusions:
Total calorie, macronutrient and fructose intake in NAFLD patients were significantly higher than in controls. Waist circumference and energy intake were significantly associated with NAFLD. Reducing total calorie intake and adopting healthy eating habits should be emphasized to NAFLD patients to manage their clinical conditions.
Abstract Objectives We report the natural history of voiding function in men with clinically localized prostate cancer after robot-assisted laparoscopic radical prostatectomy (RLRP), describing the ...trend of functional recovery, which is currently not well described using the robot-assisted laparoscopic approach. Materials and methods We determined the impact on voiding function by prospectively evaluating 100 consecutive men who underwent RLRP between May 2005 and December 2006 and compared their reported International Prostate Symptom Score (IPSS) and Quality of Life (QOL) scores at 3, 6, and 12 months with preoperative scores after surgery. Patients with preoperative IPSS of 0-7 and 8-35 were defined as having mild lower urinary tract symptoms (LUTS) and moderate to severe LUTS, respectively. Results Continence was achieved in 82%, 87%, and 91% of men at 3, 6, and 12 months after RLRP, respectively. There were statistically and clinically significant improvements in both IPSS and QOL preoperative scores at all studied time points for patients with moderate to severe preexisting LUTS. The mean IPSS scores for these patients preoperatively and at 3, 6, and 12 months after surgery were 14.1, 5.2, 3.0, and 2.9, respectively and the corresponding mean QOL scores were 3.4, 2.1, 1.6, and 1.6, respectively. Patients with mild preexisting LUTS showed no statistically significant improvement in IPSS at 3 and 6 months after surgery but significant improvement was found at 1 year ( P = 0.04). Conclusions Good continence recovery is expected in most patients undergoing RLRP. Patients with moderate to severe preexisting LUTS can expect early and clinically significant symptom and QOL improvements after RLRP. Patients with mild preexisting LUTS show significant symptom improvement at 1 year.
Background
Recent literature shows that multidisciplinary case management (MDCM) is the most cost‐effective intervention in reducing emergency department (ED) overutilization by frequent attenders ...(FAs). It is unclear whether we can extrapolate this finding to a Singapore‐based practice in light of the differences between healthcare systems and social structures.
Objectives
Our objectives were understand from the FA's perspective the reasons behind frequent ED visits and determine the clinical effectiveness of MDCM intervention in reducing ED visits by FAs at a tertiary hospital in Singapore.
Methods
We conducted a two‐stage pilot study that involved prospective recruitment of eligible patients for a qualitative study via face‐to‐face in‐depth interviews and subsequent random assignment of these patients into a dual‐arm randomized control trial with MDCM intervention.
Results
We recruited 40 patients (67.5% male, mean age = 58.25 years) between June 2014 and March 2015. Six main themes on why FAs chose to visit ED emerged: free/subsidized consultation, convenience, perceived better quality of care, perceived emergencies, third party's advice, and health services issues. Interim data analysis was conducted after 6 months’ follow‐up. The median percentage reduction of ED visits between control arm (50%, IQR = –80.00 to –5.00) and MDCM intervention arm (50%, IQR = –76.70 to 30.00) showed no significant difference (95% CI, p = 0.461).
Conclusion
While we discovered six major themes on patient's perspective of reasons behind frequent ED visits, the ability of MDCM intervention to reduce ED visits by FAs was not seen in the initial 6‐month interim analysis. Further research in FA subgroups is needed to develop more targeted interventions.
Objectives:
Copeptin, myeloperoxidase and pro-adrenomedullin have emerged as potential biomarkers for diagnosis and prognosis of acute coronary syndrome (ACS). However, their applicability in ...patients with chronic kidney disease (CKD) remains unknown as these patients were excluded from previous studies. Our objective was to determine the superior novel cardiac marker to predict 30-day and six-month adverse cardiac events (ACEs) defined as cardiac-related death, myocardial infarction and ventricular fibrillation.
Methods:
A prospective observational study was carried out. Patients were included if they presented to the emergency department with symptoms suggestive of ACS and had CKD as defined as a serum creatinine of more than 130 µmol/l. Copeptin, myeloperoxidase and pro-adrenomedulin assays were performed. Occurrence of ACE was traced from review of the patients’ case records and the registry of deaths.
Results:
A total of 724 patients were recruited: 60.6% were male and 68.6% were Chinese. The median age was 67 years. Among those recruited, 88.3% had CKD stages 4 and 5, with 33.5% on dialysis. The rates of ACE at 30 days and six months were 15.1% and 21.7%, respectively. All readings of the three biomarkers were not significantly different in patients with ACE compared with those without both at 30 days and six months. The areas under the curve for copeptin, myeloperoxidase and pro-adrenomedullin were 0.53, 0.50 and 0.45, respectively (p > 0.05).
Conclusions:
The poor performance of the biomarkers may be attributable to lack of specificity for ACS, as elevated levels could be from other causes in CKD patients. Routine testing cannot be recommended.
Objectives:
To investigate the effect of virtual reality (VR) rehabilitation on upper extremity motor performance of patients with early stroke.
Design:
Pilot randomized controlled trial.
Setting:
...Rehabilitation wards.
Participants:
Twenty three adults with stroke (mean age (SD) = 58.35 (13.45) years and mean time since stroke (SD) = 16.30 (7.44) days).
Interventions:
Participants were randomly assigned to VR group (n=11) or control group (n=12). VR group received nine 30 minutes upper extremity VR therapy in standing (five weekdays in two weeks) plus conventional therapy, which included physical and occupational therapy. Control group received only conventional therapy, which was comparable to total training time received by VR group (mean training hours (SD):VR = 17.07 (2.86); control = 15.50 (2.79)).
Main outcome measures:
The main outcome measure was the Fugl-Meyer Assessment (FMA). Secondary outcomes included Action Research Arm Test, Motor Activity Log and Functional Independence Measure. Results were taken at baseline, post intervention and 1-month post intervention. Participants’ feedback and adverse effects were recorded.
Results:
All participants improved in FMA scores (mean change (SD) = 11.65 (8.56), P<.001). These effects were sustained at one month after intervention (mean (SD) change from baseline = 18.67 (13.26), P<.001). All other outcome measures showed similar patterns. There were no significant differences in improvement between both groups. Majority of the participants found VR training useful and enjoyable, with no serious adverse effects reported.
Conclusion:
Although additional VR training was not superior to conventional therapy alone, this study demonstrates the feasibility of VR training in early stroke.
To assess the effects of hypoxia on human orbital fibroblasts (OF) on adipogenesis and adipocytokine production.
Human OF were derived from tissues obtained from patients with Graves' ophthalmopathy ...(GO) and from patients without known thyroid diseases undergoing blepharoplasty. The OF were cultured separately under normoxic and hypoxic conditions. Comparisons of adipocytokine concentrations using multiplex ELISA and lipid accumulation in the cells using Oil Red O staining were subsequently performed.
There was increased adipogenesis in OF from GO subject when exposed to hypoxic culture conditions. This was not observed in OF from normal controls. Hypoxia led to an increase in leptin and a decrease in MCP-1 secretion in OF cultures.
Hypoxia induces adipogenesis in OF and may represent a mechanism by which smoking contributes to deterioration of GO. We also found novel changes to leptin and MCP-1 production in OF cultures exposed to hypoxia suggesting important roles of these cytokines in the disease process.
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