Female trauma patients in the emergency department: should their injury prevention programme be different?

Background: (1) To compare the characteristics of female and male trauma patients seen in the Emergency Department (ED) and (2) to determine if injury prevention programmes for women should be different. Methods: A prospective survey was conducted for 11544 trauma patients, aged 15 years and above, who presented to the ED of an urban public hospital in Singapore over 6 months. The following data were collected: demography, place, type and mechanism of injury and subsequent disposition from the ED. Results: Almost half (49.5%) the injuries sustained by females occurred at home, with low falls of less than 2 metres being the most common mechanism of injury (52.7%). Victims of domestic violence were predominantly female at p<0.0001

The Role of Transabdominal Ultrasound in Office Urology

Ultrasound diagnosis was introduced in the 1970s, and rapidly became popular in the outpatient clinic because of its safety and non-invasiveness. In Urology, the transabdominal ultrasound (TAUS) is useful to assess patients with lower urinary tract symptoms, to diagnose benign prostatic hyperplasia, and to classify its severity. TAUS is also used in diagnosing stones in patients with loin pain and urinary infections. Micro and gross haematuria are common problems seen in the clinic and TAUS can help in the early diagnosis of bladder tumours. Hydronephrosis from obstructive uropathy and scrotal ultrasound for hydrocele and tumour can be easily seen. However, for more details in diagnosing kidney tumours and testicular torsion, patients need to be referred to the Radiological Department for further assessment. TAUS is useful in the clinic for diagnosing our patients early and helping in further assessment in the clinic. It is also cost effective in improving patient care

Preliminary Results of Mismatch Repair Deficiency Screening via Immunohistochemical Staining in Young Asian Colorectal Cancers

Background: The incidence of mismatch repair (MMR) deficiency in young colorectal cancers (CRC) remains unknown in Asians. This preliminary study assessed the clinicopathological features and efficacy of screening for MMR protein deficiency in young Asian CRC patients. Methods: From January 2006 to October 2009, patients under the age of 50 with immunohistochemical (IHC) staining for MMR proteins in resected CRC specimens were retrieved from a prospective computerised database. Results: Eighty unrelated patients comprising predominantly 80% Chinese (n = 64), with median age of diagnosis at 41 years (range 22–50 years) had IHC performed. Twenty-three per cent (n=18) of the patients had abnormal IHC staining. Loss of staining for MLH1, MSH2 and MSH6 proteins were observed in 18%, 2% and 6% of tumours respectively. Of the 15 patients who had abnormal staining of MLH1, three had concomitant equivocal staining for MSH6. One tumour specimen had abnormal staining in all 3 proteins. Multivariate analysis revealed that family history was the only significant predictive factor for defective MMR detection (OR 8.06, 95% CI 1.69–38.35, p=0.002). However if Amsterdam criteria alone were to be used, 72% (n=12) of the cohort would have not been detected for MMR gene defects. Conclusion: The overall burden of germline MMR deficiency in the Singapore population may be as high as 23%. Amsterdam criteria alone are insufficient to detect hereditary non-polyposis colorectal cancer (HNPCC) related patients. The use of IHC staining of at least 3 MMR proteins is a useful screening strategy for HNPCC diagnosis and routine screening of mismatch repair deficiency may be recommended for all young Asian CRC patients

Prognostic Variables in 1814 Sporadic Colon Cancers: A Review of Experience from a Single Institution from 1999–2005

Introduction: Singapore has one of the highest age-standardized incidence rates for colorectal cancer (CRC) at 35.1% in men and 29.9% in women which is almost double that of our neighboring Southeast Asian countries. Surgery is presently the mainstay in treatment of this cancer. This present study evaluates the clinical and prognostic characteristics of sporadic cancers treated by surgical resection in a single institution in an Asian population. Methods: 1814 consecutive patients with CRC from 1999–2005 treated in the Department of Colorectal Surgery in Singapore General Hospital were reviewed. The clinciopathological characteristics of these patients were collected from a prospectively collected database maintained in the department since 1987. Univariate analysis was performed, and survival curves were constructed using the Kaplan-Meier method. Multivariate analysis was carried out on independent prognostic factors that were positive on univariate analysis. Results: All patients had a minimum follow up duration of 5 years unless they were lost to follow up. There were 921 (50.8%) males and 893 (49.2%) females with a median age of 67 years (interquartile range 22–99). The predominant location of the tumour was left-sided ie distal to (and including) the splenic flexure (n=1272, 70%), and the majority presented at an advanced AJCC stage III and IV (n=1018, 56%). The most common site for solitary metastasis is in the liver (n=194, 49%) followed by the lungs (6%). Locoregional recurrence is low at 2.6% (n=46) and distant recurrence is noted at 16.8% (n=297). Disease recurrence are 5.7%, 18.1%, and 27.5% for Stages I, II and III respectively. The median five-year Cancer Specific Survival (CSS) is 58.7 % (95% CI 56.2%–61.2%). On multivariate analysis, a high pre-operative CEA, poorly-differentiated tumour grade, signet ring cell tumours, high tumour stage (T3/T4), nodal disease (N1/N2), presence of both perineural invasion and vascular emboli were all significant factors that worsened CSS. Conclusion: Our dataset confirms the current favourable survival of colonic cancers in our country which is comparable to data from the West. Future challenges in management of patients involve improving staging, selection of high risk of recurrence of patients for closer monitoring and further adjuvant treatment to improve survival and reduce locoregional recurrence

What Variables Influence Final Range of Motion Following Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: While studies have demonstrated a predictable incremental increase in the range of motion (ROM) following total ankle arthroplasty (TAA) it remains unclear what variables affect the post-operative ROM. This study was undertaken to further investigate this question with the goal of providing guidance for patients and surgeons deciding between TAA and arthrodesis. Methods: This is a prospective review of 223 consecutive patients who underwent primary TAA using a single prosthesis performed between 2010-2013 for painful ankle arthritis that failed conservative therapy. Weight bearing flexion and extension X- rays were obtained preoperatively and again at 1 year following surgery. The patients were compared for demographics, type of arthritis, preoperative malalignment, prior trauma, obesity, medical co-morbidities, and the effect of concurrent surgery on post operative ankle ROM. Results: 191 patients had adequate follow-up and met all the inclusion criteria. The preoperative diagnosis, hindfoot or ankle varus or valgus, and concurrent percutaneous tendon Achilles lengthening (TAL) procedures were positive predictors of greater improvement in ankle ROM after TAA. Patients with valgus ankle malalignment had better post TAA DF, PF and total ankle range of motion compared to those in varus (P < 0.05). Percutaneous tendon Achilles lengthening (TAL) improved the DF, but not the PF (P < 0.05). Patients with primary ankle osteoarthritis (n=105) had the best improvement in ROM with an average gain of 3.39° in dorsiflexion (DF), 2.47° in plantar flexion (PF) and 5.84° in total ankle ROM (P < 0.05). An analysis of this subgroup demonstrated greater gain in ankle ROM in patients with lower preoperative ROM compared to those with higher preoperative ankle ROM(P < 0.01). Conclusion: Our results indicated primary ankle OA, preoperative ankle valgus malalignment and intraoperative TAL are significant factors in predicting increased ankle ROM after TAA. Ultimately, ankle motion is a function of the extent of arthritis, fibrosis and the surrounding soft tissue envelope. While TAA restores the function of the joint, it may not adequately correct periarticular fibrosis. Early weight bearing and physical therapy may alleviate postoperative stiffness, and increase the post operative gain in ROM. Further study is underway to determine the effect of early weight bearing and initiation of physical therapy on the ROM following TAA

The Minimally Invasive Treatments for Benign Prostrate Hyperplasia

The prevalence of benign prostatic hyperplasia (BPH) increases with age, affecting more than 50% of men above the age of 50 to varying degrees. As it enlarges, it compresses onto the urethra causing bladder outlet obstruction. This can cause a spectrum of problems ranging from irritative and obstructive lower urinary tract symptoms (LUTS) to retention of urine with obstructive uropathy. Transurethral resection of prostate (TURP) is the standard for surgical intervention, however with the advent of an ageing population, there is an increasing number of patients who have ischaemic heart disease who require long-term anticoagulation and have multiple co-morbidities that put them at an increased risk of general anaesthesia. This review aims to critically appraise the effectiveness and evidence for use of these minimally invasive techniques. Both PubMed and Ovid were used to search for randomised control trials (RCT) comparing the various minimally invasive techniques against TURP. In cases where there were no RCTs, the results of the respective trial were compiled. This was later compiled in a summary table. An effective minimally invasive treatment modality will play a complimentary role to TURP which remains the standard of surgical treatment for BPH. Technologies progressing towards rapid re-creation of prostatic channel, minimal blood loss and non-urethral instrumentation will bridge the divide between pharmacotherapy and surgery

Instability of the Medial Column Post Triple Arthrodesis for Stage III Posterior Tibial Tendon Dysfunction

Category: Hindfoot Introduction/Purpose: Triple arthrodesis remains the ideal procedure for management of painful rigid flatfoot deformity. While concurrent extended medial column arthrodesis of either the cuneonavicular joint or the 1st tarsometatarsal joint is occasionally required, they are not routinely performed. We hypothesized that following triple arthrodesis, there will be minimal change in the alignment of the medial column joints. The aim of this study was to examine the effect of the triple arthrodesis on the stability and alignment of the medial column joints. Methods: This was a retrospective review of 212 consecutive patients who underwent triple arthrodesis between 2002-2013 for correction of painful Stage III flatfoot deformity. Radiographs of the feet were obtained preoperatively, at 6 weeks, 6 months, 1 year, 3 years and 5 years following surgery. The post operative stability and alignment of the medial column was determined by comparing the radiographs over time. Five radiological parameters were studied: medial cuneiform-calcaneus angle (CCA), medial cuneiform-1st metatarsal angle (MCA), 1st/2nd inter metatarsal angle (IMA), medial cuneiform-navicular distance (NCD) and calcaneal pitch angle. These measurements determined the presence of instability in the sagittal plane (CCA and MCA) and coronal plane (NCD and IMA) of the medial cuneonavicular (NC) joint, and the 1st tarsometatarsal(TMT) joint. Results: Our study demonstrated the presence of medial column instability after triple arthrodesis. This instability was most apparent in the sagittal plane of the NC joint (P < 0.001), and was associated with a decreased in the calcaneal pitch (P < 0.001). There was a slight decrease in the IMA(P < 0.001) as well. The coronal plane of the NC joint, and the sagittal plane of the 1st TMT joint remained stable throughout the measurements. The instability is best appreciated in Fig(B) where there is a reduction in the CCA and calcaneal pitch compared to the X-ray in Fig(A) taken 15 months earlier. Conclusion: The triple arthrodesis procedure corrects the foot deformity, but it is associated with subsequent instability of the medial column mild at the NC joint and abduction of the forefoot at the TMT joints. However, the clinical significance of this instability is not apparent from the study. Since very few patients required subsequent treatment for TMT and NC pathologies after a successful triple arthrodesis, we found insufficient justification for extending the triple arthrodesis distally

Case Report of an Internal Hernia through a Unilateral Congenital Defect of the Broad Ligament and Literature Review

We report a case of small bowel obstruction resulting from the herniation of small bowel through a unilateral defect in the broad ligament of a woman who had no prior abdominal surgery and was nulliparous. In the absence of previous uterine surgery, delivery trauma and pelvic pathology, congenital abnormality should be considered the cause of the defect in the broad ligament

Dermatitis Secondary to Hypersensitivity to Icodextrin is a Rare Complication of Icodextrin Therapy in Peritoneal Dialysis

Case report on dermatitis secondary to hypersensitivity to icodextrin, which is a rare complication of icodextrin therapy in peritoneal dialysis

Functional Improvement in Geriatric Hip Fractures

Introduction: The “Integrated Care Pathway” for geriatric intertrochanteric (IT) fractures in Singapore’s Tan Tock Seng Hospital has shown significant functional recovery in patients’ activities of daily living. However, the influence of preoperative vitamin D on functional recovery remains equivocal. This retrospective study therefore aims to determine whether patients with preoperative vitamin D deficiency have poorer functional outcomes. Method: A total of 171 patients who had surgical treatment for IT fractures were recruited in the study. They were categorized into group A (vitamin D deficient) and group B (normal vitamin D). Charlson Comorbidity Index (CCI) score and nutritional parameters including hemoglobin, albumin, and adjusted calcium levels on admission were recorded. The Modified Barthel Index (MBI) score was used to measure functional recovery at the following time intervals: at pre-fall, at discharge after surgery, at 6 months, and at 1-year follow-up. Results: The mean age of both the groups (A: 79.7 years, n = 45; B: 83.0 years, n = 126) was statistically different ( P < .05). However, the mean CCI (A: 9.42 and B: 10.13), hemoglobin (A: 12.4 and B 11.1), adjusted calcium (A: 2.39 and B: 2.38), and mean albumin (A: 33.6 and B: 33.0) of the groups were not significantly different. Furthermore, the MBI scores were not significantly different for both groups at preinjury (A: 91.5 and B: 89.4), at discharge (A: 55.2 and B: 58.9), at 6 months (A: 70.9 and B: 75.1), and at 1 year (A: 75.8 and B: 79.4). Conclusion: In our cohort, patients with vitamin D deficiency were younger. However, vitamin D deficiency at time of injury had no significant influence on functional recovery in patients with surgically treated hip fracture in our Integrated Care Pathway. In addition, patients who had a normal vitamin D levels had similar functional scores and improvement postoperatively and at 1 year (A: 82.8% and B: 88.9%)