Renal Cell Carcinoma in Young Patients is Associated with Poorer Prognosis

Abstract Introduction: Renal cell carcinoma (RCC) in young patients is uncommon but thought to represent a distinctive clinical entity from older patients with different clinico-pathologic features and outcomes. We evaluated the association of age at the time of diagnosis with pathological staging, histological parameters, disease recurrence and overall survival (OS) following radical or partial nephrectomy for non-metastatic RCC in native kidneys. Materials and Methods: A retrospective review of 316 patients with RCC after nephrectomy at a single institution between January 2001 and June 2008 was performed. Eligible patients included all histologically proven primary non-metastatic RCC treated by radical or partial nephrectomy. They were categorised into group A (≤40 years at diagnosis) and B (>40 years). Differences in clinical parameters were analysed using the Mann Whitney U test. The prognostic potential of age at diagnosis was evaluated using Cox proportional hazards regression. Survival was estimated using the Kaplan Meier method. Results: There were 33 patients in group A and 283 patients in group B. There were more non-clear cell tumours in the younger group (30% vs 14%, P <0.05). No statistical differences were found in the stage and grade of both groups. At a median follow-up time of 41 months, the younger group had a higher metastatic rate (18% vs 10.5%, P <0.05), lower 5-year cancer-specifi c survival (82% vs 98%, P <0.05) and lower 5-year OS (82 % vs 95%, P <0.05). Conclusion: Younger patients were more likely to have non-clear cell RCC with higher disease recurrence and lower OS. They should not be assumed to have similar features and outcomes as screen-detected early RCC in older patients

Atypical Presentation of High-Grade Intramedullary Osteosarcoma with Bilateral Cervical, Supraclavicular, and Axillary Lymphadenopathy: A Case Report and Literature Review

Osteosarcoma typically presents with primary site pain. The authors report a case of extensive metastatic osteosarcoma without any complaint of primary site pain during initial presentation. The 23-year-old female patient presented with simultaneous multiple cervical, supraclavicular, and axillary lymphadenopathy, as well as two large subcutaneous fat tumours. Despite initial excision biopsy of cervical lymph nodes, the diagnosis of osteosarcoma was only clinched after open biopsy of the right distal femur lesions and further histological evaluation. Though the patient was promptly started on neo-adjuvant chemotherapy and achieved excellent histological response to treatment, the disease had relapsed quickly and she succumbed to the disease one year after initial presentation. This report highlights the need to be vigilant in the workup and investigation of osteosarcoma, as the presenting symptoms may be more heterogenous than the conventional teaching of primary site pain

Perceptions of High-Fidelity Simulation Teaching by Non-Specialist Doctors in an Emergency Department in Singapore

Simulation training was introduced in 2008 as part of the core education program for non-specialist doctors posted to our department. It aims to help them improve clinical knowledge and skills, as well as to facilitate teamwork and communication. A survey was conducted to elicit their views on this training technique. All the participants felt that it was most effective in improving knowledge base in resuscitation work while 97 % felt that the session allowed them to train their critical decision making skills. Only 57% felt that the session helped them to improve their patient and doctor communication skills. Simulation training has been generally well received and deemed beneficial by the participants in our study

Smoking Cessation: Barriers, Motivators and the Role of Physicians — A Survey of Physicians and Patients

Objective: To identify the motivators of and barriers to smoking cessation and to evaluate the dynamics of the patient-physician visit. Methods: A total of 175 physicians and 347 patient-smokers completed a written questionnaire about their attitudes and behaviours toward smoking cessation. Physicians were additionally queried on their level of involvement in the smoking cessation efforts of their patients. Results: Patient smokers had an average age of 42 years and had been smoking for 15 years. Males and females smoked 17 and 8 cigarettes a day respectively. About 50% of the subjects had made 2–5 attempts to quit smoking in the past and one-third of the subjects had tried to quit once. The top 2 motivators to quit smoking citied by both smokers and physicians were concern about their own health and concern about the health of family members and friends. The third reason given by patient-smokers was the cost of cigarettes. Physicians felt it was their advice that had persuaded/convinced patient-smokers to quit. Both physicians and patient-smokers agreed that the key barriers to smoking cessation were craving/physical addiction and smokers' concern of withdrawal symptoms if they attempted quitting. While both physicians and patients identified similar barriers to smoking cessation, there was a difference in perception about the role physicians play: 55% of physicians said that they discussed smoking cessation with their patients, but only 15% of the patients agreed with this statement. In addition, 78% of physicians said they started the initial discussion while 63% of patient-smokers said they themselves started the initial discussion. Conclusion: Smokers and physicians identified similar motivators of and barriers to smoking cessation. However, there were differences in perception over the roles physicians play

Mastoid Obliteration and Reconstruction: A Review of Techniques and Results

The aim of cholesteatoma surgery is to obtain a safe, dry and self-cleaning ear. Several methods have been tried and tested to achieve this goal with varying degrees of success. This article reviews some of the more common methods for mastoid reconstruction and obliteration and their results. Current trends appear to favour a combination of mastoid obliteration and reconstructive techniques, with biologic materials such as muscle flaps and bone chips preferred over non-biologic materials such as hydroxyapatite crystals and ceramic. However, there is large variation among the type of biologic flap used, which can vary between fascia, muscle and periosteum. After an extensive review, there is no ideal method for mastoid obliteration and reconstruction, as most methods appear to have a certain degree of success. The basic principles of a low facial ridge, large meatoplasty and an oval mastoid cavity should be adhered to, and the surgeon should choose a method that he or she is comfortable with

Cell saver filtering of extravasated rhBMP-2 after degenerative scoliosis reconstruction

RhBMP-2 is a bone fusion enhancer commonly used in scoliosis reconstruction surgery. It is delivered via an absorbable collagen sponge but has been known to migrate away from its delivery site. RhBMP-2 extravasation in surgical drainage has been noted during first two days post-surgery. Cell savers are widely used in scoliosis reconstruction to limit transfusion requirements and are commonly deployed in cases where rhBMP-2 is used for fusion augmentation. It is not known whether rhBMP-2 is present in salvaged blood or filtered away during cell saver recycling. Through this case series of four patients who underwent scoliosis reconstruction, we assess cell saver efficacy in filtering rhBMP-2 molecules by quantifying the amount of rhBMP-2 present in salvaged blood obtained after postoperative drainage recycling by OrthoPAT® cell saver and comparing it to rhBMP-2 leakage in postoperative drainage without cell saver recycling. We report an almost 10-fold reduction of rhBMP-2 concentration in salvaged blood obtained after cell saver recycling of postoperative drainage, suggesting cell saver effectiveness in filtering rhBMP-2 molecules

Scarf and Weil osteotomy for symptomatic hallux valgus does not fully remove second toe residual metatarsalgia

Category: Bunion Introduction/Purpose: Patients with hallux valgus (HV) often experience concurrent second toe metatarsalgia due to altered forefoot biomechanics. Additional second toe Weil osteotomy has been performed to reduce transfer metatarsalgia as some studies have highlighted the presence of second toe pain after isolated HV correction. 1, 2 There is a paucity of literature evaluating residual second toe pain after these procedures . We hypothesize that combined Scarf/Weil osteotomy will result in less residual second toe pain while achieving good functioning outcome. The aim of this study was to evaluate the presence of second toe pain after isolated scarf osteotomy versus combined Scarf/Weil osteotomy. Methods: Between January 2007 and June 2012, 439 patients underwent a scarf osteotomy for symptomatic hallux valgus at a tertiary hospital. Patients who underwent isolated scarf osteotomy were matched 1:1 to patients who had both Scarf and second toe Weil osteotomy. The following functional outcome scores were prospectively collected preoperatively and postoperatively at 6 and 24 months: American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal (MTP-IP) Scale, Visual Analog Scale (VAS), SF36-Physical Component Score (PCS) and Mental Component Score (MCS). Radiological outcomes such as the Hallux Valgus Angle (HVA) and Intermetatarsal Angle (IMA) were measured. Statistical analysis was performed using SPSS® 20.0 and significance was defined as a p-value = 0.05. The Student’s unpaired t-test was used to compare the radiological and functional outcomes between the two groups of patients, while the paired t-test was used to analyze improvement in pre- and postoperative outcomes within each group. Results: 94.4% of the patients were female and no difference in BMI. In the Scarf/Weil group, the HVA and IMA improved by 21.2 ± 10.2 and 8.2 ± 4.7 degrees respectively (both P<0.001). At 2 years, the AOFAS-hallux score improved by 26.6 ± 20.9 (p=0.034), AOFAS-second toe by 29.3 ± 20.9, VAS-hallux by 3.1 ± 3.4 (p<0.001), VAS-second toe by 3.6 ± 3.2 (p<0.001). In the Scarf group, the HVA and IMA improved by 17.1 ± 8.0 and 5.8 ± 4.3 degrees respectively (both p<0.001). At 2 years, the AOFAS-hallux score improved by 32.2 ± 21.2 (p=0.034), AOFAS-second toe by 13.0 ± 16.3 (p <0.001), VAS-hallux by 4.4 ± 3.3 (p<0.001), VAS-second toe by 1.2 ± 2.4 (p<0.001). Conclusion: A significant finding is that at 6 months and 2 years, the VAS-2nd toe score in the isolated Scarf group was 1 ± 0 point lower than the other group (p<0.001). All other functional outcome scores were comparable between the two groups at 6 months. Our findings suggest that shortening second toe Weil osteotomy for large HV deformity may not fully resolve second toe metatarsalgia in the short-term, providing useful information for preoperative counselling

Book 1.indb

Abstract Introduction: The 12-item Expectations Regarding Aging (ERA-12) instrument measures expectations that individuals have about how their health and cognitive function will be when they age. To date, primarily assessed among older adults in Western settings, expectations regarding ageing have been associated with physical activity and healthcare seeking behaviour. It has been suggested that it may be possible to develop interventions that promote positive expectations about ageing. Assessment of expectations regarding ageing among today&apos;s middleaged population would allow for earlier interventions to help give them positive (but realistic) ageing expectations, and age successfully. We assess the reliability and validity of ERA-12 for middle-aged Singaporeans. Materials and Methods: A questionnaire that included ERA-12 was administered to 1020 patients aged 41 to 62 years attending 2 SingHealth polyclinics in Singapore. Data from 981 respondents who completed the ERA-12 instrument were analysed. ERA-12&apos;s construct validity was determined using Exploratory Factor Analysis (EFA), and through its correlation with depressive symptoms, and self-rated health and education. Internal consistency reliability was assessed using Cronbach&apos;s alpha. Results: EFA confi rmed that the ERA-12 consisted of 3 factors (each with 4 items) -expectations regarding physical health, mental health and cognitive function, together explaining 64% of the variance in ERA-12 total score with high factor loadings (range, 0.6 to 0.8). The ERA-12 total score was positively correlated with self-rated health (r = 0.13) and education (r = 0.19), and negatively correlated with depressive symptoms (r = -0.25). Cronbach&apos;s alpha exceeded 0.7 for ERA-12 overall, and for each subscale. Conclusion: ERA-12 can be used to evaluate expectations regarding ageing not only among elderly populations in the West, but also among middle-aged Singaporeans. Ann Acad Med Singapore 2010;39:394-

A Simple Technique to Remove an Incarcerated Ceramic Liner in Revision Hip Arthroplasty

Extraction of a well-fixed ceramic liner during revision total hip arthroplasty can be technically challenging, particularly when acetabular fixation screws prevent en bloc removal of the shell and insert without causing collateral damage to the adjacent pelvic bone. It is also important to remove the ceramic liner intact, as ceramic debris left in the joint may cause third body wear with premature articular wear of the revised implants. We describe a novel technique to extract an incarcerated ceramic liner when previously described strategies prove ineffective. Knowledge of this technique will help surgeons avoid unnecessary damage to the acetabular bone and optimize prospects for stable implantation of revision components

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%)