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Nassar AHM, Qandeel H, Khan KS, Ng HJ, Hasanat S, Ashour H. The "Basket-in-Catheter" technique: facilitating transcystic bile duct exploration and optimising the management of suspected ductal stones. Updates Surg 2023; 75:1893-1902. [PMID: 37537316 DOI: 10.1007/s13304-023-01610-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study evaluates its benefits in confirmed and suspected ductal stones. Retrospective analysis of prospectively collected data on patients with pre-operative or operative suspicion of bile duct stones or with positive and equivocal intraoperative cholangiographies (IOC) who had LTCE attempted using blind basket trawling, without choledochoscopy, were reviewed. The incidence and outcomes of blind basket LTCEs attempted before and after introducing the BIC technique, whether or not stones were retrieved, were analysed. Blind basket LTCE was attempted in 732 patients. Of 377 (51.5%) patients undergoing successful stone retrieval, only 62% had pre-operative clinical and radiological risk factors for ductal stones, 25% had operative risk factors and 13% had silent stones discovered on IOC. Another 355 patients (48.5%) had negative trawling, although one half had pre-operative risk factors for ductal stones and 47.6% had operative risk factors, e.g. cystic duct stones or dilatation. This cohort had equivocal cholangiography in 25.9%. Following basket trawling, repeat IOC confirmed resolution of abnormalities. As no stones were retrieved, these were not considered duct explorations. The BIC technique facilitates safe and speedy bile duct clearance when stones are confirmed, avoiding choledochotomies, without significant complications. BIC duct trawling is also beneficial in patients with suspected ductal stones, helping to resolve equivocal IOCs. It helps surgeons to acquire and consolidate ductal exploration skills.
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Affiliation(s)
- Ahmad H M Nassar
- Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland, UK.
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland.
| | - Haitham Qandeel
- Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland, UK
- The Hashemite University, Zarqa, Jordan
| | - Khurram S Khan
- Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland
- University Hospital Hairmyres, Lanarkshire, Scotland, UK
| | - Hwei J Ng
- Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland, UK
- Royal Alexandra Hospital, Paisley, Scotland, UK
| | - Subreen Hasanat
- Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland, UK
- The Hashemite University, Zarqa, Jordan
| | - Haneen Ashour
- Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland, UK
- The Hashemite University, Zarqa, Jordan
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Barman S, Ng HJ, Teo S, Blaney EM, Mansfield O. 1274 Impact of Covid 19 on Urgent Suspicion of GI Cancer Referral in a District General Hospital. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Aim
Endoscopy services across United Kingdom were affected significantly since March 2020 due to Covid-19 pandemic. Services were reduced and were more selective. We aim to compare the impact on duration between referral to colonoscopy and the detection rate of pathology between February (pre- Covid) and August (Covid impacted) 2020.
Method
Data was analysed from a prospectively maintained database of patients referred for colonoscopy to Royal Alexandra Hospital, Scotland. Patients underwent colonoscopy in month of February and August 2020 were included. Bowel screening patients were excluded. Positive findings included diverticulosis, colitis, polyp and adenocarcinoma. P value of < 0.05 was considered significant.
Results
Total number of patients included was 97 (55 in February, 42 in August). Median age was 61 and 69 years, respectively. Mean duration from referral to colonoscopy were 4 weeks in February and 7 weeks in August. qFIT test were found raised in 50.9% in February and 57.1% in August with positive findings of 47.3% in February and 66.7% in August. 46.4% in February and 16.7% in August had raised qFIT but normal findings (p < 0.05). Two high grade dysplasia polyps and two adenocarcinomas were identified in February, none found in August.
Conclusions
Covid-19 pandemic has disrupted the endoscopic services prolonging the duration from referral to colonoscopy. qFIT test is more heavily relied to prioritise urgent colonoscopies resulting in more positive findings on colonoscopy. Cancer detection rate has reduced which is a consistent finding as the UK national endoscopy study. Massive efforts are needed to restore endoscopy services.
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Affiliation(s)
- S Barman
- Royal Alexandra Hospital, Glasgow, United Kingdom
| | - H J Ng
- Royal Alexandra Hospital, Glasgow, United Kingdom
| | - S Teo
- Royal Alexandra Hospital, Glasgow, United Kingdom
| | - E M Blaney
- Royal Alexandra Hospital, Glasgow, United Kingdom
| | - O Mansfield
- Royal Alexandra Hospital, Glasgow, United Kingdom
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Au S, Bellato V, Carvas JM, Córdoba CD, Daudu D, Dziakova J, Eltarhoni K, El Feituri N, Fung ACH, Fysaraki C, Gallo G, Gultekin FA, Harbjerg JL, Hatem F, Ioannidis A, Jakobsen L, Clinch D, Kristensen HØ, Kuiper SZ, Kwok AMF, Kwok W, Millan M, Milto KM, Ng HJ, Pellino G, Picciariello A, Pronin S, van Ramshorst GH, Ramser M, Jiménez-Rodríguez RM, Sainz Hernandez JC, Samadov E, Sohrabi S, Uchiyama M, Wang JHS, Younis MU, Fleming S, Alhomoud S, Mayol J, Moeslein G, Smart NJ, Soreide K, Teh C, Verran D, Maeda Y. Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages. Br J Surg 2021; 108:1315-1322. [PMID: 34467970 DOI: 10.1093/bjs/znab275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/24/2021] [Accepted: 07/01/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally. METHODS A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. RESULTS Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance. CONCLUSION Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.
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Affiliation(s)
- S Au
- NHS Education for Scotland, Edinburgh, UK
| | | | | | - C D Córdoba
- University of Lausanne, Lausanne, Switzerland
| | - D Daudu
- Faculty of Health and Medical Sciences, University of Western Australia, Australia
| | - J Dziakova
- Hospital Clinico San Carlos, IDISSC, Madrid, Spain
| | | | | | - A C H Fung
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - C Fysaraki
- Urology Department, Mid Yorkshire Hospitals NHS Trust, UK
| | - G Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - F Ayca Gultekin
- General Surgery Department, Zonguldak Bulent, Ecevit University School of Medicine, Zonguldak, Turkey
| | - J L Harbjerg
- Department of Surgery, Research Unit C119, Aarhus University Hospital, Palle Juul-Jensens, Aarhus N, Denmark
| | - F Hatem
- Glasgow Royal Infirmary, Glasgow, UK
| | | | - L Jakobsen
- UiT, The Arctic University of Norway, University Hospital of North Norway, Tromso, Norway
| | - D Clinch
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - H Ø Kristensen
- Department of Surgery, Research Unit C119, Aarhus University Hospital, Palle Juul-Jensens, Aarhus N, Denmark
| | - S Z Kuiper
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | | | - W Kwok
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M Millan
- Coloproctology Unit, Department of Surgery, La Fe University Hospital, Valencia, Spain
| | - K M Milto
- NHS Education for Scotland, Edinburgh, UK
| | - H J Ng
- Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, UK
| | - G Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Picciariello
- Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Italy
| | - S Pronin
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - M Ramser
- Department of Surgery, Solothurner Spitäler SoH, Bürgerspital Solothurn, Solothurn, Switzerland
| | | | - J C Sainz Hernandez
- Instituto Nacional de Ciencias Médicas y Nutrición 'Salvador Zubirán', Mexico City, Mexico
| | - E Samadov
- Surgical Department, LEYLA Medical Centre, Baku, Azerbaijan
| | | | - M Uchiyama
- Showa University School of Medicine, Tokyo, Japan
| | - J H-S Wang
- Australasian Students' Surgical Association, New Zealand
| | - M U Younis
- Mediclinic City Hospital, Dubai, United Arab Emirates
| | - S Fleming
- Barts and the London School of Medicine and Dentistry, London, UK
| | - S Alhomoud
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - J Mayol
- Hospital Clinico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
| | - G Moeslein
- Ev. Bethesda Khs Duisburg, University of Witten, Herdecke, Germany
| | - N J Smart
- Royal Devon & Exeter Hospital & University of Exeter Medical School, Exeter, UK
| | - K Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - C Teh
- Department of Surgery, Makati Medical Centre, Makati, Philippines.,Department of General Surgery, National Kidney & Transplant Institute, Quezon City, Philippines
| | - D Verran
- Ramsey Health Care, Sydney, Australia
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital and University of Edinburgh, Edinburgh, UK
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Qandeel H, Nassar AHM, Ng HJ, El Zanati H. Laparoscopic Cholecystectomy for Gallbladder Dysfunction and Polyps: Incidence and Follow up. JSLS 2021; 25:JSLS.2021.00009. [PMID: 33981137 PMCID: PMC8088335 DOI: 10.4293/jsls.2021.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim This study aims to evaluate the incidence, indications, management, and long term follow up of cholecystectomy in patients with no gallstones, other than acalculous acute cholecystitis. Methods Prospectively collected data of 5675 patients undergoing laparoscopic cholecystectomy (LC) over 28 years was extracted and analyzed. Patients with biliary symptoms, no stones on ultrasound scans and abnormal hepatobiliary iminodiacetic acid scans, and those with confirmed gallbladder polyps (GBP) were included. Results Two percent of cholecystectomies were performed in patients with acalculous pathology [1.3% functional gallbladder disorder (FGBD) and 0.7% GBP]. The 114 patients were younger, had lower American Society of Anesthesiologists classification, and had fewer previous biliary admissions than those with gallstones (5560). The clinical presentations of FGBD were chronic biliary symptoms (93.1%) and acute biliary pain (6.9%). GBP patients presented with chronic biliary symptoms. LC in 98.6% FGBD and 92.8% GBP were significantly easier than those for gall stones (P < 0.0001). They were significantly (P < 0.0001 FGBD and P < 0.001 GBP) less likely to have adhesions to the gallbladder. This ease was reflected in shorter operation times and lower utilization of abdominal drains. Polyp numbers ranged from 1 to 30 and sizes from 1 mm to 11 mm. No malignant polyps were encountered. In 95.8% FGBD and 95% GBP, patients had a good symptomatic response to LC. Conclusions FGBD and GBP are uncommon in patients undergoing LC. FGBD should be considered during evaluation of right upper quadrant pain with no gall stones. Laparoscopic cholecystectomy may be considered as it achieves long term symptomatic relief in most patients with FGBD and GBP.
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Affiliation(s)
| | - Ahmad H M Nassar
- Laparoscopic Biliary Service, University Hospital Monklands, Lanarkshire, Scotland, UK
| | - Hwei J Ng
- Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, Scotland, UK
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Nassar AHM, Zanati HE, Ng HJ, Khan KS, Wood C. Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates. Surg Endosc 2021; 36:550-558. [PMID: 33528666 PMCID: PMC8741693 DOI: 10.1007/s00464-021-08316-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/09/2021] [Indexed: 02/02/2023]
Abstract
Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.
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Affiliation(s)
- Ahmad H M Nassar
- Department of Surgery, University Hospital Monklands, Airdrie, Lanarkshire, UK. .,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK.
| | - Hisham El Zanati
- Department of Surgery, University Hospital Hairmyres, East Kilbride, Lanarkshire, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Hwei J Ng
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Khurram S Khan
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
| | - Colin Wood
- Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.,Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, Scotland, ML6 0JS, UK
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Nassar AHM, Ng HJ, Wysocki AP, Khan KS, Gil IC. Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure. Surg Endosc 2020; 35:6039-6047. [PMID: 33067645 PMCID: PMC8523408 DOI: 10.1007/s00464-020-08093-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies. AIMS AND METHODS A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely. RESULTS The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions. CONCLUSION All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.
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Affiliation(s)
- Ahmad H M Nassar
- University Hospital Monklands, Airdrie, Lanarkshire, ML6 0JSb, Scotland.
| | - Hwei J Ng
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Arkadiusz Peter Wysocki
- Logan Hospital, Corner Meadowbrook and Loganlea Roads, Meadowbrook, Logan City, QLD, 4133, Australia
| | | | - Ines C Gil
- Centro Hospitalar de Leiria, Leiria, Portugal
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Nassar AHM, Ng HJ, Ahmed Z, Wysocki AP, Wood C, Abdellatif A. Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model. Surg Endosc 2020; 35:4192-4199. [PMID: 32860135 PMCID: PMC8263394 DOI: 10.1007/s00464-020-07900-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/17/2020] [Indexed: 01/12/2023]
Abstract
Aims The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning. Methods A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data. Results Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%. Conclusion Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.
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Affiliation(s)
- Ahmad H M Nassar
- Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK.
| | - Hwei J Ng
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | - Colin Wood
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Ayman Abdellatif
- Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK
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Ng HJ, Ahmed Z, Khan KS, Katbeh T, Nassar AHM. C-reactive protein level as a predictor of difficult emergency laparoscopic cholecystectomy. BJS Open 2019; 3:641-645. [PMID: 31592082 PMCID: PMC6773624 DOI: 10.1002/bjs5.50189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/09/2019] [Indexed: 12/24/2022] Open
Abstract
Background Studies focused on C‐reactive protein (CRP) as a marker of difficult laparoscopic cholecystectomy are limited to small case series. The aim of this study was to evaluate the association between preoperative CRP concentration and difficulty of laparoscopic cholecystectomy in patients admitted with a biliary emergency presentation. Methods Patients with an emergency admission for biliary disease treated between 2012 and 2017 with a documented preoperative CRP level were analysed. Elective patients and those with other concurrent causes of increased CRP concentration were excluded. The intraoperative difficulty grade was based on the Nassar scale. Statistical analysis was conducted to determine the association of preoperative CRP level with difficulty grading, adjusted for the interval to surgery. Results A total of 804 emergency patients were included. The mean preoperative peak CRP level was 64·7 mg/l for operative difficulty grade I, 69·6 mg/l for grade II, 98·2 mg/l for grade III, 217·5 mg/l for grade IV and 193·1 mg/l for grade V, indicating a significant association between CRP concentration and Nassar grade (P < 0·001). Receiver operating characteristic (ROC) curve analysis showed an area under the curve of 0·78 (95 per cent c.i. 0·75 to 0·82), differentiating patients with grade I–III from those with grade IV–V operative difficulty. ROC curve analysis found a cut‐off CRP value of 90 mg/l, with 71·5 per cent sensitivity and 70·5 per cent specificity in predicting operative difficulty of grade IV or V. Logistic regression analysis found preoperative peak CRP level to be predictive of Nassar grade I–III versus grade IV–V operative difficulty, also when adjusted for timing of surgery (odds ratio 5·90, 95 per cent c.i. 2·80 to 12·50). Conclusion Raised preoperative CRP levels are associated with greater operative difficulty based on Nassar scale grading.
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Affiliation(s)
- H J Ng
- Department of General Surgery University Hospital Monklands, NHS Lanarkshire Airdrie ML6 0JS UK
| | - Z Ahmed
- Department of General Surgery University Hospital Monklands, NHS Lanarkshire Airdrie ML6 0JS UK
| | - K S Khan
- Department of General Surgery University Hospital Monklands, NHS Lanarkshire Airdrie ML6 0JS UK
| | - T Katbeh
- Department of General Surgery University Hospital Monklands, NHS Lanarkshire Airdrie ML6 0JS UK
| | - A H M Nassar
- Department of General Surgery University Hospital Monklands, NHS Lanarkshire Airdrie ML6 0JS UK
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Wu IQ, Tan CW, Wong WH, Ng HJ. Utility of global hemostatic assays in the management of anticoagulation in a haemophilia patient. Haemophilia 2018; 24:e261-e263. [PMID: 29869428 DOI: 10.1111/hae.13530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- I Q Wu
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
| | - C W Tan
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
| | - W H Wong
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
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Reding MT, Ng HJ, Poulsen LH, Eyster ME, Pabinger I, Shin HJ, Walsch R, Lederman M, Wang M, Hardtke M, Michaels LA. Safety and efficacy of BAY 94-9027, a prolonged-half-life factor VIII. J Thromb Haemost 2017; 15:411-419. [PMID: 27992112 DOI: 10.1111/jth.13597] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/25/2016] [Indexed: 01/24/2023]
Abstract
Essentials Recombinant factor VIII BAY 94-9027 conjugates in a site-specific manner with polyethylene glycol. BAY 94-9027 was given to patients with severe hemophilia A as prophylaxis and to treat bleeds. BAY 94-9027 prevented bleeds at dose intervals up to every 7 days and effectively treated bleeds. BAY 94-9027 treatment was mainly well tolerated and no patient developed factor VIII inhibitors. Click to hear Dr Tiede's perspective on half-life extended factor VIII for the treatment of hemophilia A SUMMARY: Background BAY 94-9027 is a B-domain-deleted prolonged-half-life recombinant factor VIII (FVIII) that conjugates in a site-specific manner with polyethylene glycol. Objective Assess efficacy and safety of BAY 94-9027 for prophylaxis and treatment of bleeds in patients with severe hemophilia A. Patients/methods In this multinational, phase 2/3, partially randomized, open-label trial, men aged 12-65 years with FVIII < 1% and ≥ 150 exposure days to FVIII received BAY 94-9027 for 36 weeks on demand or prophylactically at intervals determined following a 10-week run-in period on 25 IU kg-1 body weight two times per week. Patients with > 1 bleed during the run-in subsequently received 30-40 IU kg-1 two times per week; patients with ≤ 1 bleed were eligible for randomization to every-5-days (45-60 IU kg-1 ) or every-7-days (60 IU kg-1 ) prophylaxis (1 : 1) for 26 additional weeks until randomization arms were filled. Patients who were eligible but not randomized continued twice-weekly prophylaxis. The primary efficacy outcome was annualized bleeding rate (ABR). Results The intent-to-treat population included 132 patients (prophylaxis, n = 112; on demand, n = 20). Median ABR (quartile [Q1; Q3]) for patients treated two times per week who were not eligible for randomization (n = 13) improved after dose increase (17.4 [14.3; 26.0] to 4.1 [2.0; 10.6]). Median ABR for patients randomized to every-5-days treatment (n = 43) was 1.9 (0; 4.2), similar to patients eligible for randomization but who continued treatment two times per week (n = 11). Median ABR for 32/43 patients (74%) who continued every-7-days prophylaxis until study end was 0.96 (0.0; 4.3). Six hundred and thirty-six of 702 bleeds (90.6%) were controlled with ≤ 2 infusions. No patient developed a FVIII inhibitor. Conclusions BAY 94-9027 prevented bleeding across three individually tailored dose regimens and was effective for treatment of bleeds.
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Affiliation(s)
- M T Reding
- University of Minnesota Medical Center, Minneapolis, MN, USA
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore
| | - L H Poulsen
- Centre for Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark
| | - M E Eyster
- Penn State Hershey Medical Center, Hershey, PA, USA
| | - I Pabinger
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - H-J Shin
- Division of Hematology-Oncology, Department of Internal Medicine, School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - R Walsch
- Bayer Vital GmbH, Leverkusen, Germany
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Yek JLJ, Grant D, He YK, Ng HJ, Tan TK. A difficult case of acquired haemophilia with concomitant Evan's Syndrome presenting with acute subdural haematoma. Haemophilia 2017; 23:e152-e155. [PMID: 28181354 DOI: 10.1111/hae.13162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
- J L J Yek
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - D Grant
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Y K He
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - T K Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
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12
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Kaur H, Hwang JCC, Ho LYK, Zhang X, Ng HJ. Extensive subcutaneous haematoma associated with transdermal analgesic patch in a haemophilia A patient with inhibitor. Haemophilia 2016; 22:e333-5. [PMID: 27292770 DOI: 10.1111/hae.12966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 11/28/2022]
Affiliation(s)
- H Kaur
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - J C C Hwang
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - L Y K Ho
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - X Zhang
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
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13
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Chay J, Koh M, Tan HH, Ng J, Ng HJ, Chia N, Kuperan P, Tan J, Lew E, Tan LK, Koh PL, Desouza KA, Bin Mohd Fathil S, Kyaw PM, Ang AL. A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals. Vox Sang 2015; 110:36-50. [PMID: 26178308 DOI: 10.1111/vox.12311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 05/29/2015] [Accepted: 06/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A common national MTP was jointly implemented in 2011 by the national blood service (Blood Services Group) and seven participating acute hospitals to provide rapid access to transfusion support for massively haemorrhaging patients treated in all acute care hospitals. METHODS Through a systematic clinical workflow, blood components are transfused in a ratio of 1:1:1 (pRBC: whole blood-derived platelets: FFP), together with cryoprecipitate for fibrinogen replacement. The composition of components for the MTP is fixed, although operational aspects of the MTP can be adapted by individual hospitals to suit local hospital workflow. The MTP could be activated in support of any patient with critical bleeding and at risk of massive transfusion, including trauma and non-trauma general medical, surgical and obstetric patients. RESULTS There were 434 activations of the MTP from October 2011 to October 2013. Thirty-nine per cent were for trauma patients, and 30% were for surgical patients with heavy intra-operative bleeding, with 25% and 6% for patients with gastrointestinal bleeding and peri-partum haemorrhage, respectively. Several hospitals reported reduction in mean time between request and arrival of blood. Mean transfusion ratio achieved was one red cell unit: 0·8 FFP units: 0·8 whole blood-derived platelet units: 0·4 units of cryoprecipitate. Although cryoprecipitate usage more than doubled after introduction of MTP, there was no significant rise in overall red cells, platelet and FFP usage following implementation. CONCLUSION This successful collaboration shows that shared transfusion protocols are feasible and potentially advantageous for hospitals sharing a central blood provider.
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Affiliation(s)
- J Chay
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - M Koh
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - H H Tan
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - J Ng
- Department of Surgery, Singapore General Hospital, Singapore City, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
| | - N Chia
- Department of Anaesthesiology, Khoo Teck Puat Hospital, Singapore City, Singapore
| | - P Kuperan
- Department of Haematology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - J Tan
- Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - E Lew
- Department of Anaesthesiology, KK Woman's & Children's Hospital, Singapore City, Singapore
| | - L K Tan
- Department of Haematology, National University Hospital, Singapore City, Singapore
| | - P L Koh
- Paediatrics, National University Hospital, Singapore City, Singapore
| | - K A Desouza
- Department of Anaesthesiology, Changi General Hospital, Singapore City, Singapore
| | - S Bin Mohd Fathil
- Department of Anaethesiology, Jurong Health Services, Singapore City, Singapore
| | - P M Kyaw
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - A L Ang
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
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Ng HJ, Lam J, Koh PL, Ho L, Lim CY, Akhbar Ali M, Mya D, Than H, Ho LP, Tan AM, Lee LH, Tien SL. A comprehensive study of current haemophilia care and outcomes in Singapore. Haemophilia 2015; 21:e428-31. [PMID: 26058545 DOI: 10.1111/hae.12729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2015] [Indexed: 12/01/2022]
Affiliation(s)
- H J Ng
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - J Lam
- Department of Paediatrics, Kandang Kerbau Women's and Children's Hospital, Singapore, Singapore
| | - P L Koh
- Department of Paediatrics, National University Hospital, Singapore, Singapore
| | - L Ho
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - C Y Lim
- Department of Paediatrics, Kandang Kerbau Women's and Children's Hospital, Singapore, Singapore
| | - M Akhbar Ali
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - D Mya
- Department of Paediatrics, Kandang Kerbau Women's and Children's Hospital, Singapore, Singapore
| | - H Than
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - L P Ho
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - A M Tan
- Department of Paediatrics, Kandang Kerbau Women's and Children's Hospital, Singapore, Singapore
| | - L H Lee
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - S L Tien
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
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15
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Idros R, Ho YKL, Ng HJ. Delayed recurrent bleeding from central venous catheter track after catheter removal in a haemophilia patient. Haemophilia 2015; 21:e411-2. [PMID: 26036680 DOI: 10.1111/hae.12540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2014] [Indexed: 11/28/2022]
Affiliation(s)
- R Idros
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Y K L Ho
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
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16
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Yang F, Griva K, Lau T, Vathsala A, Lee E, Ng HJ, Mooppil N, Foo M, Newman SP, Chia KS, Luo N. Health-related quality of life of Asian patients with end-stage renal disease (ESRD) in Singapore. Qual Life Res 2015; 24:2163-71. [PMID: 25800727 DOI: 10.1007/s11136-015-0964-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study aimed to identify factors associated with the health-related quality of life (HRQOL) of multiethnic Asian end-stage renal disease (ESRD) patients treated with dialysis. The role of dialysis modality was also explored. METHODS Data used in this study were from two cross-sectional surveys of Singaporean ESRD patients on haemodialysis (HD) or peritoneal dialysis (PD). In both surveys, participants were assessed using the kidney disease quality of life (KDQOL) instrument and questions assessing socio-demographic characteristics. Clinical data including co-morbidity (measured by Charlson comorbidity index [CCI]), albumin level, haemoglobin level, and dialysis-related variables (e.g. dialysis vintage and dialysis adequacy) were retrieved from medical records. The 36-item KDQOL (KDQOL-36) was used to generate three summary scores (physical component summary [PCS], mental component summary [MCS] and kidney disease component summary [KDCS]) and two health utility scores (Short Form 6-dimension [SF-6D] and EuroQol 5-dimension [EQ-5D]). Linear regression analysis was performed to examine the association of factors with each of the HRQOL scale scores. RESULTS Five hundred and two patients were included in the study (mean age 57.1 years; male 52.4 %; HD 236, PD 266). Mean [standard deviation (SD)] PCS, MCS and KDCS scores were 37.9 (9.7), 46.4 (10.8) and 57.6 (18.1), respectively. Mean (SD) health utility score was 0.66 (0.12) for SF-6D and 0.60 (0.21) for EQ-5D. In multivariate regression analysis, factors found to be significantly associated with better HRQOL included: young (<45 years) or old age (>60 years), low CCI (<5), high albumin (≥37 g/l) and high haemoglobin (≥11 g/dl) with PCS; long dialysis vintage (≥3.5 years) with MCS; old age, Malay ethnicity and PD modality with KDCS; low CCI, high albumin and high haemoglobin with EQ-5D and high albumin with SF-6D. CONCLUSIONS Clinical characteristics are better predictors of HRQOL in ESRD patients than socio-demographics in Singapore. Dialysis modality has no impact on the health utility of those patients.
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Affiliation(s)
- F Yang
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, Singapore, 117549, Singapore
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Abstract
INTRODUCTION Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS. METHODS A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed. RESULTS A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre. CONCLUSIONS ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.
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Affiliation(s)
| | - M Yule
- University of Aberdeen, UK
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18
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Yang F, Griva K, Lau T, Vathsala A, Lee E, Ng HJ, Mooppil N, Newman SP, Chia KS, Luo N. Health-Related Quality Of Life (Hrqol) Of Asian Patients With End-Stage Renal Disease (Esrd) In Singapore. Value Health 2014; 17:A471. [PMID: 27201352 DOI: 10.1016/j.jval.2014.08.1338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- F Yang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - K Griva
- Department of Psychology, Faculty of Arts and Social Sciences, National University of Singapore, Singapore
| | - T Lau
- Division of Nephrology, University Medicine Cluster, National University Health System, Singapore
| | - A Vathsala
- Division of Nephrology, University Medicine Cluster, National University Health System, Singapore
| | - E Lee
- Division of Nephrology, University Medicine Cluster, National University Health System, Singapore
| | - H J Ng
- Department of Psychology, Faculty of Arts and Social Sciences, National University of Singapore, Singapore
| | - N Mooppil
- National Kidney Foundation, Singapore
| | | | - K S Chia
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - N Luo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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19
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Ng HJ, Than H, Teo ECY. First experiences with the use of rivaroxaban in the treatment of heparin-induced thrombocytopenia. Thromb Res 2014; 135:205-7. [PMID: 24974053 DOI: 10.1016/j.thromres.2014.06.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 11/24/2022]
Affiliation(s)
- H J Ng
- Department of Haematology, Singapore General Hospital, 20 College Road, Singapore 169856, Republic of Singapore.
| | - H Than
- Department of Haematology, Singapore General Hospital, 20 College Road, Singapore 169856, Republic of Singapore
| | - E C Y Teo
- Department of Haematology, Singapore General Hospital, 20 College Road, Singapore 169856, Republic of Singapore
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20
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Lai YF, Cheen MHH, Ng HJ. The effects of fasting in Muslim patients taking warfarin: reply. J Thromb Haemost 2014; 12:808-9. [PMID: 24602237 DOI: 10.1111/jth.12548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 02/28/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Y F Lai
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
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21
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Lai YF, Cheen MHH, Lim SH, Yeo FHI, Nah SC, Kong MC, Mya D, Lee LH, Ng HJ. The effects of fasting in Muslim patients taking warfarin. J Thromb Haemost 2014; 12:349-54. [PMID: 24354801 DOI: 10.1111/jth.12496] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anticoagulation with warfarin is influenced by dietary changes but the effect of fasting on warfarin therapy is unknown. OBJECTIVES To study changes in international normalized ratio (INR) and the percentage of time within therapeutic range (%TTR) before, during and after the Muslim fasting month (Ramadan) in stable warfarinised Muslim patients. METHODS/PATIENTS In this prospective study, weekly INR readings were taken at home visits from participating patients during three study periods: before, during and after Ramadan. Readings were blinded to patients and their primary physicians except for when pre-set study endpoints were reached. RESULTS Among 32 participating patients, mean INR increased by 0.23 (P = 0.006) during Ramadan from the pre-Ramadan month and decreased by 0.28 (P < 0.001) after Ramadan. There was no significant difference (P = 1.000) in mean INR between the non-Ramadan months. %TTR declined from 80.99% before Ramadan to 69.56% during Ramadan (P = 0.453). The first out-of-range INR was seen around 12.1 days (95% CI, 9.0-15.1) after the start of fasting and returned to range at about 10.8 days (95% CI, 7.9-13.7) after Ramadan. Time above range increased from 10.80% pre-Ramadan to 29.87% during Ramadan (P = 0.027), while time below range increased from 0.57% during Ramadan to 15.49% post-Ramadan (P = 0.006). No bleeding or thrombotic events were recorded. CONCLUSIONS Fasting significantly increases the mean INR of medically stable patients taking warfarin and the likelihood of having an INR above therapeutic targets. For patients maintained at the higher end of INR target ranges or at increased risk of bleeding, closer monitoring or dosage adjustment may be necessary during fasting.
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Affiliation(s)
- Y F Lai
- Department of Pharmacy, Singapore General Hospital, Singapore
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22
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Ko HL, Ng HJ, Goh EH, Ren EC. Reduced ADP-ribosylation by PARP1 natural polymorphism V762A and by PARP1 inhibitors enhance Hepatitis B virus replication. J Viral Hepat 2013; 20:658-65. [PMID: 23910651 DOI: 10.1111/jvh.12100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 02/01/2013] [Indexed: 01/04/2023]
Abstract
HepG2 and Huh7 cell lines are frequently used as models to study viral hepatitis and hepatocellular carcinoma. However, they exhibit significantly different capacities in their ability to support hepatitis B virus (HBV) replication. To investigate the basis for this, transcription factor-binding motifs at the HBV core promoter (HBVCP) were tested in luciferase reporter constructs to identify the possible role of host factors. Among the transcription factors screened: PARP1, SP1, HNF4α, HNF3, hB1F and HNF1, deletion of the PARP1 binding motif abrogated transcriptional activity at the HBVCP in HepG2 but not Huh7 cells. Sequencing of the PARP1 gene revealed that HepG2 cells carried an Ala762 allele which has low ADP-ribosylation activity, which was shown to have increased PARP1 binding affinity to its cognate motif thus resulting in higher transcriptional activity. PARP1 inhibitors that are being developed as broad cancer therapeutics also target PARP1 ADP-ribosylation enzymatic function. Four PARP1 inhibitors: PJ-34, ABT888, AZD2281 and AG014699 were tested for their effect on HBV replication. All four small molecules effectively enhanced HBV replication in vitro, confirming the role of PARP1 in HBV replication and that alteration of ADP-ribosylation by mutation or drugs can affect HBV replication. Our data demonstrate that natural polymorphisms in the host affecting proteins such as PARP1 can have a significant effect on HBV replication. Hence, patients who are infected with HBV and are on clinical trials involving PARP1 inhibitors may be at risk from unintended side-effects such as exacerbation of HBV replication.
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Affiliation(s)
- H L Ko
- Singapore Immunology Network, A*STAR, Singapore
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Griva K, Ng HJ, Loei J, Mooppil N, McBain H, Newman SP. Managing treatment for end-stage renal disease--a qualitative study exploring cultural perspectives on facilitators and barriers to treatment adherence. Psychol Health 2012; 28:13-29. [PMID: 22780853 DOI: 10.1080/08870446.2012.703670] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Although adherence to hemodialysis (HD) regimes is important to maximise good clinical outcomes, it remains suboptimal and not well understood, particularly for those in non-Western settings and patients from Asian cultures. This qualitative study sought to explore cultural perspectives on facilitators and barriers to treatment adherence in HD patients. A descriptive exploratory design was used for the study, incorporating individual semi-structured interviews (n = 17) and three focus groups (n = 20). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted by two coders using an iterative process. Study participants identified personal and social/contextual factors as major barriers or facilitators of treatment adherence. Barriers include time consumption, forgetfulness, concerns about safety, poor knowledge/understanding, poor communication and lack of control/social pressure. Participants also identified facilitators, both internal (self-initiated) and external (initiated by family, health care professional and peers) to ensure treatment adherence. These included support from family members and social obligation towards others, risk perception, establishment of routines and peer support. Internal and external factors can hinder or facilitate adherence to diet, fluid and medications in the context of dialysis. Several of these barriers/facilitators can be effectively addressed in the context of interventions and psycho-educational programmes.
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Affiliation(s)
- K Griva
- Department of Psychology, National University of Singapore, Singapore.
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25
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Koh BCM, Chong LL, Goh LG, Iau P, Kuperan P, Lee LH, Lim LC, Ng HJ, Sia A, Tan HH, Tan LK, Tay KH, Teo LTD, Ting WC, Yong TT. Ministry of health clinical practice guidelines: clinical blood transfusion. Singapore Med J 2011; 52:209-219. [PMID: 21451931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The Health Sciences Authority (HSA) and the Ministry of Health (MOH) publish clinical practice guidelines on Clinical Blood Transfusion to provide doctors and patients in Singapore with evidence-based guidance for blood transfusion. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HSA-MOH clinical practice guidelines on Clinical Blood Transfusion, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=25700). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
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Koh MBC, Goh YT, Tan PHC, Koh LP, Hwang WYK, Loh Y, Tan D, Ng HJ, Chuah C, Lim TJ, Niam M, Suck G, Chan M, Phang CY, Lee JJ, Wee V, Ng HY, Lim CH, Yiu R, Kam G, Ang A, Linn YC. Stem cell transplantation programme at Singapore General Hospital. Bone Marrow Transplant 2008; 42 Suppl 1:S121-S124. [DOI: 10.1038/bmt.2008.139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Koh LP, Koh MBC, Ng HY, Hwang WYK, Goh YT, Linn YC, Ng HJ, Chuah CTH, Tan KW, Loh YSM, Tan DCL, Tan PHC, Tan PHC. Allogeneic Hematopoietic Stem Cell Transplantation for Patients with Severe Aplastic Anemia Following Nonmyeloablative Conditioning Using 200-cGy Total Body Irradiation and Fludarabine. Biol Blood Marrow Transplant 2006; 12:887-90. [PMID: 16864060 DOI: 10.1016/j.bbmt.2006.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2006] [Accepted: 04/15/2006] [Indexed: 11/20/2022]
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Abstract
Acquired haemophilia A (AH) is a rare bleeding disorder with significant risk of mortality. We conducted a study on the treatment and outcomes of patients with AH diagnosed between 1998 and 2004 in our institution. Fourteen patients (age range 17-89, median 64) were followed-up from between 10-64 months (average 32 months). Inhibitor levels ranged from 5 to 450 BU. Ten patients required either recombinant activated factor VIIa or prothrombin complexes for control of bleeding. All patients received a standard immunosuppressive regimen of prednisolone 1 mg kg day(-1) and oral cyclophosphamide 50-100 mg day(-1). In addition, nine patients received intravenous immunoglobulin. Complete remission (CR) was achieved in 88% (eight of nine evaluable patients) over durations ranging from 5-78 days (average 35 days). There were three mortality; from bleeding, sepsis and cerebral infarct. Two patients were lost to follow-up. There were no relapses among patients achieving CR. Conditions associated with AH were not identified at diagnosis or subsequent follow-up in all patients. This series represent one of the largest aetiologically and treatment-wise, uniformed cohort of AH patients. Despite toxicity concerns, the combination of prednisolone and cyclophosphamide remain an effective regimen and should be among the first line of treatment choices, with careful patient selection.
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Affiliation(s)
- H J Ng
- Department of Haematology, Singapore General Hospital, Singapore, Singapore.
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29
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Abstract
Patients with idiopathic hypereosinophilic syndrome (HES) show persistent hypereosinophilia of unknown etiology that is associated with end-organ damage. Different treatments, including the use of corticosteroids and cytotoxics, have been investigated for HES with modest success. We describe a patient with HES who had significant end-organ damage from hypereosinophilia and remained refractory to conventional therapy. Therapy with imatinib mesylate, a selective tyrosine kinase inhibitor that is highly effective in treating patients with BCR-ABL-positive chronic myeloid leukemia, was tried with the patient. The result was impressive, with hematologic remission achieved after 12 days of administration. Our finding concurs with recent reports that imatinib mesylate may be a promising agent in the treatment of some cases of HES.
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Affiliation(s)
- D Tan
- Department of Haematology, Singapore General Hospital, Singapore.
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Hwang WYK, Koh LP, Ng HJ, Tan PHC, Chuah CTH, Fook SC, Chow H, Tan KW, Wong C, Tan CH, Goh YT. A randomized trial of amifostine as a cytoprotectant for patients receiving myeloablative therapy for allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2004; 34:51-6. [PMID: 15208650 DOI: 10.1038/sj.bmt.1704521] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We initiated a randomized study of amifostine (the organic thiophosphate formerly known as WR-2721) given to patients during myeloablative conditioning therapy for allogeneic bone marrow transplantation. Amifostine was given at a dose of 1000 mg/day of conditioning and was well tolerated if attention was given to serum calcium levels, blood pressure and antiemetics. Since August 1998, 60 patients (30 on each arm) have completed the study. There was no significant difference in the days to neutrophil or platelet engraftment in either arm of the study. Significantly, the duration of grade I-IV mucositis was decreased in the group that received amifostine (P=0.02). Also grade III or IV infections (P=0.008), duration of antibiotic therapy (P=0.03) and duration of fever (P=0.04) were significantly reduced with amifostine. However, there were no differences in the incidence of grade III or IV mucositis, liver toxicity or renal toxicity. There were also no differences in early mortality, relapse and long-term survival. We conclude that amifostine, while reducing the duration of mucositis and infections (possibly through some preservation of gut mucosal integrity), has a modest effect in allogeneic bone marrow transplants given the multiplicity of factors influencing organ toxicity and survival in this setting.
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Affiliation(s)
- W Y K Hwang
- Department of Haematology, Singapore General Hospital, Outram Road, Singapore, Singapore
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31
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Hwang WYK, Chai LYA, Ng HJ, Goh YT, Tan PHC. Therapeutic plasmapheresis for the treatment of the thrombotic thrombocytopenic purpura-haemolytic uraemic syndromes. Singapore Med J 2004; 45:219-23. [PMID: 15143357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION The thrombotic thrombocytopenic purpura-haemolytic uraemic syndromes (TTP-HUS) are uncommon disorders that are fatal if untreated. Therapeutic plasma exchange has resulted in excellent remission and survival rates in this patient population. METHODS We reviewed our experience of therapeutic plasmapheresis for TTP-HUS syndromes for 11 patients who presented in the last five years. Parameters captured included haemoglobin and platelet counts at presentation as well as the number of plasmapheresis sessions and adjunctive treatment given. RESULTS We found a response rate of 82 percent to plasma exchange, of whom 55 percent attained complete remission. Responses were excellent in the five patients who presented with primary or idiopathic TTP (100 percent response) among whom 80 percent had sustained long term responses. Responses were poor and often unsustained (only one out of six survived) in patients who presented with thrombotic microangiopathies secondary to underlying disorders such as bone marrow transplantation and metastatic carcinoma. CONCLUSION Plasmapheresis is mandatory and extremely effective for primary TTP. However, it is at most an adjunct for patients who developed it secondary to an underlying disorder until and if the primary disorder can be successfully treated.
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Affiliation(s)
- W Y K Hwang
- Department of Haematology, Singapore General Hospital, Outram Road, Singapore 169608.
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32
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Tan AWH, Ng HJ, Ang P, Goh YT. Extensive calcinosis cutis in relapsed acute lymphoblastic leukaemia. Ann Acad Med Singap 2004; 33:107-9. [PMID: 15008575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Hypercalcaemia with calcinosis cutis occurring at relapse of acute lymphoblastic leukaemia (ALL) is rare and unusual. CLINICAL PICTURE A 19-year-old lady with B precursor ALL presented with extensive waxy, verrucous, tender plaques over the flexures of her arms and legs a week after relapse of leukaemia. She was found to have hypercalcaemia, hyperphosphataemia, hyperuricaemia and acute renal impairment. Skin biopsy was consistent with calcinosis cutis. There was no evidence of metastatic calcification in other organs. TREATMENT Hypercalcaemia was treated with aggressive hydration and intravenous pamidronate. High doses of analgesics were required for partial pain relief. OUTCOME Cutaneous lesions proved resistant to early calcium lowering and were a source of constant pain. She succumbed to leukaemia four months later. CONCLUSION Treatment of calcinosis cutis was unsatisfactory and would have been dependent on the successful treatment of the underlying leukaemia.
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33
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Koh LP, Hwang WYK, Tan CH, Linn YC, Goh YT, Chuah CTH, Ng HJ, Fook-Chong SMC, Tan PHC. Long term follow-up of Asian patients with chronic myeloid leukemia (CML) receiving allogeneic hematopoietic stem cell transplantation (HSCT) from HLA-identical sibling-evaluation of risks and benefits. Ann Hematol 2003; 83:286-94. [PMID: 15060748 DOI: 10.1007/s00277-003-0810-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2003] [Accepted: 10/09/2003] [Indexed: 10/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is the only known curative therapy for patients with chronic myeloid leukemia (CML), but is associated with significant morbidity and mortality. The recent introduction of imatinib mesylate (STI-571) and reduced intensity transplant regimens has made the choice of primary treatment for patients with CML increasingly difficult. We have evaluated the outcome of 53 patients who have received allogeneic HSCT from human leukocyte antigen (HLA)-identical sibling donors between October 1985 and March 2002, determined the variables affecting the outcome, and tried to define indications for this aggressive approach. Successful engraftment occurred in 49 (98%) of evaluable patients. Acute graft-versus-host disease (GVHD) of grade II to IV severity was observed in 63% of the evaluable patients whereas the incidence of chronic GVHD was 57.5%. The Kaplan-Meier estimate of survival at 10 years was 54% [95% confidence interval (CI): 38-70%] and 31% (95% CI: 6-56%) for patients with first chronic phase and more advanced diseases, respectively. Multivariate analysis showed that younger age, absence of grade III-IV GVHD, the use of busulphan and cyclophosphamide (BuCy) as preparative regimen, and transplantation performed after January 1992 were factors associated with improved survival. Patients who were 30 years of age or younger who had transplantation done within 1 year after diagnosis during their first chronic phase of disease had a particularly good prognosis, with a probability of surviving 10 years of 72% (95% CI: 52-92%). We conclude that allogeneic HSCT remains a feasible option for Asian patients with CML. The most favorable outcome is observed in younger patients with early phase of the disease.
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Affiliation(s)
- L P Koh
- Bone Marrow Transplantation Program, Department of Haematology, Singapore General Hospital, Outram Road, 169608, Singapore.
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Ng HJ, Koh LP, Lee LH. Successful control of postsurgical bleeding by recombinant factor VIIa in a renal failure patient given low molecular weight heparin and aspirin. Ann Hematol 2003; 82:257-8. [PMID: 12707733 DOI: 10.1007/s00277-003-0633-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2002] [Accepted: 01/30/2003] [Indexed: 11/29/2022]
Abstract
An end-stage renal failure patient with lupus nephritis was treated with low molecular weight heparin (LMWH) and aspirin for cardiac ischemia. She was then subjected to surgery to recreate a new arteriovenous fistula for dialysis 1 day after discontinuing LMWH and aspirin. Severe postsurgical bleeding required wound reexploration and multiple transfusions of blood products, which nevertheless, failed to arrest bleeding. Recombinant factor VIIa (rFVIIa) as a bolus dose of 120 microg/kg successfully secured hemostasis. Bleeding in this patient was attributed to the accumulation of low molecular weight heparin activity from poor renal clearance as well as the antiplatelet activity of aspirin. The potential of rFVIIa in securing hemostasis for excessive bleeding after use of these agents is promising.
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Affiliation(s)
- H J Ng
- Department of Hematology, Singapore General Hospital, Outram Road, 169608 Singapore, Republic of Singapore.
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Koh LP, Hwang WYK, Chuah CTH, Linn YC, Goh YT, Tan CH, Ng HJ, Tan PHC. Imatinib mesylate (STI-571) given concurrently with nonmyeloablative stem cell transplantation did not compromise engraftment and resulted in cytogenetic remission in a patient with chronic myeloid leukemia in blast crisis. Bone Marrow Transplant 2003; 31:305-8. [PMID: 12621468 DOI: 10.1038/sj.bmt.1703836] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The main obstacles to successful hematopoietic stem cell transplantation for patients with chronic myeloid leukemia (CML) in blast crisis (BC) are increased post-transplant relapse and high treatment-related mortality. We report a patient with CML in BC who was treated initially with imatinib mesylate and was then concurrently treated with a nonmyeloablative stem cell transplant. Successful engraftment of donor cells followed by complete cytogenetic remission was achieved in the absence of severe therapy-related toxicities. This case demonstrates that imatinib mesylate given through nonmyeloablative transplant is a minimally toxic therapeutic approach, which does not compromise engraftment and may result in a favorable outcome in patients with CML in BC.
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Affiliation(s)
- L P Koh
- Department of Hematology, Singapore General Hospital
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Ng HJ, Lee LH. Case report on recombinant coagulation factor VIIa in the treatment of three haemophilia A patients with inhibitors in Singapore. Ann Acad Med Singap 2002; 31:241-4. [PMID: 11957567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION We report the first experiences with use of recombinant coagulation Factor VIIa (rFVIIa) in the treatment of haemophilia A patients with inhibitors in Singapore and discuss observations in 3 patients. CLINICAL PICTURE Case 1 bled on two separate occasions into his neck muscles and vocal cord. Case 2 had gross haematuria from bleeding in the renal calyxes. Case 3 bled into the parotid muscles. TREATMENT rFVIIa in doses, ranging from 50 ug/kg to 90 ug/kg, at different dosing intervals, were used. OUTCOME Excellent responses were seen in doses of 70 and 90 ug/kg. CONCLUSIONS rFVIIa is highly effective, both clinically and cost-wise, in the treatment of these patients.
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Affiliation(s)
- H J Ng
- Department of Haematology, Singapore General Hospital, Outram Road, Singapore 169608.
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Abstract
Chronic hepatitis B infection poses a problem in patients with malignancies undergoing chemotherapy. Not uncommonly, hepatitis B virus (HBV) reactivates during or soon after chemotherapy. We report a case of a woman with acute prolymphocytic leukemia who received chemotherapy containing fludarabine and cyclophosphamide, followed by the CD 20 monoclonal antibody, rituximab. She developed fatal reactivation of hepatitis B with fulminant liver failure 3 months after completing treatment. Listeria monocytogenes was concomitantly isolated. This case indicates the importance of identifying all hepatitis B carriers and the need to closely monitor and detect reactivation early. Newer chemotherapeutic agents with potentially long-lasting effects on T cells, such as purine analogues, require extended vigilance for reactivation of HBV as well as opportunistic infections. Rituximab is increasingly used alone or in combination with other chemotherapy agents. Its possible contributory role in hepatitis B reactivation needs to be defined.
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Affiliation(s)
- H J Ng
- Department of Hematology, Singapore General Hospital, Singapore.
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