Review: Implant-Based Breast Reconstruction After Mastectomy for Breast Cancer: A Meta-analysis of Randomized Controlled Trials and Prospective Studies Comparing Use of Acellular Dermal Matrix (ADM) Versus Without ADM

BACKGROUND

Breast cancer is the world's most prevalent cancer, and many breast cancer patients undergo mastectomy as the choice of treatment, often with post-mastectomy breast reconstruction. Acellular dermal matrix (ADM) use has become a method to improve outcomes of reconstruction for these patients. We aimed to compare postoperative complications and patient-reported outcomes, which are still poorly characterized, between groups utilizing acellular dermal matrix during reconstruction and those without.

MATERIALS AND METHODS

We searched electronic databases from inception to 16 June 2022 for randomized controlled trials and prospective cohort studies comparing the outcomes of patients who have and have not received acellular dermal matrix in implant-based breast reconstruction. The results were quantitatively combined and analyzed using random-effects models.

RESULTS

A total of nine studies were included, representing 3161 breasts. There was no significant difference in postoperative outcomes, such as seroma formation (p = 0.51), hematomas (p = 0.20), infections (p = 0.21), wound dehiscence (p = 0.09), reoperations (p = 0.70), implant loss (p = 0.27), or skin necrosis (p = 0.21). Only two of the studies included evaluated patient-reported outcomes between the use and non-use of ADM in implant-based breast reconstruction using BREAST-Q questionnaire, as well as self-reported pain. There was no reported significant difference in BREAST-Q or pain scores.

CONCLUSIONS

This meta-analysis shows comparable short- and long-term outcomes between ADM and non-ADM breast reconstruction, suggesting that the use of ADM may not be necessary in all cases given their additional cost. However, there is a paucity of data for patient-reported outcomes, and further research is required to determine whether ADM use affects patient-reported outcomes.

Global prevalence of basic life support training: A systematic review and meta-analysis

BACKGROUND AND AIMS

Out-of-hospital cardiac arrest exerts a large disease burden, which may be mitigated by bystander cardiopulmonary resuscitation and automated external defibrillation. We aimed to estimate the global prevalence and distribution of bystander training among laypersons, which are poorly understood, and to identify their determinants.

METHODS

We searched electronic databases for cross-sectional studies reporting the prevalence of bystander training from representative population samples. Pooled prevalence was calculated using random-effects models. Key outcome was cardiopulmonary resuscitation training (training within two-years and those who were ever trained). We explored determinants of interest using subgroup analysis and meta-regression.

RESULTS

28 studies were included, representing 53,397 laypersons. Among national studies, the prevalence of cardiopulmonary resuscitation training within two-years and among those who were ever trained, and automated external defibrillator training was 10.02% (95% CI 6.60-14.05) and 39.64% (95%CI 29.11-50.67), and 15.70% (95% CI 10.17-22.18) respectively. Subgroup analyses by continent revealed pooled prevalence estimates of 31.58% (95%CI 18.70-46.09), 52.62% (95%CI 38.40-66.63), 18.93 (95%CI 0.00-62.94), 64.97% (95%CI 64.00-65.93), and 50.56% (95%CI 47.57-53.54) in Asia, Europe, Middle East, North America, and Oceania respectively, with significant subgroup differences (p<0.01). A country's income and cardiopulmonary resuscitation training (ever trained) (p=0.033) were positively correlated. Similarly, this prevalence was higher among the employed (p<0.00001) and highly educated (p<0.00001).

CONCLUSIONS

Large regional variation exists in data availability and bystander training prevalence. Socioeconomic status correlated with prevalence of bystander training, and regional disparities were apparent between continents. Bystander training should be promoted, particularly in Asia, Middle East, and low-income regions. Data availability should be encouraged from under-represented regions.

A systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulants vs vitamin K antagonists after transcatheter aortic valve replacement in patients with atrial fibrillation

PURPOSE

Transcatheter aortic valve replacement (TAVR) is increasingly carried out in patients with aortic valvular conditions. Atrial fibrillation (AF) is a common comorbidity among patients undergoing TAVR. Despite this, there remains a paucity of data and established guidelines regarding anticoagulation use post-TAVR in patients with AF.

METHODS

Four databases were searched from inception until 12 October 2021. A title and abstract sieve, full-text review and data extraction were conducted by independent authors, and articles including patients without AF were excluded. The Review Manager (Version 5.4) was utilised in data analysis.

RESULTS

A total of 25,199 post-TAVR patients with AF were included from seven articles, with 9764 patients on non-vitamin K antagonist oral anticoagulants (NOAC) and 15,435 patients on vitamin K antagonists (VKA). In this analysis, there was a significantly lower risk of all-cause mortality at 1 year (RR: 0.75, CI: 0.58-0.97, p = 0.04, I² = 56%), and bleeding at 1 year (RR: 0.73, CI: 0.68-0.79, p =  < 0.00001, I² = 0%), between patients on NOAC and VKA. There were no detectable differences between patients on NOAC and VKA for all-cause mortality at 2 years, stroke within 30 days, stroke within 1 year, ischaemic stroke at 1 year and life-threatening bleeding at 30 days.

CONCLUSION

While the results of this analysis reveal NOAC as a potential alternate treatment modality to VKA in post-TAVR patients with AF, further research is needed to determine the full safety and efficacy profile of NOAC (PROSPERO: CRD42021283548).

Simultaneous cardio-cerebral infarction: a meta-analysis

BACKGROUND/INTRODUCTION

Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse.

AIM

We aimed to summarize the reported cardio-cerebral infarction cases in the literature.

DESIGN

Meta-analysis.

METHODS

Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors.

RESULTS

A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported.

DISCUSSION/CONCLUSION

The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.

Obesity Measures and Definitions of Sarcopenic Obesity in Singaporean Adults - the Yishun Study

OBJECTIVES

Due to the lack of a uniform obesity definition, there is marked variability in reported sarcopenic obesity (SO) prevalence and associated health outcomes. We compare the association of SO with physical function using current Asian Working Group for Sarcopenia (AWGS) guidelines and different obesity measures to propose the most optimal SO diagnostic formulation according to functional impairment, and describe SO prevalence among community-dwelling young and old adults.

DESIGN

Obesity was defined according to waist circumference (WC), percentage body fat (PBF), fat mass index (FMI), fat mass/fat-free mass ratio (FM/FFM), or body mass index (BMI). SO was defined as the presence of both obesity and AWGS sarcopenia. Muscle function was compared among phenotypes and obesity definitions using ANOVA. Differences across obesity measures were further ascertained using multiple linear regressions to determine their associations with the Short Physical Performance Battery (SPPB).

SETTING

Community-dwelling adults 21 years old and above were recruited from a large urban residential town in Singapore.

PARTICIPANTS

535 community-dwelling Singaporeans were recruited (21-90 years old, 57.9% women), filling quotas of 20-40 participants in each sex- and age-group.

MEASUREMENTS

We took measurements of height, weight, BMI, waist and hip circumferences, body fat, muscle mass, muscle strength, and functional assessments. Questionnaire-based physical and cognitive factors were also assessed.

RESULTS

Overall prevalence of SO was 7.6% (WC-based), 5.1% (PBF-based), 2.7% (FMI-based), 1.5% (FM/FFM-based), and 0.4% (BMI-based). SO was significantly associated with SPPB only in the FMI model (p<0.05), and total variance explained by the different regression models was highest for the FMI model.

CONCLUSIONS

Our findings suggest FMI as the most preferred measure for obesity and support its use as a diagnostic criteria for SO.

Malnutrition and Sarcopenia in Community-Dwelling Adults in Singapore: Yishun Health Study

OBJECTIVES

To determine the overlapping prevalence of malnutrition and sarcopenia and the association between parameters of malnutrition with muscle mass and strength in a community-dwelling Singaporean adult population.

DESIGN

This was a cross-sectional study.

SETTING

Large north-eastern residential town of Yishun in Singapore.

PARTICIPANTS

Random sampling of community-dwelling Singaporeans aged 21-90 years old (n=541).

MEASUREMENTS

Anthropometry, body composition and handgrip strength (muscle strength) were measured. Sarcopenia was identified using dual-energy x-ray absorptiometry scan (muscle mass). Nutritional status was measured using Mini Nutritional Assessment (MNA-SF). Other questionnaires collected included physical activity and cognition. Associations between nutritional status with sarcopenia as well as with muscle mass and strength were analysed using multinomial logistics and linear regressions.

RESULTS

The overall population-adjusted prevalence of those at nutritional risk and malnourished were 18.5% and 0.1% respectively. More than a third of participants (35%) who were at nutritional risk were sarcopenic. Malnourished participants were all sarcopenic (100%, N=2) whereas those who were sarcopenic, 27.0% (N=37) were at nutritional risk/malnourished. Being at nutritional risk/malnourished was significantly associated with 2 to 3 times increased odds of sarcopenia in multivariate analyses adjusting for age, gender, physical activity level and cognition, and fat mass index. Favourable MNA parameter scores on food intake and BMI were positively associated with greater muscle mass and handgrip strength (p<0.05).

CONCLUSION

Given the overlapping clinical presentation of malnutrition and sarcopenia, community screening protocols should include combination screening of nutritional status and sarcopenia with appropriate interventions to mitigate risk of adverse health outcomes.

Tea Consumption and Depression from Follow Up in the Singapore Longitudinal Ageing Study

OBJECTIVES

Experimental evidence suggest that tea polyphenols have anti-depressant effect and tea consumption may reduce the risk and severity of depression. We investigated whether tea consumption was associated with changes in depressive symptoms over time among Asian older adults.

DESIGN

Population-based prospective cohort study with mean 4 years of follow up.

SETTING

Singapore Longitudinal Ageing Study (SLAS) of community-living older persons.

PARTICIPANTS

3177 participants overall (mean age 67 years) and 3004 participants who were depression-free at baseline.

MEASUREMENTS

Baseline tea consumption which include Chinese (black, oolong or green) tea or Western (mixed with milk) tea and change in Geriatric Depression Scale (GDS) measure of depression. Incident depression was defined by GDS≥5, and GDS depression improvement or deterioration by GDS change of ≥4 points. Estimated odds ratio and 95% confidence intervals (OR, 95%CI) were adjusted for baseline age, sex, ethnicity, education, housing type, single/divorced/widowed, living alone, physical and social activity, smoking, alcohol, number of comorbidities, MMSE, and baseline GDS level.

RESULTS

Compared to non-tea drinkers, participants who consumed ≥3 cups of tea of all kinds were significantly less likely to have worsened GDS symptoms: OR=0.32, 95% CI=0.12, 0.84. Among baseline depression-free participants, the risk of incident GDS (≥5) depression was significantly lower (OR=0.34, 95%CI=0.13, 0.90) for daily consumption of all types of tea, and Chinese (black, oolong or green) tea (OR=0.46, 95%CI=0.21,0.99).

CONCLUSION

This study suggests that tea may prevent the worsening of existing depressive symptoms and the reduce the likelihood of developing threshold depression.

Nutritional Status and Risks of Cognitive Decline and Incident Neurocognitive Disorders: Singapore Longitudinal Ageing Studies

BACKGROUND

Studies suggest that nutritional interventions using the whole diet approach such as the Mediterranean diet may delay cognitive decline and dementia onset. However, substantial numbers of older adults are non-adherent to any ideally healthy dietary pattern and are at risk of malnutrition.

OBJECTIVE

The present study investigated the relationship between global malnutrition risk and onsets of cognitive decline and neurocognitive disorders (NCD), including mild cognitive impairment (MCI) or dementia in community-dwelling older adults.

METHODS

Participants aged ≥ 55 years in the Singapore Longitudinal Ageing Studies (SLAS) were assessed at baseline using the Elderly Nutritional Indicators for Geriatric Malnutrition Assessment (ENIGMA) and followed up 3-5 years subsequently on cognitive decline (MMSE drop ≥ 2) among 3128 dementia-free individuals, and incident neurocognitive disorders (NCD) among 2640 cognitive normal individuals.

RESULTS

Individuals at high nutritional risk score (≥ 3) were more likely to develop cognitive decline (OR=1.42, 95%CI=1.01-1.99) and incident MCI-or-dementia (OR=1.64, 95%CI=1.03-2.59), controlling for age, sex, ethnicity, low education, APOE-e4, hearing loss, physical, social, and mental activities, depressive symptoms, smoking, alcohol, central obesity, hypertension, diabetes, low HDL, high triglyceride, cardiac disease, and stroke. Among ENIGMA component indicators, low albumin at baseline was associated with cognitive decline and incident NCD, and 5 or more drugs used, few fruits/vegetables/milk products daily, and low total cholesterol were associated with incident NCD.

CONCLUSION

The ENIGMA measure of global malnutrition risk predicts cognitive decline and incident neurocognitive disorders, suggesting the feasibility of identifying vulnerable subpopulations of older adults for correction of malnutrition risk to prevent neurocognitive disorders.

Development, Validation and Field Evaluation of the Singapore Longitudinal Ageing Study (SLAS) Risk Index for Prediction of Mild Cognitive Impairment and Dementia

BACKGROUND

Mild cognitive impairment (MCI) is a critical pre-dementia target for preventive interventions. There are few brief screening tools based on self-reported personal lifestyle and health-related information for predicting MCI that have been validated for their generalizability and utility in primary care and community settings.

OBJECTIVE

To develop and validate a MCI risk prediction index, and evaluate its field application in a pilot community intervention trial project.

DESIGN

Two independent population-based cohorts in the Singapore Longitudinal Ageing Study (SLAS). We used SLAS1 as a development cohort to construct the risk assessment instrument, and SLA2 as a validation cohort to verify its generalizability.

SETTING

community-based screening and lifestyle intervention Participants: (1) SLAS1 cognitively normal (CN) aged ≥55 years with average 3 years (N=1601); (2) SLAS2 cohort (N=3051) with average 4 years of follow up. (3) 437 participants in a pilot community intervention project.

MEASUREMENTS

The risk index indicators included age, female sex, years of schooling, hearing loss, depression, life satisfaction, number of cardio-metabolic risk factors (wide waist circumference, pre-diabetes or diabetes, hypertension, dyslipidemia). Weighted summed scores predicted probabilities of MCI or dementia. A self-administered questionnaire field version of the risk index was deployed in the pilot community project and evaluated using pre-intervention baseline cognitive function of participants.

RESULTS

Risk scores were associated with increasing probabilities of progression to MCI-or-dementia in the development cohort (AUC=0.73) and with increased prevalence and incidence of MCI-or-dementia in the validation cohort (AUC=0.74). The field questionnaire risk index identified high risk individuals with strong correlation with RBANS cognitive scores in the community program (p<0.001).

CONCLUSIONS

The SLAS risk index is accurate and replicable in predicting MCI, and is applicable in community interventions for dementia prevention.

Risk Factors of Progression to Frailty: Findings from the Singapore Longitudinal Ageing Study

OBJECTIVES

To investigate risk factors of incident physical frailty.

DESIGN

A population-based observational longitudinal study.

SETTING

Community-dwelling elderly with age 55 years and above recruited from 2009 through 2011 in the second wave Singapore Longitudinal Ageing Study-2 (SLAS-2) were followed up 3-5 years later.

PARTICIPANTS

A total of 1297 participants, mean age of 65.6 ±0.19, who were free of physical frailty.

MEASUREMENTS

Incident frailty defined by three or more criteria of the physical phenotype used in the Cardiovascular Health Study was determined at follow-up. Potential risk factors assessed at baseline included demographic, socioeconomic, medical, psychological factors, and biochemical markers.

RESULTS

A total of 204 (15.7%) participants, including 81 (10.87%) of the robust and 123 (22.28%) of the prefrail transited to frailty at follow-up. Age, no education, MMSE score, diabetes, prediabetes and diabetes, arthritis, ≥5 medications, fair and poor self-rated health, moderate to high nutritional risk (NSI ≥3), Hb (g/dL), CRP (mg/L), low B12, low folate, albumin (g/L), low total cholesterol, adjusted for sex, age and education, were significantly associated (p<0.05) with incident frailty. In stepwise selection models, age (year) (OR=1.07, 95%CI=1.03-1.10, p<0.001), albumin (g/L) (OR=0.85, 95%CI=0.77-0.94, p=0.002), MMSE score (OR=0.88, 95%CI=0.78-0.98, p=0.02), low folate (OR=3.72, 95%CI=1.17-11.86, p=0.03, and previous hospitalization (OR=2.26, 95%CI=1.01-5.04,p=0.05) were significantly associated with incident frailty.

CONCLUSIONS

The study revealed multiple modifiable risk factors, especially related to poor nutrition, for which preventive measures and early management could potentially halt or delay the development of frailty.

Strong Relationship between Malnutrition and Cognitive Frailty in the Singapore Longitudinal Ageing Studies (SLAS-1 and SLAS-2)

BACKGROUND

Physical frailty is well known to be strongly associated with malnutrition, but the combined impact of physical frailty and cognitive impairment among non-demented older persons (cognitive frailty) on malnutrition prevalence is not well documented.

DESIGN

Cross-sectional cohort study.

SETTING AND PARTICIPANTS

Community-dwelling older Singaporeans aged ≥55y (n=5414) without dementia in the Singapore Longitudinal Ageing Study (SLAS-1 and SLAS-2).

MEASUREMENTS

The Mini Nutritional Assessment - short form (MNA-SF) and Nutrition Screening Initiative (NSI) Determine Checklist were used to determine their nutritional status. Participants were categorized as cognitive normal (CN) or cognitive impaired (CI) by Mini Mental State Examination (MMSE<=23), as pre-frail (PF) (score=1-2) or frail (F) (score=3-5) using Fried's criteria, and as cognitive pre-frail (PF+CI) or cognitive frail (F+CI).

RESULTS

The prevalence of cognitive frailty was 1.6%, and cognitive pre-frailty was 5.5% (total, 7.1%). The prevalence of MNA malnutrition was 2.4%, and NSI high nutritional risk was 6.3%. The prevalence of MNA malnutrition was lowest among Robust-CN and highest among Frail-CI (0.5% in Robust-CN, 0.6% in Robust-CI, 2.8% in Pre-frail-CN, 7.3% in Pre-frail-CI, 15.4% in Frail-CN, and 23.1% in Frail-CI). Similarly, the prevalence of NSI high nutritional risk was lowest in Robust-CN (3.7%) and highest in Frail-CI (13.6%). Adjusted for sociodemographic and health status, pre-frailty/frailty-CI versus Robust-CN was associated with the highest odds ratio of association with MNA malnutrition (OR=8.16, p<0.001), although not the highest with NSI high nutritional risk (OR=1.48, p=0.017).

CONCLUSIONS

An extraordinary high prevalence of malnutrition was observed among older adults with cognitive frailty who should be specially targeted for active intervention.

The Long-Term Impact of Functional Disability on Hospitalization Spending in Singapore

Singapore is one of the fastest-aging populations due to increased life expectancy and lowered fertility. Lifestyle changes increase the burden of chronic diseases and disability. These have important implications for social protection systems. The goal of this paper is to model future functional disability and healthcare expenditures based on current trends. To project the health, disability and hospitalization spending of future elders, we adapted the Future Elderly Model (FEM) to Singapore. The FEM is a dynamic Markov microsimulation model developed in the US. Our main source of population data was the Singapore Chinese Health Study (SCHS) consisting of 63,000 respondents followed up over three waves from 1993 to 2010. The FEM model enables us to investigate the effects of disability compounded over the lifecycle and hospitalization spending, while adjusting for competing risk of multi-comorbidities. Results indicate that by 2050, 1 in 6 elders in Singapore will have at least one ADL disability and 1 in 3 elders will have at least one IADL disability, an increase from 1 in 12 elders and 1 in 5 elders respectively in 2014. The highest prevalence of functional disability will be in those aged 85 years and above. Lifetime hospitalization spending of elders aged 55 and above is US$24,400 (30.2%) higher among people with functional disability compared to those without disability. Policies that successfully tackle diabetes and promote healthy living may reduce or delay the onset of disability, leading to potential saving. In addition, further technological improvements may reduce the financial burden of disability.

Nutritional and Frailty State Transitions in the Singapore Longitudinal Aging Study

BACKGROUND

Malnutrition is a major determinant of the physical frailty syndrome. Dynamic transitions in frailty states over time is well documented, but few studies have documented temporal changes in nutritional states and whether they influence frailty outcomes.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

Community-dwelling older Singaporeans aged ≥55y with a 5-year follow-up (n=1162) in the Singapore Longitudinal Ageing Study 2 (SLAS-2).

MEASUREMENTS

The Mini Nutritional Assessment Short-Form (MNA-SF) was used to determine nutritional status, and the Fried's criteria (shrinking, weakness, slowness, exhaustion and inactivity) was used to assess physical frailty phenotype at both baseline and follow-up. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were adjusted for multiple baseline co-variables.

RESULTS

At baseline, being at risk of malnutrition/malnourished was associated with increased odds of prevalent pre-frailty (OR=2.76, 95% CI=1.86-4.10) and frailty (OR=4.10, 95% CI=1.41-11.9). Baseline robust individuals who were persistently at risk of malnutrition/malnourished showed an increased odds of conversion to being pre-frail/frail at follow-up (OR=3.45, 95% CI=1.00-11.9). Among baseline pre-frail/frail individuals, reversion to being robust were significantly less likely among those who were persistently at risk of malnutrition/malnourished (OR=0.26, 95% CI=0.10-0.67) and those whose baseline normal nutrition worsened at follow-up (OR=0.20, 95% CI=0.06-0.74).

CONCLUSION

Changes in nutritional states are associated with frailty state transitions, and monitoring changes in nutritional status is recommended for the prevention and severity reduction of frailty among older people in the community.

Multi-Domains Lifestyle Interventions Reduces Depressive Symptoms among Frail and Pre-Frail Older Persons: Randomized Controlled Trial

BACKGROUND

We investigated the effect of multi-domain lifestyle (physical, nutritional, cognitive) interventions among frail and pre-frail community-living older persons on reducing depressive symptoms.

METHOD

Participants aged 65 and above were randomly allocated to 24 weeks duration interventions with nutritional supplementation (N=49), physical training (N=48), cognitive training (N=50), combination intervention (N=49) and usual care control (N=50). Depressive symptoms were assessed by the Geriatric Depression Scale (GDS-15) at baseline (0M), 3 month (3M), 6 month (6M) and 12 month (12M).

RESULTS

Mean GDS scores in the control group increased from 0.52 (0M) and 0.54 (3M) to 0.74 (6M), and 0.83 (12M). Compared to the control group, interventions showed significant differences (∆=change) at 6M for cognitive versus control (∆=-0.39, p=0.021, group*time interaction p=0.14); physical versus control (∆ =-0.37, p=0.026, group*time interaction p=0.13), and at 12M for nutrition versus control (∆ =-0.46, p=0.016, group*time interaction p=0.15). The effect for combination versus control was significant at 6M (∆ =-0.43, p=0.020) and 12M (∆ =-0.51, p=0.005, group*time interaction p=0.026). Estimated 12-month cumulative incidence of depressive symptoms (GDS≥2) relative to control were OR=0.38, p=0.037 (nutrition); OR=0.71, p=0.40 (cognitive); OR=0.39, p=0.042 (physical training) and OR=0.38, p=0.037 (combination). Changes in gait speed and energy level were significantly associated with changes in GDS scores over time.

CONCLUSION

Multi-domain interventions that reverse frailty among community-living older persons also reduce depressive symptomatology. Public health education and programmatic measures combining nutritional, physical and cognitive interventions for at-risk frail older people may likely benefit psychological wellbeing.

Association between Fish Intake and Depressive Symptoms among Community-living Older Chinese Adults in Singapore: A Cross-sectional Study

OBJECTIVE

Our aim of this study was to investigate the association between fish consumption and depressive symptoms in senior ethnic Chinese residents of Singapore.

DESIGN

A population-based cross-sectional study.

SETTING

The Singapore Longitudinal Aging Studies (SLAS).

PARTICIPANT

The study consisted of 2,034 participants from the Singapore Longitudinal Aging Studies (SLAS) project who were at least 55 years old.

MEASUREMENTS

The presence of depressive symptoms was compared between those who self-reported eating fish at least three times a week versus those who ate fish less often. A score of 5 or greater on the 15-item Geriatric Depression Scale (GDS-15) was the cutoff for being designated as having depressive symptoms.

RESULTS

Fish intake was associated with a lower prevalence of depressive symptoms ([odds ratio] OR = 0.60, 95% [confidence interval] CI 0.40-0.90; P = .015) after controlling for age, sex, marital status, housing, smoking, alcohol consumption, physical exercise, social and productive activities, self-rated health, hypertension, diabetes, heart failure or attack, stroke, fruit and vegetable intake, and Mini-Mental State Examination (MMSE) scores.

CONCLUSION

Our results suggest that eating fish at least three times a week is associated with a lower odds of having depressive symptoms among Chinese adults over 55 years old living in Singapore.

Prospective study on the effects of orthotic treatment for medial knee osteoarthritis in Chinese patients: clinical outcome and gait analysis

OBJECTIVE

To evaluate the effectiveness of various orthotic treatments for patients with isolated medial compartment osteoarthritis.

DESIGN

Prospective cohort study with sequential interventions.

SETTING

University-affiliated hospital, Hong Kong.

PATIENTS

From December 2010 to November 2011, 10 patients with medial knee osteoarthritis were referred by orthopaedic surgeons for orthotic treatment. All patients were sequentially treated with flat insole, lateral-wedged insole, lateral-wedged insole with subtalar strap, lateral-wedged insole with arch support, valgus knee brace, and valgus knee brace with lateral-wedged insole with arch support for 4 weeks with no treatment break. Three-dimensional gait analysis and questionnaires were completed after each orthotic treatment.

MAIN OUTCOME MEASURES

The Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analogue scale scores, and peak and mean knee adduction moments.

RESULTS

Compared with pretreatment, the lateral-wedged insole, lateral-wedged insole with arch support, and valgus knee brace groups demonstrated significant reductions in WOMAC pain score (19.1%, P=0.04; 18.2%, P=0.04; and 20.4%, P=0.02, respectively). The lateral-wedged insole with arch support group showed the greatest reduction in visual analogue scale score compared with pretreatment at 24.1% (P=0.004). Addition of a subtalar strap to lateral-wedged insoles (lateral-wedged insole with subtalar strap) did not produce significant benefit when compared with the lateral-wedged insole alone. The valgus knee brace with lateral-wedged insole with arch support group demonstrated an additive effect with a statistically significant reduction in WOMAC total score (-26.7%, P=0.01). Compliance with treatment for the isolated insole groups were all over 90%, but compliance for the valgus knee brace-associated groups was only around 50%. Gait analysis indicated statistically significant reductions in peak and mean knee adduction moments in all orthotic groups when compared with a flat insole.

CONCLUSIONS

These results support the use of orthotic treatment for early medial compartment knee osteoarthritis.

Prognostic factors associated with clear cell sarcoma in 14 Chinese patients

PURPOSE. To identify prognostic factors associated with clear cell sarcomas in 14 Chinese patients. METHODS. Medical records of 7 men and 7 women (mean age, 36 years) with histologically confirmed clear cell sarcoma of tendons and aponeuroses were reviewed. Patient demographics, tumour characteristics, and treatment modalities were retrieved. Prognostic factors associated with favourable 5-year survival were determined. RESULTS. The most affected sites were the thigh (n=5) and the foot (n=4); the mean time from symptom onset to diagnosis was 9.5 months. The tumour stage at diagnosis was IIA in 8 patients, IIB in 2, and III in 4. The mean tumour size was 4.5 cm in diameter. One patient was lost to follow-up. For the remaining 13 patients, the mean time to disease-related mortality was 2.5 years. Nine patients had distant metastases; the most common sites were lungs and pleura (n=7), followed by distant lymph nodes (n=4), bone (n=2), pericardium (n=2), and brain (n=1). All patients underwent surgical excision. Three women and one man (mean age, 27 years) attained 5-year disease-free survival. All had stage IIA tumours at diagnosis. Their mean tumour size was 1.75 cm in diameter, which was significantly smaller than that of all patients (4.5 cm). Tumour size of ≤ 2.5 cm in diameter (p=0.004) and stage IIA tumour at diagnosis (p=0.04) were significant prognostic factors for 5-year survival. CONCLUSION. Tumour size of ≤ 2.5 cm and early stage tumour are associated with 5-year disease-free survival. Early detection is crucial for the prognosis of clear cell sarcomas.

Tea consumption and physical function in older adults: a cross-sectional study

BACKGROUND

Tea consumption has been reported to be associated with lowered risk of cardiovascular disease, stroke and osteoporosis that cause functional disability, but its association with physical function has not been investigated directly.

OBJECTIVE

We examined the association between tea consumption and performance in gait and balance, instrumental and basic activities of daily living (IADL and BADL) in a cross-sectional study of community-living older persons.

METHOD

Baseline data of 2398 adults aged ≥ 55 years in the Singapore Longitudinal Ageing Studies who completed self-reported current tea consumption, Performance Oriented Mobility Assessment (POMA) of gait and balance, and self reports of BADL and IADL were analyzed.

RESULTS

In multivariate analyses controlling for age, gender, education, housing type, co-morbidities, hospitalization, arthritis and hip fracture, GDS depression score, MMSE cognitive score, body mass index, creatinine, serum albumin, haemoglobin, physical activities score and coffee consumption, tea consumption was positively associated with better balance (β=0.06, p<0.01), gait (β=0.01, p=0.02), IADL (β=0.03, p=0.01) and BADL (β=0.01, p=0.05). Strongly positive associations were observed for black/oolong tea in multivariate analyses, and for green tea consumption only in univariate analysis, whereas coffee consumption was not associated at all.

CONCLUSIONS

Tea consumption was associated with better physical functional performances in community-living older adults.

Asymptomatic grade-2 central chondrosarcoma of the distal femur with non-aggressive radiological features

This paper discusses the case of a 57-year-old man with an incidental finding of a radiologically non-aggressive chondroid lesion and concomitant osteonecrosis in the left distal femur. The final resected specimen showed a grade-2 chondrosarcoma. This case illustrates that long-term follow-up is necessary for non-aggressive chondroid lesions. If surgical management is considered, resection with an adequate margin is superior to intralesional curettage.

A sarcoma of 23 years' duration: symptom duration is not a reliable parameter to exclude malignancy

This report describes a 31-year-old woman with a 23-year history of a right buttock mass that was otherwise asymptomatic, but was proven to be a low-grade fibromyxoid sarcoma (a fully malignant soft tissue tumour with a potential for distant metastasis). This case illustrates that a long-standing tumour does not necessarily imply a benign pathology. A vigilant approach should be taken for any tumours that are of significant size (larger than 5 cm).

Serum albumin and hemoglobin are associated with physical function in community-living older persons in Singapore

OBJECTIVES

Albumin and hemoglobin are viewed as markers of nutritional and inflammatory status. This study examined the associations of serum albumin and hemoglobin with physical function in community-living older adults.

DESIGN

Population-based cross-sectional and longitudinal study.

SETTING

The Singapore Longitudinal Aging Studies (SLAS), a community-based study in urban Singapore.

PARTICIPANTS

2762 older adults aged 55 and above assessed at baseline, and 1829 at follow up 1-2 years later.

MEASUREMENTS

Serum albumin and hemoglobin, Performance Oriented Mobility Assessment (POMA), knee extension strength at baseline, and Instrumental Activities of Daily Living (IADL) at baseline and follow up.

RESULTS

In cross-sectional multivariate analyses that adjusted for haemoglobin and other confounders, albumin showed a significant linear association (p<0.001) with POMA balance score (b=0.06, SE=0.02) and knee extension strength (b=0.70, SE=0.10). Independently of albumin, hemoglobin also showed a significant linear association with POMA balance score (b=0.09, SE=0.04). In longitudinal analyses, albumin was significantly associated with IADL decline (IADL total score drop>=1 during follow-up), OR= 0.92 (0.87 - 0.97), p=<0.01.

CONCLUSION

The findings suggest that low levels of albumin and hemoglobin are potentially useful risk markers of physical functional decline in older adults. Further research should investigate whether improvements in the levels of albumin and hemoglobin alter the level of functional disability and risk of functional decline.

Arthroscopic treatment of popliteal cyst

OBJECTIVE

To review the results of arthroscopic treatment of popliteal cysts in our centre and analyse outcomes including complications.

DESIGN

Retrospective study.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

From July 2007 to July 2009, 11 patients with symptomatic popliteal cysts were treated arthroscopically. All of them had preoperative magnetic resonance imaging to confirm the diagnosis, identify the valvular opening, and the associated intra-articular pathology. We used the Rauschning and Lindgren criteria for evaluation.

RESULTS

Intra-articular pathology like cartilage degeneration and meniscus tear were commonly associated with popliteal cysts. All patients achieved symptomatic improvement after treatment and the recurrence rate was low. No major complications were encountered. We failed to identify (and correct) any valvular opening in one patient.

CONCLUSION

From our experience, we conclude that arthroscopic treatment of popliteal cyst with correction of the valvular opening and treatment of associated intra-articular pathology is effective and safe.

Osteomalacia: a case series of patients with atypical clinical orthopaedic presentations

Osteomalacia is uncommon in an affluent subtropical city like Hong Kong, where sunlight exposure is adequate and nutritional support is good. We present three patients who had osteomalacia with different presentations. A 74-year-old male with oncogenic osteomalacia presented with multiple bone pain. His biochemical markers returned to normal 4 days postoperatively after resection of a second toe giant cell tumour of tendon sheath. A 62-year-old woman with a history of liver problem and proximal muscle weakness was admitted with atraumatic fracture of the left distal humerus due to osteomalacia. An 81-year-old vegetarian woman with inadequate sun exposure complained of multiple bone pains. Subsequent investigation revealed dietary- and sunlight-deficient osteomalacia with multiple bony abnormalities including marked femur bowing.

The influence of childhood atopic dermatitis on health of mothers, and its impact on Asian families

This study examines maternal perceptions of paediatric atopic dermatitis (AD) on family and determines risk factors including severity of AD, maternal physical and mental health (MH), quality of life of patients and sociodemographics which predict a negative family impact. A cross-sectional assessment using the Dermatitis Family Impact Questionnaire Scale to assess the impact of AD on family, Infant's Dermatitis Quality of Life Index (<5-yrs old) or Children's Dermatitis Life Quality Index (5-17 yrs old) was used to measure health-related quality of life (HRQOL) of paediatric patients with AD. A 12-item Short-Form Health Survey (SF-12) was used to assess physical and MH of their mothers. Risk factors of adverse family impact were assessed using multiple regression analysis. One hundred and four patients with AD and their mothers were studied. Their mean ages (+/-s.d.) were respectively 6.4 +/- 4.3 and 37.2 +/- 6.6 yrs. In multiple regression analysis, Severity Scoring of Atopic Dermatitis (SCORAD) appeared to be associated with negative family impact and the association remained significant after adjustment for bio-psycho-social factors and HRQOL of patients. The association remained insignificant after adjustment for physical and MH of the mothers. Our results show that the severity of paediatric AD leads to negative family impact through reduction of physical and MH of the mothers, and is independent of patients' HRQOL and sociodemographics. The current approach for managing paediatric AD in Asian society could include early multidisciplinary intervention, aiming at enhancing physical and MH of mothers while minimizing negative impact on family and social isolation. Further research will be welcomed as the results of this study mainly applied to Asian society which could be different to populations from other geographic areas.

Inter- and intra-observer errors in identifying the transepicondylar axis and Whiteside's line

PURPOSE

To assess inter- and intra-observer errors in identifying the transepicondylar axis and Whiteside's line in a cadaveric model mimicking total knee arthroplasty.

METHODS

Four cadaveric knees with intact soft tissues were used. The knees were exposed anteriorly using the Insall approach, with the patella everted laterally. Three observers (2 surgeons and one trainee) took turns to identify the anatomic landmarks of the transepicondylar axis and Whiteside's line. Each observer repeated the process 20 times. Each identification was photographed and referenced with the true values obtained from the knees after they were stripped of all soft tissue. Inter- and intra-observer errors in the anatomic landmarks were compared.

RESULTS

Inter-observer error was significant with both the transepicondylar axis and Whiteside's line (p<0.001, one-way ANOVA). The intra-observer variation was greater for Whiteside's line than the transepicondylar axis (standard deviation, 4.2 vs 2.5 degrees). The maximum potential errors in the transepicondylar axis and Whiteside's line were 13 degrees and 24 degrees, respectively.

CONCLUSION

The accuracy of rotational alignment of the transepicondylar axis and Whiteside's line were operator-dependent, and their intra-operative reproducibility was low.

Hip pain many years after fusion: a report of two cases

Arthrodesis of the hip has been employed since the late 19th century. Late complications can arise decades after fusion in patients who were previously asymptomatic. We describe two patients who developed pain in the hip many years after a successful fusion. There was no infection or loosening of the implants. After careful investigation, including oblique radiographs and diagnostic injections of local anaesthetic, the pain was found to be caused by protrusion of the implant. Subsequent removal of the device resulted in complete resolution of the symptoms.

Differential item functioning of the Geriatric Depression Scale in an Asian population

BACKGROUND

The Geriatric Depression Scale (GDS) is widely used for screening and assessment of major depressive disorder (MDD). Screening scales are often culture-specific and should be evaluated for item response bias (synonymously differential item functioning, DIF) before use in clinical practice and research in a different population. In this study, we examined DIF associated with age, gender, ethnicity and chronic illness in a heterogeneous Asian population in Singapore.

METHODS

The GDS-15 and Structured Clinical Interview for DSM-IV diagnosis of MDD were independently administered by interviewers on 4253 non-institutionalized community living elderly subjects aged 60 years and above who were users of social service agencies. Multiple Indicator Multiple Cause latent variable modelling was used to identify DIF.

RESULTS

We found evidence of significant DIF associated with age, gender, ethnicity and chronic illness for 8 items: dropped many activities and interests, afraid something bad is going to happen, prefer staying home to going out, more problems with memory than most, think it is (not) wonderful to be alive, feel pretty worthless, feel (not) full of energy, feel that situation is hopeless.

LIMITATIONS

The smaller number of minority Indian and Malay subjects and the self-report of chronic medical illnesses.

CONCLUSIONS

In a heterogeneous mix of respondents in Singapore, eight items of the GDS-15 showed DIF for age, gender, ethnicity and chronic illness. The awareness and identification of DIF in the GDS-15 provides a rational basis for its use in diverse population groups and guiding the derivation of abbreviated scales.

The association between maternal depression and frequent non-routine visits to the infant's doctor--a cohort study

BACKGROUND

Perinatal depression is common, but women typically do not seek help for it. We studied its association with frequent non-routine physician visits, which may be a form of help-seeking behaviour.

METHODS

A prospective cohort study of women in their 34th to 38th week of pregnancy at the outpatient obstetrics clinic at a Singapore tertiary hospital was done. Screening was done using the Edinburgh Postnatal Depression Scale and diagnosis of major or minor depressive disorder was made using the SCID-IV. At 6 to 12 months' post-partum, women were screened and interviewed again for depression and asked to report the frequencies with which they had brought their infants to the doctor on non-routine visits in the preceding 6 weeks. Four hundred and seventy-one of the 559 patients recruited before delivery were re-interviewed.

RESULTS

After adjusting for confounders, women who had brought their infants for three or more non-routine visits to the infant's doctor had a significantly higher prevalence of depression (32.6%) than those with fewer visits (13.6%) (OR 2.87, 95% CI 1.41 to 5.85, p=0.004). The relative risk reduction for women who did not bring their infants for frequent non-routine visits was 0.583 (95% CI 0.44 to 0.73, p=0.002). They were also more likely to have poorer perceived emotional support from their families.

LIMITATIONS

These included use of self-reported doctor visits, and relatively high educational levels of the participants.

CONCLUSIONS

Doctors should have a high index of suspicion for enquiring about depression and emotional support in mothers who bring their infants for frequent non-routine visits.

Subthreshold depression and cognitive impairment but not demented in stroke patients during their rehabilitation

BACKGROUND

Subthreshold depression (sD) and cognitive impairment but not demented (CIND) in stroke patients are associated with poorer rehabilitative outcomes. Their diagnosis can easily be operationalized using validated scales.

AIM

The aim of the study was to ascertain the prevalence of depressive symptoms and cognitive impairment in stroke patients during three crucial stages of the rehabilitative process, viz. upon admission, upon planned discharges from rehabilitation hospitals and at 6 months post-stroke, using validated scales like the Geriatric Depression Scale and Abbreviated Mental Test (recommended by the British Geriatric Society). Their baseline risk factors were also ascertained.

RESULTS

On admission, the prevalence of depressive symptoms and cognitive impairment was 60% and 54% respectively. The prevalence upon planned discharges and 6 months post-stroke, respectively, of depressive symptoms was 38% and 34% and that of impaired cognition was 33% and 40%. Baseline independent correlates at 6 months post-stroke depressive symptoms were: recurrent stroke (OR 3.34); on admission cognitive impairment (OR 4.78) and ADL dependence (OR 5.28). And that of cognitive impairment were: increasing age (OR 8.07); post-stroke dysphagia (OR 4.58); on admission cognitive impairment (OR 23.95) and on admission depressive symptoms (OR 3.50).

CONCLUSIONS

Continuous screening and appropriate intervention, especially at baseline, would significantly decrease the burden posed by stroke patients with such psychological impairments in the community.

Emotional and behavioural problems in Singaporean children based on parent, teacher and child reports

INTRODUCTION

This study aims to determine the prevalence of emotional and behavioural problems in a community sample of Singaporean children aged 6-12 years, and its agreement according to parent, teacher and child reports.

METHODS

The Child Behaviour Checklist (CBCL), Teacher Rating Form (TRF) and child report questionnaires for depression and anxiety were administered to a community sample of primary school children. 60 percent of the children sampled (n = 2,139) agreed to participate. Parents of a sub-sample of 203 children underwent a structured clinical interview.

RESULTS

Higher prevalence of emotional and behavioural problems was identified by CBCL (12.5 percent) than by TRF (2.5 percent). According to parent reports, higher rates of internalising problems (12.2 percent) compared to externalising problems (4.9 percent), were found. Parent-teacher agreement was higher for externalising problems than for internalising problems. Correlations between child-reported depression and anxiety, and parent and teacher reports were low to moderate, but were better for parent reports than for teacher reports.

CONCLUSION

The prevalence rates of emotional and behavioural problems in Singaporean children based on CBCL ratings are comparable to those in the West, but the low response rate and exclusion of children with special needs limit the generalisability of our findings. Singaporean children have higher rates of internalising problems compared to externalising problems, while Western children have higher rates of externalising problems compared to internalising problems.

Antibiotic-loaded cement articulating spacer for 2-stage reimplantation in infected total knee arthroplasty: a simple and economic method

We presented a simple and economic method of preparing articulating antibiotic-loaded cement spacers for treatment of infection after total knee arthroplasty. From 1996 to 2004, 28 infected total knee arthroplasties were treated with 2-stage reimplantation. Static spacers were used in 7 knees, and articulating spacers were used in 21 knees. A minimum of 2 years' follow-up after final treatment was evaluated. In the static group, 1 (14%) knee had recurrence of infection. In the articulating group, 2 (9%) knees had recurrence of infection with the original organism. Patients receiving articulating spacer had better range of motion, better knee score, and less bone loss than patients with static spacer.

Nutrition screening among community-dwelling older adults in Singapore

INTRODUCTION

This study aimed to describe responses to the DETERMINE checklist and the nutritional risk level of community-dwelling older Chinese in Singapore, aged 55 years and older.

METHODS

Data was collected from a community health screening project for elderly residents in Singapore. All residents aged 55 years and older in the survey area were identified in door-to-door census surveys and were invited to participate. Participants completed a questionnaire interview conducted by research nurses. The survey also included questions which were potential predictors of nutritional risk: sociodemographic factors (age, gender, education, housing type, marital status, and living arrangement) and health-related factors (self-rated health, number of medical comorbidities, hospitalisations in the past year, functional disabilities and physical health status).

RESULTS

Data for analysis was provided by 2,605 Chinese subjects aged between 55 and 98 years (mean/standard deviation 66.0/7.7). The overall prevalence of nutritional risk (according to a DETERMINE score of 3 or greater) was 30.1 percent. 1,822 (69.9 percent) subjects had no nutritional risk (scores of 2 or lower), 664 (25.5 percent) had moderate nutritional risk and 119 (4.6 percent) had high nutritional risk. The most common contributions to nutritional risks were: changing food intake due to illness (40.3 percent), taking three or more different medications daily (25.0 percent), eating alone (14.5 percent) and consuming insufficient amount of fruits, vegetables or milk products on a daily basis (9.0 percent). Respondents at nutritional risk were more likely to have three or more comorbid medical conditions, were hospitalised in the past year, were functionally dependent on one or more instrumental or basic activities of daily living, were reported to have poor or fair self-rated health, and were in the lowest tertile scores for SF-12 quality of life and depression.

CONCLUSION

Self-rated general health, lowered quality of life, functional disability and depression have meaningful non-circular associations with the checklist. These support the validity of the DETERMINE checklist in predicting the risk of adverse health conditions and events.

Effects of a self-management arthritis programme with an added exercise component for osteoarthritic knee: randomized controlled trial

AIM

This paper is a report of a study to assess the effect of an adapted arthritis self-management programme with an added focus on exercise practice among osteoarthritic knee sufferers.

BACKGROUND

Osteoarthritis of the knee is a major source of loss of function in older people. Previous studies have found self-management programmes to be effective in increasing arthritis self-efficacy and in mastery of self-management practice.

METHOD

A randomized control trial was carried out from December 2002 to May 2003 and 120 participants (65.9%, including 67 in intervention group and 53 in control group) completed the 16-week postintervention assessments. Outcome measures included arthritis self-efficacy, use of self-management techniques, pain intensity and daily activity.

FINDINGS

At 16 weeks, there was a 'statistically' significant improvement in the arthritis self-efficacy level (P <or= 0.001), in most of the self-management skills, i.e. use of cold and hot compresses, in two of three joint protective practices (P <or= 0.001; P = 0.01), an increase in the duration of light exercise practice (P <or= 0.001), reduction of current arthritis pain (P <or= 0.001) and in the ability to perform daily activities (P <or= 0.001) among the intervention group but not for the control group (P-range from 0.04 to 0.95). One joint protective practice showed a statistically significant increase in both groups (P <or= 0.001).

CONCLUSION

Our findings add to evidence showing short-term beneficial effects of self-efficacy theory in education programmes. Self-efficacy theory has great potential for empowering sufferers of chronic conditions to live with their illness.

Sagittal pelvic mal-rotation and positioning of the acetabular component in total hip arthroplasty: Three-dimensional computer model analysis

Mal-rotation of pelvis on the sagittal plane, which is common in patients with fixed spinal kyhposis, for example, ankylosing spondylitis, can cause error in cup positioning when hip arthroplasty is performed. The present study was performed to quantify the effects of sagittal pelvic mal-rotation on the final cup position and to evaluate different methods of cup positioning to compensate for the mal-rotation. Three-dimensional reconstruction of computer tomograms of 15 sets of full pelvi was performed. Two methods of cup insertion were simulated and compared: a method mimicking genuine surgery (anatomical positioning) and one that compensates for the sagittal pelvic mal-rotation (functional positioning). Sagittal pelvic mal-rotation of more than 20 degrees , if ignored, resulted in a cup with an anterversion of more than 30 degrees and an inclination of more than 55 degrees. Half of the cup surface was not in contact with host bone when the cup position was maintained at 20 degrees anteversion and 45 degrees inclination in a patient with 50 degrees sagittal pelvic mal-rotation. The usual method of cup positioning may need to be modified in patients with sagittal pelvic mal-rotation in order to maintain the desired cup position. For each 10 degrees of sagittal pelvic mal-rotation beyond 20 degrees of mal-rotation, the cup needs to be put in such that it is 5 degrees less inclined and anteverted.

Prevalence of childhood asthma and control in children assessed in a pilot school-based intervention programme in Singapore

AIM

Because of a high childhood asthma burden in Singapore, assessment of disease control status is essential for formulating school-based strategy of childhood asthma control. The aim of the present study is to assess childhood asthma prevalence and control in Singapore and the socio-demographic and help-seeking correlates.

METHODS

School-based survey using parental self-administered questionnaire, conducted from February to April 2004. Four mixed-gender primary schools selected from geographically distinct zones of Singapore. All primary one (modal age - 6.5 years) and six (modal age - 11.9 years) students from selected schools were invited to participate. Questionnaire respondents were the students' parents or guardians. The response rate was 75.2% (2123/2825).

RESULTS

Prevalence of current asthma was 8.9% (190/2123). Among them, 26.3% (46/175) were assessed to have inadequate control. Asthma was more prevalent, and less adequately controlled in children from lower socio-economic backgrounds (lower-end housing type). Children with poorly controlled asthma were more likely to be treated by emergency room physicians and hospital specialists, and to be on preventer medications.

CONCLUSIONS

In Singapore, poor asthma control is found in a sizeable proportion of school children with asthma, is identifiable for high-risk groups of children from lower socio-economic backgrounds and having asthma-related attendance at the emergency rooms.

Determinants of length of stay during post-stroke rehabilitation in community hospitals

INTRODUCTION

Length of stay (LOS) in hospitals is the largest contributor of direct stroke care cost. Rehabilitation accounts for 16 percent of healthcare cost in the six-month post-stroke period. It is important to determine factors extending LOS in rehabilitation hospitals to identify focus areas of cost-control strategies. The aim of the study was to ascertain the predictors of LOS of post-stroke patients admitted into two community hospitals offering rehabilitation.

METHODS

An observational cohort study was conducted on 200 stroke patients admitted from acute hospitals into two community hospitals. Data collected included baseline sociodemographical variables, and the National Institute of Health Stroke Scale, Abbreviated Mental Test, Geriatric Depression Scale and Barthel Index were used to assess neurological impairment, cognitive impairment, depressive symptoms and functional disability, respectively. Medical complications (defined as new or exacerbated medical problems that generated additional physician evaluation, a change in medication or additional medical intervention), after patients were admitted to the community hospitals until discharged, were recorded. The outcome variables measured were length and cost of stay.

RESULTS

The mean LOS in our study was 34.4 (standard deviation [SD] 18.4) days, and the mean cost of hospital stay was S$2,410.83 (SD S$2,167.26). Length and cost of hospital stay were significantly correlated (r equals 0.52; p-value is less than 0.01). On multiple linear regression analysis, the significant variables positively associated with LOS were medical complications and functional dependence on admission. Significant variables negatively associated with LOS were unplanned discharge and recurrent strokes.

CONCLUSION

Medical complication is a key reversible determinant of increased LOS of post-stroke patients receiving rehabilitation in community hospitals. Strategies for prevention, early detection and treatment of medical complications during stroke rehabilitation are discussed.

Coronal bowing of the femur and tibia in Chinese: its incidence and effects on total knee arthroplasty planning

PURPOSES

To study the incidence of femoral or tibial bowing in the coronal plane in a Chinese population, and how it affects the accuracy of bone cuts for total knee replacement when an intramedullary alignment system is used.

METHODS

Standing radiographs of the entire lower limb of each patient with end-stage primary osteoarthritis of the knee were analysed. All radiographs were digitised and the extent of bowing in the coronal plane measured. A bowing was marked if an angulation was more than 2 degrees. The projected error of cutting was then calculated.

RESULTS

Of 93 lower limbs, 58 (62%) of the femurs had marked bowing in the coronal plane; 41 (44%) had a mean lateral bowing of 5.3 (standard deviation [SD], 3.2) degrees; 17 (18%) had a mean medial bowing of 4.4 (SD, 1.9) degrees. Marked tibial bowing in the coronal plane was less common (30 tibias, 32%). If a cutting error of more than 2 degrees was considered unacceptable, significantly more unacceptable cuts would ensue in the groups with marked bowing (p=0.003 for femurs and p<0.001 for tibia, respectively).

CONCLUSION

The incidence of femoral or tibial bowing in the coronal plane was high in a Chinese population with end-stage osteoarthritis of the knee. This phenomenon may increase bone cut errors in total knee replacement if an intramedullary alignment system is used and the extent of bowing is not recognised.

The accuracy of extramedullary guides for tibial component placement in total knee arthroplasty

Anteroposterior radiographs that included the whole tibia were taken before and after 75 total knee arthroplasties in 48 patients. The same tibial extra-medullary alignment guide system was used in every knee. The average tibial component alignment was 0.4 (SD 2.5, range -4.9 to 6.4) degrees of valgus post-operatively. 59 tibial components (78.7%) had a tibial cut within 3 degrees from being perpendicular to the mechanical axis, ten were too valgus (13.3%) and six were too varus (8%). The chance of the tibial components becoming too varus was higher if there was lateral tibial bowing, compared with no tibial bowing (p=0.048). A smaller lateral width of the leg increased the chance of the tibial components becoming too valgus (p=0.047).

Impact of an Arthritis Self-Management Programme with an added exercise component for osteoarthritic knee sufferers on improving pain, functional outcomes, and use of health care services: An experimental study

OBJECTIVE

The aim of this study was to assess the effect of an adopted Arthritis Self-Management Programme (ASMP) with an added exercise component among osteoarthritic knee sufferers in Hong Kong.

METHODS

An experimental study with 88 participants assigned to an intervention group and 94 participants to a control group. One hundred and forty-nine participants (81.9%) completed the 1 week and 120 participants (65.6%) the 16 week post-intervention assessments. Participants in the intervention group received a 6-week ASMP with an added exercise component. Outcome measures included arthritic pain and fatigue rating, practice of light exercise routines, functional status, and number of unplanned arthritis-related medical consultations. To assess the programme's effect on outcome measures, the between-groups and within-group mean changes were compared using Mann-Whitney U-test and Friedman test.

RESULTS

At 16 weeks, there were significant mean changes between groups in four outcome measures: reduction in arthritis pain (p=0.0001) and fatigue (p=0.008), and increased duration of weekly light exercise practice (p=0.0001) and knee flexion (p=0.004). The ability to perform daily activities and the number of unplanned arthritis-related medical consultations show statistically significant improvements between three time-points within the intervention group only (p=0.0001 and p=0.005, respectively), but not between-groups (p=0.14 and p=0.86, respectively). Both groups apparently had no changes in muscle strength.

CONCLUSION

Our findings suggest that the intervention had a positive effect in reducing pain, fatigue, knee range of motion, the practice of exercise routines, the number of medical consultations and in improving functional status and over a 16-week period.

PRACTICE IMPLICATIONS

The self-management programme we applied took into account the local context and the ethnicity of the group. This process is worth further exploration and testing in different groups.

Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients

BACKGROUND

Length of hospital stay (LOHS) is the largest determinant of direct cost for stroke care. Institutional discharges (acute care and nursing homes) from rehabilitation settings add to the direct cost. It is important to identify potentially preventable medical and non-medical reasons determining LOHS and institutional discharges to reduce the direct cost of stroke care.

AIM

The aim of the study was to ascertain the total direct cost, LOHS, frequency of institutional discharges and their determinants from rehabilitation settings.

METHODOLOGY

Observational study was conducted on 200 stroke patients in two rehabilitation settings. The patients were examined for various socio-demographic, neurological and clinical variables upon admission to the rehabilitation hospitals. Information on total direct cost and medical complications during hospitalization were also recorded. The outcome variables measured were total direct cost, LOHS and discharges to institutions (acute care and nursing home facility) and their determinants.

RESULTS

The mean and median LOHS in our study were 34 days (SD = 18) and 32 days respectively. LOHS and the cost of hospital stay were significantly correlated. The significant variables associated with LOHS on multiple linear regression analysis were: (i) severe functional impairment/functional dependence Barthel Index < or = 50, (ii) medical complications, (iii) first time stroke, (iv) unplanned discharges and (v) discharges to nursing homes. Of the stroke patients 19.5% had institutional discharges (22 to acute care and 17 to nursing homes). On multivariate analysis the significant predictors of discharges to institutions from rehabilitation hospitals were medical complications (OR = 4.37; 95% CI 1.01-12.53) and severe functional impairment/functional dependence. (OR = 5.90, 95% CI 2.32-14.98).

CONCLUSION

Length of hospital stay and discharges to institutions from rehabilitation settings are significantly determined by medical complications. Importance of adhering to clinical pathway/protocol for stroke care is further discussed.

Assessment of the proximal femoral morphology using plain radiograph-can it predict the bone quality?

We evaluated the relationship between the radiological indices that assessed the proximal femoral morphology and the degree of osteoporosis in 45 Chinese cadaveric femora. Canal-calcar ratio, canal flare index, morphological cortical index, and canal bone ratio were determined in the plain anteroposterior radiographs. Canal bone ratio is the ratio between the endosteal and outer diameters of the proximal femur at 10 cm below the lesser trochanter. Bone mineral density of the proximal femora was measured with dual-energy x-ray absorptiometry, and T score that depicted the degree of osteoporosis was determined. Canal bone ratio showed a strong correlation with the T score (r = -0.71, P < .001) and the best overall performance in diagnosing osteoporosis with receiver operating characteristic curve analysis. The proximal femur was likely to be osteoporotic if the canal bone ratio was 0.49 or higher.

Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore

BACKGROUND

To investigate the prevalence, socio-cultural and psychosocial risk factors for perinatal depression in Singaporean women.

METHOD

A prospective cohort of 559 women was interviewed antenatally and at six weeks' postpartum at a tertiary hospital. Women were interviewed for diagnosis of depression using a two-stage design, with a screening questionnaire and diagnostic interview.

RESULTS

Postnatally, a negative confinement experience was associated with depression. Other independent factors included poor emotional support, a past history of depression, unplanned pregnancy and perceived potential conflicts with relatives over childcare antenatally and dissatisfaction, poor instrumental support postnatally. The prevalence of depression antenatally and postnatally was 12.2% and 6.8%, respectively.

LIMITATIONS

Measures of satisfaction with social support were based on self-report; there were high dropout rates at six weeks' postpartum; and other modulating social factors such as pre-existing interpersonal conflicts were not studied.

CONCLUSIONS

Perinatal depression in Singaporean women is common. Contrary to expectations, a negative 'confinement' experience is a significant risk factor for postnatal depression, and is not universally welcomed by women. Depression is modulated by dissimilar sets of psychosocial factors antenatally and postnatally.

Residual posterior femoral condyle osteophyte affects the flexion range after total knee replacement

We followed up 92 patients with total knee replacement and a pre-operative knee flexion of at least 90 degrees . The patients were followed up regularly at 3 months, 6 months and 1 year. The outcome measured was the amount of maximum passive knee flexion at the end of 1 year after replacement. The potential factors affecting the final flexion range were investigated. After regression analysis, apart from pre-operative knee flexion (p<0.001), the most significant independent surgical factors that predict the amount of post-operative flexion were presence of residual posterior femoral condyle osteophyte (p=0.046) and overstuffing the patella by more than 2 mm during resurfacing of the patella (p<0.001).

Intraobserver errors in obtaining visually selected anatomic landmarks during registration process in nonimage-based navigation-assisted total knee arthroplasty: a cadaveric experiment

This study investigated the intraobserver errors in obtaining visually selected anatomic landmarks that were used in registration process in a nonimage-based computer-assisted total knee replacement (TKR) system. The landmarks studied were center of distal femur, medial and lateral femoral epicondyle, center of proximal tibia, medial malleolus, and lateral malleolus. Repeated registration in the above sequence was done for 100 times by a single surgeon. The maximum combined errors in the mechanical axis of the lower limb were only 1.32 degrees (varus/valgus) in the coronal plane and 4.17 degrees (flexion/extension) in the sagittal plane. The maximum error in transepicondylar axis was 8.2 degrees. The errors using the visual selection of anatomic landmarks for the registration technique of bony landmarks in nonimage-based navigated TKR did not introduce significant error in the mechanical axis of the lower limb in the coronal plane. However, the error in the transepicondylar axis was significant in the "worst-case scenario."

Sagittal bowing of the distal femur in Chinese patients who require total knee arthroplasty

PURPOSES

The importance of the femoral sagittal bowing on total knee arthroplasty is under-recognized. The bowing could lead to potential errors in positioning of the femoral component if it is ignored. We aimed to document the femoral sagittal bowing at different segments of the Chinese femur and to discuss the implications of this sagittal bowing on total knee arthroplasty.

METHODS

One hundred lateral radiographs of the entire lower limbs of 85 Chinese patients admitted for total knee arthroplasty were digitized. The radii of curvature of the intramedullary canal of the proximal, middle and distal one-third of the femora were measured.

RESULTS

The average age of the patients was 67.3 years. The radii of curvature of the proximal, middle and distal one-third of the femora were 1081.6, 926.2 and 715.1 mm, respectively. The distal one-third of the femora was significantly more bowed than the other parts of the femora (p<0.001). The distal femoral bowing was more profound in rheumatoid patients and in those with a short femur.

CONCLUSIONS

The lateral contour of the Chinese femur is like a hockey stick. This exaggerated sagittal bowing in the Chinese femur can affect the final sagittal position of the femoral component and has implications for the choice of implant design. In revision setting, a long and straight press-fit stem might either endanger the anterior cortex or deflect the femoral component to an abnormally extended position.

Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs

OBJECTIVES

The purpose of our study was to determine the prevalence of complementary and alternative medicine (CAM) use and its clinical and psycho-social correlates, including perceived satisfaction with care and cultural health beliefs.

METHODS

A cross-sectional study was carried out in public sector primary care clinics in Singapore using a random sample of 488 adult patients with chronic diseases. The measures were CAM use, satisfaction with care and traditional health beliefs.

RESULTS

The 1 year prevalence of CAM use was 22.7%. In univariate analyses, factors associated with CAM use included: middle age, arthritis, musculoskeletal disorders and stroke, multiple conditions, poor perceived health, family use of CAM, recommendation by close social contacts, strong adherence to traditional health beliefs and perceived satisfaction with care. Patients who were dissatisfied/very dissatisfied with the cost of treatment [odds ratio (OR) = 1.79, 95% confidence interval (CI) 1.15-2.82] and waiting time (OR = 1.96, 95% CI 1.20-3.19) were more likely to use CAM. Patients who were very satisfied with the benefit from treatment were much less likely to use CAM (OR = 0.49, 95% CI 0.29-0.83). Satisfaction with doctor-patient interaction was not associated with CAM use. Being 'very satisfied' on overall care satisfaction was significantly associated with much less CAM use (OR = 0.30, 95% CI 0.14-0.68). Multivariate analyses confirmed that CAM use was significantly and independently predicted by the 'chronic disease triad' (arthritis/musculoskeletal disorders/stroke) (OR = 4.08, 95% CI 2.45-6.83), overall satisfaction with care (OR = 0.32, 95% CI 0.14-0.74) and strong adherence to traditional health beliefs (OR = 1.88, 95% CI 1.07-3.31).

CONCLUSION

CAM use in Asian patients is prevalent and associated with the 'chronic disease triad' (of arthritis, musculoskeletal disorders and stroke), satisfaction with care and cultural beliefs. In particular, CAM use is not associated with the quality of doctor-patient interaction.

Extensively coated femoral components in revision hip arthroplasty: follow-up study of 23 patients

PURPOSE

To review the outcome of revision hip arthroplasty using extensively coated femoral components.

METHODS

We reviewed the results of revision involving 24 extensively porous-coated cementless femoral components in 23 patients, whose mean age was 52.4 years (range, 28.0-79.0 years). Most revisions were performed for aseptic loosening of the previously cemented femoral component. All patients were followed up for a minimum period of 24.0 months (mean, 61.1 months).

RESULTS

Of the 24 femoral stems, 20 showed bone ingrowth, 3 showed stable fibrous ingrowth, and one was unstable because of deep infection. Intra-operative anterior femoral diaphyseal perforation occurred in 2 hips during the insertion of straight femoral components of 200 mm. Postoperative radiographs displayed marked cortical erosion in 3 other hips and cortical perforation in one.

CONCLUSION

The results from the use of extensively coated femoral components were promising. Nevertheless, anterior cortical perforations were also common, which may be related to more bowing of the femora among the Chinese patients. Caution must be exercised when inserting a long, straight, extensively coated femoral component.