CLINICAL RESEARCH UNIT
Clinical research can find answers to the things that are unknown. It can change the way healthcare professionals think and work. Recognising its importance, we continuously engage in clinical research to address questions or issues that can improve the health and the quality of life for our patients. It is an exciting journey for us, and this book is a reflection of some of the research work that we have published. We invite you to flip through its pages and go inside the human body with us as we show you some of the knowledge we have discovered through research. If you have any query regarding our services, please call 6357 8390 or 6357 8359 during office hours (Mondays to Fridays, 8.30am - 5.30pm).
Oral Decontamination for Ventilator-associated Pneumonia Prevention
HEART, LUNG & BLOOD
Australian Critical Care 2009; 22:3-4
Our Study Ventilator-associated pneumonia (VAP), the most frequent hospital-acquired infection among intensive care unit (ICU) patients who require mechanical ventilation, can prolong the need for mechanical ventilation and hospitalisation, increase health care costs and even cause premature death.
Chan Ee Yuee Nursing Service, Tan Tock Seng Hospital, Singapore
Currently there are two ways of reducing the risk of VAP: • Selective Decontamination of the Digestive tract (SDD), involving non-absorbable antibiotics applied topically to the oropharynx and gut and • Oral decontamination, involving only the topical oral application of either antibiotics or antiseptics. We wanted to determine which of these two is the best prevention strategy. Our Method We systematically reviewed published research papers on reducing its VAP. Our Findings Our findings showed that SDD can significantly reduce the risk of VAP. While we observed that oral antiseptic decontamination alone can significantly reduce the incidence of VAP, clinical trial would be required to address the optimal treatment regimen and the concern of the emergence of microbial resistance with prolonged and widespread usage.
CLINICAL RESEARCH UNIT
A Multidimensional Grading System (BODE Index) as Predictor of Hospitalisation for COPD Chest, 2005;128:3810-6
Ong Kian-Chung, Arul Earnest and Lu Suat-Jin Department of Respiratory Medicine, Tan Tock Seng Hospital, Singapore
Our Study Chronic Obstructive Pulmonary Disease (COPD) is a slowly progressive disorder characterised by irreversible airflow obstruction known to damage small airways deep in the lungs, making it difficult for air to move in. One of the commonest causes of COPD is smoking, with symptoms including breathlessness, cough and sputum, and may require the patient to be admitted to the hospital. Currently, doctors use a simple test, called the Forced Expiratory Volume (FEV) to determine how rapidly a person can expel air from the lungs. While a good indicator, the FEV does not tell the doctor how a COPD patient will fare in the future; such as the likelihood that he or she will need hospitalisation and the risk of dying from the condition. In this study, a new score called Body mass index, airflow Obstruction, Dyspnea and Exercise capacity or better known as BODE was tested to see if it can better predict patient outcomes. Our Method We evaluated the (A) body-mass index (B), the degree of airflow obstruction (O) and dyspnea (D), and exercise capacity (E) of COPD patients with a wide range of severity over a four week period to obtain each patient’s BODE Index. A total of 127 COPD patients were reviewed in this study with a majority with moderate to very sever condition. Of which, 60 patients (47%) required to be admitted once for COPD. Patients with higher BODE scores were found to have higher rates of hospitalisation. Patients with BODE scores of 5 or 6 were approximately nine times more likely to die during follow-up compared to those with BODE scores of 0 to 2. In comparison, none of the FEV categories were significantly associated with death rate.
CLINICAL RESEARCH UNIT
Our Findings This research suggests that the BODE scoring system may help in predicting the chances of hospitalisation and survival of COPD patients which can be useful in determining health care resources and treatment paths for COPD patients.
Do Young Adults With Uncomplicated Dengue Fever Need Hospitalisation? A Retrospective Analysis of Clinical and Laboratory Features
INFECTIOUS DISEASES
Singapore Medical Journal 2007; 49:476-9
Our Method Medical case-notes of 120 young adults with acute dengue were reviewed retrospectively to ascertain if their admission corresponded to the newly established criteria.
David Lye, Monica Chan, Vernon Lee, Leo Yee Sin Department of Infectious Diseases, Communicable Disease Centre, Tan Tock Seng Hospital, Singapore
CLINICAL RESEARCH UNIT
Our Study From 2000 to 2005, 80% of dengue cases were hospitalised even though the risk of developing DHF is low (1.8% to 2.8%). This research looked at hospitalised young adults with uncomplicated dengue fever to determine if these patients had significant morbidity and mortality and if admissions were in accordance with the 2005 WHO admission and discharge criteria for dengue.
Our Findings We found that 33% of hospitalised patients developed vomiting, 22% diarrhoea, 13% abdominal pain and 18% bleeding (almost all mild and self-resolving). Only one patient experienced hypotension as a result. It was also noted that DHF occurred in four per cent of patients with no deaths. Our results suggest that severe adverse outcome among young adults with dengue is uncommon. This means that if you are a young adult with dengue, daily outpatient monitoring with symptomatic treatment and medical leave may be a safe and feasible alternative to hospitalisation.
The Changing Trend of Diverticular Disease in a Developing Nation
DIGESTIVE DISEASES
Colorectal Disease 2011; 13:312-316
Our Study Diverticular disease affects the colon and is made up of two conditions, diverticulosis and diverticulitis. Diverticulosis occurs when pouches, called diverticula, form in the colon. Diverticulitis occurs if these diverticula become inflamed.
Fong Sau Shung, Tan Ern Yu, Angel Foo, Richard Sim, and Denis Mun Onn Cheong Department of General Surgery, Tan Tock Seng Hospital, Singapore
Previous studies have shown that the right-sided diverticular disease (RDD) is more prevalent in Oriental populations. But is this the case of our local population and have things changed over the past two decades? Our Method We evaluated the prevalence, site and distribution of this condition by examining all barium enema X-ray studies performed in the hospital from January 2001 to August 2002. The presence or absence of diverticular disease was then correlated with age, gender and ethnicity of the patient. Our Findings 45% of the 1662 X-ray studies reviewed had diverticular disease. Of all the cases, 57% were rightsided, 17% left-sided and the rest on both sides. Older patients were more likely to have left sided diverticular disease (LDD), whereas the Chinese ethnic group was more likely to have right diverticular disease as compared with Western patients. Both genders showed equal distribution of cases. RDD disease peaks at in the sixth decade, while LDD peaks in the seventh and eighth decades. RDD was more common in all age groups overall. Our results indicate that the Chinese race and increasing age are associated with a higher incident of RDD and LDD. When compared with studies performed two decades ago, there is an increasing incidence of both LDD and RDD. In addition, our pattern of diverticular disease seems to be becoming similar to that in the West. It is suspected that a diet low in fibre is the cause of the disease. However the consumption of whole grains, fruits and vegetables may reduce the risk of developing diverticular disease.
CLINICAL RESEARCH UNIT
Percutaneous Endoscopic Gastrostomy Outcomes: Can Patient Profiles Predict Mortality and Weaning? Singapore Medical Journal 2006; 47:383-387
Our Study Percutaneous Endoscopic Gastrostomy (PEG) is a surgical procedure for placing a feeding tube without having to perform an open operation on the abdomen. It is made percu taneously (through the skin) with the help of an endoscope (a flexible, lighted instrument) who has been inserted into the stomach to determine where to place the feeding tube. It is a safe and effective way to provide food, liquids and medications for patients who are unable to maintain sufficient oral intake. This study aimed to find what patient-related factors may help to select those who benefit from PEG feeding.
Chong Vui Heng1 and Charles Vu2
Our Method We reviewed data from 106 PEG patients from 1998 to 1999.
Gastroenterology Unit, Department of Medicine, RIPAS Hospital, Seri Begawan, Brunei 2 Department of Gastroenterology, Tan Tock Seng Hospital, Singapore
Our Findings Our results showed that older ages, presence of bedsores and abnormal nutritional status based on BMI predicted a higher chance of mortality. It was also noted that patients who are able to wean off PEG were younger and had preserved renal function.
1
CLINICAL RESEARCH UNIT
Acute Lupus Myocarditis: Clinical Features and Outcome of an Oriental Case Series Lupus, 2005;14:827–831
Law Weng Giap, Bernard Thong Yu Hor, Lian Tsui Yee, Kong Kok Ooi, Chng Hiok Hee Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
ALLERGY & IMMUNOLOGY Our Study Systemic lupus erythematosus (SLE) is an auto-immune disease in which the body’s immune system attacks its own cells. It commonly affects the skin, joints, kidneys and blood system causing inflammation, pain and possibly organ damage. In this study, we studied a rare manifestation of SLE involving acute inflammation of the heart muscle called Acute Lupus Myocarditis (ALM). The dianogsis can be made using a painless method of studying the heart in real time called echocardiography. Our Method We reviewed suitable SLE patients with ALM between 1 January 1993 and 31 December 2001. In all patients the first sign of ALM was heart failure. In 9 out of 11 patients, ALM was the first indication that they were suffering from SLE. Our Findings Our results suggest that ALM is rare but a serious manifestation of SLE. It can be the first symptom of SLE and can be treated with good outcome with prompt diagnosis and correct treatment.
CLINICAL RESEARCH UNIT
Immediate Food Hypersensitivity Among Adults Attending a Clinical Immunology / Allergy Centre in Singapore
Our Study Many Singaporeans suffer from immediate food hypersensitivity. However not much is known about the most common food allergies and the patients it affects. This study aimed to understand better the patterns and causes of food hypersensitivity.
Singapore Medical Journal 2007, 48:236-40
Our Method We reviewed the medical case-notes of 74 patients with food allergy seen at TTSH from July 1994 to April 2002.
Bernard Thong Yu Hor, Cheng Yew Kuang, Leong Khai Pang, Tang Chwee Ying and Chng Hiok Hee
Our Findings We found that the most common clinical symptoms were itchy and swollen skin, difficulty with breathing and wheezing, and hypotension (low blood pressure).
Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
The most common food that trigger an allergy were: • Seafood crustaceans e.g. prawn, crab and lobster; • Bird’s nest; • Mollusc (shellfish), which include clams, cockles, oyster and abalone but limpet was most commonly implicated. Nearly 50% of the patients had concurrent allergic such as rhinoconjunctivitis, asthma and eczema. This means you may be suffering from a food allergy if you have any of these conditions and experience symptoms such as swollen skin, difficulty with breathing and wheezing after eating certain types of food.
CLINICAL RESEARCH UNIT
Health of people with spinal cord injury in Singapore: implications for rehabilitation planning and implementation Disability and Rehabilitation 2011; 33:1460-1474
Sock Hui Joy Teo, Sharon Sew, Catherine Backman, Susan Forwell, Wing Kuen Lee, Poh Leng Chan, Elizabeth Dean Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore
BONES & MUSCLE Our Study This study aimed to investigate the secondary impairments associated with SCI, the proportion of patients who had chronic conditions and their associated risk factors, the rate of medical and hospital utilisation, and the extent of participation and life satisfaction among participants. Our Method A total of 55 patients who had sustained a traumatic SCI and had undergone inpatient rehabilitation at TTSH Rehabilitation Centre (TTSH-RC) between January 2000 and May 2009 were recruited for this study. Patients were included in the study if they had suffered a SCI from trauma, were able to communicate in English, or had a representative to communicate in English on their behalf, were 21 years of age or older and were residents of Singapore. Those with brain injuries influencing their capacity to receive, process and express information were excluded. Once recruited, participants were interviewed through telephone or an in-person which consisted of 111 questions covering physical, psychological and environmental aspects of health. Our Findings Majority of the traumatic SCI was caused by road traffic accidents (52.7%). 15% of the participants suffered SCI during work. The rest of the SCI cases (32.7%) were due by other causes, mostly falls. On average, the participants had SCI for 5 years. The main mode of mobility for most study participants was a manual wheelchair (69.1%). Only two participants (3.6%) used a motorised wheelchair. The remainder of the study participants moved with (5.5%, n=3) or without (21.8%, n=12) walking aids. Within the last 12 months of the study, the top five reported SCI-related secondary impairments were spasms (67%), pain (64%), bowel problems (51%), bladder problems (47%) and water retention (33%). The common chronic conditions reported by SCI patients were diabetes, hypertension, obesity, and high blood cholesterol. Study revealed that there is a need to further look at and tackle the various aspects of health such as participation, life satisfaction, chronic conditions and their associated risk factors, in order to raise the overall health and quality of life for SCI patients in Singapore. It also suggests that rehabilitation professionals should focus attention on facilitating community reintegration and promoting healthy lifestyles among these SCI patients.
CLINICAL RESEARCH UNIT
Botulinum Toxin Type A for Refractory Detrusor Overactivity in Spinal Cord Injured Patients in Singapore Annals of the Academy of Medicine, Singapore 2007, 36:11-7
Adela M Tow1, Khai-Lee Toh2, Siew Pang Chan3 and David Consigliere4 Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore 2 Urology Unit, Department of Surgery, Tan Tock Seng Hospital, Singapore 3 Clinical Research Unit, Tan Tock Seng Hospital, Singapore 4 Urology Unit, Department of Surgery, National University Hospital, Singapore 1
CLINICAL RESEARCH UNIT
Our Study Neurogenic Detrusor Overactivity (NDO) is a common medical condition in patients with spinal cord injury. It causes urinary urgency and incontinence which can be socially embarrassing, urinary tract infection and deterioration of kidney function.Currently, NDO is treated with anticholinergic, a form of medication. However it has side effects such as dry mouth and constipation that may discourage compliance. Surgical treatment is also not ideal because of complications. We explored using botulinum toxin type A commonly known as botox and its effectiveness in minimizing the effects of NDO for patients with spinal injury. Our Method 15 patients who experienced side effects after being treated with anticholinergic were treated with botox. Questionnaires with regard to the level of satisfaction with urinating were administered before and after their botox injections. Our Findings Our survey revealed that these patients’ urinary function improved significantly and that there were no side effects. It suggests that Botulinum Toxin Type A may be an effective treatment as the quality of life and patient satisfaction improved with it.
Screening for Dementia in the Older Chinese with a Single Question Test on Progressive Forgetfulness (PF) International Journal of Geriatric Psychiatry, 2006; 21:442–8
Chong Mei Sian , Chin Jing Jih1, Saw Seang Mei2, Chan Siew Pang3, N. Venketasubramanian, Louis Tan C. S.4, Hong Ching Ye2 and Suresh Sahadevan1 1
Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore 2 Department of Community, Occupational and Family Medicine, National University of Singapore 3 Clinical Epidemiology Unit, Tan Tock Seng Hospital, Singapore 4 Department of Neurology, Tan Tock Seng Hospital, Singapore 1
BRAIN Our Study Dementia is an illness which affects the brain, causing the brain cells to die at a faster rate than normal. It is NOT normal ageing. As a result, the mental abilities of the person with dementia declines. This leads to failing memory, deterioration of intellectual function and personality changes. Alzheimer’s disease is the most common cause of dementia. Globally it is estimated that 63 million people in 2030 and 114 million by 2050 will have Alzheimer’s disease. According to the Ministry of Health, Singapore had 7000 cases in 2000. This figure is expected to increase to 24,000 in 2030. The cause of Alzheimer’s disease is as yet unknown but it is likely that there are several different factors contributing to its development. With no cure, early assessment and diagnosis and help provide support in coping with the challenges of the disease. We wanted to explore if a single question about Progressive Forgetfulness (PF) might be useful as quick and simple way to screen for dementia. Our Method 4705 elderly Chinese subjects (50 years of age and above) stayed in Ang Mo Kio (AMK), were randomly selected for this study. In phase 1 of the study, trained assessors used Abbreviated Mental Test (AMT) – a brief, 10-item mental status test to detect pre-defined abnormalities. Phase 2 involved a group of neurologist and geriatricians who interviewed the co-residing relatives or friends for presence dementia in the patient using Diagnostic and Statistical Manual (DSM-IV) criteria set by American Psychological Association. Our Findings Our results showed that when PF is present, the probability of dementia increases significantly. This means that a single question about PF can be used to screen for dementia which may be appropriate assessment in a busy primary care setting.
CLINICAL RESEARCH UNIT
Ethnic Differences in Singapore’s Dementia Prevalence: the Stroke, Parkinson’s Disease, Epilepsy, and Dementia in Singapore Study Journal of American Geriatrics Society, 2008; 56:2061-8
Suresh Sahadevan, Saw Seang Mei, Gao Wei, Louis C.S. Tan, Chin Jing Jih, Hong Ching ye and Narayanaswamy Venketasubramanian Department of General Medicine, Tan Tock Seng Hospital, Singapore
Our Study Dementia is a slow, progressive illness which affects many areas of the function of our brain such as memory, attention, language and problem solving. Often, it is irreversible and the affected person deteriorates over time. Globally 24 million people aged 60 and older have dementia. This figure is estimated to double every 20 years till 2040. In Singapore, previous studies have shown that dementia affects 4 to 6% of our population. We wanted better understand this condition by determining the prevalence of dementia in Singapore more accurately as well as study the differences in the ethnic groups and risks factors of the disease. Our Method We conducted a very large community study with 14, 817 people. Individuals aged 50 and older, residing in Ang Mo Kio, Bishan, Serangoon, Toa Payoh and Yishun were randomly invited to participate in it. In Phase 1 of the study, trained interviewers used the Abbreviated Mental Test (AMT), a brief 10item mental test to screen for dementia. Following which, phase 2 involved a detailed assessment by clinicians using the Diagnostic and Statistical Manual (DSM-IV) of the American Psycholoigical Association. Our Findings 244 or 1.3% participants were found to have dementia. It was noted that the prevalence of dementia was higher in Indians (1.9%), than in Malays (1.6%), and Chinese (1.2%). A higher age and lower education level were also found to be significantly associated with the disease.
CLINICAL RESEARCH UNIT