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Background: Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches., Methods: This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality., Results: There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis., Conclusions: Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised., (© 2024. The Author(s).)

Introduction: Asthma guidelines have advocated for the use of quality-of-care indicators (QCIs) in asthma management. To improve asthma care, it is important to identify effective QCIs that are actionable. This study aimed to evaluate the effect of the presence of 3 QCIs: asthma education, Asthma Control Test (ACT) and spirometry testing on the time to severe exacerbation (TTSE)., Method: Data collected from the SingHealth COPD and Asthma Data Mart (SCDM), including asthma patients managed in 9 SingHealth polyclinics and Singapore General Hospital from January 2015 to December 2020, were analysed. Patients receiving Global Initiative for Asthma (GINA) Steps 3-5 treatment, with at least 1 QCI recorded, and at least 1 severe exacerbation within 1 year before the first QCI record, were included. Data were analysed using multivariate Cox regression and quasi-Poisson regression models., Results: A total of 3849 patients in the registry fulfilled the criteria. Patients with records of asthma education or ACT assessment have a lower adjusted hazard ratio (HR) for TTSE (adjusted HR=0.88, P=0.023; adjusted HR=0.83, P<0.001). Adjusted HR associated with spirometry is higher (adjusted HR=1.22, P=0.026). No QCI was significantly associated with emergency department (ED)/inpatient visits. Only asthma education and ACT showed a decrease in the number of exacerbations for multivariate analysis (asthma education estimate: -0.181, P<0.001; ACT estimate: -0.169, P<0.001). No QCI was significant for the number of exacerbations associated with ED/inpatient visits., Conclusion: Our study suggests that the perfor-mance of asthma education and ACT was associated with increased TTSE and decreased number of exacerbations, underscoring the importance of ensuring quality care in clinical practice., Competing Interests: MSK reports grant support from Astra-Zeneca, outside the submitted work. The SCDM used in this study is funded by the GlaxoSmithKline plc (study number PRJ3057). Apart from these, all authors declare that they have no other competing interest.

Purpose: The SingHealth-Duke-GlaxoSmithKline COPD and Asthma Real-world Evidence (SDG-CARE) collaboration was formed to accelerate the use of Singaporean real-world evidence in research and clinical care. A centerpiece of the collaboration was to develop a near real-time database from clinical and operational data sources to inform healthcare decision making and research studies on asthma and chronic obstructive pulmonary disease (COPD)., Methods: Our multidisciplinary team, including clinicians, epidemiologists, data scientists, medical informaticians and IT engineers, adopted the hybrid waterfall-agile project management methodology to develop the SingHealth COPD and Asthma Data Mart (SCDM). The SCDM was developed within the organizational data warehouse. It pulls and maps data from various information systems using extract, transform and load (ETL) pipelines. Robust user testing and data verification was also performed to ensure that the business requirements were met and that the ETL pipelines were valid., Results: The SCDM includes 199 data elements relevant to asthma and COPD. Data verification was performed and found the SCDM to be reliable. As of December 31, 2019, the SCDM contained 36,407 unique patients with asthma and COPD across the spectrum from primary to tertiary care in our healthcare system. The database updates weekly to add new data of existing patients and to include new patients who fulfil the inclusion criteria., Conclusions: The SCDM was systematically developed and tested to support the use RWD for clinical and health services research in asthma and COPD. This can serve as a platform to provide research and operational insights to improve the care delivered to our patients., (© 2023. The Author(s).)

Background: Chronic pain has a major impact on a patient's quality of life, affecting physical and psychological functioning. It has debilitating consequences on social and economic aspects too. This study aimed to explore the status of health-related quality of life (HRQoL) of Malaysian patients suffering from chronic non-malignant pain., Methods: Four hospitals offering pain clinic services were involved in this multicentre cross-sectional study conducted between June and September 2020. Adult patients who had been diagnosed with non-malignant chronic pain lasting for at least three months and able to communicate in English or Malay language were recruited in this study. Participants were informed about the study and were made aware that their participation was entirely voluntary. A battery of questionnaires consists of the EuroQol-5 dimensions-5 levels questionnaire (EQ-5D-5L) and the EuroQol visual analogue scale (EQ VAS), the Pain Self-Efficacy questionnaire (PSEQ) and the Pain Catastrophizing Scale (PCS) were self-administered by the patients. Besides, a structured questionnaire was used to collect their socio-demographic information, pain condition, sleep quality and working status. Participants' usage of pain medications was quantified using the Quantitative Analgesic Questionnaire (QAQ)., Results: A total of 255 patients participated in this study. A median EQ-5D index value of 0.669 (IQR: 0.475, 0.799) and a median EQ VAS score of 60.0 (IQR: 50.0, 80.0) were recorded. Malay ethnicity (Adj. B: 0.77; 95% CI: 0.029, 0.126; p = 0.002) and a higher level of self-efficacy (Adj. B: 0.008; 95% CI: 0.006, 0.011; p < 0.001) were predictors of a better HRQoL, while suffering from pain in the back and lower limb region (Adj. B: -0.089; 95% CI: - 0.142, - 0.036; p = 0.001), the use of a larger amount of pain medications (Adj. B: -0.013; 95% CI: - 0.019, - 0.006; p < 0.001), and a higher degree of pain magnification (Adj. B: -0.015; 95% CI: - 0.023, - 0.008; p < 0.001) were associated with a poorer HRQoL., Conclusions: These findings suggested that Malay ethnicity and a higher level of self-efficacy were predictors of a better HRQoL in patients with chronic pain, whereas pain-related factors such as higher usage of medication, specific pain site and pain magnification style were predictors of poorer HRQoL., (© 2022. The Author(s).)

Background and Objective: Simulation enhances a physician's competency in procedural skills by accelerating ascent of the learning curve. Training programmes are moving away from the Halstedian model of 'see one, do one, teach one', also referred as medical apprenticeship. We aimed to determine if a 3-month structured bronchoscopy curriculum that incorporated simulator training could improve bronchoscopy competency among pulmonary medicine trainees., Methods: We prospectively recruited trainees from hospitals with accredited pulmonary medicine programmes. Trainees from hospitals (A, B and C) were assigned to control group (CG) where they received training by traditional apprenticeship while trainees from hospital D were assigned to intervention group (IG) where they underwent 3-month structured curriculum that incorporated training with the bronchoscopy simulator. Two patient bronchoscopy procedures per trainee were recorded on video and scored independently by two expert bronchoscopists using the modified Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) forms. A 25 multiple choice questions (MCQ) test was administered to all participants at the end of 3 months., Results: Eighteen trainees participated; 10 in CG and eight in IG with equal female:male ratio. Competency assessed by modified BSTAT and MCQ tests was variable and not driven by volume as IG performed fewer patient bronchoscopies but demonstrated better BSTAT, airway anaesthesia and MCQ scores. Bronchoscopy simulator training was the only factor that correlated with better BSTAT (r = 0.80), MCQ (r = 0.85) and airway anaesthesia scores (r = 0.83), and accelerated the learning curve of IG trainees., Conclusion: An intensive 3-month structured bronchoscopy curriculum that incorporated simulator training led to improved cognitive and technical skill performance as compared with apprenticeship training., (© 2021 Asian Pacific Society of Respirology.)

The Covid-19 pandemic has focused attention on airborne transmission of viruses. Using realistic air flow simulation, we model droplet dispersion from coughing and study the transmission risk related to SARS-CoV-2. Although this model defines most airborne droplets as 8-16 µm in diameter, we infer that larger droplets of 32-40 µm in diameter may potentially be more infectious due to higher viral content. Use of face masks is therefore recommended for both personal and social protection. We found social distancing effective at reducing transmission potential across all droplet sizes. However, the presence of a human body 1 m away modifies the aerodynamics so that downstream droplet dispersion is enhanced, which has implications on safe distancing in queues. At 1 m distance, we found that an average of 0.55 viral copies is inhaled for a cough at median loading, scalable up to 340 copies at peak loading. Droplet evaporation results in significant reduction in droplet counts, but airborne transmission remains possible even under low humidity conditions.

Introduction: The National Early Warning Score (NEWS) is well established in acute medical units to identify acutely deteriorating patients and is shown to have good prognostic value. NEWS, however, has only been used in the Emergency Department as a triage tool. We aimed to evaluate the validity of NEWS in Acute Medical Ward (AMW) that treats predominantly acute infection-related conditions to the Internal Medicine service., Materials and Methods: We undertook a retrospective cohort study and analysed NEWS records of all patients admitted to AMW at Singapore General Hospital between 1 August 2015 and 30 July 2017. The outcome was defined as deterioration that required transfer to Intermediate Care Area (ICA), Intensive Care Unit (ICU) or death within 24 hours of a vital signs observation set., Results: A total of 298,743 vital signs observation sets were obtained from 11,300 patients. Area under receiver operating characteristic curve for any of the 3 outcomes (transfer to ICA, ICU or death) over a 24-hour period was 0.896 (95% confidence interval, 0.890-0.901). Event rate was noted to be high above 0.250 when the score was >9. In the medium-risk group (score of 5 or 6), event rate was <0.125., Conclusion: NEWS accurately triages patients according to the likelihood of adverse outcomes in infection-related acute medical settings.

The use of the oXiris® haemofilter during continuous veno-venous haemodiafiltration (CVVHDF) for acute kidney injury (AKI) and severe sepsis is not completely understood. Although this filter has in vitro adsorptive properties for blood-borne cytokines and other humoural mediators of sepsis, its clinical usefulness is uncertain. Given its inherent adsorptive limitation for septic mediators, we developed a CVVHDF protocol in which the oXiris haemofilter was electively changed every 12 h even though there was no clotting or adverse circuit pressures. Augmented filter membrane adsorption was conducted for 3 consecutive days. We treated a critically ill patient with severe sepsis secondary to a gram-negative bacterial infection and sepsis-associated acute kidney injury (SA- AKI) in this way. The patient required high-dose vasopressor support, required mechanical ventilation, had received 12 h of CVVHDF with conventional M100 haemofilter, was on broad spectrum antibiotics and other conventional intensive care unit (ICU) care, prior to institution of the frequent oXiris haemofilter change protocol. Following the start of elective 12 hourly oXiris filter change, the patient showed reduction in the need for vasopressor and by Day 4 of this SA- AKI frequent filter change protocol, vasopressor requirement ceased, he was extubated. He survived ICU and but not hospital stay. To this end, more clinical studies are needed., (© 2019 The Author(s). Published by S. Karger AG, Basel.)

Clinical practice guidelines (CPGs) have become ubiquitous in every field of medicine today but there has been limited success in implementation and improvement in health outcomes. Guidelines are largely based on the results of traditional randomised controlled trials (RCTs) which adopt a highly selective process to maximise the intervention's chance of demonstrating efficacy thus having high internal validity but lacking external validity. Therefore, guidelines based on these RCTs often suffer from a gap between trial efficacy and real world effectiveness and is one of the common reasons contributing to poor guideline adherence by physicians. "Real World Evidence" (RWE) can complement RCTs in CPG development. RWE-in the form of data from integrated electronic health records-represents the vast and varied collective experience of frontline doctors and patients. RWE has the potential to fill the gap in current guidelines by balancing information about whether a test or treatment works (efficacy) with data on how it works in real world practice (effectiveness). RWE can also advance the agenda of precision medicine in everyday practice by engaging frontline stakeholders in pragmatic biomarker studies. This will enable guideline developers to more precisely determine not only whether a clinical test or treatment is recommended, but for whom and when. Singapore is well positioned to ride the big data and RWE wave as we have the advantages of high digital interconnectivity, an integrated National Electronic Health Record (NEHR), and governmental support in the form of the Smart Nation initiative.

Introduction: The aim of this study was to identify patient characteristics and risk factors associated with in-hospital mortality of patients with pulmonary tuberculosis (PTB) requiring intensive care unit (ICU) management., Methods: A retrospective chart review was conducted of all patients with active PTB admitted to the ICU at Singapore General Hospital, Singapore, between January 2005 and December 2010., Results: There were 2,155 patients with active PTB diagnosed, of whom 83 (3.9%) patients were admitted to the ICU, but eight were excluded because their admission to the ICU was unrelated to PTB. The most common comorbidities were diabetes mellitus (n = 23, 30.7%) and immunocompromised host (n = 25, 33.3%). A few (n = 4, 5.3%) of the patients had HIV coinfection. A majority (n = 67, 89.3%) of patients required mechanical ventilation and the mean duration of mechanical ventilation was 8.05 ± 14.43 days. Mean duration of ICU stay and hospital stay were 10.23 ± 15.8 days and 33.7 ± 50.7 days, respectively. In-hospital mortality was 62.7% (n = 47), and 36 of these patients died while in the ICU (ICU mortality, 48.0%). Univariate analysis identified ischaemic heart disease, low albumin, Acute Physiology and Chronic Health Evaluation score, disseminated intravascular coagulation, shock and multiorgan failure as significantly associated with mortality. Multivariate analysis showed that low albumin on the day of ICU admission was the only significant independent predictor of death (p = 0.033)., Conclusion: In-hospital mortality from active PTB requiring ICU admission was 62.7%, and low albumin was an independent predictor of mortality in this study., (Copyright: © Singapore Medical Association)

Introduction: In the past 20 years, our understanding of acute respiratory distress syndrome (ARDS) management has improved, but the worldwide incidence and current outcomes are unclear. The reported incidence is highly variable, and no studies specifically characterise ARDS epidemiology in Asia. This observation study aims to determine the incidence, mortality and management practices of ARDS in a high income South East Asian country., Methods: We conducted a prospective, population based observational study in 6 public hospitals. During a one month period, we identified all ARDS patients admitted to public hospital intensive care units (ICU) in Singapore, according to the Berlin definition. Demographic information, clinical management data and ICU outcome data was collected., Results: A total of 904 adult patients were admitted to ICU during the study period and 15 patients met ARDS criteria. The unadjusted incidence of ARDS was 4.5 cases per 100,000 population, accounting for 1.25% of all ICU patients. Most patients were male (75%), Chinese (62%), had pneumonia (73%), and were admitted to a Medical ICU (56%). Management strategies varied across all ICUs. In-hospital mortality was 40% and median length of ICU stay was 7 days., Conclusion: The incidence of ARDS in a developed S.E Asia country is comparable to reported rates in European studies.

Introduction: This study aimed to examine the validity and accuracy of wrist accelerometers for classifying sedentary behavior (SB) in children., Methods: Fifty-seven children (5-8 and 9-12 yr) completed an ~170-min protocol, including 15 semistructured activities and transitions. Nine ActiGraph (GT3X+) and two GENEActiv wrist cut points were evaluated. Direct observation was the criterion measure. The accuracy of wrist cut points was compared with that achieved by the ActiGraph hip cut point (≤25 counts per 15 s) and the thigh-mounted activPAL3. Analyses included equivalence testing, Bland-Altman procedures, and area under the receiver operating curve (ROC-AUC)., Results: The most accurate ActiGraph wrist cut points (Kim; vector magnitude, ≤3958 counts per 60 s; vertical axis, ≤1756 counts per 60 s) demonstrated good classification accuracy (ROC-AUC = 0.85-0.86) and accurately estimated SB time in 5-8 yr (equivalence P = 0.02; mean bias = 4.1%, limits of agreement = -20.1% to 28.4%) and 9-12 yr (equivalence P < 0.01; -2.5%, -27.9% to 22.9%). The mean bias of SB time estimates from Kim were smaller than ActiGraph hip (5-8 yr: 15.8%, -5.7% to 37.2%; 9-12 yr: 17.8%, -3.9% to 39.5%) and similar to or smaller than activPAL3 (5-8 yr: 12.6%, -39.8% to 14.7%; 9-12 yr: -1.4%, -13.9% to 11.0%), although classification accuracy was similar to ActiGraph hip (ROC-AUC = 0.85) but lower than activPAL3 (ROC-AUC = 0.92-0.97). Mean bias (5-8 yr: 6.5%, -16.1% to 29.1%; 9-12 yr: 10.5%, -13.6% to 34.6%) for the most accurate GENEActiv wrist cut point (Schaefer: ≤0.19 g) was smaller than ActiGraph hip, and activPAL3 in 5-8 yr, but larger than activPAL3 in 9-12 yr. However, SB time estimates from Schaefer were not equivalent to direct observation (equivalence P > 0.05) and classification accuracy (ROC-AUC = 0.79-0.80) was lower than for ActiGraph hip and activPAL3., Conclusion: The most accurate SB ActiGraph (Kim) and GENEActiv (Schaefer) wrist cut points can be applied in children with similar confidence as the ActiGraph hip cut point (≤25 counts per 15 s), although activPAL3 was generally more accurate.

Background: Studies on diagnostic tests for exercise-induced bronchoconstriction (EIB) have centered around the asthmatic and elite athletic population. Traditionally, the exercise challenge test (ET) was recommended to assess EIB. We aimed to compare the performance of surrogate testing, mainly the hypertonic saline (HS) test, and methacholine challenge test (MCT) versus ET in identifying EIB among non-athletic subjects., Methods: We prospectively recruited subjects who did not have confirmed active asthma, but who reported exercise-induced dyspnoea. The participants underwent HS and ET on separate days within two weeks. MCT performed within one year were obtained retrospectively from medical records. The sensitivity, specificity, and accuracy of each diagnostic test were calculated using ET as the gold standard., Results: We recruited 27 participants (mean age 20.6±2.5 years; 92.6% male). Five (18.5%) had a history of self-reported asthma prior to recruitment. Eleven participants (40.7%) had a positive ET test. The sensitivity, specificity and accuracy of HS in diagnosing EIB was 90.9%, 62.5% and 74.1%; while that of MCT was 88.9%, 83.3% and 85.7% respectively. Six subjects were positive to HS but had negative ET test., Conclusions: Both HS and MCT were found to be suitable alternatives to ET in screening for EIB in the non-athletic population in this pilot study. Further large scale studies are required to confirm this finding. These tests have the potential to replace ET for the diagnosis of EIB in centres without ET equipment or facilities., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objectives: To validate activPAL3™ (AP3) for classifying postural allocation, estimating time spent in postures and examining the number of breaks in sedentary behaviour (SB) in 5-12 year-olds., Design: Laboratory-based validation study., Methods: Fifty-seven children completed 15 sedentary, light- and moderate-to-vigorous intensity activities. Direct observation (DO) was used as the criterion measure. The accuracy of AP3 was examined using a confusion matrix, equivalence testing, Bland-Altman procedures and a paired t-test for 5-8y and 9-12y., Results: Sensitivity of AP3 was 86.8%, 82.5% and 85.3% for sitting/lying, standing, and stepping, respectively, in 5-8y and 95.3%, 81.5% and 85.1%, respectively, in 9-12y. Time estimates of AP3 were equivalent to DO for sitting/lying in 9-12y and stepping in all ages, but not for sitting/lying in 5-12y and standing in all ages. Underestimation of sitting/lying time was smaller in 9-12y (1.4%, limits of agreement [LoA]: -13.8 to 11.1%) compared to 5-8y (12.6%, LoA: -39.8 to 14.7%). Underestimation for stepping time was small (5-8y: 6.5%, LoA: -18.3 to 5.3%; 9-12y: 7.6%, LoA: -16.8 to 1.6%). Considerable overestimation was found for standing (5-8y: 36.8%, LoA: -16.3 to 89.8%; 9-12y: 19.3%, LoA: -1.6 to 36.9%). SB breaks were significantly overestimated (5-8y: 53.2%, 9-12y: 28.3%, p<0.001)., Conclusions: AP3 showed acceptable accuracy for classifying postures, however estimates of time spent standing were consistently overestimated and individual error was considerable. Estimates of sitting/lying were more accurate for 9-12y. Stepping time was accurately estimated for all ages. SB breaks were significantly overestimated, although the absolute difference was larger in 5-8y. Surveillance applications of AP3 would be acceptable, however, individual level applications might be less accurate., (Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Objectives: This study aimed to validate SenseWear Mini software algorithm versions 2.2 (SW2.2) and 5.2 (SW5.2) for estimating energy expenditure (EE) in children., Design: Laboratory-based validation study., Methods: 57 children aged 5-12 y completed a protocol involving 15 semi-structured sedentary (SED), light-intensity (LPA), and moderate- to vigorous-intensity (MVPA) physical activities. EE was estimated using portable indirect calorimetry (IC). The accuracy of EE estimates (kcal·min -1 ) from SW2.2 and SW5.2 were examined at the group level and individual level using the mean absolute percentage error (MAPE), Bland-Altman plots and equivalence testing., Results: MAPE values were lower for SW5.2 (30.1±10.7%) than for SW2.2 (44.0±6.2%). Although mean differences for SW5.2 were smaller than for SW2.2 during SED (-0.23±0.22 vs. -0.61±0.20kcal·min -1 ), LPA (-0.69±0.76 vs. -1.07±0.46kcal·min -1 ) and MVPA (-2.22±1.15 vs. -2.57±1.15kcal·min -1 ), limits of agreement did not decrease for the updated algorithms. For all activities, SW2.2 and SW5.2 were not equivalent to IC (p>0.05). Errors increased with increasing intensity., Conclusion: The current SenseWear Mini algorithms SW5.2 underestimated EE. The overall improved accuracy for SW5.2 was not accompanied with improved accuracy at the individual level and EE estimates were not equivalent to IC., (Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Background: To validate the activPAL3 algorithm for predicting metabolic equivalents (TAMETs) and classifying MVPA in 5- to 12-year-old children., Methods: Fifty-seven children (9.2 ± 2.3y, 49.1% boys) completed 14 activities including sedentary behaviors (SB), light (LPA) and moderate-to-vigorous physical activities (MVPA). Indirect calorimetry (IC) was used as the criterion measure. Analyses included equivalence testing, Bland-Altman procedures and area under the receiver operating curve (ROC-AUC)., Results: At the group level, TAMETs were significantly equivalent to IC for handheld e-game, writing/coloring, and standing class activity (P < .05). Overall, TAMETs were overestimated for SB (7.9 ± 6.7%) and LPA (1.9 ± 20.2%) and underestimated for MVPA (27.7 ± 26.6%); however, classification accuracy of MVPA was good (ROC-AUC = 0.86). Limits of agreement were wide for all activities, indicating large individual error (SB: -27.6% to 44.7%; LPA: -47.1% to 51.0%; MVPA: -88.8% to 33.9%)., Conclusions: TAMETs were accurate for some SB and standing, but were overestimated for overall SB and LPA, and underestimated for MVPA. Accuracy for classifying MVPA was, however, acceptable.

Guidewire retention is a severe but preventable complication from central venous catheter (CVC) insertion. There were three cases of guidewire retention during CVC insertion in the medical intensive care unit (MICU) in Singapore General Hospital, in the period between December 2011 and February 2012. The primary objective of this quality improvement project was to eliminate future incidences of guidewire retention during CVC insertion in the MICU and medical intermediate care area (MICA) via a structured educational program and a cost effective modified CVC set. The secondary objective was to perform a cost analysis and comparison between the use of the conventional hospital CVC set and drape with our newly modified CVC dressing kit. Root cause analysis of the three cases identified major factors leading to guidewire retention. Interventions were planned and tested using PDSA cycles. Internal medicine trainees rotating through MICU and MICA during the period between February 2012 and June 2013 underwent a multi-modal structured CVC insertion training program with hands on simulation. They also used a newly modified CVC dressing kit and drape. The CVC dressing kit was modified (CVC PLUS) to include a sterile drape with reminder stickers stating "REMOVE the GUIDEWIRE," as well as a sterile ultrasound sleeve. The total number of CVC insertions performed and guidewire retentions were monitored. During the period of study there were 320 CVC insertions in the MICU and MICA. Since this quality improvement project was initiated, and up to the submission of this article, there have not been any further cases of guidewire retention in the MICU and MICA. The total cost reduction per use of CVC PLUS was S$29.26 (Singaporean Dollars). A multi-modal structured training program, integrated with a modified, pre-packed CVC set, and drapes with reminder stickers (all included in CVC PLUS) were cost effective, and improved patient safety by eliminating guidewire retention during CVC insertion.

Objectives: This purpose of this study was to examine clinical-pathologic factors--particularly smoking and brain metastases--in EGFR mutation positive (M(+)) lung adenocarcinoma (ADC) to determine their impact on survival in patients treated with first line EGFR TKI., Methods: A retrospective review of EGFR mutation reflex testing experience for all ADC diagnosed at a tertiary Asian cancer centre from January 2009 to April 2013. Amongst this cohort, patients with advanced EGFR M(+) ADC treated with first line EGFR TKI were identified to determine factors that influence progression free and overall survival., Results: 444/742 (59.8%) ADC reflex tested for EGFR mutations were EGFR M(+.) Amongst never-smokers (n=468), EGFR M(+) were found in 74.5% of females and 76.3% of males, and amongst ever smokers (n=283), in 53.3% of females and 35.6% of males. Exon 20 mutations were found more commonly amongst heavy smokers (> 50 pack years and > 20 pack years, Pearson's chi square p=0.044, and p=0.038 respectively). 211 patients treated with palliative first line TKI had a median PFS and OS of 9.2 and 19.6 months respectively. 26% of patients had brain metastasis at diagnosis. This was significantly detrimental to overall survival (HR 1.85, CI 1.09-3.16, p=0.024) on multivariate analysis. There was no evidence that smoking status had a significant impact on survival., Conclusions: The high prevalence of EGFR M(+) in our patient population warrants reflex testing regardless of gender and smoking status. Smoking status and dosage did not impact progression free or overall survival in patients treated with first line EGFR TKI. The presence of brain metastasis at diagnosis negatively impacts overall survival.

Doripenem is approved in the Asia-Pacific (APAC) region for treating nosocomial pneumonia (NP) including ventilator-associated pneumonia (VAP), complicated intra-abdominal infections (cIAIs) and complicated urinary tract infections (cUTIs). Clinical usage of doripenem (500mg intravenously, infused over 1h or 4h every 8h for 5-14 days) in APAC was evaluated in a prospective, open-label, non-comparative, multicentre study of inpatients (≥18 years) with NP, VAP, cIAI or cUTI. A total of 216 [intention-to-treat (ITT)] patients received doripenem: 53 NP (24.5%); 77 VAP (35.6%); 67 cIAI (31.0%); and 19 cUTI (8.8%). Doripenem MIC90 values for Pseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli and Klebsiella pneumoniae were 32, 32, 0.094 and 0.64μg/mL, respectively. Doripenem was used most commonly as monotherapy (86.6%) and as second-line therapy (62.0%). The clinical cure rate in clinically evaluable patients was 86.7% at the end of therapy (EOT) and 87.1% at test of cure (TOC) (7-14 days after EOT). In the ITT population, overall clinical cure rates were 66.2% at EOT and 56.5% at TOC. The median duration of hospital stay, intensive care unit (ICU) stay and mechanical ventilation was 20, 12 and 10 days, respectively. Of 146 discharged patients, 7 were re-admitted within 28 days of EOT; 1 VAP patient was re-admitted to the ICU. The all-cause mortality rate was 22.7% (49/216). The most common treatment-related adverse events were diarrhoea (1.4%) and vomiting (1.4%). Doripenem is a viable option for treating APAC patients with NP, VAP, cIAI or cUTI. [ClinicalTrials.gov: NCT 00986102]., (Copyright © 2014 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.)

The burden of disease associated with Streptococcus pneumoniae infection in adults can be considerable but is largely preventable through routine vaccination. Although substantial progress has been made with the recent licensure of the new vaccines for prevention of pneumonia in adults, vaccine uptake rates need to be improved significantly to tackle adult pneumococcal disease effectively. Increased education regarding pneumococcal disease and improved vaccine availability may contribute to a reduction in pneumococcal disease through increased vaccination rates. The increase in the elderly population in Singapore as well as globally makes intervention in reducing pneumococcal disease an important priority. Globally, all adult vaccines remain underused and family physicians give little priority to pneumococcal vaccination for adults in daily practice. Family physicians are specialists in preventive care and can be leaders in ensuring that adult patients get the full benefit of protection against vaccine-preventable diseases. They can play a key role in the immunization delivery of new and routine vaccines by educating the public on the risks and benefits associated with vaccines. Local recommendations by advisory groups on vaccination in adults will also help to tackle vaccine preventable diseases in adults.

Introduction: Adenovirus causing severe fatal pneumonia has been well described in infants, children, and patients with immunocompromised function, but reports in previously healthy adults are rare. We report 3 cases of severe adenovirus pneumonia in whom conventional mechanical ventilation failed and required extracorporeal membrane oxygenation support., Methods: Retrospective case records review of 3 patients admitted to the medical intensive care unit, Singapore General Hospital, a tertiary care university-affiliated hospital, with severe adenovirus pneumonia requiring extracorporeal membrane oxygenation support from February to March 2013., Results: All 3 patients were previously healthy immunocompetent adults from the community with negative HIV serology. Duration prior to development of respiratory failure requiring intubation and invasive mechanical ventilation was 2, 8 and 3 days. Veno-venous extracorporeal membrane oxygenation (ECMO) support as rescue ventilation was instituted in all 3 patients after 2, 16, and 5 days of conventional mechanical ventilator support. Duration on ECMO support was 16, 22, and 9 days and mechanical ventilation was 18, 62, and 19 days respectively. Length of stay in intensive care unit was 18, 68, and 21 days, and length of stay in hospital was 20, 70, and 31 days respectively. Two of the 3 patients died., Conclusion: The mainstay of treatment for patients with severe adenovirus pneumonia is still supportive, with the use of antivirals not apparently effective. Whilst ECMO support for rescue ventilation may be considered, the outcomes do not appear as promising as other viral pneumonias, mirroring that previously described in the paediatric population., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Aim: To examine the clinical characteristics and outcomes of malignant pleural mesothelioma (MPM) in Singapore., Methods and Materials: A retrospective case note review of patients diagnosed with MPM between 1997 and 2007. Overall survival (OS), locoregional recurrence-free survival (LRS) and metastasis-free survival (MFS) were estimated using Kaplan Meier method and comparison were done using log rank test. Multivariate analysis was not done due to the small number of patients., Results: There were 39 patients diagnosed with MPM. Fifty-nine percent of patients presented with Stage III and IV disease. Eight (21%) patients had surgery with 2 patients receiving trimodality treatment and adjuvant chemotherapy respectively. Three patients received adjuvant RT and one patient had no adjuvant therapy. Twelve patients received palliative RT or chemotherapy. Median follow-up was 27.0 weeks. Median overall survival (OS) for all patients was 8.0 months (95% CI 6.3-9.7). One-year and 2-year OS were 25.6% and 6.4% respectively. Thirty-eight patients died of progressive disease and one patient died of other cause. Locoregional recurrences and distant metastases occurred in 3/8 and 5/8 surgically treated patients respectively. Overall, distant metastases occurred in 44% of patients. Surgery did not affect survival outcomes although patients with dual modality treatment showed a trend towards improved survival. Epithelioid tumours had better prognosis (median OS 10.2 months) compared to biphasic (median OS 8.0 months) and sarcomatoid tumours (median OS 1.4 months)., Conclusion: Future management of MPM will need to emphasize on both locoregional and systemic control and hence, inclusion of patients in clinical trials for multimodality treatment should be encouraged.

We report the first case of massive hemorrhage after argon plasma coagulation of an endobronchial tumor that obstructed the right main bronchus. This is the first report of bleeding complication with argon plasma coagulation while attempting to remove the tumor. The patient was successfully resuscitated and discharged without sequelae.

Background: Transbronchial needle aspiration (TBNA) is a bronchoscopic technique that provides access to masses within the mediastinum. It is operator dependent, and factors such as needle type, lymph node site, and endobronchial ultrasosonography (EBUS) have been implicated as having an impact on its accuracy. This study aimed to develop a strategy for TBNA and specimen preparation techniques as the first step toward improving TBNA yield, and to determine whether EBUS can augment its application., Methods: Intervention included standardizing the use of the histology needle and the direct smear method. As competency improved, radial probe (RP) and linear EBUS were incorporated into TBNA., Results: The study assessed 35 conventional TBNA procedures before and 45 of these procedures after intervention as well as 45 RP-EBUS and 50 linear EBUS-guided TBNA procedures. Frequently sampled lymph node stations were 7, 4R, and 4L in the American Thoracic Society classification. The preintervention conventional TBNA yield was 43%, which improved to 82% after intervention. Although EBUS did not have an impact on TBNA yield (p = 0.44) compared with the intervention (p = 0.001), EBUS was useful for lymph nodes smaller than 2 cm (p < 0.0001). Linear EBUS did not confer higher diagnostic accuracy than RP-EBUS (p = 0.47)., Conclusion: Proper TBNA and specimen preparation techniques are the first steps toward improving TBNA yield, and EBUS can be used to guide TBNA of small lymph nodes.

Introduction: Haemodynamic monitoring is an essential element in the management of critically ill patients in the intensive care unit (ICU). However, there have been increasing concerns about the clinical utility and safety profile of the invasive pulmonary artery catheter (PAC). Oesophageal Doppler (ED) monitoring has emerged recently as a safer and less invasive tool which can be used by the intensivist to estimate cardiac output in the critically ill patient. Validation studies have thus far only been performed in surgical patients perioperatively and in mixed surgical/medical ICU patients. Currently, minimal data are available in any sizeable Asian population or in patients with severe sepsis. The assumption that these normograms and data hold true for our local medical ICU patients may not be valid due to differences in body habitus., Materials and Methods: Our primary aim is to validate the oesophageal Doppler as a reliable measure of cardiac index, systemic vascular resistance (SVR) and preload in our local Asian population of patients with severe sepsis and septic shock in the medical ICU. This was a prospective pilot study on 12 consecutive mechanically ventilated patients in our medical ICU with the diagnosis of septic shock as defined by SCCM/ESICM/ACCP/ATS/SIS International Sepsis definitions Conference-Critical Care Medicine 2003 and required PAC haemodynamic monitoring as indicated by Medical Intensive Care Unit attending., Results: Ninety-seven paired cardiac output measurements were made. Cardiac output ranged from 2.87 to 11.0 L/ min (calculated cardiac index ranging from 1.73 to 6.36 L/min/m2) when measured using the PAC with thermodilution technique and from 2.0 to 12.1 L/min (calculated cardiac index of 1.2 to 7.2 L/min/m2) using the trans-oesophageal Doppler. There was moderately good correlation between CIpac and CIed (correlation coefficient, r = 0.762 with PCA = 58%). The mean bias was 0.26 L/min/m2 (P <0.07), while the limit of agreement was +/- 1.44 L/min/m2., Conclusion: ED has good correlation with PAC in measuring cardiac index in Asians with septic shock but is an unreliable measure of both pre-load and SVR.

Empirical research has shown that exposure to race-related stressors in the military by Asian American Pacific Islander Vietnam veterans, now reliably measurable, contributes uniquely and significantly to post-traumatic stress disorder (PTSD) symptoms and generalized psychiatric distress; moreover, studies reveal that adverse race-related events can meet Diagnostic and Statistical Manual of Mental Disorders-IV criteria for a PTSD diagnosis. Competence in treating PTSD or general psychiatric distress requires understanding the types of, and effects of, adverse race-related events experienced by ethnic minority veterans. Case studies highlight two types of race-related stressors-"bicultural identification and conflict" and "racial stigmatization"-which placed the veteran at greater risk of death and reduced cohesion with fellow service members. The studies demonstrate the presence of race-related stressors in one or more of the four major types of war zone stressors: traditional combat, atrocities-abusive violence, perceived threat, and malevolent environment. These case studies supplement the empirical findings on race-related stressors and PTSD, enlarging the clinician's understanding of this unique type of mental health risk factor.

Treatment for symptoms arising from exposure to adverse race-related events is critical to culturally competent healthcare delivery to ethnic minorities, particularly in light of recent findings demonstrating significant relationships between adverse race-related events and post-traumatic stress disorder (PTSD) and general psychiatric distress. This article offers a developmental model consisting of stages by which psychological symptoms develop in response to race-related stressors in the military. This article also describes a model of group treatment for ethnic minority veterans related to psychological symptoms arising from exposure to race-related stressors. Both models were used in a race-related support group for Pacific Islander Vietnam veterans diagnosed with PTSD. A combined approach of group intervention, psychosocial education, identity reframing, cognitive differentiation, and cognitive restructuring, which included 'depersonalizing discrimination' and rejection of faulty beliefs, appear to offer an effective approach to treating psychological sequelae arising from adverse race-related events. This article offers an intervention model that is linked to a developmental model of race-related stressors for Asian American Pacific Islander minority personnel in the military.

Few studies have explored the relationship between exposure to adverse race-related events and posttraumatic stress disorder (PTSD). This study examined whether adverse race-related events can give rise to symptoms that meet the criteria for a PTSD diagnosis as specified in the DSM-IV. Three hundred Asian American Vietnam veterans were administered a Mississippi Scale and a questionnaire that assessed exposure to adverse race-related events in the military and associated PTSD symptoms. A subsample was administered the Clinician-Administered PTSD Scale. A majority of the participants (77%) reported exposure to adverse race-related events. Depending on the number of events to which they were exposed, between 13% and 36% reported symptoms consistent with meeting full criteria for PTSD. Mississippi Scale scores increased significantly as a function of frequency of exposure to adverse race-related events. These results converge with the Clinician-Administered PTSD Scale findings to demonstrate that adverse race-related events can be traumatic and associated with PTSD. These findings support the construct and convergent validity of race-related PTSD.

Objective: Childhood abuse and other adverse childhood experiences (ACEs) have historically been studied individually, and relatively little is known about the co-occurrence of these events. The purpose of this study is to examine the degree to which ACEs co-occur as well as the nature of their co-occurrence., Method: We used data from 8,629 adult members of a health plan who completed a survey about 10 ACEs which included: childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing domestic violence, parental marital discord, and living with substance abusing, mentally ill, or criminal household members. The bivariate relationship between each of these 10 ACEs was assessed, and multivariate linear regression models were used to describe the interrelatedness of ACEs after adjusting for demographic factors., Results: Two-thirds of participants reported at least one ACE; 81%-98% of respondents who had experienced one ACE reported at least one additional ACE (median: 87%). The presence of one ACE significantly increased the prevalence of having additional ACEs, elevating the adjusted odds by 2 to 17.7 times (median: 2.8). The observed number of respondents with high ACE scores was notably higher than the expected number under the assumption of independence of ACEs (p <.0001), confirming the statistical interrelatedness of ACEs., Conclusions: The study provides strong evidence that ACEs are interrelated rather than occurring independently. Therefore, collecting information about exposure to other ACEs is advisable for studies that focus on the consequences of a specific ACE. Assessment of multiple ACEs allows for the potential assessment of a graded relationship between these childhood exposures and health and social outcomes.

Objective: Normative data for cardiopulmonary exercise testing (CPET) may vary among subjects of different races. The objectives of the present study were to: (i) establish normal standards for cardiopulmonary responses during incremental cycle ergometer testing in order to derive predictive equations for clinically useful variables during CPET of Chinese subjects; and (ii) determine the validity of existing prediction equations of maximal exercise performance for use in our local Chinese population., Methodology: The maximal and submaximal cardiopulmonary responses were analysed for 95 healthy sedentary adult Chinese subjects (48 men and 47 women; aged 20-70 years) who underwent CPET using a cycle ergometer and an incremental work-rate protocol until symptom limitation., Results: Measurements, at maximal exercise, of oxygen uptake (VO2(max)), power output and heart rate were regressed on age, height, weight and gender. The predictive equations for these exercise parameters performed better than those published previously in out-sample predictive accuracy. Comparison with previous studies also showed that prediction equations of VO2(max) derived from studies based predominantly or exclusively on Caucasian populations overestimated the actual values for our subjects., Conclusions: Previously established prediction equations for maximal exercise performance during CPET based on non-Chinese populations may not be applicable to Chinese subjects in our population.

This article describes the development and validation of the Race-Related Stressor Scale (RRSS), a questionnaire that assesses exposure to race-related stressors in the military and war zone. Validated on a sample of 300 Asian American Vietnam veterans, the RRSS has high internal consistency and adequate temporal stability. Hierarchical regression analyses revealed that exposure to race-related stressors accounted for a significant proportion of the variance in posttraumatic stress disorder (PTSD) symptoms and general psychiatric symptoms, over and above (by 20% and 19%, respectively) that accounted for by combat exposure and military rank. The RRSS appears to be a psychometrically sound measure of exposure to race-related stressors for this population. Race-related stressors as measured by the RRSS appear to contribute uniquely and substantially to PTSD symptoms and generalized psychiatric distress.

Cannabinoid receptor (CB1) agonists strongly inhibit behavioral responses to acute noxious stimuli, but their effects on behavioral responses in persistent pain states are less clear. Here, we examined the effects of intrathecal (i.t.) administration of a CB1 agonist, WIN55,212-2, on mechanical allodynia (decreased withdrawal threshold) produced by injections of complete Freund's adjuvant (CFA) in the plantar surface of the rat hindpaw. We measured mechanical thresholds with calibrated von Frey filaments before and after CFA and used Fos expression as a marker of the activity of spinal cord neurons during inflammation and in response to a CB1 antagonist. One day post CFA-induced injury, mechanical sensitivity was significantly increased in the hindpaw ipsilateral to the CFA injection, as was the number of neurons that express Fos. Intrathecal injection of WIN55,212-2, significantly, reversed the allodynia at doses that had no effect on the mechanical threshold of the contralateral paw of CFA-treated or the withdrawal thresholds in naive animals. This effect was blocked by coadministration of the CB1 antagonist, SR141716A, with WIN55212-2. By itself, SR141716A, had no effect on mechanical thresholds in normal animals. In inflamed animals, SR141716A did not further reduce mechanical thresholds in the inflamed paw, but it significantly enhanced mechanical sensitivity 'contralateral' to the inflammation. Furthermore, i.t. injection of SR141716A increased Fos expression in both normal and inflamed animals, to a different extent in different laminae. In normal animals, the increase was primarily in laminae V-VI and in the ventral horn; in animals with persistent inflammation SR141716A increased the number of Fos neurons in laminae I-II and V-VI. These results demonstrate that WIN55212-2 reverses inflammation-induced allodynia at doses that do not produce analgesia and that SR141716A differentially affects the pattern of Fos expression in the spinal cord, depending on the presence or absence of inflammation. Taken together, these results suggest that the CB1 receptor system is tonically active in the spinal cord under normal conditions and that its activity is increased in response to injury.

Although many pharmacological studies indicate that bulbospinal noradrenergic projections contribute to antinociception, lesions of the major brainstem noradrenergic cell groups have provided conflicting evidence. Here we used a new immunotoxin, anti-dopamine beta-hydroxylase-saporin, to re-examine the contribution of noradrenergic pathways to nociception and to morphine analgesia. We treated rats intrathecally by lumbar puncture with the immunotoxin and examined dopamine beta-hydroxylase (DbetaH) immunoreactivity seven and 14 days after treatment. There was no change in DbetaH staining at 7 days; however, 14 days after treatment we demonstrated significant destruction of noradrenergic neurons in the locus coeruleus and in the A5 and A7 cell groups. There was a concomitant loss of noradrenergic axons in the dorsal and ventral horns of the lumbosacral and cervical cord. Consistent with the lack of anatomical changes, we found no difference in nociceptive responses in the hot-plate, tail-flick or formalin tests one week post-toxin. On day 14 we examined the behavioral response to injection of formalin into the hindpaw and found that responses during the second phase of pain behavior were significantly reduced. There was no change during the first phase. Formalin-evoked fos expression in the spinal cord was also reduced. We also evaluated morphine analgesia in the formalin test and found that toxin-treated animals exhibited enhanced morphine analgesia. These results establish the utility of using this immunotoxin to selectively destroy subpopulations of noradrenergic cell groups and provide evidence that acute and persistent nociception are differentially regulated by descending noradrenergic pathways.

Tracheobronchial foreign body is rare in adults. Diagnosis is difficult and requires a high index of suspicion. We report 6 cases of tracheobronchial foreign bodies in adults and their removal, as well as a literature review of this topic. Case records, chest radiographs and computed tomographies (CT) of the thorax were reviewed. There were 5 males and 1 female with a median age of 63.5 years. One patient could not protect his airway (tracheostomy). Foreign bodies were sutures (2), vegetable matter like peanuts, vegetables and popcorn (3), and a voice prosthesis. Main symptoms were cough, haemoptysis and breathlessness. There were few signs on physical examination and chest X-rays were not helpful in diagnosis. All patients had fibreoptic bronchoscopy although 3 subsequently required rigid bronchoscopy for foreign body removal. All foreign bodies were successfully removed without any complications.

This article addresses theoretical principles and clinical descriptions of the phenomenon of race-related stress and trauma experienced by Asian American Vietnam veterans. A conceptual model of race-based stress is presented, comprised of five principles, by which to understand mental health difficulties that can arise in regard to race-based stressors. The model describes (a) the relationship between life threat and physical similarity to the "enemy," (b) the relationship between fear and prejudice, (c) dehumanization as it impacts race hate and combat indoctrination, (d) additive life threat related to exploitation of one's physical similarity to the "enemy," and (e) race-based remorse. The article delineates factors affecting treatment seeking and disclosure of race-based stresses, guidelines for interviewing veterans about race-related events and ethnic self-worth, and the harmful effects of race hate.

Two previously conducted clinical studies assessed lost nonworkplace activity time and lost workplace productivity time due to migraine symptoms in subjects using sumatriptan for 6 months to treat their migraines after a 12- to 18-week period of using their usual therapy without sumatriptan. Although statistically significant differences in lost nonworkplace activity time and lost workplace productivity time between the usual therapy and sumatriptan treatment periods were detected using the Wilcoxon signed-rank test, this test could not determine whether differences were attributable to inherent trends in the data. This current study employed time series analysis, which detects and controls for preexisting trends in data, to further explore the possibility that the observed reductions in lost time in the two clinical studies were related to management of the subjects with sumatriptan. The intercepts and slopes of the computed linear models suggest that the initiation of sumatriptan therapy produced savings of 0.8 hours of nonworkplace activity time and 0.5 hours of workplace productivity time per patient per week. These savings were sustained throughout the sumatriptan treatment period. Preexisting trends in the data were not detected in the models. Thus the productivity gains are not associated with either time effects or the statistical phenomenon of regression to the mean, but variables that are extreme in initial measurements will tend to be closer to the center of the distribution in subsequent measurements. This strengthens the hypothesis that management of migraine with sumatriptan is associated with reductions in lost productivity time.

This article presents a conceptual framework by which to understand race-related post-traumatic stress disorder (PTSD) for the Asian American Vietnam veteran. The framework draws from cognitive schema theory, social behaviorism, the notion of cumulative racism as trauma, and the assumption that bifurcation and negation of one's bicultural identity is injurious. Classifications of race-related stress or trauma that may be experienced by Asian American Vietnam veterans, with exemplifying clinical case material, are presented. These types of stressors include being mistaken for Vietnamese, verbal and physical assaults that are race-related, death and near-death experiences that are race-related, racial stigmatization, dissociation from one's Asian identity, and marginalization. As studies of combat trauma and sexual assault forced the psychological stresses attendant to war and sexist oppression into public consciousness, so this article addresses psychological stress and trauma attendant to racism.