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Pivot and cluster strategy (PCS) is a cognitive forcing strategy designed to achieve diagnostic accuracy through the analytical deployment of a cluster of differential diagnoses (Cluster) specific to the initial most likely diagnosis (Pivot) recalled by a clinical diagnostician. This approach has been widely implemented and has effectively decreased diagnostic errors. Kahneman et al. have introduced innovative notions of noise and decision hygiene. Noise refers to the variance of errors, with numerous individuals’ errors in judgment pointing in different directions. They suggest a “decision hygiene” (DH) template, w preventative technique meant to reduce noise in decision-making. This paper introduced an interpretation of the existing strategy of PCS from new perspectives of noise and DH, which would allow us to further understand the usefulness of PCS, thereby contributing to a positive effect on the quality of diagnosis.

Sepsis is a major healthcare concern, and remains a leading cause of mortality and critical illness worldwide (1). The global healthcare burden is astronomical; in the largest systematic review that extrapolated data from published national and local population estimates, an estimated 50 million cases and 3 million deaths are associated with sepsis yearly (2). In addition, sepsis is also associated with significant long-term cognitive and functional disability in survivors (3). Recognizing the disease importance and burden, the World Health Assembly, the World Health Organization’s decision-making body, adopted a resolution on improving the prevention, diagnosis and management of sepsis recently on 26th May 2017 (4).

Pneumonia in the tropics poses a heavy disease burden. The complex interplay of climate change, human migration influences and socio-economic factors lead to changing patterns of respiratory infections in tropical climate but also increasingly in temperate countries. Tropical and poorer countries, especially South East Asia, also bear the brunt of the global tuberculosis (TB) pandemic, accounting for almost one-third of the burden. But, as human migration patterns evolve, we expect to see more TB cases in higher income as well as temperate countries, and rise in infections like scrub typhus from ecotourism activities. Fuelled by the ease of air travel, novel zoonotic infections originating from the tropics have led to global respiratory pandemics. As such, clinicians worldwide should be aware of these new conditions as well as classical tropical bacterial pneumonias such as melioidosis. Rarer entities such as co-infections of leptospirosis and chikungunya or dengue will need careful consideration as well. In this review, we highlight aetiologies of pneumonia seen more commonly in the tropics compared with temperate regions, their disease burden, variable clinical presentations as well as impact on healthcare delivery.

A low test threshold for pulmonary embolism(PE) and over reliance on imaging, especially CT pulmonary angiograms(CTPA) is a common behaviour pattern among physicians. Interventions to improve this low threshold for CTPA testing have been mostly ineffective. The innovative Dutch YEARS study reported fewer CTPA examinations in PE diagnosis(van der Hulle et al. Lancet 2017;390:289). However, the YEARS algorithm have not been evaluated in routine clinical practice. Thus, we examined the effects of implementing a pragmatic, modified version of the YEARS algorithm in PE diagnosis. Methods: This is a prospective study of consecutive hospitalized adult patients who underwent CTPA for PE in an acute medicine department. In 2016 we initiated an audit-feedback program to improve the adherence to evidence based guidelines for PE diagnosis and thus, increase the diagnostic rate of PE from CTPA. In 2018 we implemented a modified YEARS protocol. Results: In 2016 the PE detection rate from CTPA was 7.8%. This was associated with more frequent assessment of pre-test risks and D-dimer testing but an insignificant increase in PE diagnosis from CTPA compared with 2015(7%). In 2018, following the introduction of the modified YEARS protocol, this PE diagnosis rate increased to 25%(p Conclusions: Physician education and real-time feedback had a small effect in improving adherence to PE diagnostic protocols and reducing CTPA testing. Implementation of the YEARS protocol resulted in further improvements and merits more extensive evaluation in secular practice.

Introduction: Early diagnosis and treatment of pulmonary tuberculosis (PTB) remains fundamental in reducing transmissions and death. Sputum induction is recommended for the diagnosis of pulmonary tuberculosis (PTB) in patients who are unable to expectorate or smear negative. Objective: The aim of this study was to evaluate the diagnostic accuracy of pooling two induced sputum specimens into one microbiological test over a single day for the diagnosis of PTB. Methods: We prospectively enrolled consecutive hospitalized adults with suspected PTB from 2009–2016. Two induced sputum specimens were obtained on the same day and pooled together for AFB smear, culture and Xpert MTB/RIF testing. The final diagnosis of PTB was based on a positive culture from any respiratory specimen. All patients were followed up for 3 months. Results: Of 420 patients, 86(20.5%) were diagnosed with PTB based on a positive respiratory culture. The sensitivity, specificity, positive and negative predictive values for pooled induced sputum were 98.8% (CI 93.7–100%), 100% (CI 98.9–100%) and 100% (94.6–100%) and 99.7% (CI 98.1–100%) respectively. Xpert MTB/RIF in pooled induced sputum was positive in 88.4% of the PTB patients. Conclusion: In the diagnosis of PTB, testing two induced sputum specimens which were pooled together for one microbiological testing process may be comparable to repeat testing. Keywords: Detection, Reduce transmissions, Smear negative, Induced sputum

Neuropeptide Y, a widely circulating neurotransmitter, plays a pivotal role in energy balance, immunomodulation and asthma, and several NPY polymorphisms are promising genetic risk factors for asthma and obesity. We explored the associations of candidate NPY gene polymorphisms with prevalent asthma and its relationship with obesity in young adult asthma patients free of other chronic medical morbidity.Five common gene variants of NPY (rs16147 (-399T/C), rs17149106 (-602G/T), rs16140 (+1000C/G), rs5573 (+1201A/G), rs5574 (+5327C/T)) previously validated to account for most of the NPY expression in vitro and in vivo were investigated in 126 physician-diagnosed asthma patients without other chronic medical morbidity and 182 healthy controls (21-35years). Plasma levels of NPY, adiponectin, and CRP were determined using ELISA, and IL-6 was measured by Luminex in a subgroup of 70 patients and 69 age- and sex-matched healthy controls.In logistic regression models controlling for gender and obesity, the CT genotype of rs5574 (OR=0.54, 95%CI: 0.30-0.89) and the GT genotype of rs17149106 (OR=5.58, 95%CI: 1.09-28.54) were significantly associated with asthma. No significant interaction between NPY SNP polymorphisms and obesity were detected. Plasma NPY level was correlated with adiponectin levels (p0.05). Compared with the healthy controls, patients with asthma had higher BMI (p0.001), adiponectin (p0.05), IL-6 (p=0.001) and CRP (p0.001), and lower NPY levels (p0.01).The CT genotype of rs5574 and the GT genotype of rs17149106 are significantly associated with prevalent asthma.

INTRODUCTION The presence of trigger factors may help to distinguish asthma from chronic obstructive pulmonary disease (COPD). Knowing and avoiding trigger factors for both asthma and COPD can facilitate the design of comprehensive management programmes that can aid disease control. This study aimed to describe the relative frequency and range of various trigger factors in asthma and COPD. METHODS We conducted a telephone-based survey involving asthma and COPD patients on follow-up at a university hospital in Singapore. RESULTS A total of 779 asthma patients and 129 COPD patients participated in this study. Among these patients, 93.8% of those with asthma and 42.6% of those with COPD had trigger factors (p < 0.001). The median number of trigger factors was greater among asthma patients than among those with COPD (3 vs. 0, p < 0.001). Trigger factors found to be significantly more prevalent among asthma patients compared to those with COPD include tobacco smoke, alcohol, upper respiratory tract infections, incense smoke, perfume, laughter, a dusty environment, air-conditioning, heavy rain, heavy traffic fumes, citrus fruits, gastro-oesophageal reflux, household pets, flowers/pollen, medications and psychological triggers. Trigger factors that were not previously described, such as bathing, fatigue, insufficient sleep, crowded places and overeating, were also reported. CONCLUSION Trigger factors, although found in both groups of patients, were more common among asthma patients. Knowledge of these trigger factors may be useful in distinguishing between the two diseases and optimising disease management.

Background and objective COPD is a complex condition with a heavy burden of disease. Many multidimensional tools have been studied for their prognostic utility but none has been universally adopted as each has its own limitations. We hypothesize that a multidimensional tool examining four domains, health-related quality of life, disease severity, systemic effects of disease and patient factors, would better categorize and prognosticate these patients. Methods We first evaluated 300 patients and found four factors that predicted mortality: BMI, airflow obstruction, St George's Respiratory Questionnaire and age (BOSA). A 10-point index (BOSA index) was constructed and prospectively validated in a cohort of 772 patients with all-cause mortality as the primary outcome. Patients were categorized into their respective BOSA quartile group based on their BOSA score. Multivariate survival analyses and receiver operator characteristic (ROC) curves were used to assess the BOSA index. Results Patients in BOSA Group 4 were at higher risk of death compared with their counterparts in Group 1 (hazard ratio (HR): 0.29, 95% CI: 0.16–0.51, P

Keywords: asthma; biomarkers; chronic obstructive pulmonary disease; environment; eosinophils; rehabilitation

Purpose of review Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Acute exacerbations of COPD (AECOPD) are major driver for healthcare utilization with each exacerbation begetting the next exacerbation. It is, therefore, important to treat each episode effectively to prevent the next. However, this can be challenging as AECOPD result from complex interactions between host, environment and infective agents. The benefits of starting antibiotics in AECOPD, which are not life-threatening (e.g. not requiring mechanical ventilation) or not complicated by pneumonia remain controversial. Recent findings The use of procalcitonin to guide antibiotic therapy in AECOPD has gained interest in recent years. The main advantage of this approach is a safe reduction in antibiotic use in a large group of patients, which may potentially translate to several other benefits. These include reduced antibiotic-related side-effects, reduced risk of developing antibiotic-resistant organisms and cost savings. This approach is associated with no increase in mortality or morbidity such as treatment failure, re-admission, admission to ICU. Summary Procalcitonin-guided antibiotic therapy in AECOPD is a promising and safe approach, which may be ready for the prime time.

Introduction: Asthma mortality in Singapore is high despite moderate asthma prevalence and having a modern, well-resourced healthcare system. Aim: To perform a national audit of severe life-threatening asthma (SLTA) in Singapore and identify gaps in care. Methods: Review of SLTA cases in 4 public hospitals in Singapore between 2011-2015. SLTA was defined as exacerbation requiring mechanical ventilation or intensive care unit/high dependency admission. “Adverse outcomes” (AO) was defined as death, hypoxic ischemic encephalopathy or respiratory arrest. Results: 340 patients accounted for 384 SLTA events, age 55±18y, 56% female and 28.4% had history of SLTA. AO occurred in 59 (15.4%). There was a high proportion of current smokers (22.9%) compared to national smoking rate of 13.3%. Prior to the index SLTA, 17.1% had no regular asthma follow-up, and 32.1% were not on inhaled corticosteroid (ICS) i.e. Step 1 of GINA. The proportion of patients on Step 1 GINA was most prevalent in those not on regular follow-up (79.3%) and those followed-up with private GPs (56.6%) or private pulmonologists (40.0%), and least in patients on follow-up with polyclinic (16.7%) or restructured hospitals (4.6%) (p Conclusion: We identified underuse of ICS and spirometry, lack of regular-follow-up, and high defaulter and smoking rates as gaps in care and potential future areas of intervention among SLTA cases in Singapore.

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Chronic Obstructive Pulmonary Disease (COPD) to provide doctors and patients in Singapore with evidence-based treatment for COPD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on COPD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: https://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Background Obesity is associated with asthma risk and severity, but the underlying biological mechanisms are poorly understood. We hypothesized that cytokine markers of systemic inflammation, and adiponectin and neuropeptide Y (NPY) markers of immuno-modulating and neurohormonal regulation are involved in the obesity–asthma association. Methods We explored the relationships between body mass index (BMI), C-reactive protein (CRP), IL-6, TNF-α, adiponectin and NPY with asthma prevalence and IL-4 levels in 70 youth with asthma and 69 age- and gender-matched healthy controls using cross-sectional and longitudinal data. Results Mean BMI level was higher among patients with asthma than healthy controls (p

Precision in fluid management for shock could lead to better clinical outcomes. We evaluated the association of protocol-based fluid management with intensive care unit (ICU) and hospital mortality. We performed an observational study of mechanically ventilated patients admitted directly from our emergency department to the ICU from August 2011 to December 2013, who had circulatory shock in the first 24 h of ICU stay (systolic blood pressure 4 mmol/L). Patients with onset of shock beyond 24 h of ICU stay were excluded. Protocol-based fluid management required close physician-nurse cooperation and computerized documentation, checking for fluid response (≥10% arterial pulse pressure or stroke volume increase after two consecutive 250-mL crystalloid boluses), and fluid loading with repeated 500-mL boluses until fluid response became negative. Six hundred twelve mechanically ventilated patients with shock (mean [±SD] age, 63.0 years [16.5]; 252 or 41.2% females; mean Acute Physiology and Chronic Health Evaluation II score, 30.2 [8.8]) were studied. The fluid management protocol was used 455 times for 242 patients (39.5% of 612 patients) within the first 24 h of ICU stay, with 244 (53.6% of 455) positive responses. Adjusted for age, sex, Acute Physiology and Chronic Health Evaluation II score, comorbidity, and admission year, protocol use was associated with reduced ICU mortality (odds ratio, 0.60; 95% confidence interval, 0.39-0.94; P = 0.025) but not hospital mortality (odds ratio, 0.82; 95% confidence interval, 0.54-1.23; P = 0.369). Among mechanically ventilated patients with shock within the first 24 h of ICU stay, about half had positive fluid responses. Adherence to protocol-based fluid management was associated with improved ICU survival.

Background & aim: Self-administered asthma action plans (AAPs) are a key element in the maintenance of long term asthma control. The role of self-administered oral steroids in this setting is undefined.(1) Thus, we performed this study to evaluate the effectiveness of self-administered oral prednisolone(OP) in the management of acute asthma exacerbations(AAEs) with AAPs. Methods: This is a before Vs after study of consecutive adult patients attending an asthma clinic all of whom had previously received training in AAPs. During the intervention period, we deliberately and actively promoted the prescription of “standby” OP by physicians and the use of OP by patients during their execution of AAPs during AAEs. Results: We compared patient behavior and clinical outcomes in 94 AAEs before Vs 342 AAEs after the intervention. There was a significant increase in the use of OP from 30/94(32%) to 220/342(66%), p=0.0002. There was a significant reduction in the proportion of patients who needed emergency room visits and/or hospitalizations during AAEs: 26/94(28%) Vs 56/342(16%), p=0.013. After our intervention, unscheduled doctor visits were still needed in 109/342(32%) despite OP being self-administered in 98/109(79%) of these failed AAPs. The duration of OP use was 5 or more days in 168/220(76%) of AAPs which received OP. Conclusions: Promoting the self-administration of OP improved the effectiveness of AAPs. Asthma self -management may fail despite adequate doses and duration of OP. To further optimize the management of AAEs, further evaluation of preventable factors and case-specific interventions such as for poor baseline control, undisclosed triggers and delays in taking APP steps may be indicated. (1)Cochrane2016Dec12:CD0121.

The sine qua non of septic shock is hemodynamic failure, and it is expected that therapy for septic shock is directed at stabilizing the blood pressure, while avoiding complications such as volume overload. Some prior evidence existed to suggest that hyperoxia could induce vasoconstriction (1), while hypertonic saline could be used as a volume-sparing agent for fluid resuscitation. To simultaneously investigate the effectiveness of both hyperoxia and hypertonic saline in septic shock to reduce mortality, Asfar and colleagues conducted the HYPERS2S two-by-two factorial randomized controlled trial (2).

Context The script concordance test (SCT) assesses clinical reasoning under conditions of uncertainty. Relatively little information exists on Z-score (standard deviation [SD]) cut-offs for distinguishing more experienced from less experienced trainees, and whether scores depend on factual knowledge. Additionally, a recent review highlighted the finding that the SCT is potentially weakened by the fact that the mere avoidance of extreme responses may greatly increase test scores. Objectives This study was conducted in order to elucidate the best cut-off Z-scores, to correlate SCT scores with scores on a separate medical knowledge examination (MKE), and to investigate potential solutions to the weakness of the SCT. Methods An analysis of scores on pulmonary and critical care medicine tests undertaken during July and August 2013 was performed. Clinical reasoning was tested using 1-hour SCTs (Question Sets 1 or 2). Medical knowledge was tested using a 3-hour, computer-adapted, multiple-choice question examination. Results The expert panel was composed of 16 attending physicians. The SCTs were completed by 16 fellows and 10 residents. Fourteen fellows completed the MKE. Test reliability was acceptable for both Question Sets 1 and 2 (Cronbach's alphas of 0.79 and 0.89, respectively). Z-scores of − 2.91 and − 1.76 best separated the scores of residents from those of fellows, and the scores of fellows from those of attending physicians, respectively. Scores on the SCT and MKE were poorly correlated. Simply avoiding extreme answers boosted the Z-scores of the lowest 10 scorers on both Question Sets 1 and 2 by ≥ 1 SD. Increasing the proportion of questions with extreme modal answers to 50%, and using hypothetical question sets created from Question Set 1 overcame this problem, but consensus scoring did not. Conclusions The SCT was able to differentiate between test subjects of varying levels of competence, and results were not associated with medical knowledge. However, the test was vulnerable to responses that intentionally avoided extreme values. Increasing the proportion of questions with extreme modal answers may attenuate the effect of candidates exploiting the test weakness related to extreme responses.

Psychiatric comorbidity is reported to be common among adolescents with asthma, but little is known about its underlying psychological factors.This study explored the profile of anxiety and depressive comorbidities among adolescents with well-controlled and poorly controlled asthma and the contribution of neuroticism and perceived stress.The Revised Child Anxiety and Depression Scale, Neuroticism subscale of Big Five Inventory, Perceived Stress Scale, and Asthma Control Test were administered to 198 adolescents (aged 12-19 years) with well-controlled (n = 137) and poorly controlled asthma (n = 61) as well as 171 healthy neighborhood controls.Adolescents with poorly controlled asthma, compared with well-controlled asthma patients and healthy controls, had higher scores of depression (p = .006), panic attacks (p = .002), total anxiety (p = .038), and total internalizing symptoms (p = .017), after adjusting for gender, age, ethnicity, smoking status, and family housing type. Adolescents with asthma had higher neuroticism (p = .025), perceived stress (p = .022), and body mass index (p = .006) and lower self-rated health (p.001) than healthy controls. No significant differences in psychiatric comorbidity scores were observed after accounting for differences in underlying psychological and physical factors. Among asthma patients, increased asthma control was associated with decreased scores of psychiatric comorbidity (p.01), but the association was not significant after allowing for decreased neuroticism and perceived stress.The diagnosis of asthma and poor asthma control in adolescents is associated with excess psychiatric comorbidity, which is likely due to increased neuroticism and perceived stress.

Background and objective Pleural procedures such as tube thoracostomy and chest aspirations are commonly performed and carry potential risks of visceral organ injury, pneumothorax and bleeding. In this context limited information exists on the complication rates when non-pulmonologists perform ultrasound-guided bedside pleural procedures. Bedside pleural procedures in our university hospital were audited to compare complication rates between pulmonologists and non-pulmonologists. Methods A combined safety approach using standardized training, pleural safety checklists and ultrasound-guidance was initially implemented in a ∼1000-bed academic medical centre. A prospective audit, over approximately 3.5 years, of all bedside pleural procedures excluding procedures done in operating theatres and radiological suites was then performed. Results Overall, 529 procedures (295 by pulmonologists; 234 by non-pulmonologists) for 443 patients were assessed. There were 16 (3.0%) procedure-related complications, all in separate patients. These included five iatrogenic pneumothoraces, four dry taps, four malpositioned chest tubes, two significant chest wall bleeds and one iatrogenic hemothorax. There were no differences in complication rates between pulmonologists and non-pulmonologists. Presence of chronic obstructive pulmonary disease (COPD) independently increased the risk of complications by nearly sevenfold. Conclusions Results from this study support pleural procedural practice by both pulmonologists and non-pulmonologists in an academic medical centre setting. This is possible with a standard training program, pleural safety checklists and relatively high utilization rates of ultrasound guidance for pleural effusions. Nonetheless, additional vigilance is needed when patients with COPD undergo pleural procedures.

The effect of employing severity scores to identify severe community-acquired pneumonia (SCAP) cases for early aggressive resuscitation is unknown. Optimising pre-intensive care unit (ICU) care may improve outcomes in patients at risk of SCAP. We conducted a before-and-after study of patients classified into control and intervention groups (January 2004 to December 2007 and January 2008 to December 2010, respectively). Our intervention was two-pronged, using the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) minor criteria to identify SCAP for aggressive emergency department resuscitation. Patients with SCAP, defined as those with three or more IDSA/ATS minor criteria, were targeted. Differences in mortality, triage and compliance with emergency department resuscitation were compared between the groups. The hospital mortality rate was lower in the intervention versus the control group (5.7% versus 23.8%, p

Background and objective Bedside ultrasound allows direct visualization of pleural collections for thoracentesis and tube thoracostomy. However, there is little information on patient safety improvement methods with this approach. The effect of a checklist on patient safety for bedside ultrasound-guided pleural procedures was evaluated. Methods A prospective study of ultrasound-guided pleural procedures from September 2007 to June 2010 was performed. Ultrasound guidance was routine practice for all patients under the institution's care and the freehand method was used. All operators took a half-day training session on basic thoracic ultrasound and were supervised by more experienced operators. A 14-item checklist was introduced in June 2009. It included systematic thoracic scanning and a safety audit. Clinical and safety data are described before (Phase I) and after (Phase II) the introduction of the checklist. Results There were 121 patients in Phase I (58.7 ± 18.9 years) and 134 patients in Phase II (60.2 ± 19.6 years). Complications occurred for 10 patients (8.3%) in Phase I (six dry taps, three pneumothoraces, one haemothorax) and for 2 patients (1.5%) in Phase II (one significant bleed, one malposition of chest tube) (P = 0.015). There were no procedure-related deaths. The use of the checklist alone was associated with fewer procedure-related complications. This was independent of thoracostomy rate, pleural effusion size and pleural fluid ultrasound appearance. Conclusions A pleural checklist with systematic scanning and close supervision may further enhance safety of ultrasound-guided procedures. This may also help promote safety while trainees are learning to perform these procedures.

Background: Little is known of long term patterns of non-invasive ventilation (NIV) initiated in the emergency department (ED) setting. Aim: To determine the trends and outcomes for patients who had NIV initiated in the ED for acute respiratory failure (ARF). Methods: We enrolled consecutive patients who had received NIV in the ED from January 2004 to December 2015 to assess disease trends and hospital outcomes. Results: There were 849 episodes of ARF requiring NIV in the ED with an increasing trend [increase of 7 (95% CI 3 to 12 cases per year, p = 0.006]. The top causes of ARF were COPD 317 (37.3%) and acute pulmonary edema (APO) 292 (34.4%). Initially COPD was the most frequent cause of ARF requiring NIV but, by 2009, APO had overtaken COPD as the most frequent cause. The overall in-hospital mortality was 8.7%. Adjusting for case load, there was decrease in mortality of 0.732% (95% CI 0.2% to 1.4%) per year (p=0.04). The overall endotracheal intubation (ETI) rate was 10.8%. There is no difference in the mortality and ETI rates for COPD versus other causes of ARF (p> 0.05). In COPD patients who were for active resuscitation, the in-hospital mortality was 3.6% (5/165) with zero mortality in the last 3 years and the ETI rate was 15.2% (25/165). Conclusion: Despite the increasing usage of NIV in the ED, we observed a decrease in mortality. APO has overtaken COPD as the most frequent cause of ARF towards the latter half of the study. For COPD patients, there was consistently low in-hospital mortality.

Hiang Ping Chan,1,2 Amartya Mukhopadhyay,1,2 Pauline Lee Poh Chong,1,2 Sally Chin,1,2 Xue Yun Wong,1,2 Venetia Ong,1,2 Yiong Huak Chan,3 Tow Keang Lim,1,2 Jason Phua1,2 1Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Health System, 2Department of Medicine, 3Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Background: How well the 2011 Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification prognosticates for Asian patients with COPD is unknown.Objective: The authors aimed to study the predictive utility of the GOLD 2011 classification for exacerbations and mortality as compared with other multidimensional tools in an Asian population.Methods: In all, 1,110 COPD patients were prospectively followed between March 2008 and March 2013. They were classified using the 2011 and 2007 GOLD guidelines, modified Medical Research Council score, St. George’s Respiratory Questionnaire (SGRQ), and Body mass index, Obstruction, Dyspnea (BOD) index. Outcome measures were exacerbations and mortality. Multivariable survival analyses and receiver operating characteristic (ROC) curves were used to assess the different classification systems.Results: Time-to-event analyses demonstrated earlier exacerbations in 2011’s GOLD D when compared with GOLD A (hazard ratio [HR] 0.54, 95% confidence interval [CI]: 0.31–0.95, P=0.032) and GOLD B (HR 0.62, 95% CI: 0.45–0.85, P=0.003) and higher mortality when compared with GOLD A (HR 0.37, 95% CI: 0.16–0.88, P=0.025) and GOLD B (HR 0.46, 95% CI: 0.31–0.70, P0.05).Conclusion: The 2011 GOLD classification predicts exacerbations and mortality moderately well in Asian COPD patients. Its prognostic utility is similar to that of other multidimensional systems. Keywords: COPD, guideline, morbidity, mortality, prognosis

There is evidence that aspirin and non-aspirin non-steroidal anti-inflammatory drug (NSAID) have anti-carcinogenic properties, but their effect on lung cancer, in particular in never-smokers, is unclear. Information on past or current use of anti-inflammatory medication was obtained in 398 Chinese female primary lung cancer cases and 814 controls in a hospital-based study in Singapore. 65% of cases and 88% of controls were never-smokers. Controls were excluded if they had been admitted for conditions associated with aspirin or NSAID use (n=174). Regular aspirin use (twice a week or more, for a month or more) was associated with a reduced risk of lung cancer (adjusted odds ratio [OR] 0.50, 95% confidence intervals [95%CI] 0.31-0.81 in non-smokers; OR 0.38, 95%CI 0.16-0.93 in smokers). Regular use of non-aspirin NSAID, paracetamol, steroid creams and steroid pills was uncommon and no association with lung cancer was detected. Our results suggest that aspirin consumption may reduce lung cancer risk in Asian women and are consistent with current understanding of the role of cyclooxygenase in lung carcinogenesis.

Background and objective: Pneumonia Severity Index (PSI) predicts mortality better than Confusion, Urea >7 mmol/L, Respiratory rate >30/min, low Blood pressure: diastolic blood pressure 65 years (CURB-65) for community-acquired pneumonia (CAP) but is more cumbersome. The objective was to determine whether CURB enhanced with a small number of additional variables can predict mortality with at least the same accuracy as PSI. Methods: Retrospective review of medical records and administrative data of adults aged 55 years or older hospitalized for CAP over 1 year from three hospitals. Results: For 1052 hospital admissions of unique patients, 30-day mortality was 17.2%. PSI class and CURB-65 predicted 30-day mortality with area under curve (AUC) of 0.77 (95% confidence interval (CI): 0.73–0.80) and 0.70 (95% CI: 0.66–0.74) respectively. When age and three co-morbid conditions (metastatic cancer, solid tumours without metastases and stroke) were added to CURB, the AUC improved to 0.80 (95% CI: 0.77–0.83). Bootstrap validation obtained an AUC estimate of 0.78, indicating negligible overfitting of the model. Based on this model, a clinical score (enhanced CURB score) was developed that had possible values from 5 to 25. Its AUC was 0.79 (95% CI: 0.76–0.83) and remained similar to that of PSI class. Conclusions: An enhanced CURB score predicted 30-day mortality with at least the same accuracy as PSI class did among older adults hospitalized for CAP. External validation of this score in other populations is the next step to determine whether it can be used more widely.

Aim: We sought to compare the effectiveness of acute geriatric units with usual medical care in reducing short-term mortality among seniors hospitalized for pneumonia in the real world. Methods: In a retrospective cohort study, we merged chart and administrative data of seniors aged 65 years and older admitted to acute geriatric units and other medical units for pneumonia at three hospitals over 1 year. The outcome was 30-day mortality. Hierarchical logistic regression modeling was carried out to estimate the treatment effect of acute geriatric units for all seniors, those aged 80 years and older, and those with premorbid ambulation impairment, after adjusting for demographic and clinical characteristics, and accounting for clustering around hospitals. Results: Among 2721 seniors, 30-day mortality was 25.5%. For those admitted to acute geriatric and other medical units, this was 24.2% and 25.8%, respectively. Using hierarchical logistic regression modeling, treatment in acute geriatric units was not associated with significant mortality reduction among all seniors (OR 0.72, 95% CI 0.52–1.00). However, significant mortality reduction was observed in the subgroups of those aged 80 years and older (OR 0.73, 95% CI 0.54–0.99), and with premorbid ambulation impairment (OR 0.65, 95% CI 0.46–0.93). Conclusions: Acute geriatric units reduced short-term mortality among seniors hospitalized for pneumonia who were aged 80 years and older or had premorbid ambulation impairment. Further research is required to determine if this beneficial effect extends to seniors hospitalized for other acute medical disorders. Geriatr Gerontol Int 2013; 13: 55–62.

The authors examined relations between reproductive factors and 5 estrogen pathway gene polymorphisms (CYP17 rs743572, CYP19A1 rs10046, ERβ rs1256049, ERβ rs4986938, and COMT rs4680) among 702 Singapore Chinese female lung cancer cases and 1,578 hospital controls, of whom 433 cases (61.7%) and 1,375 controls (87.1%) were never smokers. Parity (per child, odds ratio (OR) = 0.92, 95% confidence interval (CI): 0.87, 0.97) and menstrual cycle length (for ≥30 days vs.

The relationship between diet and lung cancer, apart from the protective effect of fruit and vegetables, is poorly understood. Reports on the role of dietary components such as meat are inconsistent, and few studies include sufficient numbers of nonsmokers. We examined the relationship between meat consumption and never-smoking lung cancer in a hospital-based case-control study of Singapore Chinese women, a population with low smoking prevalence. Three hundred and ninety-nine cases and 815 controls were recruited, of whom 258 cases and 712 controls were never smokers. A standardized questionnaire (which included a food frequency questionnaire module) was administered by trained interviewers. Among these never smokers, fruit and vegetable intake were inversely associated with lung cancer risk. Seventy-two percent of meat consumed was white meat (chicken or fish). Meat consumption overall was inversely associated with lung cancer [adjusted odds ratio (OR), 0.88, 0.59 for second, third tertiles, P (trend) = .012]. An inverse relationship between fish consumption and lung cancer (adjusted OR, 0.81, 0.47 for 2nd, 3rd tertiles, P (trend).001) was observed. No association was seen between consumption of processed meats and lung cancer, nor between dietary heterocyclic amines and lung cancer. Our data suggest that fish consumption may be protective against lung cancer in never smokers.

Inflammation appears to be important in lung carcinogenesis among smokers, but its role among never-smokers is not well established. We hypothesized that inflammatory medical conditions and gene polymorphisms interact to increase lung cancer risk in never-smokers. We interviewed 433 Singaporean female never-smoker lung cancer patients and 1375 hospital controls, and evaluated six polymorphisms in the interleukin 1-β, interleukin 6 (IL6), cyclooxygenase-2, peroxisome proliferator-activated receptor-γ and interleukin 1-β receptor antagonist (IL1RN) genes. Tuberculosis was associated with a non-significant elevated risk of lung cancer [odds ratio (OR) 1.58, 95% confidence interval (CI) 0.95―2.62]. There was no effect of asthma, atopy or chronic productive cough individually. However, the presence of one or more of these conditions (asthma, cough or atopy) increased risk (OR 2.24, 95% CI 1.15―4.38) in individuals possessing the T/T genotype at interleukin 1-β -31T/C, but not in those possessing the C/T (OR 0.87, 95%CI 0.51―1.57) or C/C genotypes (OR 0.58, 95%CI 0.27―1.27), and in individuals having the * 2 variable number of tandem repeat allele of IL1RN [OR 5.09 (1.39―18.67)], but not in those without (OR 0.93, 95%CI 0.63―1.35). The IL6-634 G allele increased the risk of lung cancer (OR 1.44, 95%CI 1.07―1.94). Lung cancer risk also increased with the number of polymorphism sites where at least 1 'risk' allele was present [interleukin 1-β -31T/C (T allele), IL1RN ( * 2 allele) and IL6-634C/G (G allele)] among those with asthma, cough or atopy (P trend 0.001) but not in those without (P trend 0.47). Our results suggest that the effect of inflammatory medical conditions on lung cancer in never-smokers is modulated by host genetic susceptibility and will need to be confirmed in other studies conducted in similar populations.

Background Epidemiologic data suggest that Chinese women have a high incidence of lung cancer in relation to their smoking prevalence. In addition to active tobacco smoke exposure, other sources of fumes and airborne particles in the indoor environment, such as cooking and burning of incense and mosquito coils, have been considered potential risk factors for lung cancer. Objectives We used a case–control study to explore effects of inhalants from combustion sources common in the domestic environment on lung cancer and their modification by active tobacco smoking. Methods We analyzed 703 primary lung cancer cases and 1,578 controls. Data on demographic background and relevant exposures were obtained by face-to-face interviews in the hospital. Results We observed a positive relationship with daily exposure to incense or mosquito coils and to cooking fumes only among smokers, and no association among lifetime nonsmokers. Interactions between smoking and frequency of cooking, or exposure to incense or mosquito coils were statistically significant and consistent with synergistic effects on lung cancer. The odds ratio (OR) comparing smokers without daily incense or mosquito coil exposure with nonsmokers without daily exposure was 2.80 [95% confidence interval (CI), 1.86–4.21], whereas the OR comparing smokers with daily exposure to the same referent group was 4.61 (95% CI, 3.41–6.24). In contrast, daily exposure to incense or mosquito coils was not associated with lung cancer among nonsmokers (OR = 0.91; 95% CI, 0.72–1.16). We observed the same pattern of associations for smokers without (OR = 2.31; 95% CI, 1.52–3.51) and with (OR = 4.50; 95% CI, 3.21–6.30) daily cooking exposure compared with nonsmokers, with no evidence of an association with daily cooking exposure among nonsmokers. Conclusion Our results suggest that active tobacco smoking not only is an important risk factor for development of lung cancer, but also may cause smokers to be more susceptible to the risk-enhancing effects of other inhalants.

Sepsis is a leading cause of mortality and critical illness worldwide (1). In recognising the significant disease burden, the World Health Assembly, the World Health Organisation’s decision-making body, adopted a resolution on improving the diagnosis, management and prevention of sepsis in May 2017 (2).

To describe the outcomes of patients with bronchiectasis and acute respiratory failure (ARF) treated with noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) after a failure of conservative measures, and to identify the predictors of hospital mortality and NIV failure.Retrospective review of bronchiectatic patients on NIV (n = 31) or IMV (n = 26) for ARF over 8 years in a medical intensive care unit (ICU) experienced in NIV.At baseline, the NIV group had more patients with acute exacerbations without identified precipitating factors (87.1 vs. 34.6%, p0.001), higher pH (mean 7.25 vs. 7.18, p = 0.008) and PaO(2)/FiO(2) ratio (mean 249.4 vs. 173.2, p = 0.02), and a trend towards a lower APACHE II score (mean 25.3 vs. 28.4, p = 0.07) than the IMV group. There was no difference in hospital mortality between the two groups (25.8 vs. 26.9%, p0.05). The NIV failure rate (need for intubation or death in the ICU) was 32.3%. Using logistic regression, the APACHE II score was the only predictor of hospital mortality (OR 1.19 per point), and the PaO(2)/FiO(2) ratio was the only predictor of NIV failure (OR 1.02 per mmHg decrease).The hospital mortality of patients with bronchiectasis and ARF approximates 25% and is predicted by the APACHE II score. When selectively applied, NIV fails in one-third of the patients, and this is predicted by hypoxemia. Our findings call for randomised controlled trials to compare NIV versus IMV in such patients.

The 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) guidelines defined severe community-acquired pneumonia (CAP) and recommended intensive care unit (ICU) admission when patients fulfilled three out of nine minor criteria. These criteria have not been validated.All patients admitted to our hospital from 2004 to 2007 for CAP were reviewed retrospectively. Patients who fulfilled any IDSA/ATS major criteria for severe CAP at the emergency department (ie, the need for mechanical ventilation or vasopressors) were excluded. The predictive characteristics of the IDSA/ATS minor criteria were compared with those of the Pneumonia Severity Index (PSI) and the CURB-65 score for hospital mortality and ICU admission.1242 patients were studied (mean age 65.7 years, hospital mortality 14.7%). The areas under the receiver operating characteristic curves for the IDSA/ATS minor criteria were 0.88 (95% CI 0.86 to 0.91) and 0.85 (95% CI 0.81 to 0.88) for predicting hospital mortality and ICU admission, respectively. These were greater than the corresponding areas for the PSI and the CURB-65 score (p0.05). The sensitivity, specificity, positive and negative predictive values of the minor criteria were 81.4%, 82.9%, 45.2% and 96.3%, respectively, for hospital mortality and 58.3%, 90.6%, 52.9% and 92.3%, respectively, for ICU admission. The minor criteria were more specific than the PSI and more sensitive than the CURB-65 score for both outcomes.These findings support the use of the IDSA/ATS minor criteria to predict hospital mortality and guide ICU admission in inpatients with CAP who do not require emergency mechanical ventilation or vasopressors.

Introduction: The Singapore National Asthma Program (SNAP) was launched in 2001 to address the high burden of asthma in Singapore. One component of the SNAP was directed at improving asthma control in the community by promoting preventive treatment with inhaled corticosteroids. This paper describes the program on prescription patterns of preventor and reliever medication for asthma in the polyclinics. Materials and Methods: We monitored the prescription pattern for asthma as the preventor-reliever (PR) drug ratio. The PR ratio was employed both as a positive feedback tool and as a key performance indicator (KPI) for the program. Individual clinics were encouraged to implement locally relevant and effective initiatives to increase the KPI and facilitate this process. The different methods included chronic care models, multidisciplinary teams, enhanced primary care clinics, pre-counselling screening, decision support tools, self-management support, a patient information system and community education. Results: In the course of the program, the case load for asthma in the polyclinics increased by 31%. During the same period, the average PR ratio increased significantly from 0.68 to 1.80 (P