Irwani Binte Ibrahim
Email Address
surii@nus.edu.sg
Organizational Units
YONG LOO LIN SCH OF MEDICINE
faculty
SURGERY
dept
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Publication 24-hr observation unit is safe location for rapid glucose control in uncomplicated severe hyperglycaemia(BMC, 2021-05-30) Ibrahim, I; Macatangay, R; Chai, CY; Khoo, CM; Mahadevan, M; Dr Chew Yian Chai; MEDICINE; SURGERYBackground: Uncomplicated hyperglycaemia is a common presentation in the emergency department (ED). Rapid glucose control is associated with the risk of iatrogenic hypoglycaemia. We sought to determine the safety of a rapid glucose control protocol delivered in a 24-h emergency department observation unit (OU). Methods: This is a retrospective chart review of patients admitted to the OU for hyperglycaemia where the assessing clinician deemed there was no other reason for medical admission apart from hyperglycaemia; and that the patient could be safely discharged provided their hyperglycaemia was adequately treated. The rapid glucose control protocol consists of 4–6 hourly glucose monitoring and insulin injections according to a sliding scale. We report the demographics, reduction in glucose values and the incidence of hypoglycaemia in the OU. We also determine the rate of discharge from OU and the rate of hospital admission at 30 days. Results: We included 101 patients. The mean age was 53.5 years (95% CI 50.4–56.6) and 64% of patients were male. The mean HbA1c value was 12.8% (95% CI 12.3–13.3). The mean admission and discharge glucose values were 27.2 (95% CI 26.3–28.1) and 13.9 (95% CI 13.2–14.6) mmols/l respectively. There was no incidence of hypoglycaemia in the OU. We successfully discharged 90.1% of the patients from the OU, of which 3 (3.3%) patients were admitted to the hospital within 30 days of discharge. Conclusion: ED OU is a safe location to deliver effective management for patients presented with uncomplicated severe hyperglycaemia.Publication Superior performance of N-terminal pro brain natriuretic peptide for diagnosis of acute decompensated heart failure in an Asian compared with a Western setting(WILEY, 2017-02-01) Ibrahim, Irwani; Sen Kuan, Win; Frampton, Chris; Troughton, Richard; Liew, Oi Wah; Chong, Jenny Pek Ching; Chan, Siew Pang; Tan, Li Ling; Lin, Wei Qin; Pemberton, Chris J; Ooi, Shirley Beng Suat; Richards, A Mark; Dr Lin Weiqin; MEDICINE; SURGERY© 2016 The Authors. European Journal of Heart Failure © 2016 European Society of Cardiology Aims: This study was conducted to test the diagnostic performance of NT-proBNP for discrimination of acute decompensated heart failure (ADHF) among breathless patients presenting in an Asian compared with a Western centre. Methods and results: Patients with breathlessness were prospectively and contemporaneously recruited in Emergency Departments in Singapore and New Zealand (NZ). The diagnosis of ADHF was adjudicated by two clinician specialists. A total of 606 patients were recruited in Singapore and 500 in NZ. The discriminative power of NT-proBNP for ADHF was superior in Singapore compared with NZ [area under the curve (AUC) 0.926 vs. 0.866; P = 0.012] both overall and among selected subgroups stratified according to age, renal function, body mass index, and presence or absence of AF or diabetes. Previously established cut-off point values of plasma NT-proBNP yielded comparable sensitivity and negative predictive values, but superior specificity and accuracy in Singapore compared with NZ. The difference in test performance was driven by the younger age (median age 56 years vs. 73 years; P < 0.001), associated with better renal function (estimated glomerular filtration rate 89 vs. 62 mL/min/1.73 m2; P < 0.001), and lower prevalence of AF (9.7% vs. 25.7%; P < 0.001) in acutely breathless patients in Singapore. Conclusion: Considering emerging evidence of a lower average age of presentation with ADHF over most of Asia compared with Western countries, NT-proBNP is likely to be more accurate when applied in Asian centres than in the West.Publication Impact of 24-hour specialist coverage and an on-site CT scanner on the timely diagnosis of acute aortic dissection(SINGAPORE MEDICAL ASSOC, 2020-02-01) Ibrahim, Irwani; Chua, Mui Teng; Tan, Desmond Wei; Yap, Si Hui; Shen, Liang; Ooi, Shirley Beng Suat; DEPT OF SURGERY; DEAN'S OFFICE (MEDICINE); SURGERYINTRODUCTION Acute aortic dissection (AAD) is a rare and potentially fatal condition that has been known to be missed in diagnoses. Our primary objective was to determine if the availability of 24-hour emergency department (ED) specialist coverage and an on-site computed tomography (CT) scanner reduced the rate of missed diagnoses of AAD. METHODS We selected records of patients diagnosed with dissection of the aorta from a hospital's discharge database and death register in the period of January 1998 to December 2014. AAD was defined as missed if imaging to diagnose AAD or a cardiology/cardiothoracic surgical consultation was not obtained in the ED. We compared the rates of missed diagnosis before and after the availability of 24-hour ED specialist coverage and an on-site CT scanner in the ED. RESULTS Among 145 patients, 42 (29.0%) had a missed diagnosis. The proportion of missed AAD was lower in the post-implementation period compared to the pre-implementation period (20.0% vs. 37.3%, odds ratio [OR] 0.42, 95% confidence interval [CI] 0.20-0.89; p = 0.023). After adjusting for confounders, the difference remained significant (OR 0.31, 95% CI 0.14-0.70; p = 0.005). In the post-implementation period, concurrent signs of congestive cardiac failure (OR 33.51, 95% CI 1.42-789.20; p = 0.024) and absence of a widened mediastinum on chest radiography (OR 11.52, 95% CI 1.37-96.80; p = 0.029) were independent predictors of missed diagnoses. CONCLUSION The availability of 24-hour ED specialist coverage and an on-site CT scanner improved the diagnosis of AAD in our study.Publication Emergency Department Management of Sepsis Patients: A Randomized, Goal-Oriented, Noninvasive Sepsis Trial(MOSBY-ELSEVIER, 2016-03-01) Kuan, Win Sen; Ibrahim, Irwani; Leong, Benjamin SH; Jain, Swati; LU QINGSHU; Cheung, Yin Bun; Mahadevan, Malcolm; Dr Win Sen Kuan; SURGERY; DUKE-NUS GRADUATE MEDICAL SCHOOL S'POREStudy objective The noninvasive cardiac output monitor and passive leg-raising maneuver has been shown to be reasonably accurate in predicting fluid responsiveness in critically ill patients. We examine whether using a noninvasive protocol would result in more rapid lactate clearance after 3 hours in patients with severe sepsis and septic shock in the emergency department. Methods In this open-label randomized controlled trial, 122 adult patients with sepsis and serum lactate concentration of greater than or equal to 3.0 mmol/L were randomized to receive usual care or intravenous fluid bolus administration guided by measurements of change of stroke volume index, using the noninvasive cardiac output monitor after passive leg-raising maneuver. The primary outcome was lactate clearance of more than 20% at 3 hours. Secondary outcomes included mortality, length of hospital and ICU stay, and total hospital cost. Analysis was intention to treat. Results Similar proportions of patients in the randomized intervention group (70.5%; N=61) versus control group (73.8%; N=61) achieved the primary outcome, with a relative risk of 0.96 (95% confidence interval [CI] 0.77 to 1.19). Secondary outcomes were similar in both groups (P>.05 for all comparisons). Hospital mortality occurred in 6 patients (9.8%) each in the intervention and control groups on or before 28 days (relative risk=1.00; 95% CI 0.34 to 2.93). Among a subgroup of patients with underlying fluid overload states, those in the intervention group tended to receive clinically significantly more intravenous fluids at 3 hours (difference=975 mL; 95% CI -450 to 1,725 mL) and attained better lactate clearance (difference=19.7%; 95% CI -34.6% to 60.2%) compared with the control group, with shorter hospital lengths of stay (difference=-4.5 days; 95% CI -9.5 to 2.5 days). Conclusion Protocol-based fluid resuscitation of patients with severe sepsis and septic shock with the noninvasive cardiac output monitor and passive leg-raising maneuver did not result in better outcomes compared with usual care. Future studies to demonstrate the use of the noninvasive protocol-based care in patients with preexisting fluid overload states may be warranted.Publication An unusual cause of food-induced anaphylaxis in mothers(2017) Soh, J.Y; Chiang, W.C; Huang, C.H; Woo, C.K; Ibrahim, I; Heng, K; Pramanick, A; Lee, B.W; SURGERY; DUKE-NUS MEDICAL SCHOOL; PAEDIATRICSBackground: Galacto-oligosaccharides (GOS) are prebiotics added to commercial milk formula of infants and mothers. In recent years, cases of allergy related to GOS in atopic children have been reported in the South East Asian region. Case presentations: We describe a series of pregnant (n = 4) and lactating mothers (n = 2) who developed anaphylactic reactions after consumption of maternal milk formula containing GOS. All six subjects had pre-existing atopy and a positive skin prick test to GOS and 5/5 of the subjects who were tested had positive basophil activation tests to GOS. All of the mothers and their babies had normal neonatal outcomes after the reactions. Conclusions: The supplementation of GOS into milk and beverages in the Asian region should take into account the rare chance of allergenicity of GOS in the atopic population. @ 2017 The Author(s).Publication Appropriateness of blood culture: A comparison of practices between the emergency department and general wards(Elsevier BV, 2019-02-01) Choi, ECE; Chia, YH; Koh, YQ; Lim, CZQ; Lim, JC; Ooi, SBS; Ibrahim, I; Kuan, WS; Dr Kuan Win Sen; SURGERY© 2018 Australasian College for Infection Prevention and Control Background: The decision to perform a blood culture is influenced by factors, such as the pretest probability of bacteremia, resource availability and individual clinician's preference. The lack of formal guidelines results in inconsistencies in practices and an inappropriate or overuse of blood cultures. The primary aim of this study is to compare the rate of positive blood cultures in the emergency department (ED) and general ward. The secondary aim of this study is to analyze factors associated with a positive blood culture. Methods: We compared 200 consecutive patients in the ED with 200 consecutive patients with first blood cultures done within 24 h of admission from ED to the general ward. We analyzed the clinical characteristics, proportion of positive blood cultures, and variables associated with a positive blood culture. Results: The percentage of positive blood cultures was 13.5% (n = 27) in the ED group, compared with 6.0% (n = 12) in the general ward group. Contamination rates were higher in the ED compared to general ward (4% vs 0.5%). Heart rate and rigors were independently associated with a positive blood culture in a multivariate logistic regression model. Conclusion: There was a lower rate of positive blood cultures in the general ward group. Reasons may include a lower threshold for performing blood cultures in the general ward, and prior antibiotics in the ED reducing the sensitivity of blood cultures taken in the general ward. Adherence to clinical decision rules and education of junior staff are needed to improve the efficiency of blood culture taking practices.Publication Asynchronous platform for a resident research showcase(WILEY, 2020-09-10) Ibrahim, Irwani; Kuan, Win Sen; Tan, Eugene Yi Qun; See, Kay Choong; Dr Win Sen Kuan; MEDICINE; SURGERY; DEPARTMENT OF COMPUTER SCIENCEPublication Computed tomography of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?(SINGAPORE MEDICAL ASSOC, 2018-04-01) Tan, Desmond Wei; Lim, Annabelle Mei En; Ong, Daniel Yuxuan; Peng, Li Lee; Chan, Yiong Huak; Ibrahim, Irwani; Sen Kuan, Win; Dr Kuan Win Sen; DEAN'S OFFICE (MEDICINE); SURGERY© 2018, Singapore Medical Association. All rights reserved. INTRODUCTION This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability to the Singapore adult population with minor head injury. METHODS We conducted a retrospective study over six months of consecutive patients who presented to the adult emergency department (ED) with minor head injury. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR was assessed by comparing the recommendations for head computed tomography (CT) to its actual usage. RESULTS In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). 249 (71.3%) patients underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. According to the CCHR, head CT was recommended for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) was associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2-36.3) and absence of headache (OR 10.8, 95% CI 1.3-87.4). CONCLUSION Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians’ practices and patients’ preferences may be carried out to evaluate reasons for noncompliance.Publication From ICU to emergency department: 9-year experience with non-invasive ventilation for COPD(2014) Ibrahim, I.; Phua, J.; Goh, E.L.; Mahadevan, M.; Lim, T.K.; MEDICINE; SURGERYIntroduction: Non-invasive ventilation (NIV) has been shown to be beneficial for chronic obstructive pulmonary disease (COPD) patients with persistent respiratory acidosis during acute exacerbations. This clinical study described the experience of implementing an NIV program in the emergency department for COPD patients. Methods: In the pre-implementation phase, patients who presented to the emergency department were transferred to the intensive care unit for NIV. Following the NIV program, patients had NIV commenced in the emergency department. We reported the change in hospital outcomes pre and postimplementation. Results: A total of 153 patients received NIV, 34 in the pre-implementation phase and 119 patients in the post-implementation phase. The mean pH was 7.22±0.07 and the Acute Physiology and Chronic Health Evaluation (APACHE) II score was 18.9±4. Hospital mortality was lower in the post-implementation phase (1.7% versus 11.8%; p=0.008). The median door-to-NIV time was shorter in the post-implementation phase (64 minutes; interquartile range [IQR] 35-113) versus (457 minutes; IQR 143-1320). Conclusions: NIV program in the emergency department is feasible and is associated with better hospital outcomes in patients with COPD.Publication Not all unexplained hypoxia is pulmonary embolism(Singapore Medical Association, 2015) Chua, Mui Teng; Sim, Tiong Beng; Ibrahim, Irwani; SURGERY
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