Malcolm Mahadevan
University Health System
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Featured researches published by Malcolm Mahadevan.
Critical Care | 2011
H. Bryant Nguyen; Win Sen Kuan; Michael Batech; Pinak Shrikhande; Malcolm Mahadevan; Chih-Huang Li; Sumit Ray; Anna Dengel
IntroductionImplementation of the Surviving Sepsis Campaign (SSC) guidelines has been associated with improved outcome in patients with severe sepsis. Resolution of lactate elevations or lactate clearance has also been shown to be associated with outcome. The purpose of the present study was to examine the compliance and effectiveness of the SSC resuscitation bundle with the addition of lactate clearance.MethodsThis was a prospective cohort study over 18 months in eight tertiary-care medical centers in Asia, enrolling adult patients meeting criteria for the SSC resuscitation bundle in the emergency department. Compliance and outcome results of a multi-disciplinary program to implement the Primary SSC Bundle with the addition of lactate clearance (Modified SSC Bundle) were examined. The implementation period was divided into quartiles, including baseline, education and four quality improvement phases.ResultsA total of 556 patients were enrolled, with median (25th to 75th percentile) age 63 (50 to 74) years, lactate 4.1 (2.2 to 6.3) mmol/l, central venous pressure 10 (7 to 13) mmHg, mean arterial pressure (MAP) 70 (56 to 86) mmHg, and central venous oxygen saturation 77 (69 to 82)%. Completion of the Primary SSC Bundle over the six quartiles was 13.3, 26.9, 37.5, 45.9, 48.8, and 54.5%, respectively (P <0.01). The Modified SSC Bundle was completed in 10.2, 23.1, 31.7, 40.0, 42.5, and 43.6% patients, respectively (P <0.01). The ratio of the relative risk of death reduction for the Modified SSC Bundle compared with the Primary SSC Bundle was 1.94 (95% confidence interval = 1.45 to 39.1). Logistic regression modeling showed that the bundle items of fluid bolus given, achieve MAP >65 mmHg by 6 hours, and lactate clearance were independently associated with decreased mortality - having odds ratios (95% confidence intervals) 0.47 (0.23 to 0.96), 0.20 (0.07 to 0.55), and 0.32 (0.19 to 0.55), respectively.ConclusionsThe addition of lactate clearance to the SSC resuscitation bundle is associated with improved mortality. In our study patient population with optimized baseline central venous pressure and central venous oxygen saturation, the bundle items of fluid bolus administration, achieving MAP >65 mmHg, and lactate clearance were independent predictors of outcome.
European Respiratory Journal | 2014
Hui Fang Lim; Jason Phua; Amartya Mukhopadhyay; Wang Jee Ngerng; Mei Ying Chew; Tiong Beng Sim; Win Sen Kuan; Malcolm Mahadevan; Tow Keang Lim
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<0.001). On multivariate analysis, the intervention group was associated with lower mortality (OR 0.24, 95% CI 0.09–0.67). ICU admission rates decreased from 52.9% to 38.6% (p=0.008) and inappropriately delayed ICU admissions decreased from 32.0% to 14.8% (p<0.001). There was increased compliance with the aggressive resuscitation protocol after the intervention. A combined intervention, using a pneumonia score to identify those at risk of SCAP early and an aggressive pre-ICU resuscitation protocol may reduce mortality and ICU admissions. IDSA/ATS minor criteria can help identify at-risk SCAP patients for early resuscitation http://ow.ly/rVday
Pediatric Allergy and Immunology | 2015
Yanxia Lu; Hugo Van Bever; Tow Keang Lim; Win Sen Kuan; Daniel Yam Thiam Goh; Malcolm Mahadevan; Tiong Beng Sim; Roger C.M. Ho; Anis Larbi; Tze Pin Ng
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.
Neuropeptides | 2016
Yanxia Lu; Anand Kumar Andiappan; Bernett Lee; Roger C.M. Ho; Tow Keang Lim; Win Sen Kuan; Daniel Yam Thiam Goh; Malcolm Mahadevan; Tiong Beng Sim; De Yun Wang; Hugo Van Bever; Olaf Rötzschke; Anis Larbi; Tze Pin Ng
OBJECTIVE 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. METHODS 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. RESULTS 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 (p<0.05). Compared with the healthy controls, patients with asthma had higher BMI (p<0.001), adiponectin (p<0.05), IL-6 (p=0.001) and CRP (p<0.001), and lower NPY levels (p<0.01). CONCLUSIONS The CT genotype of rs5574 and the GT genotype of rs17149106 are significantly associated with prevalent asthma.
Emergency Medicine Journal | 2013
Heidi Rafman; Siang Ngin Lim; Swee Chye Quek; Malcolm Mahadevan; Chanelle Lim; Aymeric Lim
Background Delayed access to specialist care for emergency patients is associated with increased risk of morbidity and mortality, and increased patient anxiety. Objectives (1) To provide timelier access to inpatient and urgent outpatient specialist care for emergency patients. (2) To influence multiple stakeholders to modify their traditional practices and sustain changes. Setting National University Hospital of Singapore, an academic medical centre with 997 beds in Singapore and over 34 sub-specialties. Methods A set of six interventions was implemented to meet three goals: (1) provide timely access to urgent outpatient specialist care requested by the emergency department ED; (2) increase early inpatient discharges (in order to better match timing of emergency admissions); and (3) provide earlier defined care by inpatient specialists at the ED. An eight-step organisational change management plan was implemented to ensure all specialties complied with the changes. Results The goals were achieved. (1) Specialist outpatient appointments given within the timeframe requested by the ED doctor increased from 51.7% to 80.8%. (2) Early discharges increased from 11.9% to 26.6% and were sustained at 27.2%. (3) 84% of eligible patients received earlier defined specialist care at the ED. The change management achieved excellent clinician compliance rates ranging from 84% to 100%. However the median wait for admission remained unchanged. Conclusion The interventions reduced the time for ED patients to access specialist outpatient and inpatient care. The systematic organisational change management approach resulted in sustained compliance.
International Journal for Quality in Health Care | 2012
Sungwon Na; Win Sen Kuan; Malcolm Mahadevan; Chih-Huang Li; Pinak Shrikhande; Sumit Ray; Michael Batech; H. Bryant Nguyen
Journal of Adolescent Health | 2014
Yanxia Lu; Roger C.M. Ho; Tow Keang Lim; Win Sen Kuan; Daniel Yam Thiam Goh; Malcolm Mahadevan; Tiong Beng Sim; Tze Pin Ng; Hugo Van Bever
European Respiratory Journal | 2014
Kay Choong See; Joy Dizon; Malcolm Mahadevan; Tow Keang Lim; Jason Phua
European Respiratory Journal | 2016
Marion Christine Carteciano; Irwani Ibrahim; Yiong Huak Chan; Malcolm Mahadevan; Tow Keang Lim
European Respiratory Journal | 2013
Hui Fang Lim; Jason Phua; Amartya Mukhopadhyay; Wang Jee Ngerng; Malcolm Mahadevan; Tow Keang Lim