Original Article
Machine learning to risk stratify chest pain patients with non-diagnostic electrocardiogram in an Asian emergency department
Risk stratification of patients presenting with chest pain poses a frequent, often difficult, challenge to the emergency physician. Cardiac biomarkers such as troponin are an important part of the evaluation of the patient suspected of having acute coronary syndrome (ACS). Serial readings are traditionally needed for troponin, given that...
Original Article
The impact of Anchor, a home visitation programme for maltreated children, on child developmental and behavioural outcomes
Adverse childhood experiences (ACEs) can occur in the form of abuse (physical, emotional, sexual), neglect (physical, emotional) and household dysfunction. The first ACEs study published in 1998 demonstrated the association between ACEs and multiple risk factors of mortality in adulthood.1 The greater the number of ACEs exposure, the higher...
Commentary
Re-evaluating adjuvant systemic therapy in cancer treatment: Scientific rigour to guide policy and practice
In the 1980s, perioperative chemotherapy succeeded in improving survival for children with osteosarcoma and validated a fundamental premise: eradication of micrometastatic disease reduces distant relapse and improves survival for a proportion of patients with solid tumours undergoing curative surgery.1 This data was built upon preclinical insights suggesting that cytotoxic...
Review Article
Pregnancy-associated breast cancer: Management of the mother, fetus and tumour
Breast cancer (BC) is the most common cancer affecting females worldwide, accounting for more than 50% of cancers in young females.1 It occurs in 1 in 3000–10,000 pregnancies, with reported incidence rising with delayed childbearing.2 The age standardised incidence rate in Singapore increased by 24.2% from 1993 to 2002.3...
Letter to the Editor
Optical coherence tomography and acetylcholine provocation for diagnosing coronary vasospasm in MINOCA patients
Dear Editor,
Myocardial infarction with non-obstructive coronary artery disease (MINOCA) occurs in up to 14% of patients presenting with acute coronary syndrome (ACS).1 Clinically, such patients present with ACS symptoms, elevation of troponin and coronary angiograms showing non-obstructive coronary arteries (<50% stenosis).2 MINOCA has myriad aetiologies, which are classified according...
Commentary
A person-centred approach to decision-making and care for persons living with dementia
Assessing mental capacity in persons living with dementia (PLWDs) in high-stakes decision-making is becoming more frequent amid an ageing population with a rising prevalence of cognitive impairment and dementia. A study estimated that the population of PLWDs globally will almost triple by 2050.1
Among the 4 ethical principles—autonomy, beneficence, non-maleficence...
Letter to the Editor
Implementing a fantasy space-themed video distraction programme to reduce sedation in paediatric MRI
Dear Editor,
Magnetic resonance imaging (MRI) is an important diagnostic imaging modality, especially in children where radiation exposure is an important concern. As children undergoing MRI scans need to lie still for an extended period of time in an environment with loud noises, sedation is often required.1 However, its use...
Original Article
Clinical and echocardiographic differences between rheumatic and degenerative mitral stenosis
Mitral stenosis (MS) commonly arises from either rheumatic heart disease or a degenerative calcification of the mitral valve (MV) apparatus.1 Rheumatic heart disease is overall the leading cause of valvular heart disease in the developing world, and rheumatic MS (RMS), with its association with rheumatic fever, remains prevalent in...
Letter to the Editor
Acute respiratory tract infections management in private primary healthcare in Singapore
Dear Editor,
Antibiotic use is medically unnecessary for the majority of Acute Respiratory Infections (ARIs), which are mostly of viral aetiology and self-limiting in nature. Despite this, high rates of antibiotic use in the treatment of ARI persist, particularly in primary care where the most ARI cases are managed.1 In...
Editorial
Enhancing HIV pre-exposure prophylaxis using telehealth: Insights from the iPARTY study
Human immunodeficiency virus (HIV) infections are increasing globally despite significant advancements in preventive and treatment programmes.1 This alarming trend is particularly pronounced within high-risk populations, especially among young men who have sex with men (YMSM). Given these rising infection rates, studies such as the iPARTY study are highly pertinent...
Original Article
iPARTY study: Increasing pre-exposure prophylaxis access and reach via telehealth for young men who have sex with men in Singapore 2022–2023
Human immunodeficiency virus (HIV) infection remains a significant global health challenge worldwide, with 39 million people living with HIV as of 2022.1 In Singapore, there were 209 newly diagnosed cases of HIV infections in 2023, a 3% increase from 2022.2 Although highly active antiretroviral therapy (HAART) effectively suppresses viral...
Letter to the Editor
vNOTES hysterectomy with a homemade glove port: Initial experience in Singapore
Dear Editor,
Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an established surgical method of performing hysterectomy via the vaginal route and is one of the latest editions to the realm of minimally invasive surgery. Since the first vNOTES performed by Su et al. in Taiwan in 2012, vNOTES has...
Original Article
Health-related quality of life in Singapore: Population norms for the EQ-5D-5L and EORTC QLQ-C30
Health-related quality of life (HRQOL) is a multidimensional assessment of the impact of disease and treatment on physical, psychological and social aspects of individuals’ lives.1,2 HRQOL is an important outcome measure of healthcare interventions that is increasingly used in clinical research and practice.1,3 HRQOL instruments may be generic or...
Editorial
Strengthening HRQOL Assessment in Singapore: Updated Norms for EQ-5D-5L and EORTC QLQ-C30
Health-related quality of life (HRQOL) is increasingly used as an important indicator of health outcomes for measuring the impact of illness and treatment among individuals with mental or physical conditions. The EuroQol 5-dimension (EQ-5D) questionnaire is one of the most widely used generic measures for HRQOL and estimating the...
Review Article
Premature ovarian insufficiency: When ovaries retire early
Illustration by LadyFingers Co.
Premature ovarian insufficiency (POI, also known as primary ovarian insufficiency) refers to loss of ovarian activity before the age of 40 years, leading to hypergonadotropic hypoestrogenism and 4 months or more of menstrual disturbance.1 In ovarian insufficiency, the ovarian dysfunction is not necessarily definitive, which is...
Letter to the Editor
A review on adverse airway events during anaesthesia over 6 years in a tertiary referral hospital
Dear Editor,
Comprehensive reviews of perioperative critical airway events (CAE) have been conducted through audits and closed claims analyses. However, there is currently limited published data specific to Singapore. Our study aims to analyse CAE at a tertiary hospital in Singapore, ascertain their frequency, identify risk factors, and compare findings...
Review Article
The efficacy and safety of radiofrequency ablation in papillary thyroid carcinoma: A systematic review and meta-analysis
Malignant nodules account for 5–15% of all thyroid nodules and papillary thyroid carcinoma (PTC) accounts for 85% of that.10 Most guidelines recommend surgery as the first-line treatment for PTC.11 However, surgery does carry a risk for complications, such as hypothyroidism and recurrent laryngeal nerve damage leading to voice hoarseness.12-17...
Letter to the Editor
Effectiveness of an online patient education video for transcatheter aortic valve implantation
Dear Editor,
Anxiety and gaps in medical knowledge have been shown to adversely affect treatment decisions amongst patients and their next-of-kin (NOK).1-3 In a busy clinical setting, physicians may find it time-consuming and challenging to address all aspects of a complex procedure, like transcatheter aortic valve implantation (TAVI) for the...
Letter to the Editor
Barriers to cervical cancer screening and the potential role of HPV self-sampling in Singapore: A cross-sectional study
Dear Editor,
Cervical cancer is a common female cancer and a leading cause of cancer deaths, with about 170 deaths annually in Singapore.1 Despite a population-based screening programme, with government subsidies and affordable co-payments, the current screening rate of 45.4% among 25–74 year-olds,2 falls far below the 70% national target....
Letter to the Editor
Digital health’s impact on the patient-doctor relationship in a primary healthcare setting: A qualitative study
Dear Editor,
The integration of digital health is reshaping the patient-doctor relationship in primary care by challenging its core principles of trust, knowledge, regards, empathy and care continuity. While digital health improves access and empowers patients, it also destabilises the delicate nature of this relationship. Our qualitative study—conducted in 6...
Commentary
Beyond BMI: The Janus-like effect of muscle versus fat on midlife women’s health
Janus—the Roman goddess of natural cycles, change and transitions—is an appropriate symbol for the life-changing shift from the reproductive period to the post-menopausal stage of life. Since the average age of menopause is 50 years,1 it is a universal life stage for long-living Singaporean women. The menopausal transition is...
Original Article
Development and validation of the sarcopenia composite index: A comprehensive approach for assessing sarcopenia in the ageing population
The screening process for sarcopenia typically begins with tests of grip strength and walking speed, with muscle mass evaluated if these initial measurements reveal declines. Diagnostic cut-offs for these indicators are then applied to determine whether values are within normal ranges or indicate deficiencies. Since both muscle function and...
Original Article
Adolescent self-harm and suicide attempts: An analysis of emergency department presentations in Singapore
Within 3 years from 2019 to 2021, adolescent suicide rates in Singapore almost doubled from 5.35 to 9.14 per 100,000 population.1,2 This is against a backdrop of a silently brewing adolescent behavioural and mental health crisis locally and globally, which started before the COVID-19 pandemic but has since been...
Editorial
Complexity in primary care: Beyond multimorbidity in Healthier SG
The global ageing population, particularly older adults with complex biopsychosocial needs, drives increased healthcare utilisation, burdening both the health system and wider society.1,2 Primary care physicians (PCPs) may be uniquely positioned to manage patients with complex health needs, given their role in providing continuous, comprehensive, and coordinated care as a first...
Editorial
Adolescent self-harm and suicide attempts in the emergency department in Singapore
The youth mental health crisis has taken centre stage globally in recent years with increased reporting of young persons suffering from mental health problems and mental illnesses. Singapore is not spared. The COVID-19 pandemic has been largely blamed for the onset of the mental health crisis due to its...
Letter to the Editor
Infected ovarian endometrioma: Case series and management outcomes
Illustration by LadyFingers Co.
Dear Editor,
Infected endometrioma, which is the superimposed infection and abscess formation of ovarian endometrioma, is increasingly understood to be a distinct clinical entity from tubo-ovarian abscess (TOA). The pathophysiology of infected endometriosis has been postulated to be a result of endometriotic fluid acting as a culture...
Letter to the Editor
Navigating the risks of contrast extravasation in CT scans: A 3-year study of 26,544 automated power injector cases
Dear Editor,
We present findings from our large-scale retrospective study on contrast media extravasation (CME) in computed tomography (CT) examinations. Over 3 years, we analysed 26,544 adult CT examinations with intravenous contrast media administered via a power injector to determine CME incidence and evaluate associated risk factors.
CME is a recognised...
Letter to the Editor
Navigating health challenges: Singapore’s National University Health System’s approach to child and family well-being
Dear Editor,
Singapore’s progressive commitment to addressing child and family well-being is anchored in its forward-thinking public health agenda. Recognising that long-term population health outcomes are shaped by early-life interventions, Singapore has directed increasing attention towards addressing complex health challenges that emerge during childhood and across the family unit. These...
Original Article
Prevalence of complexity in primary care and its associated factors: A Singapore experience
As Singapore’s population ages, the incidence of non-communicable chronic diseases will rise in tandem.1 There exists a subset of individuals, oftentimes elderly with multiple chronic conditions, whose care needs are particularly complex.2 While there is no universal definition of a person with complex needs, these individuals have been found...
Review Article
Mechanisms and roles of hydroxychloroquine in pregnancy in rheumatic diseases
With the prevalence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) around the world, hydroxychloroquine (HCQ) has once again come into public attention due to its potential therapeutic role in COVID-19. HCQ is a classic antimalarial drug that belongs to the 4-aminoquinoline phospholipase A2 inhibitors. It was first introduced...
Board of Reviewers
Board of Reviewers 2024
Our sincere thanks to the following peer reviewers who completed and returned their reviews between 1 January 2024 and 31 December 2024. Your expertise and time generously given have been major factors in maintaining the Annals’ high standards. We apologise if we have inadvertently omitted any names. Please inform...
Editorial
Organ donation in the paediatric intensive care unit: Time for change?
Organ transplantation remains the definitive treatment option for improving the lives of patients with end-stage organ failure. To our knowledge, the first solid organ transplantation performed in Singapore in July 1970 involved a kidney from a deceased donor.1 Since then, rapid advancements in both transplant surgery and immunosuppressive medical...
Letter to the Editor
Exploring the perspectives of child health strategy stakeholders on resilience and well-being in children and youths in Singapore: A qualitative study
Dear Editor,
Resilience has been defined as the capacity of a dynamic system to adapt well to potential threats,1 while mitigating the negative impact of behavioural and physiological changes due to chronic stress,2 and the resumption of positive functioning thereafter.3 Resilience enables one to adapt positively to adversities in life...
Letter to the Editor
Knowledge and attitudes towards sarcopenia among healthcare professionals
Dear Editor,
Sarcopenia is the age-related loss of skeletal muscle mass as well as muscle strength and/or performance.1 Sarcopenia is an important public health issue as it has a significant impact on patient health outcomes, and personal and social economic outcomes. It leads to increased adverse outcomes such as increased...
Review Article
Consensus guidelines for the management of treatment-naïve chronic lymphocytic leukaemia in Singapore (2024)
Chronic lymphocytic leukaemia (CLL) is a lymphoid neoplasm characterised by clonal expansion of mature B-lymphocytes and has a characteristic immunophenotypic pattern. CLL prevalence varies considerably across populations. Although CLL is the most common leukaemia in adults in Western countries (25–30% of all leukaemia cases), it is much less common...
Original Article
Radiologic placement of totally implantable venous access devices: Outcomes and complications from a large oncology cohort
Long-term intermittent venous access has proven to be indispensable for oncology patients who require frequent intravenous (IV) infusions and repeated phlebotomies apart from facing the discomfort of frequent venepuncture.1 Totally implantable venous access devices (TIVADs) or ports are preferred to external catheters, especially in these patients, due to their...
Original Article
Long-term survival and clinical implications of allogeneic stem cell transplantation in relapse/refractory lymphoma: A 20-year Singapore experience
Over the past few decades, a wide array of novel therapies has become available for the treatment of relapsed/refractory (R/R) lymphoma. Despite these advancements, outcomes and the durability of disease control remain poor for many patients. While autologous hematopoietic stem cell transplantation (auto-HSCT) may be appropriate for some lymphoma...
Editorial
Interventional radiology placement of totally implantable venous access devices in oncology practice
In November 1929, Werner Forssmann, a German surgical resident, attempted the first documented central venous catheter with a 35 cm-long catheter via his left antecubital vein.1 Although revolutionary for his time, this innovation encountered significant opposition, and he was expelled from his training programme for this unauthorised experimentation. Despite...
Letter to the Editor
Improving school teachers’ self-efficacy and knowledge on food allergy and management of anaphylaxis using a virtual multidisciplinary workshop
Dear Editor,
Children with food allergies are at risk of inadvertent allergic reactions that range from mild to potentially life-threatening anaphylaxis, even with appropriate dietary avoidance.1 This risk is often increased in community settings such as schools via accidental exposure to allergens during learning activities or meal times. A quarter...
Commentary
Navigating the evolving landscape in the prescribing of medications for insomnia in Singapore: Principles and considerations from a psychiatrist’s perspective
The risks of prescribing benzodiazepines and Z-drugs for insomnia are well recognised by regulators, where the prescribing of such medications in contravention of guidelines has been the subject of regulatory action.1,2 Medical practitioners involved in the prescription of such medications need to grapple with complex clinical, legal, ethical and...
Original Article
Epidemiology of paediatric intensive care unit admissions, deaths and organ donation candidacy: A single-centre audit
With advancements in medical care, mortality rates in critically ill patients have decreased substantially.1,2 Contemporary studies from developed countries report paediatric intensive care mortality rates of 2–3%3,4 in 2014 to 2019, whereas mortality in developing countries can be as high as 50%5 as of 2024, indicating large disparities in...
Original Article
Perioperative emergency laparotomy pathway for patients undergoing emergency laparotomy: A propensity score matched study
Patients requiring emergency laparotomy (EL) are a vulnerable subset within general surgery, with reported 30-day mortality rates ranging from 9% to 18%, which is 3 times higher than similar elective operations.1-3 Unlike elective surgeries, the care for EL patients is time-sensitive as they move from the emergency department, radiology...
Letter to the Editor
Knowledge, attitudes and readiness of final-year medical students towards clinical goals-of-care discussion
Dear Editor,
In a rapidly ageing global population,1 there is increasing recognition of the importance of clinical goals-of-care (GOC) discussions aimed at understanding patients’ goals, wishes and care preferences in the event of serious illness or end-of-life situations,2 in order to affirm patient-centred decision-making, improve quality of life and facilitate...
Letter to the Editor
COVID-19 residual symptoms and adverse drug reactions after oral antiviral therapy in the Singapore primary care setting
Dear Editor,
The COVID-19 pandemic remains a significant public health threat with over 7 million deaths worldwide (as of 14 January 2024).1 In Singapore, oral antivirals (OAVs) nirmatrelvir/ritonavir and molnupiravir were approved in 2022 for treating mild-to-moderate COVID-19 in adults at risk of progression to severe disease.2,3 Clinical trials in...
Letter to the Editor
Enhancing care in nursing homes: Qualitative insights from the ENHANCE programme
Dear Editor,
Empower Nursing Homes And improve staNdards of CarE (ENHANCE) was a pilot programme introduced by Sengkang General Hospital to address the challenges faced by Singapore’s ageing population. With nearly 1 in 4 Singaporeans projected to be aged 65 years and above by 2030, the demand for effective long-term...
Review Article
Pharmacogenomics in psychiatry: Practice recommendations from an Asian perspective (2024)
Pharmacogenomic testing in psychiatry is an emerging area with the potential clinical application of guiding medication choice and dosing. Interest in this area has been fanned by commercial pharmacogenomic providers, who have commonly marketed multiple-gene or combinatorial panels that are direct-to-consumer tests. However, this has not been adopted widely...
Editorial
The promise and challenges of pharmacogenomics in psychiatry
Pharmacogenomics (PGx) is an expanding field within precision medicine that is poised to play a crucial role in optimising patient outcomes, particularly in the realm of psychiatry. The remission rate for the initial antidepressant prescribed in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial was only approximately 30%,...
Editorial
Intrapleural fibrinolytic therapy: How low can we get?
Pleural infection is a common medical problem with significant mortality and morbidity.1 Despite advances in antibiotic therapy, the incidence of pleural infection is increasing in the Western world. The management of complicated pleural infections usually involves drainage of pleural effusion from the infected pleural cavity, typically with a pleural...
Review Article
Optimising dementia screening in community-dwelling older adults: A rapid review of brief diagnostic tools in Singapore
Persons living with dementia experience chronic and progressive cognitive decline in 1 or more cognitive domains, affecting their everyday activities.1 Globally, the number of persons living with dementia is expected to rise from 55 million in 2019 to 139 million in 2050, with an estimated two-thirds in lower- and...
Original Article
Intrapleural fibrinolytic therapy for pleural infections: Outcomes from a cohort study
Pleural infection, defined as bacterial infection and replication in the pleural space,1 remains a significant cause of mortality.2 Over 80,000 cases of pleural infection are diagnosed each year in the US and the UK.3,4 Data from East Asia suggest that the annual incidence of pleural infections is 8.4 to...
Letter to the Editor
Prevalence and causes of rifampicin-resistance genotypic/phenotypic discrepancy detected on Xpert MTB/RIF in Singapore
Dear Editor,
The Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) (Cepheid, Sunnyvale, CA, US) has been pivotal in tuberculosis (TB) diagnostics, enabling the rapid detection of both TB and RIF resistance. Xpert, a nucleic acid amplification test (NAAT), is recommended by both the World Health Organization (WHO)1 and Singapore's clinical management guidelines2 as...
Commentary
Transforming medical education in the AI era: Balancing technological expertise with humanistic care in tomorrow’s doctors
Standing at the precipice of a new era in healthcare, the integration of artificial intelligence (AI) into clinical practice is progressing at an unprecedented pace. From AI algorithms detecting tumours with remarkable accuracy to predictive models forecasting patient outcomes, these technological marvels are not only changing how we practice...
Editorial
Evolving therapies for atopic dermatitis: Bridging guidelines and practice
Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin condition characterised by dysregulated type 2 immune responses, skin barrier dysfunction and intense pruritus (itching). The disease burden of AD is substantial, affecting at least 171 million individuals worldwide in 2019, representing 2.23% of the global population.1 Among skin diseases,...
Review Article
Updated consensus guidelines for management of moderate-to-severe atopic dermatitis in Singapore: Integrating biologics, Janus kinase inhibitors and conventional therapies
Atopic dermatitis (AD) is a chronic inflammatory skin disease characterised by dry skin, localised red scaly patches, intense itching and skin pain.1-4 Although its onset most commonly occurs before the age of 5, AD can develop during later childhood, adolescence or adulthood.1-3 Recurrence can also follow extended periods of...
Letter to the Editor
Interdisciplinary approach of conservative kidney management with a community nurse-led programme
Dear Editor,
Conservative kidney management (CKM) should be considered when the burdens of dialysis treatment outweigh the benefits and compromise quality of life. The availability, accessibility and quality of care vary across the world depending on healthcare structure and resources. We explored the feasibility of integrating a nurse-led CKM community...
Commentary
Towards a unified approach: Standardising radiological diagnosis and grading of vertebral compression fractures
Vertebral compression fractures (VCFs) are frequently missed on frontal and lateral chest radiographs.1 Even with abdominal computed tomography, where sagittal imaging is readily available, up to 84% of grades 2–3 compression fractures can be unreported.2 In patients with acute hip fractures, vertebral fractures were found to be unreported in...
Original Article
Unplanned hospitalisations among subsidised nursing home residents in Singapore: Insights from a data linkage study
Hospitalisations pose hazards and safety risks to nursing home (NH) residents who may be frail, cognitively impaired, suffering from multi-morbidities and physically dependent,1 with propensity to develop adverse outcomes such as functional, psychological or cognitive decline, iatrogenic complications, and be subjected to over-investigation.2 There is an imperative for health...
Editorial
Can a Bayesian approach clarify if corticosteroids are beneficial for severe community-acquired pneumonia?
Despite advances in the antimicrobial treatment of sepsis and organ support in the intensive care unit (ICU), community-acquired pneumonia (CAP) remains a leading cause of mortality and disability-adjusted life years lost globally.1 Severe CAP, where CAP becomes complicated by acute hypoxaemic respiratory failure or shock, is also the most...
Letter to the Editor
Natural Language Processing for serious illness communications in palliative surgical oncology
Dear Editor,
Approximately one-fifth of surgeries performed at major cancer centres worldwide are palliative in nature, and one-third of advanced cancer patients receive surgery during their last year of life.1,2 Serious illness communication (SIC) is an essential component of palliative care. In the context of palliative surgical oncology, the surgical...
Review Article
Corticosteroids in critically ill patients with community-acquired pneumonia: A systematic review and Bayesian meta-analysis
Community-acquired pneumonia (CAP) is a common cause of hospital mortality. Each year, in the US alone, more than 1.5 million pneumonia patients are hospitalised, and 1 in 3 of them die within 1 year.1 Mortality is the highest among patients requiring organ support in the intensive care unit (ICU)....
Original Article
Gender dysphoria in children and adolescents: A retrospective analysis of cases in Singapore
The understanding of gender dysphoria (GD) has evolved significantly, from early conflations of sexual orientation and gender identity to its recognition as a distinct condition characterised by gender incongruence. GD is now classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).1 GD is currently defined...
Letter to the Editor
Traction alopecia in women: An under-recognised cause of hair loss
Dear Editor,
Alopecia ranks among the most common clinical complaints encountered by dermatologists.1 In particular, affected women often experience great psycho-emotional stress leading to a reduction in quality of life.2
We conducted a prospective epidemiological study conducted over 77 weeks from 1 August 2022 to 23 January 2024 at an outpatient...
Editorial
Stemming the tide of chronic kidney disease: A focus on primary care prevention
The prevalence of chronic kidney disease (CKD) among Singapore residents aged 18 to 74 years rose significantly from 8.8% in 2019–2020 to 13.8% in 2021–2022.1,2 Singapore ranks third globally for treated end-stage kidney disease (ESKD), with a median survival of 6 years post-dialysis.3 Diabetic nephropathy was the leading cause...
Editorial
Journey towards a smoke-free nation
“A journey of a thousand miles begins with a single step.” Singapore’s journey towards a smoke-free society started early in the 1970s when legislations were introduced to restrict smoking in certain public spaces and ban tobacco advertising.1 The National Smoking Control Programme was launched in 1986 with important objectives...
Letter to the Editor
Serum progesterone in the management of pregnancy of unknown location: A Singapore experience
Dear Editor,
The management of pregnancy of unknown location (PUL) currently encompasses multiple blood tests to trend serum beta-human chorionic gonadotropin (hCG) levels every 48 hours and ultrasound scans (USS). This results in multiple hospital visits for patients, causing emotional and economic distress. Therefore, it is important to identify women...
Letter to the Editor
Cost-effectiveness and clinical outcomes of artificial intelligence-enhanced screening for diabetic foot ulcers: A simulation study
Dear Editor,
Diabetic foot ulcers (DFUs) are a serious complication of diabetes mellitus, with a lifetime risk estimated to be between 19% and 34%.1 Without timely prevention and management, DFUs can lead to lower extremity amputations (LEAs) and premature death.2,3 DFUs also impose significant healthcare and societal costs, especially in...
Original Article
Factors influencing smoking cessation: Insights from Singapore’s nationwide health and lifestyle survey
The global prevalence of smoking has declined over the years. According to authors utilising data from the Global Burden of Disease, Injuries, and Risk Factors Study, from 1990 to 2020, the number of male smokers fell by 27.2%, whereas female smokers fell by 37.9%.1 Moreover, the decline in smoking...
Original Article
Five-year outcomes of a holistic programme for managing early chronic kidney disease in primary care
Singapore has the third highest incidence and sixth highest prevalence of end-stage kidney disease (ESKD) in the world.1 Globally, chronic kidney disease (CKD) is estimated to affect over 850 million people, with a prevalence of 13.4% among adults worldwide.2 Diabetes is the main cause of ESKD in new patients...
Letter to the Editor
Intravenous epoprostenol therapy in the treatment of pulmonary arterial hypertension in Singapore
Illustration by Nata Blackthorn
Dear Editor,
Pulmonary arterial hypertension (PAH) is a progressive disease characterised by significant morbidity and mortality. Intravenous (IV) epoprostenol (Veletri, Johnson & Johnson, US), a prostacyclin analogue, has been shown to improve exercise tolerance, PAH symptoms, haemodynamics and survival.1,2 However, there is a lack of data on...
Letter to the Editor
Automated Cobb angle measurement in scoliosis radiographs: A deep learning approach for screening
Dear Editor,
Adolescent idiopathic scoliosis is the most common paediatric spinal deformity, impacting 1 in 300 children.1 In Singapore and other countries, national screening programmes have been established to detect scoliosis early, with the aim of using bracing to prevent progression to moderate or severe scoliosis, which may require surgical...
Original Article
Enhancing guidelines for managing cognitively impaired drivers: Insights from Western evidence for Asian adaptation
Licensing authorities rely on medical certifications of fitness-to-drive when renewing licence for drivers who are at higher risk of crashes. Drivers with cognitive impairment are 2 to 8 times more likely to be involved in a crash compared to those without such impairments,1 and studies show they have a...
Letter to the Editor
Facing death alone: An exploration of terminally ill individuals living alone in palliative care
Dear Editor,
Home palliative care clinicians provide end-of-life care for patients from diverse social and economic backgrounds. They include patients who live alone—a single-person household.1 Auon et al. found that 7–12% of patients under palliative care lived alone for more than a year.3 Demographic trends increasingly highlight this group to...
Review Article
2023 guidelines on the management of psoriasis by the Dermatological Society of Singapore
Psoriasis is a chronic multisystem, autoimmune and inflammatory dermatological condition. It usually persists throughout one’s lifetime, and spontaneous remission is rarely seen. As per the World Health Organization (WHO), the global prevalence of psoriasis is about 0.09%–11.4%.1
Psoriasis may be linked to other serious diseases, such as depression, psoriatic arthritis...
Original Article
Predictors of early removal of intragastric balloon due to intolerance: Insights from a multiethnic Asian cohort
Obesity, affecting over 2.1 billion people globally, is an escalating health crisis with serious economic consequences.1 It is associated with multiple comorbidities including type 2 diabetes mellitus (T2DM), hypertension, coronary artery disease, stroke, sleep apnea, osteoarthritis and even certain cancers.2 In the US alone, USD190 billion per year is...
Editorial
Optimising paediatric urinary tract infection diagnosis
Urinary tract infection (UTI) is the most common cause of serious bacterial illness among children and infants.1 Up to 2% of boys and 8% of girls will develop at least 1 episode of UTI by the age of 7 years.1,2 Of these, it is estimated that 12% to 30%...
Editorial
Beyond survival: Addressing gaps in psychosocial support for survivors of childhood cancer
I read with great interest the study conducted by Fong et al. published in this issue of Annals, which evaluated psychological symptoms and health-related quality of life (HRQOL) among a cohort of 143 young adult survivors of childhood cancer in Singapore.1 Almost 1 in 4 survivors demonstrated significant psychological...
Original Article
Investigating urinary characteristics and optimal urine white blood cell threshold in paediatric urinary tract infection: A prospective observational study
Urinary tract infection (UTI) is a common diagnosis in the paediatric emergency department (ED). It accounts for an estimated 5–14% of paediatric ED visits yearly in the US.1-3 It is a common cause of serious bacterial infections in children, and the most common microorganism is Escherichia coli (65–75%), followed...
Original Article
Mental wellness and health-related quality of life of young adult survivors of childhood cancer in Singapore
Advancements in technology and cancer treatments have improved childhood cancer survival rates, with up to 85% surviving 5 years or more.1 The Malaysia-Singapore Leukaemia Study Group reported an improvement in overall 5-year survival for the past 20 years in Singapore, from 69% to 91% for acute lymphoblastic leukaemia, which...
Letter to the Editor
Evolving landscape of sports injuries and recommendations on injury preventions: A retrospective analysis in Singapore
Dear Editor,
Sports have become increasingly integral to the daily lives of Singaporeans. According to the National Sport and Exercise Participation Survey, the percentage of Singaporeans exercising weekly rose from 54% in 2015 to 73% in 2023.1 While this surge in sports activities brings numerous health benefits, it also results...
Letter to the Editor
Assessing the accuracy and consistency of generative pretrained transformers in assigning Eastern Cooperative Oncology Group performance status
Dear Editor,
The Eastern Cooperative Oncology Group (ECOG) is a commonly used performance status (PS) scale in oncology. It influences cancer treatment decisions and clinical trial recruitment. However, there can be significant inter-rater variability in ECOG-PS scoring, due to subjectivity in human scoring and innate cognitive biases.1,2 We propose that...
Letter to the Editor
Evaluating the role of technology in disseminating education to patients with chronic kidney disease
Dear Editor,
The optimal management of chronic kidney disease (CKD) requires lifestyle changes and adherence to long-term medications. Knowledge is a component of health literacy and is needed for self-management. Limited health literacy can lead to negative outcomes, such as adverse clinical events and mortality.1
Using technology to improve patients’ knowledge...
Letter to the Editor
“Leveraging ChatGPT to aid patient education on coronary angiogram”: Correspondence
Dear Editor,
“Leveraging ChatGPT to aid patient education on coronary angiogram”1 is an interesting article. The study assessed ChatGPT’s ability to conversely provide information regarding the coronary angiography process, pointing out its advantages and disadvantages. Although ChatGPT provided information in an exhaustive and methodical manner, it also had flaws, including...
Editorial
Deep brain stimulation in Parkinson’s disease: Looking back, looking forward
Patients with Parkinson’s disease (PD) may present with prodromal (e.g. hyposmia, sleep disorders, constipation), motor (e.g. tremors, rigidity, bradykinesia, postural dysfunction) and non-motor (e.g. cognitive dysfunction, depression) symptoms.1 Treatment is symptomatic, targeting motor and non-motor manifestations, but there is presently no effective disease modifying treatment.1 Although PD therapies have...
Letter to the Editor
Impact of risk stratification on cardiovascular outcomes in patients with stable chest pain
Dear Editor,
Chest pain is a common presenting complaint among patients visiting primary care1 and is a frequent reason for referral to the outpatient cardiology clinic. The European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines advocate estimating pre-test probability (PTP) of obstructive coronary artery...
Letter to the Editor
Isolated remote site musculoskeletal Mycobacterium bovis infections after BCG immunisation in immunocompetent children
Dear Editor,
The Bacillus Calmette–Guerin (BCG) vaccine, derived from wild-type Mycobacterium bovis, is administered in an attenuated form to prevent Mycobacterium tuberculous (MTB) infections in children residing in endemic regions. Since the introduction of the Singapore Tuberculosis Elimination Programme in 1997—specifying mandatory BCG-immunisation at birth—the incidence fell drastically to 32.6...
Original Article
Repetitive transcranial magnetic stimulation for major depression and obsessive-compulsive disorders in Singapore
Repetitive transcranial magnetic stimulation (rTMS) is a novel and noninvasive neuromodulation therapy used for treatment-resistant major depressive disorder (MDD)1 and obsessive-compulsive disorder (OCD).2 OCD and depression are disabling psychiatric disorders, which have a detrimental impact on individuals, their families and society.3,4 The lifetime prevalence of depression is high at...
Editorial
Transcranial magnetic stimulation in psychiatry: A Singapore perspective
The use of repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD) and obsessive-compulsive disorder (OCD) has not been described in Singapore. Reports on the effectiveness of rTMS in populations outside of Western countries are also limited. Thus, Ye et al.’s study on the naturalistic outcomes of rTMS...
Original Article
Long-term outcomes of subthalamic nucleus deep brain stimulation for Parkinson’s disease in Singapore
Parkinson’s disease (PD) is a chronic and progressive neurodegenerative disorder characterised by motor symptoms such as limb bradykinesia, rigidity and resting tremor.1 Non-motor symptoms, including mood disturbances, cognitive impairment, autonomic dysfunction, and sleep disorders, are also common. Disease progression often leads to motor fluctuations and dyskinesias, along with worsening...
Review Article
Quality of life of family caregivers of children and young adults with Down syndrome: A systematic review and meta-analysis
The family caregiver is “any relative, partner, friend or neighbor who has a significant personal relationship with, and provides a broad range of assistance for a person with a chronic or disabling condition.”1 Family caregivers for children with chronic illnesses are commonly parents, who fulfil their children’s physical and...
Editorial
Living longer and stronger: Are children and young adults with Down syndrome experiencing healthier and better lives?
Down syndrome (DS) is the most common genetic cause of intellectual disability and is associated with multiple medical conditions affecting various organ systems, impacting the individual’s health, development and function.1 In Singapore, the life-birth prevalence of DS was 0.89 per 1000 births in the 1990s, a figure expected to...
Review Article
Quality of life of children and young adults with Down syndrome from caregivers’ perspective: A systematic review and meta-analysis
Down syndrome (DS), with an incidence of about 1/1000 to 1/1100 live births1 is the most common autosomal trisomy and genetic cause of intellectual disability. Individuals with DS may have multiple comorbidities including congenital cardiac and gastrointestinal anomalies, obesity, sleep disorders, and visual and hearing impairments.2,3 Despite the comorbidities,...
Editorial
How close are we from achieving demographic diversity in clinical trials? Insights from Singapore
Clinical trials are essential for assessing the efficacy and safety of new therapies. Because different patient subgroups may respond variably to treatments, it is important to emphasise diversity among participants. This approach ensures that the trial population accurately reflects the patients who will use the medication in real-world settings...
Others
Correction to Letter to the Editor ‘‘Normative data for baseline and longitudinal neuropsychological assessments in Singapore’’ [Ann Acad Med Singap 2024;1:48]
The authors would like to make a correction in the publication of the original article.
The “modified version of Logical Memory (Immediate and Delayed Recall of an adapted version of Story B)” is removed from the Letter, due to irreconcilable differences in the way the test was administered across the...
Review Article
Demographic diversity of participants in clinical trials conducted in Singapore
Randomised controlled trials (RCTs) and systematic reviews are the most reliable ways of relaying information on the most effective treatments for our patients in clinical practice. The careful design of trials to minimise the possibility of bias ensures that findings are internally valid, but this may threaten their clinical...
Original Article
Trends in fluid overload-related hospitalisations among patients with diabetes mellitus: The impact of chronic kidney disease
Diabetes mellitus (DM) is a major global health problem, contributing to significant clinical disease burden, healthcare expenditure and societal costs.1 In Singapore, DM accounts for 2.9% of disability-adjusted life years and 4.3% of years lived with disability.2,3 By 2030, it is projected to cost approximately USD 1.89 billion in...
Original Article
Association between alcohol flushing syndrome and cancer: A systematic review and meta-analysis
Alcohol flushing syndrome (AFS) is characterised by intense facial flushing, often accompanied by palpitations, headache and nausea shortly after the consumption of alcohol. This phenomenon occurs in up to 46% of East Asians and to a much lesser extent Caucasians, due to the accumulation of acetaldehyde, a metabolic byproduct...
Editorial
The alcohol flushing syndrome: A risk factor for cancer
Globally, alcohol consumption is responsible for an estimated 3 million deaths annually and contributes to over 740,000 new cancer cases each year.1 Acetaldehyde, a byproduct of alcohol metabolism, has been designated as first-class carcinogens by the International Agency for Research on Cancer.2 In East Asian countries such as China,...
Letter to the Editor
Using artificial intelligence as an ethics advisor
Dear Editor,
Ethical dilemmas are common in the practice of medicine and can lead to an array of seemingly reasonable decisions unless policies or regulations mandate certain actions. Choosing the appropriate solution requires not only biomedical evidence, but also requires the balancing of possibly divergent preferences, values, contextual factors and...
Letter to the Editor
The emergence of otter attacks in Singapore: A case series and strategies for management
Dear Editor,
Singapore is experiencing an unprecedented increase in the number of smooth-coated otters (Lutrogale perspicillata). Since 2017, the local otter population has more than doubled to at least 170. This has led to an increase in the number of otter-human attacks since 2021.1,2 While common animal attacks like dog...
Letter to the Editor
Gaps in primary care management of urinary tract infections in Singapore
Dear Editor,
Urinary tract infection (UTI) is a common presentation in primary care, but gaps of care have not been well established in Singapore. UTIs are one of the most common bacterial infections worldwide,1 constituting around 1% of all ambulatory clinic visits.2 The healthcare burden of UTIs remains highly significant,...
Original Article
Screen time and social-emotional skills in preschoolers with developmental, behavioural or emotional issues in Singapore
Preschool children, particularly those with developmental, behavioural or emotional (DBE) issues, are highly vulnerable to the negative effects of excessive screen viewing time (SVT) on their social and emotional development.1,2 Singapore, an island nation with a declining birth rate,3 places significant emphasis on human potential, particularly the social and...
Editorial
Balancing screen time: Insights and impact on preschool children
Over the past decade, the exposure of young children to screen devices at home and preschool has become increasingly common. Screen viewing time (SVT) has risen alongside the surge in ownership of screen devices such as television, smartphones, tablets and laptops worldwide.1 In many countries, screen time and digital...
Editorial
Evaluating the effectiveness of cervical cancer screening and prevention in Singapore
Cervical cancer is the fourth most common cancer in women globally, with approximately 660,000 new cases and 350,000 deaths reported in 2022.1 In Singapore, it ranks as the 11th most common cancer among women and the 5th most frequent cancer among young women aged 15–44 years, with 309 new...
Letter to the Editor
Tele-ECG collaboration between tertiary and primary care in Singapore: Outcomes and learning over a 6-year period
Dear Editor,
An electrocardiogram (ECG) is the mainstay of cardiac evaluation available in primary care, after which assessment in relation to clinical symptoms and signs is made by family physicians to assess the patients holistically. Subsequently, based on this clinical evaluation, patients may then be referred for tertiary review at...
Letter to the Editor
Seroprevalence of cytomegalovirus over the last 2 decades (2001–2020): A retrospective data analysis from a single laboratory in Singapore
Dear Editor,
Cytomegalovirus (CMV) is ubiquitous and infects human of all ages, where it remains latent after primary infection and can reactivate upon various triggers.1 Reactivated CMV may cause complications and end organ damages in immunocompromised hosts, leading to increased morbidity and mortality.2 In addition, the presence of actively replicating...
Letter to the Editor
Predictors of complicated influenza infection in children presenting in a tertiary hospital in a tropical country: A case-control study
Dear Editor,
Influenza causes significant healthcare burden globally1 with highest risks in children and the elderly. In children, multiple studies have identified risk factors for severe influenza such as young age (<5 years), presence of comorbidities, abnormal vital signs (e.g. hypoxia, shock) and bacterial coinfections.2-4 We found similar findings in...
Review Article
Consensus recommendations for optimising the diagnosis and treatment of paroxysmal nocturnal haemoglobinuria in Singapore
Paroxysmal nocturnal haemoglobinuria (PNH) is a rare clonal blood disorder caused by acquired mutations in haematopoietic stem cells.1 Mutations in the X-linked phosphatidylinositol glycan class A (PIG-A) gene and consequent impairment in glycosylphosphatidylinositol (GPI) anchor synthesis result in the deficiency of complement-inhibiting proteins, CD55 (decay accelerating factor) and CD59...
Original Article
Impact of family and caregiver factors on development and behaviours in maltreated young children
Child maltreatment is defined as the neglect and abuse of children under 18 years old. It encompasses physical/emotional ill-treatment, sexual abuse, negligence and/or exploitation that causes harm to the child.1 Evidence has shown that Adverse Childhood Experiences (ACEs), such as maltreatment experienced during childhood, have a significant impact on...
Original Article
Assessing the impact of frailty in elderly patients undergoing emergency laparotomies in Singapore
The ageing population is a growing global phenomenon. In 2019, 14.4% of the population in Singapore, equivalent to 3.9 million people, were aged 65 years or older.1 This percentage is expected to increase to 25% by 2030, primarily due to increased life expectancy and lower fertility rates.1 Consequently, older...
Original Article
Improving the effectiveness of cervical cancer screening: Managing positive high-risk human papillomavirus results
Cervical cancer is one of the most preventable public health challenges worldwide.1-3 In 2020, a global estimate reported that 604,127 new cases of cervical cancer were diagnosed and 341,831 died from it.4 The World Health Organization launched a Cervical Cancer Elimination Initiative in 2018, with an aim to reduce...
Editorial
The value of frailty assessments in older surgical patients undergoing emergency laparotomies in Singapore
Mortality in emergency laparotomy (EL) far exceeds that of elective bowel surgery, and standards for the National Emergency Laparotomy Audit (NELA) in the UK were introduced due to the high mortality within 1 month of EL.1 In Singapore, 30-day mortality varies between 5.4% and 14.7% after EL.2,3 However, 30-day...
Letter to the Editor
A consensus survey of neurologists and clinical geneticists on spinal muscular atrophy treatment in Singapore
Dear Editor,
Just a decade ago, spinal muscular atrophy (SMA) was considered a debilitating, progressive neuromuscular disease that inevitably led to chronic disability and a shortened lifespan. Now, it is treatable with nusinersen, onasemnogene abeparvovec (OAV) and risdiplam—the 3 disease-modifying drugs approved by the US Food and Drug Administration, the...
Letter to the Editor
Group B Streptococcus screening with antenatal culture and intrapartum polymerase chain reaction: A prospective cohort study
Dear Editor,
Group B Streptococcus (GBS) is a common genital and gastrointestinal tract commensal in healthy women. Vertical transmission of GBS may cause neonatal early-onset GBS disease (EoGBS), and this is prevented by intrapartum antibiotic prophylaxis (IAP) GBS colonisation,1 coupled with long turnaround time of GBS culture, challenges the accuracy...
Letter to the Editor
Optimising percutaneous valve-in-valve TAVI with bioprosthetic valve fracture
Dear Editor,
Percutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable patients, for high, intermediate and low surgical-risk patients over 65 years old with severe aortic valve stenosis (AS).1,2 Valve-in-valve (ViV) TAVI is an approved indication for patients with degenerated aortic surgical bioprostheses.
Several ViV TAVI registries...
Letter to the Editor
Factors affecting outcomes among older trauma patients in Singapore: A retrospective observational study
Dear Editor,
Singapore faces a rapidly ageing population with its median age projected to be above 45 years by 2030. Our greying demographics is accompanied by a rise in chronic diseases and medication use, including polypharmacy.1 Longer life expectancy and increased activity levels have contributed to higher incidence of geriatric...
Letter to the Editor
Physician sentiments on low-value investigations in Singapore: Part of Choosing Wisely campaign
Dear Editor,
Low-value investigations provide marginal benefit and may result in harm to the patient or disproportionate healthcare costs.1 The introduction of Singapore’s Choosing Wisely (CW) campaign in 2012 aims to reduce such investigations.2 CW was designed to encourage conversations between physicians and patients to weigh the risk-benefit ratio behind...
Letter to the Editor
Understanding treatment burden in adults with multimorbidity in the Singapore primary care setting: An exploratory study using the Multimorbidity Treatment Burden Questionnaire
Dear Editor,
Patients with multimorbidity often undertake several tasks to manage their health. These include learning about their conditions, taking medications correctly, implementing lifestyle changes, etc., which can be overwhelming and burdensome.1 Their perceptions of the effort required to manage their health conditions and its impact on their general well-being...
Review Article
Holistic preconception care: Providing real-time guidance via a mobile app to optimise maternal and child health
Global fertility rates have decreased by more than half since 1950, recorded at 2.3 births per woman in 2021.1 By 2056, this figure is projected to decline further to 2.09, which falls below the replacement fertility rate of 2.1 children per woman.1 In Singapore, the fertility rate has reached...
Original Article
Delayed presentation is associated with serious bacterial infections among febrile infants: A prospective cohort study
Young infants ≤90 days old are at risk of serious bacterial infections (SBIs) due to their immature immune systems and may develop severe complications resulting in neurocognitive deficits, hearing loss and even mortality.1,2 The diagnosis of SBIs remains challenging as fever may be the only symptom of SBIs in...
Original Article
Diagnostic performance of classification criteria for systemic lupus erythematosus: A validation study from Singapore
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with a broad spectrum of clinical presentation.1 Clinical diagnosis by rheumatologists remains the gold standard, but the diagnosis is often challenging due to variability in disease expression mimicking other conditions.
As such, classification criteria have been developed to establish homogeneous groups...
Letter to the Editor
Comparing the effectiveness, safety and cost of teleconsultation versus face-to-face model of pharmacist-led anticoagulation clinic: A single institution experience
Dear Editor,
Teleconsultation-based (TELE) anticoagulation clinic (ACC) is an alternative modality, but its use in Singapore’s clinical setting has not been well studied. In Tan Tock Seng Hospital (TTSH), the TELE ACC service was established to enrol patients who (1) perform self-testing using a loaned point-of-care (POC) international normalised ratio...
Original Article
Prevalence and risk factors of depression and anxiety in primary care
The global prevalence of individuals living with a mental disorder in 2019 was 970 million, with anxiety and depressive disorders being the most common.1 The Singapore Mental Health Study 2016 showed that the lifetime prevalence of at least one mood, anxiety or alcohol use disorder was 13.9% in the...
Letter to the Editor
Prevalence of tramadol misuse: A pilot multicentre cross-sectional survey in Singapore
Dear Editor,
In Singapore, especially in our healthcare institution, the use of strong opioids for the treatment of chronic non-cancer pain is relatively rare.1 Contrastingly, weak opioids such as tramadol are frequently prescribed for this condition, partly stemming from the widespread belief that tramadol has a better safety profile...
Letter to the Editor
Screening of nasopharyngeal cancer in high-risk familial cohort: A practical approach using a screening algorithm
Dear Editor,
In Singapore, nasopharyngeal cancer (NPC) is among the top 3 cancers afflicting middle-aged males (30–49 years old).1 Unfortunately, patients with early-stage NPC are often asymptomatic, and most patients (approx. 70%) are diagnosed with advanced disease with adversely reduced survival. First-degree relatives of NPC patients have about 4 to...
Commentary
Health District at Queenstown: Catalyst for translational research
Ageing societies dominating global demographics is not new. However, the pace of global population ageing is causing disquietude. In 2017, the global population over age 60 years exceeded those below 5 years for the first time in history, and only 3 years later, the population over age 65 surpassed...
Review Article
Challenges in genetic screening for inherited endocrinopathy affecting the thyroid, parathyroid and adrenal glands in Singapore
In the current landscape of medicine, it is well known that most diseases incorporate a genetic component to some degree. Genetic testing of human diseases originated in the 1950s, and screening for genetic disorders followed a decade after.1 It is worthwhile noting that the Human Genome Project (1990–2003), which...
Review Article
2023 clinical practice guidelines on autism spectrum disorder in children and adolescents in Singapore
(illustration by Nata Blackthorn)
Autism spectrum disorder (ASD) is a neurodevelopmental condition that presents as differences in social communication and social interaction, together with restricted, repetitive behaviours.1 These social communication and interaction differences, as well as restricted, repetitive behaviours, are also referred to as the “core symptoms” of autism. The...
Original Article
Healthcare burden of cognitive impairment: Evidence from a Singapore Chinese health study
Individuals with cognitive impairment (CI) are predisposed to injuries, infections and treatment complications,1 have poorer treatment compliance, and face greater difficulties with post-discharge care.2 These challenges, exacerbated by comorbidities,3-6 lead to poorer ambulatory care management, reduced contacts with primary and outpatient care providers, and greater use of emergency department...
Original Article
Prevalence of consumption of illicit drugs and associated factors from a nationwide epidemiological survey: The Singapore Health and Lifestyle Survey
Substance use disorders (SUDs) are characterised by the uncontrolled use of a substance by an individual despite its harmful consequences.1,2 The prevalence of consumption of substances and SUDs varies widely across countries. This difference in prevalence can be attributed to factors such as study methodology (the substance included in...
Editorial
Promoting evidence-based care for children and adolescents on the autism spectrum
Autism spectrum disorder (ASD) is a neurodevelopmental disorder that has been increasing in worldwide prevalence,1 including Singapore. In this latest issue of the Annals, we share the latest Singapore Clinical Practice Guidelines (CPG) for Autism in Children and Adolescents, discussed by Wong et al.2 This is the culmination of...
Editorial
Illicit drug consumption in Singapore: Where are we in the fight against drugs?
Illicit drug consumption is associated with significant negative health, financial and social consequences. Yet, illicit drug consumption remains highly prevalent and continues to be a growing problem worldwide. In 2021, 1 in 17 people aged 15–64 in the world had used a drug in the past 12 months. Notwithstanding...
Letter to the Editor
VOWELS: A communication framework for disclosing medical errors in medical oncology and palliative care
Dear Editor,
Recognising the impact of medical errors on patients and the doctor-patient relationship has underscored the need for better communication.1,2 For the most part, these efforts are informed by Chafe et al.’s 6 steps that entail: (1) the identification of the error in a timely fashion; (2) determination of...
Letter to the Editor
Patient’s degree of adherence, challenges & preferences towards medicine taking (PACT) in Singapore
Dear Editor,
Medication nonadherence is a prevalent public health problem that compromises patients’ health outcomes and increases healthcare expenditures.1 Studies in Singapore showed that 25.7%–38.9% of patients are nonadherent.2,3 Studies investigating the association between patients’ reasons for nonadherence and their preferences towards adherence enablers are limited. We aimed to (1)...
Letter to the Editor
HLA-B*5801 testing: Is it time to consider mandatory testing prior to prescribing allopurinol in Singapore?
Dear Editor,
Stevens-Johnsons Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe, life- threatening mucocutaneous reactions that most commonly occur as drug-related reactions.1 In recent years, several risk factors for the develop- ment of SJS/TEN, such as genetic factors, have been identified. Notably, carriers of the HLA-B*5801 and HLA-B*1502 alleles ...
Letter to the Editor
Validating two international warfarin pharmacogenetic dosing algorithms for estimating the maintenance dose for patients in Singapore
Dear Editor,
Predicting optimal warfarin dosing is difficult due to complex pharmacodynamics and pharmacokinetics, narrow therapeutic index and susceptibility to many factors.1 Genetic variations of the CYP2C9 and VKORC1 enzymes, occurring in different frequencies in different populations, play a significant role in determining warfarin dosing.1-4 Using pharmacogenetic dosing algorithms to...
Review Article
Clinical performance of automated machine learning: A systematic review
In medicine, machine learning (ML) has been applied in a wide variety of contexts ranging from administration to clinical decision support, driven by greater availability of healthcare data and technological development.1-5 Automated ML (autoML) enables individuals without extensive computational expertise to access and utilise powerful forms of artificial intelligence...
Review Article
The impact of media reporting of suicides on subsequent suicides in Asia: A systematic review
Globally, around 703,000 people die by suicide annually, 77% of which occur in low- to middle-income countries.1 In 2019, suicide was the 4th leading cause of death among younger adults (15–29 years).1 Approximately 60% of the global suicide rates were attributed to Asian countries in 2012,2 with the data...
Original Article
Health practices, behaviours and quality of life of low-income preschoolers: A community-based cross-sectional comparison study in Singapore
Poverty is a serious concern that has been found to bring about various adverse psychological, social and developmental outcomes.1 Living in poverty as a child can affect an individual’s life well into adulthood2 due to risks including poor nutrition, poorly controlled chronic ailments and unstable environments.3,4 Overall, these children...
Original Article
Mitigating adverse social determinants of health in the vulnerable population: Insights from a home visitation programme
Strong evidence consistently links low income to Adverse Childhood Experiences (ACEs) and children’s long-term health, developmental, educational and social outcomes.1,2
Poverty increases parenting stress, and this is especially important in early childhood when the home environment and parent-child bond are the main contributing factors in shaping children’s biological and psychosocial...
Editorial
Bridging expertise with machine learning and automated machine learning in clinical medicine
In this issue of the Annals, Thirunavukarasu et al.'s systematic review on the clinical performance of automated machine learning (autoML) highlights its extensive applicability across 22 clinical specialties, showcasing its potential to redefine healthcare by making artificial intelligence (AI) technologies accessible to those without advanced computational skills.1 This enables...
Editorial
Asian media reporting on suicide: Concerning trends
Asharani et al. present an enlightening study of media influences on suicidality and suicides from multinational data, all within Asia.1 This is important, as knowledge based on media and suicide has been dominated by Western cultures and English and other European languages. Pulling together various independent studies, as Asharani...
Review Article
Singapore tuberculosis (TB) clinical management guidelines 2024: A modified Delphi adaptation of international guidelines for drug-susceptible TB infection and pulmonary disease
Tuberculosis (TB) is an infectious disease caused by the Mycobacterium tuberculosis complex. For decades, it was the leading cause of death worldwide from a single infectious disease before being displaced by COVID-19 during the pandemic years.1
TB is endemic in Singapore, with over 2000 cases of TB disease (formerly active TB)...
Editorial
Fluid management in renal transplantation: Is it time to move towards goal-directed directed therapy?
Achieving optimal fluid balance for a patient undergoing major surgery, especially transplant surgery, has always been the lofty goal of peri-operative care,1 which often proves to be an elusive target. While keeping the patient well hydrated improves organ perfusion, being too generous with fluids can result in morbidity, such...
Letter to the Editor
Challenges to smoking cessation in patients with substance use disorders
Dear Editor,
Despite significant progress in tobacco control measures and stringent smoking policies, cigarette smoking remains one of the largest preventable causes of death and disability worldwide. The World Health Organization estimates that over 8 million global deaths are attributed to smoking yearly, and in Singapore, more than 2,000 Singaporeans...
Letter to the Editor
Hantavirus haemorrhagic fever and renal syndrome, caused by the Hantaan virus in Singapore: A case report
Dear Editor,
We outline a case of a 59-year-old Malaysian man of Indian origin with no known past medical history apart from diabetes mellitus and hypertension, who presented with a 7-day history of unrelenting fever, myalgia, confusion and unsteady gait. He worked as a shipyard engineer and travelled between Singapore...
Letter to the Editor
Oral antiviral utilisation among older adults with COVID-19 in primary care: A population-wide study during successive Omicron waves in Singapore
Dear Editor,
Studies have repeatedly demonstrated the real-world effectiveness of oral antivirals (OAVs) in preventing hospitalisation and death in patients with mild-to-moderate COVID-19 at high risk for progression to severe COVID-19 when initiated within 5 days of symptom onset, even during waves of Omicron transmission.1 However, there is a need...
Commentary
The potential of RNA therapeutics in dermatology
Graphic design by Liu Yujia
Ribonucleic acid (RNA) therapeutics involving, among others, microRNAs (miRNAs), small interfering RNAs (siRNAs) and/or antisense oligonucleotides (ASOs) hold great potential for the advancement of medical treatments in dermatology.
First, there are now novel ways to treat several dermatological conditions where existing treatments have been largely unsatisfactory....
Review Article
Consensus statements and guideline for the diagnosis and management of plantar fasciitis in Singapore
Plantar fasciitis (PF) is a degenerative disorder of the plantar aponeurosis at the insertion of the plantar fascia into the calcaneus, most commonly at the medial tubercle of the calcaneus.1,2 Plantar fascia, or plantar aponeurosis, supports the medial longitudinal arch of the weight-bearing foot. With excessive mechanical loading of...
Original Article
Frailty-aware surgical care: Validation of Hospital Frailty Risk Score (HFRS) in older surgical patients
Frailty is a clinically recognisable state of vulnerability in older people, resulting from age-associated decline in physiological reserves and function across multiple organ systems, such that the ability to cope with acute stressors is compromised.1 Frailty is prevalent among older people2 and is associated with higher rates of utilisation...
Original Article
Defining breast cancer-related lymphedema (BCRL) prevalence and risk factors: A pragmatic approach to lymphedema surveillance
Breast cancer-related lymphedema (BCRL) is a chronic progressive pathological condition of the lymphatic system that can lead to significant impact on the quality of life after breast cancer treatment.1 It is characterised by swelling and accumulation of protein-rich fluid in body tissues, leading to pain, tightness, skin changes such...
Original Article
Effect of drug interactions with non-vitamin-K oral anticoagulants on thromboembolic events in patients with nonvalvular atrial fibrillation
Atrial fibrillation (AF), a type of arrhythmia for which the incidence and prevalence are rising in the older population, has become a global epidemic.1 The estimated prevalence of AF is approximately 2% to 4%,2,3 and its prevalence is projected to increase by 2.3-fold by 2030.3 Older patients with AF...
Editorial
Breast cancer-related lymphedema (BCRL): Should we be doing more or less for the axilla?
Breast cancer mortality has declined steadily over the years with breast cancer screening, and improvement in diagnostic and therapeutic regimens. Despite cancer survivors living longer, breast cancer-related lymphedema (BCRL) is a significant complication after major breast surgery that can impact quality of life adversely. The incidence of BCRL reported...
Editorial
Direct oral anticoagulant: Looking beyond convenience
Since the 2010 Food and Drug Administration approval of Dabigatran as the first non-vitamin-K antagonist oral anticoagulants or direct oral anticoagulants (DOACs) as it is now more commonly referred to, there has been much development in the field with increasing availability of different DOACs and an expansion in indications...
Board of Reviewers
Board of Reviewers 2023
Our sincere thanks to the following peer reviewers who completed and returned their reviews between 1 January 2023 and 31 December 2023. Your expertise and time generously given have been major factors in maintaining the Annals’ high standards. We apologise if we have inadvertently omitted any names. Please inform...
Letter to the Editor
Redefining seropositive rheumatoid arthritis: Clinical implications of anti-carbamylated protein on remission, radiographic damage and quality of life
Dear Editor,
Rheumatoid arthritis (RA) is a chronic disabling disease where continued disease activity translates to irreversible articular damage. Seropositivity for rheumatoid factor (RF) and anticitrullinated protein antibody (ACPA) are markers of poorer prognosis; with increased disease activity, radiographic progression and even mortality.1 However, other than ACPA, no other biomarker...
Letter to the Editor
Development of immediate and chronic spontaneous urticaria following mRNA COVID-19 vaccination: Tolerability of revaccination and immunological study
Dear Editor,
Coronavirus 2019 (COVID-19) vaccination remains one of the key public health measures against the SARS-CoV-2 infection, significantly reducing illness severity and mortality rates. Urticaria and/or angioedema are cutaneous reactions that have been reported in response to messenger RNA (mRNA) COVID-19 vaccination and potentially affect fitness for revaccination.1...
Letter to the Editor
Perinatal outcomes of pregnancies affected by COVID-19 in Singapore: A cohort study
Pregnant women and infants were not spared from the coronavirus disease 2019 (COVID-19) after it was first identified in December 2019.1,2 In the beginning of the pandemic, a lack of data on transmission risks and outcomes of pregnancies affected by SARS-CoV-2, impacted perinatal clinical decision-making.1,3 We report the perinatal...
Letter to the Editor
Normative data for baseline and longitudinal neuropsychological assessments in Singapore
The authors have made a correction to this article at
https://doi.org/10.47102/annals-acadmedsg.2023-98correction
Dear Editor,
Neuropsychological assessments play a vital role in the early detection of cognitive disorders. However, the lack of Singapore-specific norms has resulted in a reliance on international, usually Western, norms that potentially reduce the accuracy and reliability of assessments due...
Commentary
Call for a Singapore National Action Plan for Sepsis (SNAPS): Stop sepsis, save lives
Sepsis is a life-threatening organ dysfunction syndrome caused by a dysregulated host response to an infection.1 It affects up to 48.9 million people globally every year and causes 11 million sepsis-related deaths, accounting for 1 in every 5 deaths worldwide.2 The huge disease burden leads to significant consumption of...
Review Article
Oocytes on ice: Exploring the advancements in elective egg freezing for women
Elective egg freezing (EEF), otherwise known as oocyte cryopreservation for age-related fertility loss, has become a viable option for single women to preserve their fertility.1 It is well known that female fertility decreases gradually, but significantly after the age of 32 and even more rapidly after age 37.2,3 As...
Review Article
Strategies to prevent cardiovascular disease in Singapore: A call to action from Singapore Heart Foundation, Singapore Cardiac Society and Chapter of Cardiologists of the Academy of Medicine, Singapore
Despite the success of Singapore’s public health systems in providing medical care through the country, there is still much to be achieved in terms of optimising the cardiovascular (CV) health of its 6 million residents. According to the 2019 Global Burden of Disease report, while the incidence rate of...
Original Article
Caregiver reported long-term outcomes in children with major trauma and traumatic brain injuries: A single-centre retrospective study
Traumatic injuries in children are a significant cause of mortality and morbidity worldwide.1 Children with major trauma are at risk of poor outcomes.2-4 These include disabilities that require assistance with activities of daily living, intellectual disability and behavioural problems.5 In the US, it is estimated that more than 50...
Original Article
Anti-osteoporosis drugs reduce mortality in cancer patients: A national cohort study of elderly with vertebral fractures
Osteoporotic vertebral fractures (OVFs) are the most prevalent type of fragility fractures, affecting 25% of adults in their early 70s and 43% of those over the age of 80.1,2 Following an OVF, persistence of the vertebral deformity may lead to spinal kyphosis, which is associated with chronic lower back...
Editorial
Freezing hope: Balancing realism and optimism in elective egg freezing
The 2022 White Paper on Singapore Women’s Development, which aimed at a fair and inclusive society where both women and men can pursue their aspirations fully, announced the option for elective egg freezing (EEF) and that the age limit for EEF was planned to be set at 35 years....
Editorial
Anti-osteoporosis drugs and reduction of mortality in cancer patients
Osteoporosis and cancer share a complex relationship, with each condition influencing the progression and outcomes of the other.1 Multiple factors, such as chemo- and hormonal therapies, and the direct invasion of bone tissue by malignant cells contribute to the accelerated bone loss seen in cancer patients.1 Various anti-osteoporosis drugs,...
Letter to the Editor
Knowledge, attitudes and practices of doctors on constipation management in Singapore
Dear Editor,
Constipation is a common gastrointestinal disorder, affecting about 15% of the global population and severely impacting patients’ quality of life.1 The global constipation treatment market is estimated to worth USD22.93 billion in 2025. Patients with functional constipation had the highest treatment dissatisfaction at 63.4%. Poor satisfaction was reported...
Letter to the Editor
Four cases of HIV infection in men taking pre-exposure prophylaxis in Singapore
Dear Editor,
Pre-exposure prophylaxis (PrEP) with co-formulated tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) is an effective prevention strategy against sexual transmission of human immunodeficiency virus (HIV) in at-risk populations.1 It can be taken daily, or on-demand for cisgender men who have sex with men (MSM) and transwomen who have...
Letter to the Editor
Outcomes of COVID-19 infection in patients on dialysis and kidney transplant recipients: A single-centre audit
Dear Editor,
Patients with end-stage kidney disease (ESKD) are at increased risk of adverse outcomes following COVID-19 infection. Their vulnerability stems from multiple factors including kidney failure, comorbid illnesses, close contact in the haemodialysis centre, and transplant immunosuppression. European registry data in the pre-vaccination era report a COVID-19 mortality rate...
Commentary
Artificial intelligence in medicine: Ethical, social and legal perspectives
“Our future is a race between the growing power of our technology and the wisdom with which we use it. Let's make sure that wisdom wins.” — Stephen Hawking
The tsunami of artificial intelligence (AI) has arrived in medicine, penetrating every clinical specialty. Deep learning algorithms enable highly sensitive and...
Review Article
A systematic review and meta-analysis on the effect of goal-directed fluid therapy on postoperative outcomes in renal transplantation surgeries
Renal transplantation is the superior treatment for chronic kidney disease patients, providing better survival outcomes and quality of life compared with other renal replacement therapies.1 The recipient's intraoperative fluid management is crucial due to its impact on postoperative graft function, morbidity and mortality.2-6 However, fluid management in such patients...
Review Article
Polycystic ovary syndrome v.2023: Simplified diagnostic criteria for an East Asian phenotype
Polycystic ovary syndrome (PCOS) is a common endocrine condition affecting 6–19% of women of reproductive age, depending on the reference population and definition used.1,2 The incidence of PCOS is increasing and the syndrome can be considered the single most common endocrine abnormality among women of reproductive age.3 Although its...
Original Article
An augmented reality mobile application for weight estimation in paediatric patients: A prospective single-blinded cross-sectional study
Drug and defibrillation energy doses for children rely on accurate weight measurement, making it essential during emergencies.1,2 However, quickly weighing children in distress is often a challenging task.3,4 Conventionally, age-dependent formulas and length-based tapes like the Broselow tape (BT) and Paediatric Advanced Weight Prediction in the Emergency Room extra-long...
Original Article
Understanding the use of evidence-based medical therapy in patients with peripheral artery disease: A qualitative study using TCID Framework
The global burden of peripheral artery disease (PAD) has been increasing, with 237 million adults living with PAD worldwide in 2015,1 rising from 202 million in 2010.2 A population-based study in Singapore found the overall prevalence in Chinese, Malays and Indians to be 3.5%, 5.2% and 5.6%, respectively.3 Given...
Editorial
Enhancing the accuracy of polycystic ovary syndrome diagnosis
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder, experienced by 1 in 10 women of childbearing age. Its aetiology is multifactorial and complex, and its clinical presentation is heterogeneous with menstrual irregularities, high levels of androgens and the presence of multiple follicles or cysts in the ovaries...
Editorial
Vascular surgeons and best medical therapy: Missed opportunities?
Multiple guidelines recommend the use of best medical therapy (BMT) as secondary prevention for patients with peripheral arterial disease (PAD) but prescription and adherence are generally sub-optimal.1 The issue is not specific to vascular surgeons. Patients referred with suspected peripheral arterial disease are only started on antiplatelet agents and...
Letter to the Editor
Outcomes of a targeted congenital cytomegalovirus infection screening approach among infants born ≥35 weeks gestation
Dear Editor,
Cytomegalovirus (CMV) is a common cause of congenital viral infection. The estimated incidence of congenital CMV (CCMV) is about 1–6% worldwide, although reliable estimates from Singapore and surrounding countries are unavailable.1,2 Previous local serologic studies among pregnant women reported high rates of CMV seropositivity (>80%),3 highlighting the possible...
Letter to the Editor
The practice patterns and perceptions of surgeons in Singapore regarding breast-conserving surgery
Dear Editor,
Breast-conserving surgery (BCS) is often the preferred treatment in operable breast cancer.1 While tumour biology and systemic therapy are major determinants of disease control, surgical effectiveness remains a key factor in ipsilateral breast tumour recurrence.1 As heterogeneity in surgical approach has been observed, we sought to understand Singaporean...
Commentary
Value the patient as a person: Answering the call for a person-centred model of care
There has been a change in patients’ attitudes towards healthcare professionals in recent decades, coupled with an increasingly evident shift in the care paradigm. In 2015, the World Health Organization released a framework of care that recommends healthcare professionals consciously consider the perspectives of individuals, carers, families and communities....
Review Article
Improving visual outcomes in patients with rare paediatric eye diseases
Rare diseases are generally understood as those that affect less than 1 in 2000–2500 people in the general population.1 They are defined to affect fewer than 200,000 people in the US, lesser than 1 in 2000 people in Europe and lesser than 1 in 2500 people in Japan.2 Rare...
Review Article
AL amyloidosis: Singapore Myeloma Study Group consensus guidelines on diagnosis, treatment and management
Amyloidosis refers to disorders characterised by the deposition of insoluble amyloid fibrils, which are pathogenic,1 resulting in organ dysfunction. Amyloidoses differ in the protein precursor undergoing aggregation and downstream target organs implicated. Consequently, clinical manifestations are varied, from localised amyloidosis in Alzheimer’s disease, to systemic amyloidosis such as immunoglobulin...
Original Article
Clinical utility of PET/MRI in multiple myeloma
Multiple myeloma (MM) is a haematological malignancy characterised by abnormal accumulation of malignant plasma cells and is associated with anaemia, renal impairment, hypercalcemia and bone lesions. A sensitive method to detect bone lesions is crucial as it could determine the decision to start treatment. In this era, the International...
Original Article
Real-world data on the use of emicizumab in patients with haemophilia A with and without inhibitors in Singapore
Haemophilia A is an X-linked hereditary bleeding disorder caused by pathogenic genetic variants, which results in a deficiency of factor VIII (FVIII).1 The mainstay of treatment is FVIII replacement, which can be administered as prophylaxis or on-demand.2 While FVIII replacement has greatly improved outcomes in people with haemophilia A,...
Original Article
Risk of dementia in the elderly with non-alcoholic fatty liver disease: A nested case-control study in the Republic of Korea
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease affecting about 25% of the general population.1,2 NAFLD has a broad disease spectrum ranging from simple hepatic steatosis to non-alcoholic steatohepatitis (NASH)/liver cirrhosis, resulting in increased risk of developing not only liver-related complications but also extrahepatic morbidities.3...
Original Article
Burden of antibiotic resistance in infections among very-low-birthweight infants in Singapore
Recent reports have described an increased predominance of Gram-negative organisms (Escherichia coli, Klebsiella species ) among invasive bacterial infections in early- and late-onset neonatal sepsis in many settings.1-5 This changing pattern of infections is particularly concerning due to the global spread of drug resistance among Gram-negatives, leading to increasingly...
Editorial
Improving management of AL amyloidosis
In this issue of the Annals, Tan et al. on behalf of Singapore Myeloma Study Group presented the consensus guidelines on light chain (AL) amyloidosis.1 This is an encouraging effort as AL amyloidosis is a rare disease, with diagnostic and therapeutic challenges. A comprehensive review examining its pathophysiology, diagnostic...
Editorial
Paradigm shifts in haemophilia A therapy with emicizumab prophylaxis in Asia
Over the past decade, the development of emicizumab, the first-in-class factor VIII (FVIII)-mimetic monoclonal antibody bispecific to activated factor IX and factor X, has ushered in a significant revolution in non-factor replacement therapy for patients with congenital FVIII deficiency or haemophilia A (HA). This groundbreaking therapy has been unequivocally...
Letter to the Editor
How do current paediatrics residency selection criteria correlate with residency performance?
Dear Editor,
The selection process for potential residents needs to be reviewed regularly and assessed if effective in selecting the best-fit residents who can achieve academic and professional excellence. Objective measures must take precedence over subjective criteria to reduce selection bias while ensuring transparency and accountability. However, the predictors of...
Letter to the Editor
Treatment outcomes of micropulse cyclophototherapy in uveitic glaucoma
Dear Editor,
We present a case series, describing the utility of micropulse cyclophototherapy in the treatment of uveitic glaucoma.
Prevalence of glaucoma in patients suffering from uveitis was estimated to be 7.6% at 12 months after acute uveitis, and 11.1% at 5 years with chronic uveitis.1,2 Uveitic glaucoma is usually associated...
Commentary
Singapore’s experience in managing the COVID-19 pandemic: Key lessons from the ground
In the early days of the pandemic when information on COVID-19 infection was lacking, all COVID-19 positive patients were admitted into acute hospitals for isolation and monitoring. With the exponential increase in the number of infections, COVID-19 Treatment Facilities (CTFs) were set up to help hospitals manage in-patient loads....
Review Article
Cardiovascular effects of COVID-19 in children
The global coronavirus disease 2019 (COVID-19) pandemic was caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While the respiratory system is the primary infectious target of SARS-CoV-2, systemic symptoms are fairly common and organ systems throughout the body can be affected with multisystem organ failure in the...
Original Article
Long COVID prevalence, risk factors and impact of vaccination in the paediatric population: A survey study in Singapore
On 5 May 2023, more than 3 years since the start of the COVID-19 pandemic, the World Health Organization (WHO) declared that COVID-19 no longer constituted a public health emergency. Despite high numbers of children and younger persons (CYPs) having acute COVID-19,1 information on the quality of health and...
Original Article
Thiazide and thiazide-like diuretics associated with improved cardiovascular and renal outcomes for chronic kidney disease patients
Chronic kidney disease (CKD) is an increasingly pressing global health issue due to its strong link to serious complications such as end stage renal disease (ESRD), cardiovascular disease (CVD) and mortality.1 Over the last few decades, its impact has become more severe, moving from 27th to 18th on the...
Original Article
Association of quality-of-care indicators with asthma outcomes: A retrospective observational study for asthma care in Singapore
Asthma, a chronic inflammatory disorder of the airways,1 is a common respiratory condition, with an estimated 262 million people affected worldwide.2 In Singapore, 5% of residents aged 18–69 years are affected.3 Despite the high standard of healthcare in Singapore, asthma control is a concern, as evidenced by high mortality...
Editorial
COVID-19: The virus, vaccine and paediatric heart
The coronavirus disease 2019 (COVID-19) pandemic has resulted in much morbidity and mortality around the world. The development of vaccines has cushioned the effect of the virus and thus, provided hope in the fight against the disease.1 Yet, there are still small battles with COVID-19, at the bench and...
Editorial
Thiazide diuretics in chronic kidney disease: Is there still a role?
“The young physician starts life with 20 drugs for each disease, and the old physician ends life with one drug for 20 diseases.” — William Osler
Hypertension is both a cause and consequence of chronic kidney disease (CKD). As such, the prevalence of hypertension is high among CKD patients and...
Editorial
Real-world data to measure and improve quality of asthma care
In this issue of the Annals, the paper “Association of quality-of-care indicators with asthma outcomes: An observational study for asthma care in Singapore” by Lam et al.1 illustrates the use of real-world data to generate real-world evidence in the area of asthma care in Singapore.
Asthma is a chronic health...
Letter to the Editor
Outcomes of patients admitted for drowning
Dear Editor,
According to the latest Utstein-style consensus, drowning is defined as the primary respiratory impairment resulting from submersion or immersion in a liquid medium.1 Patients may experience hypothermia, acute respiratory distress syndrome and shock.1 The pathophysiology is poorly understood, but could relate to physiological responses to temperature, water swallowing...
Letter to the Editor
A case series of higher-order multifetal pregnancies managed at a tertiary maternity unit
Dear Editor,
Delayed childbearing and increased use of assisted reproduction technology (ART) have resulted in a dramatic rise in the incidence of multifetal pregnancies. In 2022, the incidence of twin birth was 1 in 38.2 (932 live births) and triplet birth 1 in 1978 (18 live births) in Singapore.1 Preterm...
Letter to the Editor
Impact of an ageing population on the intensive care unit
Dear Editor,
Intensive care unit (ICU) resources are scarce and expensive, and deciding if intensive care is suitable for older patients involves complex clinical reasoning, ethical challenges and cost considerations. Although some studies show that ICU mortality increases with age, others suggest that age alone is not predictive of poor...
Commentary
Transforming radiology to support population health
The recent launch of Healthier SG—a national initiative by Singapore’s Ministry of Health (MOH) focusing on preventive health—will have far-reaching effects on the delivery of health services in Singapore.1 Part of it involves a shift away from tertiary hospital-based to community-based care, to improve diagnostic imaging services in the...
Review Article
Consensus statement on Singapore perinatal mental health guidelines on depression and anxiety
Perinatal mental health conditions have been recognised as a key area of focus by the World Health Organization, with the new guide published in September 20221 highlighting the importance of screening, diagnosis and management of perinatal mental health conditions that are integrated into maternal and child health (MCH) services....
Original Article
Development and validation of a new self-assessment tool to measure professionalism among medical students
Professionalism is a concept that is difficult to define, but in relation to medical practice, it can be summarised as values, behaviours and conduct that foster the public’s trust in doctors. It comprises a complex interplay of abstract concepts that have led to many attempts at defining professionalism.1-4 With...
Original Article
Preoperative shock index in major abdominal emergency surgery
Major abdominal emergency surgery (MAES) is a complex and high-risk procedure with a significantly greater risk of complications and mortality as compared to elective surgery.1-3 Mortality rates in MAES can range from 14% to 20%,2,4 with current literature quoting rates as high as 45%.5
To objectively assess the perioperative surgical...
Editorial
Perinatal mental health in Singapore: Implementation opportunities and relevance of gender-carer roles in screening
In this issue of the Annals, the consensus statement on perinatal mental health by Chen et al. covers the handling of depression and anxiety symptoms in pregnancy, childbirth and the postnatal period.1 The guidelines were developed by a workgroup involving experts in perinatal mental health and obstetrics using a...
Editorial
Nurturing professional behaviours and ethical practice: From students to professionals
Medical professionalism refers to the set of values, behaviours, and ethical principles that guide the conduct of medical professionals in their interactions with patients, peers and the broader healthcare system. From a training perspective, it is easier to focus on striving to achieve excellence in medical practice and meeting...
Editorial
Shock index: Easy to use, but can it predict outcomes following major abdominal emergency surgery?
Major abdominal emergency surgery (MAES) is commonly performed for various potentially life-threatening intra-abdominal surgical conditions with high perioperative mortality of up to 45%.1 Certain patient factors (e.g. advanced age, frailty, and presence of multiple comorbidities) and disease factors (e.g. perforated viscus and intra-abdominal sepsis) have been shown to predict...
Letter to the Editor
Evaluation on the adoption of eHealth App for electronic health record sharing system in Hong Kong
Dear Editor,
In Hong Kong, the eHealth App was launched in January 2021, as part of Stage Two development of the Electronic Health Record Sharing System. It provides the healthcare recipients, that is, those who have registered in the system, a series of functions to manage their health, such as...
Letter to the Editor
Outcomes of nurse-led cryotherapy treatment for viral warts
Dear Editor,
Cryotherapy is a cost-effective treatment that can be performed by non-dermatologists for viral warts, which are very common.1,2 The National University Hospital, Singapore runs a nurse-led wart clinic where nurses are trained to administer cryotherapy. This study reviewed eradication rates and side effects in patients treated at the...
Letter to the Editor
Managing and preventing severe hand injuries among sugarcane juicer operators
Dear Editor,
Of all hand injuries encountered at an emergency department, 54% are sustained in the workplace,1 in part contributed by occupational injuries among food and beverage operators that caused a loss of 16,197 man-hours in 2021 alone.2 Commonplace in Singapore and in parts of South and Southeast Asia is...
Letter to the Editor
Breast conservation treatment and frozen section analysis of margins
Dear Editor,
Re. Surgical margins assessment reduces re-excision rates in breast-conserving surgery I read with interest the article by Woon et al. published in a recent issue of the Annals on the reduction of re-excision rates with the use of intraoperative frozen section (FS) analysis.1 This certainly has the potential...
Original Article
Fetal congenital heart diseases: Diagnosis by anatomical scans, echocardiography and genetic tests
Congenital heart diseases (CHDs) are the most common major congenital anomaly at up to 28%1 and are responsible for 5.7% of all infant mortality.2 While earlier studies in developed countries reported an overall CHD birth prevalence of 3.7–5.54 per 1000 live births,3,4 more recent studies report a global and...
Original Article
Poorer outcomes following COVID-19 infection for patients with depression: A cohort analysis in South Korea
In the early days of the pandemic, a major public health focus was to slow the spread of COVID-19. Therefore, the emphasis was on protecting the elderly, immunocompromised, and patients with respiratory and other underlying medical conditions. However, as COVID-19 continues to prolong, the concept of a new “normal”...
Original Article
Plasma selenium and zinc alter associations between nephrotoxic metals and chronic kidney disease: Results from NHANES database 2011–2018
Chronic kidney disease (CKD) is a clinical condition comprising persistent changes in kidney function or structure, or both. It is characterised by irreversible and progressive evolution, increasing the risk of complications and mortality. As the 16th leading cause of mortality worldwide, CKD affects 8–16% of the global population.1,2 Clinically,...
Original Article
Association of anticoagulation use during continuous kidney replacement therapy and 90-day outcomes: A multicentre study
Acute kidney injury (AKI) affects 21.6% of critically ill adult patients,1 with 5–7% requiring kidney replacement therapy (KRT).2 AKI carries significant prognostic and socioeconomic implications—chronic kidney disease (CKD) progression over 1 year has been described in 21%, 30%, and 79% of initial survivors with septic AKI reversal, recovery and...
Editorial
Impact of pre-existing depression on severe COVID-19 outcomes
The outbreak of the COVID-19 virus in 2019 had rapidly developed into a global pandemic, causing more than 6.8 million deaths and impacting the lives of billions of individuals around the world.1 Public healthcare around the work have mainly focused on the clinical manifestations and treatment of the deadly...
Editorial
Micronutrients and kidney health
Chronic kidney disease (CKD) is a structural and functional disorder of the kidney caused by many diseases, such as diabetes, hypertension and glomerular disease.1 There are many factors that contribute to the development and progression of CKD, and often, we do not look at the exposure of heavy metals...
Letter to the Editor
Script concordance test to assess diagnostic and management reasoning in acute medicine
Dear Editor,
Clinical reasoning, an essential skill for patient care, can be difficult to assess. We created and validated a script concordance test (SCT) to assess clinical reasoning in acute medicine. This tool was used to provide feedback and targeted remediation for Postgraduate-Year-1 (PGY1) doctors, guide teaching and learning, and...
Letter to the Editor
Improving neonatal counselling service for premature births
Dear Editor,
Despite the substantial advancement of neonatal care leading to increased survival of infants of periviable gestation, as young as 22 weeks,1 the anticipated birth of an extremely low gestational age infant remains challenging for both the parents and physician, with regard to decision-making in initiating resuscitation post-delivery. Ideally,...
Letter to the Editor
Systemic methotrexate in the management of ectopic pregnancy and pregnancy of unknown location
Dear Editor,
Ectopic pregnancy (EP) occurs in 2% of all spontaneous conceptions. It can be a life-threatening condition and is the most common cause of mortality during the first trimester of pregnancy, contributing to 7% of all pregnancy-related deaths.1,2 The risk factors for EP include tubal damage following surgery or...
Commentary
Leveraging ChatGPT to aid patient education on coronary angiogram
Natural-language artificial intelligence (AI) is a promising technological advancement poised to revolutionise the delivery of healthcare.1 Traditionally, inclusion of technology in the augmentation of healthcare communication comprised the use of chatbots, which is limited by a predetermined set of queries and matched answers.2 However, natural-language AI models prompt a...
Review Article
Molecular testing in non-small cell lung cancer: A consensus recommendation
Lung cancer is a leading cause of cancer mortality worldwide, with an estimated 2.21 million new cases and 1.80 million deaths in 2020.1 In Singapore, lung cancer is the third most frequent cancer in men and women, and accounts for the highest and third highest number of cancer deaths...
Original Article
Clinical outcomes of hospitalised individuals with spin-induced exertional rhabdomyolysis
Rhabdomyolysis is a clinical and biochemical syndrome caused by the breakdown of myocytes and release of intracellular components into the bloodstream.1 A subset of rhabdomyolysis is exertional rhabdomyolysis (ER), which is caused by strenuous physical activity. Risk factors for ER include lack of physical endurance, increased duration and intensity...
Original Article
Effects of sex on clinical outcomes of hypertrophic cardiomyopathy in Singapore
Hypertrophic cardiomyopathy (HCM) is a common inherited cardiomyopathy.1 The phenotypic expression of HCM is highly diversified with varying extents of myocardial hypertrophy, which can affect different parts of the heart and result in varying extents of left ventricular outflow tract (LVOT) obstruction, diastolic dysfunction and arrhythmic potential. The large...
Original Article
Association between genetic polymorphisms in fibrinogen genes and bleeding risk in patients treated with direct oral anticoagulants
Direct oral anticoagulants (DOACs) are widely prescribed for the prevention and treatment of stroke, systemic embolism and venous thromboembolism.1 Their mechanism of action involves direct binding to and inhibition of activated coagulation factors—factor Xa and thrombin—thereby preventing excessive blood clotting.2 Overall, DOACs have favourable efficacy and safety profiles but...
Editorial
Promise and pitfalls of ChatGPT for patient education on coronary angiogram
The past decade has seen extraordinary and rapid progress in the field of artificial intelligence (AI), which produces computer systems capable of performing tasks that typically require human intelligence. These advancements have yielded wide-ranging applications across various domains that are revolutionising industries and transforming the way humans live and...
Editorial
Incorporating assessment of fibrinogen gene polymorphisms and bleeding risk in patients treated with direct oral anticoagulants
Direct oral anticoagulants (DOACs) have become entrenched as the dominant anticoagulant over the last decade for patients with venous thrombosis and atrial fibrillation.1 Compared to warfarin, bleeding risk is similar or lower for patients on DOACs but clinically relevant bleeding is still a risk, especially for patients with impaired...
Letter to the Editor
Streamlining multidisciplinary care in sarcoma management
Dear Editor,
Sarcomas are rare and heterogenous tumours that constitute fewer than 1% of adult solid cancers.1 Owing to their aggressive behaviour, relative rarity and occurrence at multiple anatomical sites, sarcomas can be challenging to treat.2 Timely referral to specialist sarcoma centres is thus paramount and reduces the incidence...
Letter to the Editor
A perfect match: The story of robotics in gynaecology
Dear Editor,
The first use of surgical robotics started in the domain of orthopaedic and urological surgery. However, it was the initial concept of using a robot in performing remote damage control surgeries on the battlefield that sparked the commercialisation of robotic surgical technology for use in operating rooms.1 The...
Letter to the Editor
Emergency department falls interventions improve osteoporosis management in frail older adults
Dear Editor,
Singapore’s population is ageing rapidly and by 2030, around 1 in 4 citizens will be aged 65 and above.1 Older adults represent 21–40% of emergency department (ED) users and proportionally are the highest users of ED services.2
One-third of community dwellers over 65 years of age fall each year,...
Letter to the Editor
Preferences for oral anticoagulant medications for managing atrial fibrillation
Dear Editor,
Stroke prevention in patients with atrial fibrillation (AF) using anticoagulants involves weighing the benefits of reduced ischemic stroke1,2 against the elevated risks of serious bleeding events.3 Warfarin and direct oral anticoagulants (DOACs) are the available oral anticoagulants for this indication. We developed a discrete choice experiment (DCE) survey4...
Letter to the Editor
Minimal monitoring is a safe but underutilised strategy for hepatitis C virus management in Singapore
Dear Editor,
Chronic hepatitis C virus (HCV) infection is estimated to affect 57 million people globally.1 Despite the availability of safe and effective pan-genotypic direct acting antivirals,2-5 many countries have yet to achieve the WHO goal of HCV elimination by 2030.1 To facilitate HCV elimination, current guidelines recommend using a...
Review Article
Consensus statement on Singapore integrated 24-hour activity guide for early childhood
Early childhood is a critical period for growth and development, setting the foundation for future and lifelong well-being.1 Adopting healthy lifestyle behaviours in early childhood can potentially influence and shape behaviours later in life.2 Frameworks have been developed, such as from the Center on the Developing Child at Harvard...
Original Article
Evaluation of a return to work coordination programme for injured workers in a public hospital in Singapore
Workers who have sustained an injury at work often face difficulties returning to work, according to a study showing that over 40% of injured workers in Singapore experienced increased lethargy at work and that about 40% had difficulties in performing work at pre-injury standards.1 One in 4 workers also felt...
Original Article
Restaging of rectal cancer with hybrid positron emission tomography magnetic resonance imaging after preoperative chemoradiotherapy
Neoadjuvant chemoradiotherapy (CRT) followed by surgery is the current standard of care for locally advanced rectal cancers. Randomised trials have shown that a neoadjuvant approach results in improved tumour downstaging, improved R0 resections, improved local control and increased sphincter preservation rates.1 Reliable response assessment and restaging post-CRT add invaluable...
Original Article
Comparison of existing methods of low-density lipoprotein cholesterol estimation in patients with type 2 diabetes mellitus
Elevated low-density lipoprotein cholesterol (LDL-C) levels are a major risk factor for the development of atherosclerotic cardiovascular disease (ASCVD). A reduction in LDL-C levels has been shown to significantly reduce the risk of incident ASCVD1 and all-cause mortality.2 LDL-C levels are hence key treatment targets in the prevention of...
Editorial
Proactive steps to population health: Starting early, starting right
The global burden of non-communicable diseases is rising, with continued projected increases in the prevalence of metabolic syndrome (MetS) in the future. This epidemic, albeit of a metabolic nature, poses broad socioeconomic and healthcare burdens worldwide. Population health improvement and optimisation of healthcare are important to addressing these burdens....
Letter to the Editor
Investigating the stressors and coping mechanisms of students in medical school: A qualitative study
Dear Editor,
Medical school can be a stressful experience for students, with burnout being increasingly common.1 Stressors in medical education include a heavy academic workload, pressure of good academic performance, and comparison with peers of high aptitude.2 Stress can be either beneficial or detrimental to development, depending on personal regulation...
Letter to the Editor
Eosinophilic esophagitis and immunoglobulin E-mediated food allergy
Dear Editor,
Food allergy (FA) is an adverse reaction to a specific food antigen—normally harmless to the healthy population—which is mediated by immunological mechanisms and arises in an individual susceptible to that particular allergen.1 FA is a public health problem affecting children and adults, and its prevalence has been increasing...
Letter to the Editor
Poor survival rate of pregnancy-associated breast cancer in Asian countries
Dear Editor,
Asia has a lower incidence of breast cancer than North America, Oceania, and Western Europe. However, breast cancer rates have been rising fast in recent decades.1 Breast cancer cases in Asian countries now constitute 40% of all cases diagnosed globally, and mortality due to breast cancer has similarly...
Letter to the Editor
Healthcare worker job burnout, anxiety and depression: A one-year comparison during COVID-19 in Singapore
Dear Editor,
The mental health of our healthcare workforce has never been as scrutinised as it has the last three years since the COVID-19 pandemic. Worldwide, appreciation of healthcare workers (HCWs) as the first line of defence during the pandemic soared, even as studies of HCW mental wellness increased exponentially.1,2...
Original Article
Clinical efficacy of primary human papillomavirus (HPV) screening with partial genotyping for HPV-16 and HPV-18 subtypes in women from 25 years old
The World Health Organization has launched a campaign to eliminate cervical cancer on the basis of effective vaccines against oncogenic human papillomavirus (HPV) subtypes, with mass screening and eradication of high-grade pre-malignant lesions, cervical intraepithelial neoplasia grade-2 (CIN2) and grade-3 (CIN3).1,2 HPV-based screening has been shown to be sensitive...
Original Article
Risk and protective factors of mental health during the COVID-19 pandemic: A cross-sectional study in Singapore
The COVID-19 pandemic has significantly impacted people’s well-being globally.1 Individuals faced several stressors during the pandemic, including fear of contracting the disease, experiencing severe symptoms of COVID-19, losing loved ones to the disease, financial insecurity, and social isolation. Furthermore, children and youths experienced disruption to their usual routine such...
Original Article
Impact of COVID-19 on mental health and social service provision in Singapore: Learnings from a descriptive mixed-methods study for future resource planning
Coronavirus disease 2019 (COVID-19) was declared a global health emergency by the World Health Organization in January 2020.1 Singapore reported its first case of COVID-19 on 23 January 2020 and the subsequent emergence of clusters led to a string of restrictions to contain the outbreak and protect the health...
Original Article
Comparison of four electrocardiographic criteria for the detection of cardiac abnormalities in Singapore athletes
Sudden cardiac death in athletes during exercise is rare, with an estimated incidence of 1–2 per 100,000 people per year in young athletes,1 and approximately 1 per 7,000 per year in adult athletes.2 The predominant aetiology of these cases is cardiovascular in nature, with conditions such as hypertrophic cardiomyopathy...
Editorial
Impact of COVID-19 on mental health and healthcare service delivery
The COVID-19 pandemic has claimed more than 6.8 million lives globally.2 While there is yet a cure for the disease, vaccines are now available to minimise transmission risk and protect against severe infection. However, COVID-19 vaccines have had a mixed reception, with concerns of their side effects and of...
Editorial
Improving electrocardiogram interpretation in Asian athletes: A call to action
The field of sports cardiology has evolved substantially over the past 2 decades due to improved understanding of the athlete’s heart, causes of sudden cardiac death (SCD) in athletes, as well as differentiation between physiological cardiac remodelling and pathological cardiac conditions in athletic individuals. Application of this knowledge forms...
Letter to the Editor
Sublingual ondansetron for treatment of acute gastroenteritis in children in the children’s emergency
Dear Editor,
Acute gastroenteritis (GE) is a leading cause of death globally in children aged below 5 years and the third most common indication for hospital admission in some countries.1,2 Currently, norovirus is the most common cause of GE in children in developed countries.3 Rehydration, either orally or intravenously, is...
Letter to the Editor
Outcomes of selexipag for treatment of pulmonary arterial hypertension in an Asian population
Dear Editor,
Pulmonary arterial hypertension (PAH) is a progressive condition characterised by increased pulmonary arterial pressure and pulmonary vascular resistance, resulting in right ventricular dysfunction and eventually cardiac failure. In the early days, this was an often a fatal disease with significant morbidity. In recent years, there has been increasing...
Letter to the Editor
Suboptimal adherence to medical therapy in patients undergoing lower limb angioplasty in Singapore
Dear Editor,
Chronic limb-threatening ischaemia (CLTI) is the advanced stage of peripheral arterial disease (PAD) and patients with this condition face a very high risk of major adverse cardiovascular events and mortality. Several guidelines strongly recommend evidence-based medical therapy (EBMT) to reduce cardiovascular risk.1-3 Specifically, all CLTI patients should be...
Letter to the Editor
Real-world challenges when facilitating terminal discharge in Singapore
Dear Editor,
During the Ministry of Health workplan seminar held on 2 June 2022, Minister Ong Ye Kung expounded the notion of a good death and outlined the Ministry’s vision and strategy for better care (and experience) for all near the end of life.1 Specifically, he aimed to reduce the...
Commentary
Artificial intelligence innovation in healthcare: Relevance of reporting guidelines for clinical translation from bench to bedside
Artificial intelligence (AI) and digital innovation have revolutionised many sectors and industries, prominently including healthcare during the coronavirus disease 2019 (COVID-19) pandemic.1 For example, deep learning, which is a subset of the state-of-the-art machine learning techniques, has shown robust performance in image recognition, speech recognition and natural language processing.2...
Original Article
Association between body mass index, body image and self-esteem with sexual function: A survey of young women in Singapore
Satisfaction with sexual activity is a good predictor of global life satisfaction.1 Problems with sexual function can lead to lower partner satisfaction and affect a woman’s mental and physical health.2 The prevalence of sexual dysfunction in premenopausal women globally was found to be 40.9% (95% confidence interval 37.1–44.7).3...
Original Article
Transitional care strategies at emergency department for elderly patients: A multicentre study in Singapore
In Singapore, greater efforts are being directed towards developing an integrated health and social ecosystem under the new Healthier SG strategy announced by the Ministry of Health. This life-course approach aims to promote overall healthier living in collaboration with key community partners (e.g. intermediate and long-term care service providers)...
Original Article
Benefits of leisure-related physical activity and association between sedentary time and risk for hypertension and type 2 diabetes
Diabetes mellitus and hypertension are serious public health issues. Approximately 451 million individuals worldwide aged 18–99 years were living with diabetes in 2017, and this number is expected to increase to 693 million by 2045.1 More than 90% of all diabetes cases were type 2 diabetes mellitus (T2DM).2 For...
Editorial
Self-esteem and positive body image to overcome female sexual dysfunction
Human sexuality is arguably one of the main pillars of health, like nutrition and sleep. Improvements in diagnostic and therapeutic biotechnologies have enabled focus on not only deadly diseases, but also on the quality of life and sexual functions of men and women. Digital media also play a considerable...
Editorial
Promoting physical activity for population health
The chronic disease burden has risen globally. In Singapore, between 2007 and 2021, the crude prevalence of hyperlipidaemia (8.2–13.9%), hypertension (12.7–15.7%) and diabetes (4.9–6.9%) has increased.1 Based on the Global Burden of Disease Study (2019), lack of physical activity and other modifiable risk factors contribute 35% of the disability-adjusted...
Images in Medicine
Middle-aged woman with painless neck swelling
A 57-year-old woman presented with a 2-month history of an asymptomatic left neck lump. She is a non-smoker, does not drink alcohol, and has no family history of head and neck cancers. On examination, there was a 2cm left cervical level II ovoid and mobile nodule, which appeared to...
Letter to the Editor
Robotic surgery in morbidly obese women with endometrial cancer in Singapore
Dear Editor,
The standard of care for endometrial cancer is a total hysterectomy with bilateral salpingo-oophorectomy, and pelvic lymph node dissection (THBSO-PLND). Obesity is a known risk factor for endometrial cancer, and obese patients are challenging to operate on due to their anatomy and comorbidities. A recent database search showed...
Letter to the Editor
Delayed treatment with nirmatrelvir/ritonavir could remain effective in patients with Omicron BA2.2 variant of COVID-19
Dear Editor,
In late February 2022, the Omicron BA.2.2 subvariant drove the outbreak of COVID-19 and rapidly spread through many parts of the world. Omicron-infected individuals aged ≥80 years who are unvaccinated are particularly at high risk of poor outcomes.
COVID-19 vaccines and antiviral therapeutics have protected individuals most at risk...
Letter to the Editor
Rash characteristics of paediatric patients with COVID-19 in Singapore
Dear Editor,
Children with COVID-19 infection can present with a variable spectrum of clinical manifestations, and sometimes mucocutaneous manifestations can be the only manifestation of COVID-19 infection in children.1,2,3 We report 4 cases of paediatric patients who had COVID-19 with mucocutaneous involvement, admitted to a tertiary children’s hospital in Singapore....
Commentary
Re-examining the roles of generalists and specialists in healthcare
Singapore is one of many Asian countries facing the challenge of an ageing population. Its population grew from 1.65 million to 5.45 million from 1960 to 2021. By 2030, 25% will be aged 65 or older.1 Meanwhile, the proportion of older adults with three or more chronic diseases nearly...
Review Article
An approach to genetic testing in patients with metastatic castration-resistant prostate cancer in Singapore
Prostate cancer is the fifth most common cancer in Asian men, and with its rising incidence, is emerging as a health priority in Asia.1 Across Asian countries, age-standardised incidence rates (ASIRs) of prostate cancer range from 0.9 to 56.1 per 100,000 population, with the second highest ASIR reported in...
Original Article
Association between lower phase angle and chronic kidney disease progression in type 2 diabetes patients
Chronic kidney disease (CKD) is a global public health problem with an estimated prevalence of 13.4%.1 One of the key drivers of the global increase in CKD is the rising prevalence of diabetes mellitus (DM).1 CKD affects about 25–40% of patients with type 2 diabetes mellitus (T2DM).2 A few...
Original Article
Clinical outcomes and management of contrast hypersensitivity in patients requiring repeated computed tomography imaging
Allergic and non-allergic hypersensitivity reactions to iodinated contrast media (ICM) are increasingly recognised, particularly the latter where there is greater clarity on pathomechanisms.1 There is limited evidence for the use of corticosteroids as premedication to prevent the occurrence of contrast-related reactions. At our institution, a dose of 30mg oral...
Editorial
Preventing recurrent hypersensitivity reactions to iodinated contrast media
Iodinated contrast media (ICM) is one of the most commonly used drugs in the practice of modern medicine. ICM, as the name implies, is a contrast media that contains iodine. It is frequently used in computed tomography (CT) and angiographic procedures, to highlight important anatomical structures and for the...
Editorial
Challenges with mainstreaming genetic testing for metastatic prostate cancer treatment in Singapore
Compared with other solid tumours, patients with metastatic prostate cancer typically have better survival in the range of years.1 The long survival translates to a high prevalence, and thus, a large number of men living with prostate cancer. Singapore has one of the highest age-standardised incidence rates of prostate...
Letter to the Editor
The role of PIVKA-II in hepatocellular carcinoma surveillance in an Asian population
Dear Editor,
Alpha-fetoprotein (AFP) is the most established biomarker for surveillance of hepatocellular carcinoma (HCC) in at-risk individuals. However, its sensitivity and specificity are not very satisfactory.1 Protein induced by vitamin K absence or antagonist-II (PIVKA-II) is a newer biomarker for HCC but without a widely established cut-off.2,3 Recent...
Letter to the Editor
Reducing non-clinical working hours of junior doctors could benefit patient outcomes
Dear Editor,
An 80-hour duty limit for residents was first introduced by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, with the further addition of a 16-hour continuous duty period limit for first-year residents in 2011. Prior studies1 have demonstrated an association between longer working hours and...
Letter to the Editor
Safety and effectiveness of nitrous oxide procedural sedation in a paediatric emergency department
Dear Editor,
Nitrous oxide (N2O) produces dissociative euphoria, amnesia and analgesia, and is a common sedative for procedural sedation in paediatric emergency departments (EDs) due to its non-parenteral administration and good safety profile.1-3 Suitable procedures include fracture reduction, toilet and suturing, incision and drainage, and application of burn dressings. The...
Commentary
Approach to bradyarrhythmias: A proposed algorithm
Bradyarrhythmias are common and occur in both physiological and pathological states. Bradycardia is defined as a heart rate of fewer than 60 beats per minute, and bradyarrhythmias can be caused by sinus node dysfunction or atrioventricular (AV) conduction blocks.1,2 Atrial fibrillation (AF) with a slow ventricular response may also...
Review Article
Through the eyes into the brain, using artificial intelligence
Neurological dysfunction is a leading cause of disability, affecting more than 276 million people worldwide.1 Over the last decades, the prevalence of neurological dysfunction has increased, particularly in the ageing population which is commonly affected by dementia, stroke and brain tumours.1,2 The increasing number of patients suffering from neurological...
Original Article
Immune and coagulation profiles in 3 adults with multisystem inflammatory syndrome
A spectrum of immune dysregulation has been described following SARS-CoV-2 infections—from the cytokine storm in the acute phase, to hyperinflammatory syndromes that occur after the resolution of the initial infection.1 Multisystem inflammatory syndrome (MIS) was first reported in children in April 2020 as a hyperinflammatory syndrome with features similar...
Original Article
Factors associated with deep infiltrating endometriosis, adenomyosis and ovarian endometrioma
Endometriosis is a chronic inflammatory gynaecologic disease marked by the presence of endometrial-like tissue outside the uterus.1 Debilitating chronic pelvic pain, dysmenorrhoea, and subfertility in women of reproductive age are commonly associated with endometriosis. The disease is estimated to affect about 1 in every 10 women of reproductive age,...
Original Article
Concordance of self-reporting of diabetes compared with medical records: A comparative study using polyclinic data in Singapore
Approximately 422 million people worldwide have diabetes and 1.6 million deaths are attributed to diabetes each year,1 contributing to high economic costs worldwide. Diabetes education and awareness of the disease contribute significantly to minimising complications and reducing morbidity and mortality.2 In addition, there is also a strong impetus to...
Editorial
The eye as a window to the brain
Over the last 20 years, it has become evident that the age-old expression, “the eye is the window into the soul”, might in fact hold more truth than previously thought. We are currently able to distinguish a variety of systemic diseases by funduscopic inspection. Following the dawn of high-resolution...
Editorial
Diabetes: Know thy foe
During the COVID-19 pandemic in 2022, Singapore’s Minister for Health Ong Ye Kung mentioned, “After the COVID-19 pandemic has passed, we need to tackle a far more challenging pandemic—which is longer-term chronic illness, and diabetes is a major one.”1
Truly, in the past decade, there has been an invisible global...
Board of Reviewers
Board of Reviewers 2022
Our sincere thanks to the following peer reviewers who completed and returned their reviews between 1 January 2022 and 31 December 2022. Your expertise and time generously given have been major factors in maintaining the Annals’ high standards. We apologise if we have inadvertently omitted any name. Please inform...
Letter to the Editor
Association between self-care and chronic kidney disease in patients with type 2 diabetes mellitus
Dear Editor,
Chronic kidney disease (CKD) is one of the key complications occurring in 25–40% of patients with type 2 diabetes mellitus (T2DM).1 Our earlier study also showed that CKD was present in 53% of patients with T2DM recruited from a secondary care diabetes centre and primary care polyclinic...
Letter to the Editor
Surgical margins assessment reduces re-excision rates in breast-conserving surgery
Dear Editor,
Breast-conserving surgery (BCS) followed by radiation therapy for breast cancer offers improved cosmetic results and comparable long-term survival rates as mastectomy.1 However, BCS is associated with a higher risk for local recurrence, and published literature has reported re-excision rates as high as 20–70% due to positive resection...
Letter to the Editor
Clinical outcome of bacterial endogenous endophthalmitis in 15 patients
Dear Editor,
Endophthalmitis refers to the inflammation of the ocular cavities and their immediate adjacent structures without extension beyond the sclera, usually secondary to infection. Endogenous endophthalmitis (EE) results from haematogenous spread of microorganisms in patients with bacteraemia or fungaemia into the eye and represents 2–15% of endophthalmitis cases.1-3...
Letter to the Editor
Case studies of fetal mosaicisms detected by non-invasive prenatal testing
Dear Editor,
The American College of Medical Genetics and Genomics recommended that all pregnant women be offered non-invasive prenatal testing (NIPT) regardless of the patient’s risk profile.1 With increasing NIPT uptake, encounters with genetic conditions other than the 3 common fetal trisomies are becoming prevalent. We report 2 cases of...
Review Article
Ablation therapies for paroxysmal atrial fibrillation: A systematic review and patient-level network meta-analysis
Atrial fibrillation (AF) is a pertinent health condition that is seeing a sustained rise in global incidence and prevalence.1 In particular, paroxysmal AF (PAF), despite its transient nature, is associated with a slow but steady progression to persistent AF2 and increased mortality compared to patients without AF.3 Furthermore, patients...
Review Article
Combating a resurgence of poliomyelitis through public health surveillance and vaccination
Singapore was certified poliomyelitis (polio)-free by the World Health Organization (WHO) on 29 October 2000, together with 36 other countries in the Western Pacific Region.1 Prior to certification, there were multiple outbreaks in 1958, 1960 and 1963 with 415, 196 and 74 paralytic polio cases, respectively.2-4 The nationwide immunisation...
Original Article
Clinical efficacy and long-term immunogenicity of an early triple dose regimen of SARS-CoV-2 mRNA vaccination in cancer patients
The spread of the SARS-CoV-2 virus has led to the ongoing worldwide COVID-19 pandemic. Initial studies have reported an increased vulnerability of patients with solid and haematological malignancies to SARS-CoV-2 infections.1,2 Global efforts to combat SARS-CoV-2 led to the unprecedented rapid development of multiple vaccines, with reported efficacies of...
Editorial
Catheter ablation as first-line treatment for paroxysmal atrial fibrillation
Pharmacotherapy has been the mainstay of atrial fibrillation (AF) treatment. As AF progresses from paroxysmal to persistent, electrical and structural remodelling of the atria may become irreversible, rendering future rhythm-control therapies less effective. Results of earlier trials on rhythm control were disappointing and failed to establish the superiority of...
Editorial
Early COVID-19 booster is beneficial in cancer patients
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its corresponding coronavirus disease (COVID-19) was first reported as a cluster of pneumonia cases in Wuhan, China, on 31 December 20191 and led to an unprecedented pandemic in modern times. It quickly overwhelmed healthcare systems around the world, and rendered...
Editorial
Vaccination and surveillance: Two basic tools for a final poliomyelitis eradication
Over the past 3 decades, the Global Polio Eradication Initiative (GPEI) has strived to achieve a poliomyelitis (polio)-free world. Wild poliovirus (WPV) types 2 and 3 were eradicated in 2015 and 2019, respectively. The World Health Organization (WHO) South-East Asia Region was declared free of poliovirus in 2014, and...
Images in Medicine
Lichen planus pemphigoides after pembrolizumab immunotherapy in an older man
An 84-year-old Chinese man with stage IV non-small cell lung cancer was initiated on pembrolizumab, an anti-programmed cell death (PD)-1 monoclonal antibody, 4 times per week. Seven weeks later, on the day of his third cycle, he developed a rash on his chest and right axilla, which subsequently resolved...
Letter to the Editor
Diagnostic accuracy of multiparametric MRI in endometrial cancer and its adjunctive value in identifying high-risk women requiring surgical staging
Dear Editor,
Endometrial cancer is the most common gynaecological cancer in developed countries, with a five-year survival rate of 81%.1,2 Prognostic factors include the International Federation of Gynecology and Obstetrics (FIGO) stage, depth of myometrial invasion (MI), lymph node involvement, cervical stromal involvement, and histological grade. Total hysterectomy with bilateral...
Letter to the Editor
Rapid exome sequencing to aid diagnostics in genetic disorders: Implementation and challenges in the Singapore context
Dear Editor,
There is a high burden of genetic disorders in patients admitted to the intensive care unit (ICU), ranging from 45–56%,1,2 and delayed definitive diagnoses with a long diagnostic odyssey often contribute to increased healthcare costs.3 The application of clinical exome sequencing in ICU has been gaining traction, where...
Letter to the Editor
Tozinameran (Pfizer-BioNTech COVID-19 vaccine)-induced AGEP-DRESS syndrome
Dear Editor,
A 40-year-old woman with scalp psoriasis was maintained on topical mometasone furoate therapy from 2019 with no major psoriatic flares until she presented with one week of an acute generalised pustular eruption and fever in June 2021. Physical examination revealed numerous discrete and confluent pustules studded on her...
Letter to the Editor
Multidisciplinary lung cancer clinic: An emerging model of care
Dear Editor,
Lung cancer management is progressively complex and multidisciplinary input is often needed. The recent publication of CheckMate 816 heralds a paradigm shift in the treatment of resectable non-small cell lung cancer (NSCLC),1 with many other perioperative trials soon to follow.2 Oligometastasis and oligoprogression in stage IV NSCLC...
Commentary
Meeting today’s healthcare needs: Medicine at the interface
The demographic of Singapore has undergone dramatic changes. Historically, younger patients with communicable diseases predominated; however, patients are now older with chronic multimorbidity and functional impairment. This demographic shift challenges existing health and social care systems in Singapore, which must pivot to meet the changing need. The consequences of...
Review Article
Drug interactions between common dermatological medications and the oral anti-COVID-19 agents nirmatrelvir-ritonavir and molnupiravir
In December 2021, an Emergency Use Authorisation was issued by the U.S. Food and Drug Administration (FDA) for the use of the orally active antiviral medications nirmatrelvir-ritonavir (NMV/r, PAXLOVID) and molnupiravir (LAGEVRIO) in the treatment of patients with mild COVID-19, who are at risk of developing severe disease resulting...
Original Article
Low skeletal muscle mass predicts poor prognosis of elderly patients after emergency laparotomy: A single Asian institution experience
Emergency laparotomy (ELAP) for elderly patients is associated with higher mortality and increased postoperative complications compared with those undergoing elective surgery.1-3 Elderly patients, who are more likely to have comorbidities, have lower functional reserves to cope with the increased physiological demand due to their acute illness and eventual surgical...
Original Article
Characteristics of anti-transcriptional intermediary factor 1 gamma autoantibody-positive dermatomyositis patients in Singapore
Idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of acquired, systemic autoimmune conditions characterised by muscular and extramuscular manifestations. As a subset within the family of IIM, dermatomyositis is distinguished by cutaneous features and has twice the risk of associated malignancy than polymyositis.1-3
Various meta-analyses have shown that between 10%...
Editorial
Pharmacokinetic and pharmacogenomic considerations in managing use of nirmatrelvir-ritonavir and molnupiravir and dermatological treatments
The COVID-19 pandemic has been unprecedented in its impact on global health, economic, financial, psychosocial and political systems. The World Health Organization estimates approximately 627 million confirmed cases and 6.5 million deaths reported globally.1 In Singapore, the swift and prompt public health response of the government during the early...
Editorial
Idiopathic inflammatory myopathies: Not nearly the end of the road
The clinical spectrum of idiopathic inflammatory myopathies (IIM) has broadened over the past half century from a simple disease characterised primarily by muscle and skin manifestations, to a potentially life-threatening complex condition of multiple organ involvement. In the recent decade, the discovery and addition of novel autoantibody profiles including...
Images in Medicine
A recurring nasal mass
A 56-year-old Chinese man presented to the Ear, Nose and Throat clinic with months of unilateral right-sided nasal obstruction. He reported occasional mucopurulent discharge and denied any hyposmia, episodes of epistaxis, or loss of weight and appetite. Nasoendoscopy revealed a right-sided nasal mass between the septum and middle turbinate....
Letter to the Editor
A strategy to make COVID-19 vaccination more accessible to the elderly
Dear Editor,
Singapore embarked on the COVID-19 National Vaccination Programme in early 2021. The main modality employed to achieve the mass vaccinations has been the Vaccination Centres (VCs). These are dedicated facilities created with the sole purpose of providing the public with safe and convenient access to vaccination services.
While the...
Letter to the Editor
Erdheim-Chester disease: Imaging spectrum of multisystemic manifestations
Dear Editor,
Erdheim-Chester disease (ECD) is a rare non-Langerhans histiocytosis, usually affecting middle-aged to older adults. It is a multisystemic disease with protean clinical manifestations. It can involve single or multiple organs, and presentations range from asymptomatic lesions detected incidentally on imaging to severe organ dysfunction. Hence, accurate and timely...
Letter to the Editor
Implementation of an AI model to triage paediatric brain magnetic resonance imaging orders
Dear Editor,
Artificial intelligence (AI) is viewed as the most important recent advancement in radiology with the potential to achieve Singapore’s objective of delivering value-based patient-centric care.1
We have developed and implemented a deep-learning model using bidirectional long short-term memory (Bi-LSTM) neural network to enable automated triage of unstructured free-text...
Letter to the Editor
Early rehabilitation to improve functional outcomes in childhood cancer in Singapore
Dear Editor,
We conducted a prospective, single-centre cohort study to review the impact of a multidisciplinary rehabilitation programme in children with cancer in Singapore. The Template for Intervention Description and Replication (TIDieR) checklist was used to allow sufficient details for replication of the study (see Appendix in online Supplementary...
Letter to the Editor
Self-sampling HPV DNA test for cervical cancer screening in Singapore: A prospective study
Dear Editor,
Cervical cancer is known to be the most preventable malignancy through both vaccination and screening. However, it remains the tenth most common cancer among women in Singapore. Cervical cancer screening is opportunistic in Singapore and only 1 in 2 women undergo regular screening in Singapore.1 Under-screened women...
Commentary
‘Roe’lling with the punches: Telehealth contraception and abortion
Unsafe abortion is a global health issue as it is a key preventable cause of maternal mortality. It has been estimated that up to 13% of maternal deaths per year are due to unsafe abortions.1 Women in developing countries make up 97% of all unsafe abortions and more than...
Review Article
The Omicron-transformer: Rise of the subvariants in the age of vaccines
The emergence and evolution of SARS-CoV-2 have been publicly tracked in unprecedented detail through a combination of intensive genomic sequencing and open-access sharing of data.1 This surveillance information describes how waves of COVID-19 infections have been driven by the emergence of new variants of concern (VOCs) and their subvariants....
Review Article
National surgical antibiotic prophylaxis guideline in Singapore
Surgical antibiotic prophylaxis (SAP) refers to the administration of antibiotics prior to clean and clean-contaminated surgeries to prevent postoperative surgical site infections (SSIs). An optimal SAP should be highly effective in preventing SSI. An ideal prophylactic antibiotic regimen is: (1) effective against pathogens—generally skin flora—most likely to contaminate the...
Original Article
Non-alcoholic fatty liver disease screening in type 2 diabetes mellitus: A cost-effectiveness and price threshold analysis
Non-alcoholic fatty liver disease (NAFLD) is a growing epidemic and has become a major cause of liver-related mortality and indication for liver transplantations globally. It is estimated that nearly 25% of the world’s population and more than 60% of type 2 diabetes mellitus (T2DM) patients have NAFLD. A prior...
Original Article
Improving drug allergy label accuracy by supervised safety- and protocol-driven evaluation
Self-reported drug allergies1 are common, and the majority of these have been shown to be inaccurate. Recording of drug allergy details is also often incomplete and inaccurate.2 Consequences of inaccurate drug labelling include unnecessary avoidance of effective medications, restricted access to appropriate antibiotics, impact on antimicrobial stewardship, and public...
Original Article
Multisystem inflammatory syndrome in children in Singapore
While children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulting in coronavirus disease 2019 (COVID-19) have milder manifestations compared to adults,1,2 a rare multisystem inflammatory syndrome leading to multiorgan failure and shock (multisystem inflammatory syndrome in children ) has been recognised to affect children with exposure to...
Editorial
Multisystem inflammatory syndrome in children: A unique manifestation of COVID-19
During the coronavirus disease 2019 (COVID-19) pandemic, children have been relatively spared from the severe symptomatic infection affecting adults, particularly the elderly and those with comorbidities. One of the most challenging aspects of paediatric SARS-CoV-2 infection has been the discovery of a unique late manifestation of infection characterised by...
Images in Medicine
A man with bark-like skin
A 65-year-old Chinese man was admitted for evaluation of chronic anaemia. He had a history of hypertension and chronic kidney disease, and his regular medications were nifedipine and losartan. He was a retired cleaner who lived with friends and had no contact with his family.
He was referred to the...
Letter to the Editor
Tragus pressure-guided removal of airway devices for safe emergence from sedation: A randomised controlled trial
Dear Editor,
Emergence from anaesthesia and deep sedation is the transition from unconsciousness to the return of awareness and airway reflexes. The chief patterns of unsafe recovery include sudden unpredictable emergence or delayed return of airway tone and reflex with risk of airway obstruction.1 Agitation includes straining, sitting up, screaming...
Letter to the Editor
Child passenger safety training for healthcare professionals in Singapore
Dear Editor,
Road traffic injuries are a preventable cause of childhood morbidity and mortality.1,2 Use of age-appropriate child car seats (CCS) lowers the risk of injury and death by about 82% and 28%, respectively.3-5 In Singapore, although the Road Traffic Act states that CCS use is mandatory,6 many children...
Letter to the Editor
Clinical characteristics of macrolide-resistant Mycoplasma pneumoniae infections among hospitalised children in Singapore
Dear Editor,
Mycoplasma pneumoniae has become the leading cause of paediatric community-acquired pneumonia in countries where pneumococcal vaccination is included in the national immunisation programme, including Singapore.1 M. pneumoniae is intrinsically resistant to beta-lactams due to the absence of cell walls. Macrolides, tetracyclines, and fluoroquinolones are used to treat M....
Letter to the Editor
Childhood interstitial lung disease: The end of a diagnostic odyssey
Dear Editor,
Childhood interstitial lung disease is a heterogeneous group of rare disorders featuring pulmonary interstitial remodelling and diffuse parenchymal infiltrates on imaging.1 Incidence is estimated at 0.13–16.2 cases/100,000 children per year.1 ABCA3 (ATP-Binding Cassette, Subfamily A, Member 3) (OMIM #601615) is expressed in alveolar type II cells involved...
Commentary
Low-dose computerised tomography screening for lung cancer in Singapore: Practical challenges of identifying participants
INTRODUCTION
In March 2022, the European Commission on cancer screening suggested the inclusion of low-dose computerised tomography (LDCT) for lung cancer, targeted at current and former smokers.1 The aim of LDCT screening is to increase early detection, decrease diagnoses at metastatic stage of the disease and improve overall 5-year...
Review Article
Managing adult asthma during the COVID-19 pandemic: A 2022 review and current recommendations
Asthma is the most prevalent chronic respiratory disease, estimated to affect more than 300 million people worldwide.1 First recognised in December 2019, the coronavirus disease 2019 (COVID-19), which is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has evolved into an ongoing global pandemic.2 In May...
Review Article
Nutrition therapy in the older critically ill patients: A scoping review
The increasing levels of life expectancy and decreasing fertility are shifting the age structure of the world population towards older ages.1 From year 2020 to 2050, population aged ≥65 years is expected to rise from 9.3% to 16%.1 The number of older intensive care unit (ICU) patients are expected...
Review Article
Exploring loss and grief during the COVID-19 pandemic: A scoping review of qualitative studies
As of mid October 2022, the World Health Organization recorded that more than 620 million people worldwide have been infected by SARS-CoV-2, the virus causing COVID-19, while over 6.5 million have succumbed to the disease. Many have lost family members and friends as well as jobs and familiar lifestyles,...
Original Article
Impact of aortic annular size and valve type on haemodynamics and clinical outcomes after transcatheter aortic valve implantation
The management of severe aortic stenosis (AS) in patients with small aortic annulus (SAA) represents a therapeutic challenge due to the increased mortality and major adverse cardiac events (MACE) seen in this group of patients even after surgical aortic valve replacement (SAVR).1,2
In recent times, the role of transcatheter aortic...
Original Article
Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febrile infants
The diagnostic approach and management of febrile infants <90 days of age remain a challenge, given that the majority of these infants have no localising signs and symptoms, and may appear clinically well at presentation.1 In addition, the majority of these infants have benign viral illnesses, for which hospitalisation...
Editorial
ICU nutrition: Bracing for the silver tsunami
The global population’s life expectancy is growing with a steady increase in the proportion of older patients admitted to the intensive care unit (ICU).1 Up to 13% of the ICU patients are above the age of 80.2 Older critically ill patients have lower physiological reserves of the various organ...
Editorial
The impact of COVID-19 pandemic on loss and grief
As of 17 October 2022, the COVID-19 pandemic has claimed more than 6.5 million lives globally, with 1,639 deaths reported in Singapore.1 With numerous countries imposing measures such as lockdowns and social distancing measures that isolate individuals, there has been a steady increase in a variety of mental disorders...
Images in Medicine
TB or not TB? The axillary lump question
An 81-year-old woman of healthy weight presented with a 2-week history of a painless right axillary lump. Physical examination revealed a 2cm firm nodule with a central keratinous plug in the right axilla (Fig. 1). The surrounding skin was pigmented, non-tender and indurated. Sonography of the nodule demonstrated an...
Letter to the Editor
Antiphospholipid and other autoantibodies in COVID-19 patients: A Singapore series
Dear Editor,
Thrombosis is an unexpected complication of COVID-19 initially reported in 3 patients from China.1 These patients tested positive for immunoglobulin (Ig) A anticardiolipin (ACA), IgG anti-β2-glycoprotein I antibodies (aβ2GPI) and IgA aβ2GPI, though not for the lupus anticoagulant (LAC).
In a Singapore study comprising 47,527 patients, 19 (0.04%) developed...
Letter to the Editor
Prevalence of perceived weight-based stigmatisation in a multiethnic Asian population
Dear Editor,
People with obesity contend with obesity-related stigmas, in addition to health complications.1 In contrast to the West, literature documenting the prevalence of such stigmas in Asia is sparse. We report the prevalence of perceived weight-based stigmatisation in Singapore.
An anonymised questionnaire was administered to 101 consecutive patients presenting to...
Letter to the Editor
Safety and efficacy of combined antiplatelet and low-dose rivaroxaban in patients with chronic limb threatening ischaemia in Singapore
Dear Editor,
Peripheral artery disease (PAD) is characterised by the debilitating atherosclerotic occlusion of arteries in the lower extremities, with chronic limb threatening ischaemia (CLTI) representing the most advanced stage of this disease process. Left untreated, these sequelae will invariably progress to major lower extremity amputation (LEA) and premature death....
Letter to the Editor
Employers’ attitudes towards employing people with mental health conditions
Dear Editor,
The advantages of employment for young people with mental health conditions (PMHC) are well known and documented,1 but many remain unemployed. Besides offering monetary benefits, employment provides a better self and social identity, helps the person gain a sense of personal achievement, and enhances mental well-being. Being unemployed...
Letter to the Editor
High burden of respiratory viral infection-associated mortality among critically ill children
Dear Editor,
Acute lower respiratory infections (ALRIs) are a leading cause of under-5 mortality globally—two-thirds could be attributable to respiratory viral infections (RVIs).1,2 The burden of paediatric RVIs in settings of tropical climate with year-long virus circulation is relatively underreported.3,4 Previous studies in these areas have estimated that around 8–11%...
Review Article
Periodontal disease and systemic health: An update for medical practitioners
Care for the oral cavity lies in the intersection of dentistry and medicine. As the oral cavity serves as an entry to the gastrointestinal tract and the point where the digestion process begins, it is often recognised as an important gateway to dietary and nutritional health. Oral health, however,...
Original Article
Cost analysis of a Patient-Centred Medical Home for community-dwelling older adults with complex needs in Singapore
The Patient-Centred Medical Home (PCMH) is a model of chronic care that replaces episodic primary care, with the delivery of primary care to patients, families and communities. It is guided by the principles of first-contact accessibility, comprehensiveness and whole-person orientation, integration and care coordination, sustained clinician-patient relationships, and quality...
Original Article
Sex and ethnicity modified high 1-year mortality in patients in Singapore with newly diagnosed atrial fibrillation
Atrial fibrillation (AF) is the most common clinically significant arrhythmia and is associated with increased risks of stroke, dementia, heart failure (HF) and death.1 Globally, 33.5 million people were reported to have AF in 2010,2 with numbers expected to increase exponentially by 2050.3-7 While in part due to ageing...
Original Article
Non-motorised active mobility device use by children in Singapore: Injury patterns and risk factors for severe injury
The Active Mobility Act was introduced in Singapore in 2017 to promote the safe use of personal mobility devices. Non-motorised active mobility devices (AMDs) are popular among children and include tricycles, bicycles, scooters, inline skates, skateboards, longboards and waveboards. While the use of AMDs contributes towards an active lifestyle...
Editorial
From Astana to Singapore: Primary Health Care is key to the long-term success of Singapore’s health system
The Ministry of Health, Singapore (MOH) has launched a wide-ranging and ambitious initiative for a life-course approach to drive the population’s health.1 This approach aims at ensuring the sustainability of the healthcare system. Crucially, it also embodies core principles of the health systems orientation that have long been advocated...
Editorial
Different strokes for different folks
Atrial fibrillation (AF) remains the most common arrhythmia since William Harvey’s observation of fibrillating auricles in open chest animal models in 1628. Willem Einthoven first documented ECG tracing of AF in 1906. Fast forward several hundred years since its first observation, AF remains a mystery from its pathogenesis and...
Editorial
Inclusive and safe active mobility
Physical activity is considered the “best buy” in public health practice to prevent non-communicable diseases. This perspective overshadows the importance of avoiding injuries due to physical activity in vulnerable populations.1-3 Non-communicable conditions are considered the third most common cause of mortality in people aged 5–19 years.4 However, injuries are...
Images in Medicine
Neck pain with prevertebral soft tissue thickening
A 37-year-old man presented with a history of sudden-onset neck pain, which was worse on movement and neck extension. He reported no history of trauma or infection. He denied any neurological symptoms. A physical examination showed limited neck motion in all directions due to pain. Blood tests showed total...
Images in Medicine
White precipitate in a dialysis circuit
An 81-year-old man who had been fully vaccinated against COVID-19 was admitted to the medical intensive care unit on day 5 of his COVID-19-induced pneumonia for high flow nasal oxygen treatment. He had hypoxaemic respiratory failure secondary to acute respiratory distress syndrome (ARDS) from the COVID-19-induced pneumonia. He had...
Letter to the Editor
Development and feasibility of a mobile-based vestibular rehabilitation therapy application for healthy older adults
Dear Editor,
Vestibular hypofunction (VH) is the clinical condition where there is partial or complete loss of the vestibular organs and/or vestibular nerves. Symptoms of VH include vertigo, postural unsteadiness, and oscillopsia with head movements.1,2 These symptoms, if untreated, can affect an individual’s daily activities, occupational performance and mobility,...
Letter to the Editor
A case of rapidly progressive insomnia and dysautonomia
Dear Editor,
A 43-year-old woman with no past medical history presented with 8 months of progressive memory loss and irritability, which led to her resigning from her office job. She frequently misplaced belongings, asked for deceased relatives, and could no longer bathe herself. When listening to conversations around her,...
Letter to the Editor
Teaching and learning during the COVID-19 pandemic: Perspectives of medical students in Singapore
Dear Editor,
The coronavirus disease 2019 (COVID-19) pandemic has resulted in many changes to medical education, including the site and mode of teaching, conducting of examinations and a shift towards prioritising the mastery of clinical skills relevant to infection control. Hence, Ng et al.’s suggestions on how to maximise learning...
Letter to the Editor
Screening for somatisation in an Asian children’s hospital emergency setting
Dear Editor,
In recent years, self-harm is the leading cause of morbidity and mortality among adolescents in Singapore.1,2 This is just the tip of the iceberg as youths with undiagnosed mental health disorders often present to the healthcare system with non-psychiatric symptoms.3 These psychosomatic symptoms do not have an organic...
Commentary
Activating Code Crimson in the emergency department: Expediting definitive care for trauma patients with severe haemorrhage in Singapore
Public healthcare institutions (PHIs) in Singapore have a range of policies and guidelines for the management of patients presenting to the emergency department (ED) with blunt or penetrating major trauma. “Trauma team activation” is initiated by the ED specialist through the hospital call-centre, and is a process that mobilises...
Review Article
Barriers to breast cancer screening in Singapore: A literature review
Breast cancer is a major public health concern and a leading cause of cancer death among women worldwide, including Singapore.1 According to the 2018 Singapore Cancer Registry report, breast cancer has been consistently ranked as a leading cancer (29.3% of all cancers in Singapore) among women in Singapore for...
Original Article
Nationwide study of the characteristics of frequent attenders with multiple emergency department attendance patterns
Emergency department (ED) overcrowding is a growing issue that threatens public health in various parts of the world,1 including the US,2 UK,3 Australia,4 Japan5 and Taiwan.6
Individuals who visit the ED repeatedly, known as frequent attenders (FAs), have been identified as a possible driver of ED overcrowding. While the...
Original Article
Interaction of sex and diabetes in Asian patients with heart failure with mildly reduced left ventricular ejection fraction
Diabetes mellitus (DM) is a common comorbidity worldwide with global prevalence among adults above 18 years of age increasing from 4.7% in 1980 to 8.5% in 2014.1 DM has been shown to be a common comorbidity in heart failure (HF) patients ranging from 4.3–28%2 and when present, portends a...
Original Article
Global monkeypox outbreak 2022: First case series in Singapore
Monkeypox has been declared a public health emergency of international concern. Up until 2022, most cases of monkeypox have been reported in parts of Africa. On 7 May 2022, a returning traveller from Nigeria to the UK was confirmed to have contracted monkeypox. By the end of May 2022,...
Editorial
Frequent attenders to multiple emergency departments in Singapore
The problem of overcrowding, of which access block is one of the main causes, continues to plague emergency departments (EDs) worldwide.1 Some of its negative effects include adverse impact on patient safety, medical errors and staff burnout. In addition, high volume of patients waiting to be seen (ED input)...
Editorial
Impact of sex and diabetes in patients with heart failure with mildly reduced ejection fraction
With increasing global awareness of sex differences in the heart failure population and the new entity of heart failure with mildly reduced ejection fraction (HFmrEF), much has yet to be fully understood with regard to patient demographic, clinical presentation, response to guideline-directed heart failure therapies, and outcome across the...
Editorial
The global emergence of monkeypox
Monkeypox is so named because the poxvirus was first identified in 2 outbreaks among cynomolgus monkeys housed at the Statens Serum Institut, Denmark, in 1958.1 Both outbreaks occurred approximately 2 months after the monkeys arrived by plane from Singapore.1 However, the natural reservoir of the virus is not monkeys...
Letter to the Editor
Response to letters arising from publication of the Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting
Dear Editor,
The Academy of Medicine, Singapore (AMS) guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting and an accompanying editorial were published in the January 2022 issue of the Annals.1,2 An evidence-based approach was used with reference made to relevant published literature. The...
Images in Medicine
An unusual case of ear pain in a child
A previously healthy 4-year-old French boy presented to the children’s emergency department complaining of left otalgia for 3 days. He had initially experienced left ear itch, which progressed to increasing sharp pain. There was no associated otorrhoea, blood-stained ear discharge or hearing loss. The child did not experience fever,...
Letter to the Editor
Sedation in gastrointestinal endoscopy in Singapore
Dear Editor,
I refer to the editorial “Ensuring safe sedation during gastroendoscopy”1 and the original article “Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during endoscopy in the hospital setting”2 in your journal in January 2022.
The American Society of Gastrointestinal Endoscopy (ASGE) and the European...
Letter to the Editor
Non-anaesthesiologists administering propofol in the Singapore context
Dear Editor,
Propofol is a potent intravenous sedative-hypnotic agent. Its popularity for sedation has increased in the last 3 decades because of its smooth, rapid onset of action and fast post-procedural recovery.1 Nonetheless, propofol depresses cardiorespiratory function and could result in life-threatening adverse effects.
A workgroup, mainly consisting of gastroenterologists and...
Letter to the Editor
Sedation by non-anaesthesiologists in gastrointestinal endoscopy
Dear Editor,
We read with interest the paper by Ang et al.1 on Singapore guidelines in the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. We are especially intrigued by Statement 6, stating that propofol sedation for endoscopy can be safely and effectively administered by trained...
Letter to the Editor
Knowledge and perception of fall prevention in hospital: A survey of nursing staff
Dear Editor,
Hospital falls are a common debilitating problem worldwide and are associated with negative patient outcomes and increased financial costs to organisations.1,2 While current research has demonstrated the positive impact of a multifaceted fall prevention programme in hospitals, results have been mixed in showing a statistically significant decline...
Letter to the Editor
Iatrogenic atrial septal defect after catheter ablation—to close or not to close?
Dear Editor,
Transseptal access to the left heart is increasingly performed for electrophysiological procedures and for structural heart disease interventions such as balloon mitral valvuloplasty (BMV), left atrial appendage closure (LAAC) and transcatheter mitral valve repair (TMVr). Most of the iatrogenic atrial septal defects (iASDs) close spontaneously, and for those...
Commentary
Cardiac sarcoidosis: Difficulties in diagnosis and treatment
Sarcoidosis is a multisystem, granulomatous disorder of unknown aetiology. It affects the lungs in 90% of cases, but is also known to affect other organs including the skin, liver, spleen, kidneys and heart.1 Cardiac sarcoidosis (CS) is thought to clinically affect 5% of those with sarcoidosis, manifesting as conduction...
Review Article
Academy of Medicine, Singapore clinical guideline on endoscopic surveillance and management of gastric premalignant lesions
Gastric cancer (GC) is the 7th most common cancer in men and the 9th most common cancer in women in Singapore. More than two-thirds of patients with GC are diagnosed at stage III or IV, when the 5-year survival rate is <5%.1 In contrast, early GC (EGC) is associated...
Original Article
Prevalence of burnout among healthcare professionals in Singapore
Burnout was first described in 1974 by Herbert Freudenberger, where he discussed the concept based on physical signs, behavioural indicators, judgment, emotional factors, and the preventive measures to avoid burnout.1 In 2019, the World Health Organization defined burnout as an occupational phenomenon in the International Classification of Diseases 11th...
Original Article
Effects of electroconvulsive therapy on cognition and quality of life in schizophrenia
Schizophrenia is a severe mental disorder with a profound impact on patients, their families, caregivers and society. The global prevalence of lifetime schizophrenia is 0.2–0.4% without significant differences between sex and ethnicity, nor between urban and rural environments.1 The health and economic burden of schizophrenia is significant, given the...
Original Article
Treating acutely ill patients at home: Data from Singapore
Inpatient hospitalisation is the conventional strategy to care for acutely ill patients. However, demand for hospital beds and clinical manpower is escalating as populations age, and hospitals are expensive to build and run.1 There is increasing recognition of the risk of hospitalisation from potent nosocomial infections2,3 (exacerbated by the...
Editorial
Bridging electroconvulsive therapy in schizophrenia with cognition and quality of life
Schizophrenia is one of the most debilitating severe mental illnesses with significant impact,1 irrespective of culture or socioeconomic class.2 Over the decades, antipsychotic medication has been the mainstay of treatment for patients with schizophrenia. Nevertheless, about 25% of patients do not respond to first-line antipsychotic medication, with more than...
Editorial
Treating patients at home: A novel solution for old problems
Hospital-at-home (HaH) programmes deliver hospital-type treatments to patients located in their own homes, often in substitution for an acute inpatient admission or to support early discharge from hospitals. They are associated with high patient satisfaction rates, improved health outcomes and reduced risks of delirium and nosocomial infections.1 HaH services...
Images in Medicine
Cause of vaginal spotting in an older woman
A 77-year-old Chinese woman with a past medical history of Sjogren’s syndrome, nodular goitre and right-sided neck lymphadenopathy, presented to the gynaecological service for per-vaginal spotting. On clinical examination, she was noted to have a cervical polyp. A polypectomy was performed and the specimen was sent for histological examination.
The...
Letter to the Editor
Palliative dialysis in hospice: A paradox or promising answer?
Dear Editor,
End-stage renal disease (ESRD) patients have higher mortality, hospital admissions and invasive procedures towards the end of life.1 However, many of them (82%) prioritise minimising suffering over life prolongation. Although twice as many patients prefer dying at home and inpatient hospice (65%) compared to hospital (27%), hospice utilisation...
Letter to the Editor
Safe time interval for screening estimated glomerular filtration rate prior to gadolinium-enhanced MRI scan
Dear Editor,
Magnetic resonance imaging (MRI) contrast media are commonly used in medical imaging and are usually gadolinium-based contrast agents (GBCAs). They can be divided into 3 groups. Group I consists of compounds with linear molecular structures. Group II consists of compounds with macrocyclic molecular structures. Group III currently includes...
Letter to the Editor
Perception of disease, well-being and financial burden by patients with chronic hepatitis B: A self-reported assessment
Dear Editor,
Chronic hepatitis B (CHB) infection affects approximately 248 million individuals in the world1 and 3.6% of the Singapore population.2 Given the natural history of CHB, regular surveillance with blood tests is necessary to ensure early detection of complications such as cirrhosis and hepatocellular carcinoma in patients. Our study...
Letter to the Editor
Neuralgic amyotrophy in COVID-19 infection and after vaccination
Dear Editor,
Various neurological manifestations associated with coronavirus disease 2019 (COVID-19) have been described,1 conditions which left a significant proportion of patients with permanent disability. Continued vigilance is crucial with emergence of new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants that cause the disease. Vaccination against COVID-19 remains the...
Letter to the Editor
Attitude towards screening for congenital cytomegalovirus infection in newborns in Singapore
Dear Editor,
Cytomegalovirus (CMV) infection is the most common congenital infection.1 A systematic review that included 77 studies from 36 countries reported that the overall prevalence of CMV was 0.67% in their newborn population.1 Among newborns with CMV, it was estimated that 15–20% will suffer from potentially deleterious effects including...
Commentary
Congenital cytomegalovirus infection: Advocating for screening and education
Cytomegalovirus (CMV) infection is the leading non-genetic cause of congenital neurosensory hearing loss in children, accounting for 21% of cases of hearing loss at birth and 25% of deafness at age 4 years.1 It can also give rise to other serious sequelae such as cerebral palsy, cognitive impairment, seizures...
Original Article
Functional improvement after inpatient rehabilitation in community hospitals following acute hospital care
Early inpatient rehabilitation therapy has been known to have beneficial impact on physical function and mobility, psychological status and cognitive function of patients following an acute medical event requiring hospitalisation.1 Following an acute hospital care, those who have been identified to have potential for functional improvements are often transferred...
Original Article
Epidemiological trends and outcomes of children with aural foreign bodies in Singapore
Aural foreign bodies (FBs) commonly present to the emergency department (ED) worldwide. Children represent the majority of the population, believed to be due to their inquisitive minds and experimental nature.1 Aetiologies for aural FBs include accidental or intentional insertion of FBs into body orifices, ear irritation caused by rhinitis...
Original Article
Inter-hospital trends of post-resuscitation interventions and outcomes of out-of-hospital cardiac arrest in Singapore
Out-of-hospital cardiac arrest (OHCA) have notoriously been a medical issue with high morbidity and mortality.1 It is a multifaceted problem with a multitude of aetiologies,2 and as such various factors influence the outcome of OHCA patients.
The management of OHCA can generally be outlined by the “Chain of Survival”, a...
Original Article
Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore
Within 3 weeks of the World Health Organization declaring the COVID-19 pandemic on 11 March 2020, the Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) developed a set of nutrition guidelines that addresses issues on nutrition assessment; timing and feeding route; caloric...
Editorial
Out-of-hospital cardiac arrest in Singapore: Can we do better?
Cardiac arrests are unpredictable events that frequently result in death or significant residual morbidity among survivors. These sudden events affect not only the individual, but are understandably also significant life events and stressors for the family and friends. As such, the impact of cardiac arrests is felt on a...
Editorial
Challenges and considerations in delivering nutritional therapy in the ICU during COVID-19 pandemic
Coronavirus disease 2019 (COVID-19) has created unprecedented challenges for healthcare workers in Singapore and across the world. Providing clinical nutrition and metabolic care to patients with COVID-19 has been highly challenging. In this issue of the Annals, Lew et al.1 reported the results of a multicentre retrospective observational study...
Images in Medicine
Nitrous oxide and cervical myelopathy
A 25-year-old woman presented with progressive paraesthesia and numbness, both of which started from the left hand. Her symptoms progressed to the fingertips of her right hand and bilateral soles over a few days. There was associated confusion and altered mental status on admission. There was no weakness of...
Letter to the Editor
Psychosocial impact and treatment trends of hidradenitis suppurativa in Singapore
Dear Editor,
Hidradenitis suppurativa (HS) is a common disease with a prevalence of about 1%.1 Patients commonly suffer from pain, disfigurement and psychosocial embarrassment, and have a worse quality of life compared to other dermatologic conditions.2,3 It is frequently misdiagnosed as other skin infections and delays in diagnosis are associated...
Letter to the Editor
Optimum follow-up period of arthroscopic and mini-open rotator cuff repairs
Dear Editor,
Rotator cuff disorders are the most common cause of disability related to the shoulder,1 and rotator cuff repairs—via mini-open or arthroscopic techniques—are considered in patients with refractory symptoms.2 While there are multiple studies analysing short- and long-term follow-ups, there are no clear consensus regarding the minimum follow-up...
Letter to the Editor
Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) hysterectomy in Singapore
Dear Editor,
Hysterectomy is one of the most common gynaecological procedures, and various approaches are available such as abdominal, laparoscopic and vaginal.1 Several studies demonstrated that vaginal hysterectomy is preferable to laparotomy for superior surgical safety, less postoperative pain, and shorter hospital stay.2,3 However, its use is limited by...
Letter to the Editor
BNT162B2 COVID-19 mRNA vaccination did not promote substantial anti-syncytin-1 antibody production nor mRNA transfer to breast milk in an exploratory pilot study
Dear Editor,
Vaccine hesitancy still threatens global efforts to end the COVID-19 pandemic caused by SARS-CoV-2 and its emerging variants. Social media-driven “conspiracy theories” cast doubts on vaccine safety for reproductive health,1 including concerns that vaccine-induced SARS-CoV-2-neutralising antibodies (NAb) cross-react with human syncytin-1—a protein involved in gamete fertilisation and...
Commentary
COVID-19 vaccination acceptance of healthcare workers in Singapore
The Coronavirus disease 2019 (COVID-19) pandemic resulted in 511.0 million cases of confirmed SARS-CoV-2 infection and almost 6.2 million deaths globally as of end April 2022.1 With the introduction of vaccines that are effective in reducing severe COVID-19 illnesses and deaths, Singapore had since pivoted from a COVID-19 elimination...
Commentary
The Lancet Commission on diagnostics: What it means for Singapore
Effective healthcare systems depend on a functioning healthcare value chain—defined as a care cascade comprising screening, diagnosis, treatment and follow-up. The tremendous heterogeneity and global disparity regarding this healthcare value chain has been one of the fundamental problems with prioritised urgency since the United Nation’s Millennium Development Goals were...
Review Article
Consensus statement on Singapore integrated 24-hour activity guide for children and adolescents
The World Health Organization’s Global action plan for the prevention and control of noncommunicable diseases 2013–2020 provided guiding principles for national efforts in controlling and reducing non-communicable diseases (NCDs).1 The major NCDs include cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes—they form a major public health challenge, and are...
Original Article
Prevalence and correlates of psychological distress and coronavirus anxiety among hospital essential services workers in Singapore
The Coronavirus Disease 2019 (COVID-19) has affected almost all geographies in the world since 2020. Many countries have imposed strict isolation measures to contain the spread of this disease. While the majority of the population has been working from home, essential workers continue manning the frontlines, facing risks such...
Original Article
Sepsis, cardiovascular events and short-term mortality risk in critically ill patients
Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host immune response to infection”.1 It is one of the most common conditions afflicting intensive care unit (ICU) patients, causing a high mortality rate. An estimated 48.9 million incident cases of sepsis and 11 million sepsis-related deaths were...
Original Article
Prevalence, risk factors and parental perceptions of gastroesophageal reflux disease in Asian infants in Singapore
Functional gastrointestinal (GI) disorders, such as colic, gastroesophageal reflux (GER) and constipation, are common in infants under 1 year. They are a frequent cause of concern for parents and result in a significant healthcare burden1,2 due to their negative impact on feeding behaviours, caregivers’ mental wellbeing and quality of...
Editorial
Sepsis and cardiovascular events: The story so far
Sepsis is a state of life-threatening organ dysfunction that results from a dysregulated host immune response to infection.1 Sepsis is a common condition that leads to admission to the intensive care unit (ICU). Although advances have been made in the management of sepsis, mortality from sepsis remains high.2 Among...
Editorial
Gastroesophageal reflux disease in Asian infants: Similar condition, different perceptions
Gastroesophageal reflux disease (GERD), a common problem in infancy, may lead to troublesome symptoms or complications such as oesophagitis or oesophageal stricturing in a small minority of infants.1 In the majority of cases, however, frequent regurgitations, the commonest symptoms of GERD, resolves with age spontaneously without any medical intervention.2,3...
Images in Medicine
A 52-year-old woman with beading of intracranial arteries
A 52-year-old woman of Indian ethnicity with a history of well-controlled hypertension, hyperlipidaemia and recurrent transient ischaemic attacks presented with altered mentation and slurred speech. Physical examination revealed generalised weakness. Initial blood tests showed raised total white cell count, raised erythrocyte sedimentation rate at 35mm/h and fasting low-density lipoprotein...
Letter to the Editor
An initial experience with laser haemorrhoidoplasty in addition to mucopexy for symptomatic haemorrhoids
Dear Editor,
Symptomatic haemorrhoids is the most common anorectal disorder, where up to 75% of people experience symptoms sometime in their lives.1
The current gold standard for the surgical management of haemorrhoids is the Milligan-Morgan haemorrhoidectomy,2 with unrivalled long-term results.3 However, the technique is associated with significant postoperative pain,4,5 leading to...
Letter to the Editor
Previous history of hyperthyroidism in emergency department patients with atrial fibrillation does not increase the risk of thromboembolism and death
Dear Editor,
Atrial fibrillation (AF) is frequently encountered in the emergency department (ED) and is a major risk factor for thromboembolic events. The clinical decision for anticoagulation is guided by risk scoring systems that include factors such as age, sex and comorbidities.1,2 AF can sometimes occur in patients with active...
Letter to the Editor
Injection site reactions after COVID-19 mRNA vaccination
Dear Editor,
The Pfizer-BioNTech (BNT162b2 mRNA) and Moderna (mRNA-1273) COVID-19 vaccinations were approved for use in Singapore in December 2020 and February 2021, respectively. To date, over 10 million doses of mRNA vaccines have been administered for the primary series and booster doses.1 Initial studies have shown that 0.8% of...
Letter to the Editor
Haemoglobin H disease and outcomes in Singapore
Dear Editor,
Haemoglobin H (HbH) disease is a haemoglobinopathy affecting 3 of 4 α-globin genes on chromosome 16. It results from the deletion of 2 linked α-globin genes (α0-thalassaemia) on one chromosome and either a single α-globin gene deletion (--/-α) or non-deletional gene mutation (--/αTα) on the other chromosome. The...
Letter to the Editor
Retrospective analysis of neonates born after assisted reproductive technology and admitted to the neonatal intensive care unit
Dear Editor,
There are limited studies evaluating neonatal outcomes after assisted reproductive technology (ART) in Asia, especially Southeast Asia, hence this study aimed to fill this gap in literature. We conducted a retrospective study on a group of neonates conceived via ART performed at the National University Hospital (NUH),...
Commentary
Health economics of kidney replacement therapy in Singapore: Taking stock and looking ahead
Burden of ESKD in Singapore. The incidence of chronic kidney disease (CKD) stage 5 in Singapore increased by 31% from 383.9 per million population (pmp) in 2010 to 503 pmp in 2018. The prevalence of patients with end-stage kidney disease (ESKD) on dialysis increased by 58% from 1,218 pmp...
Review Article
Medicolegal aspects of non-rapid eye movement parasomnias
Parasomnia is a clinical sleep disorder, which involves undesirable physical or behavioural phenomena that arise predominantly during sleep.1,2 This can occur during any stage of sleep, including the transition from wakefulness to sleep, while asleep, or during awakening.3
One category of parasomnias occurs primarily during sudden but incomplete awakening from...
Review Article
Circular RNAs in the pathogenesis of sepsis and their clinical implications: A narrative review
Sepsis is a condition with life-threatening organ dysfunction, resulting from abnormal responses of the host to various infections.1 The underlying pathogenic mechanisms include an imbalanced inflammatory response, immune disorder, neuroendocrine abnormality, coagulopathy, mitochondrial damage and endoplasmic reticulum stress.2 A recent study reported that the age-standardised sepsis incidence rate fell...
Original Article
Comparison of planned-start, early-start and deferred-start strategies for peritoneal dialysis initiation in end-stage kidney disease
Peritoneal dialysis (PD) is a well-established long-term dialysis modality for patients with end-stage kidney disease (ESKD).1 It is recommended that a PD catheter should be placed at least 2 weeks prior to the anticipated need of long-term PD treatment for a planned-start PD.2 Despite wide-spread promotion of planned-start dialysis for...
Original Article
Diagnosis and management of polycystic ovary syndrome: Perspectives of clinicians in Singapore
Polycystic ovary syndrome (PCOS) is a common endocrine disorder estimated to affect 4–21% of women, depending on the diagnostic criteria used.1 Clinical manifestations of the syndrome are varied, and multiple parameters are needed for its diagnosis.2,3 This complicates the diagnosis of PCOS and may cause patient dissatisfaction arising from delayed...
Editorial
Circular RNAs and sepsis: New frontiers in diagnostics and therapeutics?
Circular RNAs (circRNAs) are a group of endogenous RNAs characterised by their covalently closed-loop structures. These molecules are part of a large class of non-coding RNAs that includes microRNAs (miRNAs) and long non-coding RNAs (lncRNAs). CircRNAs were initially thought to be of low abundance and represent errors in splicing....
Editorial
Polycystic ovary syndrome in Singapore
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in young women, affecting approximately 10% of women. It is a heterogeneous condition that can present with a wide spectrum of signs and symptoms, including acne, hirsutism, obesity, menstrual irregularities and infertility. It is a complex trait that is...
Images in Medicine
Unusual biliary gem: Cause of acute obstructive suppurative cholangitis and pancreatitis in a patient with Billroth II anastomosis
A 72-year-old man with a 10-year history of subtotal gastrectomy with Billroth II anastomosis and laparoscopic cholecystectomy presented with abdominal pain, high fever and altered mental status. His blood pressure was 94/50mmHg, heart rate 136bpm and body temperature 39.4°C. Laboratory examination revealed the following: white blood cell count 16,200/μL;...
Letter to the Editor
Change in hepatitis B virus DNA status in patients receiving chronic immunosuppressive therapy for moderate-to-severe skin disease
Dear Editor,
Hepatitis B virus (HBV) infection poses a global health burden. Clinically, patients may present with chronic HBV infection, occult HBV infection, and fulminant hepatic failure. In 2010, the hepatitis B surface antigen (HBsAg) seroprevalence in Singapore was 3.6%.1
Patients with dermatological conditions receive prolonged corticosteroid and other immunosuppressive therapy...
Letter to the Editor
Intravascular large B-cell lymphoma associated with sudden stridor arising from thyroid mucormycosis and concomitant bacterial infection
Dear Editor,
Mucormycosis is a life-threatening fungal infection that mainly affects immunocompromised patients. It typically has low prevalence, but fatality rate is as high as 50%.
We present a patient with intravascular lymphoma with secondary bacterial infection and invasive mucormycosis involving the thyroid gland, who experienced good outcomes following surgical...
Letter to the Editor
Acute hypercapnic respiratory failure in thyroid storm and the role of plasma exchange
Dear Editor,
Thyroid storm is a life-threatening condition due to excessive release of thyroid hormone. Cardiovascular, gastrointestinal and neurological manifestations have been described.1 Acute respiratory failure as the initial presentation of a thyrotoxic crisis may occur due to pre-existing cardiopulmonary disease. Management is supportive, with medications aimed at inhibiting synthesis...
Letter to the Editor
Evaluation of a health screening protocol for recovered COVID-19 patients before “return-to-play” and strenuous physical activity
Dear Editor,
We conducted a prospective, single-centre cohort study to develop guidance for military personnel returning to strenuous activities following SARS-CoV-2 infection. The patients underwent a clinical review followed by a protocol to screen for cardiac, respiratory, haematological, endocrine/renal and neurological complications after recovery from infection.
Both the study and screening...
Letter to the Editor
Telepalliative care during the pandemic: Lessons for the future
Dear Editor,
Mok et al. gave hope for cautious optimism for the acceptance of telemedicine for palliative care—which will be referred to as “telepalliative care” in this article—during the COVID-19 pandemic.1 Properly organised, telepalliative care can save time, provide flexibility, improve access for patients2,3 and possibly reduce the need for...
Review Article
Determinants of emergency department utilisation by older adults in Singapore: A systematic review
Older adults in Singapore contribute to a disproportionately higher number of visits to the emergency department (ED), mirroring trends around the world.1,2 For instance, hospital admissions among those aged ≥65 years have been on the rise from 2018 to 2020, contributing a growing burden to ED services over the...
Original Article
Identifying high-risk hospitalised chronic kidney disease patient using electronic health records for serious illness conversation
In-hospital cardiopulmonary resuscitation (CPR) for chronic kidney disease (CKD) patients is shown to have lower survival1 and a higher proportion of survivors on maintenance haemodialysis were discharged to skilled nursing facilities.2 Despite that, haemodialysis patients still preferred CPR during cardiac arrest3 and there are lower do-not-resuscitate orders for the...
Original Article
Pre- and apnoeic high-flow oxygenation for rapid sequence intubation in the emergency department (the Pre-AeRATE trial): A multicentre randomised controlled trial
Critically ill patients in the emergency department (ED) have shorter safe apnoea times due to physiological distress from decreased cardiac output, increased shunting and reduced pulmonary reserves.1 Hypoxia is a commonly encountered adverse event during rapid sequence intubation (RSI)2 and is associated with cardiac arrest, neurological injury and death.3...
Original Article
Diagnostic thresholds for absolute systolic toe pressure and toe-brachial index in diabetic foot screening
Diabetes mellitus is a global healthcare problem. In Singapore, the rising disease burden of this metabolic condition places considerable strain on the healthcare system, with healthcare costs for diabetes mellitus exceeding 1 billion Singapore dollars a year.1 An important complication of diabetes is lower limb loss. As diabetic foot...
Original Article
Death and cardiovascular outcomes in end-stage renal failure patients on different modalities of dialysis
End-stage renal failure (ESRF) is a major cause of morbidity and mortality worldwide, including Asia.1 In Singapore, incidence of chronic kidney disease (CKD) stage 5 has increased from 383.9 per million population (PMP) in 2010 to 414.8 PMP in 2015. Incidence of patients requiring dialysis has increased in tandem....
Editorial
Pressures, indexes and peripheral arterial disease: Time to rethink our approach?
Most patients with peripheral arterial disease (PAD) are asymptomatic. Despite the absence of symptoms, these patients have a significantly increased risk of death and adverse vascular events.1 Early detection of individuals with asymptomatic PAD facilitates prompt introduction of secondary prevention (lifestyle modification, smoking cessation, anti-platelet medications and lipid management)....
Editorial
Survival outcome of haemodialysis and peritoneal dialysis
End-stage renal disease (ESRD) is a challenging and growing health issue, with number of patients increasing globally. The use of dialysis has greatly improved the survival and life expectancy of ESRD patients. Haemodialysis (HD) and peritoneal dialysis (PD) are 2 broad dialysis modalities used for ESRD. Despite the advancement...
Board of Reviewers
Board of Reviewers
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Subject Index
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Author Index
Author Index
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Mesothelial Splenic Cyst—A Case Report
Non-parasitic cystic lesions of the spleen are unusual. They are classified essentially as primary (true, epithelial) and secondary (pseudo, non-epithelial) based on the presence or absence of lining epithelium.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
A Case Report of Heparin Resistance due to Acquired Antithrombin III Deficiency
Intravenous heparin therapy is used in the management of angina and myocardial infarct with increasing frequency in recent years. Those patients who have been on heparin therapy for several days may exhibit resistance to heparin given before cardiopulmonary bypass.
This article is available only as a PDF. Please click on...
Others
Cryptococcal Prostatic Abscess in an Immunocompromised Patient: A Case Report and Review of the Literature
Cryptococcosis is a well-recognised infection in immunocompromised patients, although its prevalence varies with the type of immune defect. We report a patient with myasthenia gravis (MG) on steroid therapy and non-insulin dependent diabetes mellitus (NIDDM) who developed cryptococcal meningitis and in whom a search for a persistent focus by...
Others
Cutaneous Polyarteritis Nodosa: A Case Report and Literature Review
Cutaneous polyarteritis nodosa (CPN) is an uncommon form of vasculitis of the small-and medium-sized arteries in the reticular dermis and subcutaneous tissue. It remains limited and runs a chronic, benign course.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full...
Others
Sezary Syndrome: A Case Report and a Review of the Molecular Pathomechanism and Management
Our patient is a 64-year-old Malay man who first presented in July 1993 with a history of rash starting on the hands 1½ years earlier progressing to generalised eczema 5 months prior to consultation. He was diagnosed to have generalised exfoliative dermatitis (GED).
This article is available only as a...
Others
A Case Report of Neutrophilic Eccrine Hidradenitis in a Patient Receiving Chemotherapy for Acute Myeloid Leukaemia
Neutrophilic eccrine hidradenitis (NEH) is a neutrophilic dermatosis primarily affecting the eccrine glands and occurs most commonly in patients undergoing chemotherapy for a malignancy.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Pericardial Injury Following Severe Sepsis from Faecal Peritonitis—A Case Report on the Use of Continuous Cardiac Output Monitoring
The intermittent manual bolus thermodilution method is the most common means of determining cardiac output in critically ill patients. Although widely used, there are many factors which may affect the accuracy of this technique such as the volume, temperature and timing of the injectate.
This article is available only as...
Others
Creutzfeldt-Jakob Disease Presenting with Visual Blurring, Diplopia and Visual Loss: Heidenhain’s Variant
The electroencephalographic pattern is distinctive in many but not in all patients with Creutzfeldt-Jakob disease (CJD). Often, it is one of diffuse and non-specific slowing in the background with stereotypical generalised periodic high-voltage slow and sharp wave complexes.
This article is available only as a PDF. Please click on “Download...
Others
Case Series of Bronchoscopic Removal of Tracheobronchial Foreign Body in Six Adults
Gustav Killian reported the first case of bronchoscopic removal of foreign body (FB) from the trachea in 1897. Since then, rigid bronchoscopy under general anaesthesia by the cardiothoracic surgeon has remained the procedure of choice for FB removal in the airways, failing which thoracotomy and bronchotomy is performed.
This article...
Review Article
An Overview of Anaesthetic Issues in Phaeochromocytoma
New developments in technology, monitoring and pharmacology over the last decade have improved our understanding of phaeochromocytoma and its management. This review summarises the pathophysiology and clinical features of phaeochromocytoma.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Original Article
A Randomized Trial of the Use of Print Material and Personal Contact to Improve Mammography Uptake Among Screening Non-attenders in Singapore
Breast cancer is the most common cancer among females in Singapore. Although lower than incidence rates in North America and the United Kingdom the incidence of breast cancer here has doubled from 20 to 38.8 per 100,000 women per year over the past 2 decades, and the disease is...
Original Article
A Review of Pedestrian Fatalities in Singapore from 1990 to 1994
Fatal road accidents are by no means uncommon in Singapore, a modern tropical metropolis with a population of approximately 3 million. Statistics provided by the Traffic Police Department show that, although the accident fatality rate had fallen sharply from 13.4 per 100,000 population in 1984, to 8.0 per 100,000...
Original Article
A Descriptive Study of the Demography, Symptomology, Management and Outcome of the First 300 Patients Admitted to an Independent Hospice in Singapore
Modern society views death as an aberration which has to be postponed and, if possible, prevented at all cost. Death is just unacceptable and cannot be regarded as a natural process of life.
This article is available only as a PDF. Please click on “Download PDF” on top to view...
Original Article
Glaucoma Pattern Amongst the Elderly Chinese in Singapore
Glaucoma is a major cause of world blindness in developing and developed nations. The WHO Global data on blindness show that over half of the blind due to glaucoma reside in Asia, the majority being Chinese.
This article is available only as a PDF. Please click on “Download PDF” on...
Original Article
Risk Factors for Predicting Mortality in a Paediatric Intensive Care Unit
Following the rapid advances in medical therapy and critical care technology over the past 30 years, coupled with the spiralling cost of medical care, outcome analysis including mortality risk prediction has become a challenge for the modern day intensivists. During the early 90s, the focus has shifted from the...
Original Article
The Profile of Hospitalised Patients with Parkinson’s Disease
Prevalence studies in various parts of the world have shown that Parkinson’s disease (PD) is relatively common among the aged in all countries. Crude prevalence rates range from 10 to 450 per 100 000 population.
This article is available only as a PDF. Please click on “Download PDF” on top...
Original Article
Reduction in Retake Rates and Radiation Dosage Through Computed Radiography
New computed radiography imaging systems are slowly gaining a foothold in radiological departments worldwide. By computed radiography we mean a digital imaging system which exposes a photostimulable phosphor image receptor plate to obtain a latent image using existing radiographic equipment.
This article is available only as a PDF. Please click...
Original Article
Computed Tomographic and Magnetic Resonance Imaging Findings in Paranasal Sinus Involvement in Nasopharyngeal Carcinoma
Nasopharyngeal carcinoma (NPC) is an aggressive infiltrative neoplasm. Spread into the paranasal sinuses is often seen but the frequency is documented in only a few series.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Original Article
Drug Treatment of Hypercholesterolaemia
Serum cholesterol has been established as a major risk factor for coronary heart disease (CHD). There is a linear association between serum cholesterol level and CHD mortality and morbidity.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Original Article
A Study of Idiopathic Thrombocytopenic Purpura (ITP) Patients over a Ten-year Period
Idiopathic thrombocytopenic purpura (ITP) is an immunoregulatory disorder in which antibodies damage platelets leading to their removal by cells of the reticuloendothelial system (RES). This occurs mainly in the spleen which is also the primary site of synthesis of these antiplatelet antibodies.
This article is available only as a PDF....
Original Article
Goldberger’s Triad in Dilated Cardiomyopathy—Can it Predict the Severity of Left Ventricular Dysfunction?
In 1982, Goldberger described a novel electrocardiogram (ECG) triad that was highly specific for patients with dilated cardiomyopathy and congestive heart failure (attributable to various aetiologic factors), with a sensitivity of 70%, a specificity of 99%, and a positive predictive value of 91%. For unknown reasons, ventricular dilation causes...
Original Article
Is it Feasible to Use Magnesium Sulphate as a Hypotensive Agent in Oral and Maxillofacial Surgery?
Although deliberate hypotension during surgery may potentially cause organ ischaemia, in particular of the myocardium and cerebrum, it is widely used as an adjuvant technique in oral and maxillofacial surgery aimed at reducing blood loss and improving the surgical field. Deliberate hypotension was reported as the fourth commonest cause...
Original Article
Anthropometry of Anterior Cruciate Ligament in Singaporean Chinese
Anterior cruciate ligament (ACL) reconstruction is a technically precise and demanding operation. Attention to factors such as the tunnel position, graft selection, fixation and rehabilitation play an important role in determining the final outcome.
This article is available only as a PDF. Please click on “Download PDF” on top to...
Original Article
Surgical Results of Open Reduction and Plating of Humeral Shaft Fractures
Management of humeral shaft fractures has been the subject of controversy (Böhler, Ekkernkamp and Muhr, Nast-Kolb and Schweiberer). The problem of non-union, wound infection and most important of all iatrogenic radial nerve palsy led many to favour a conservative approach.
This article is available only as a PDF. Please click...
Original Article
Stereotactic Microelectrode-guided Posteroventral Pallidotomy and Pallidal Deep Brain Stimulation for Parkinson’s Disease
Medications for Parkinson’s disease (PD) is effective for several years, but is followed by motor fluctuations, dyskinesias and progression of bradykinesia and rigidity. This is the reason why surgical therapies for PD have enjoyed a resurgence of interest.
This article is available only as a PDF. Please click on “Download...
Original Article
Operative Treatment of Displaced Talar Neck Fractures
Talus is a weight bearing bone with peculiar anatomy and blood supply. It forms the ankle joint with the medial and lateral malleoli, subtalar joint with the calcaneum and talonavicular joint with the navicular bone.
This article is available only as a PDF. Please click on “Download PDF” on top...
Original Article
Abdominal Surgery in Human Immunodeficiency Virus (HIV) Infected Patients—Early Local Experience
The prevalence of human immunodeficiency virus (HIV) infection is rising at an exponential rate in Singapore. The surgical experience with this disease remains limited.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Editorial
Academic Medicine in Singapore
Academic medicine is currently grappling with the problem of whether the triple-threat academician is a species threatened with extinction in the 21st century, given the extraordinary growth of knowledge during the past decades. Academicians, by this definition, were expected to be original and productive investigators, inspiring teachers and outstanding...
Others
Thyroid Storm Presenting as Jaundice and Complete Heart Block
Thyroid storm is defined as a severe and often life-threatening exacerbation of thyrotoxicosis which is usually characterised by hyperthermia, tachycardia, severe agitation and altered mental status. With the “apathetic” variant of hyperthyroidism, the classical features may not be evident.
This article is available only as a PDF. Please click on...
Others
Frontal Sinus Mucoceles Causing Proptosis—Two Case Reports
Frontal mucoceles are collections of inspissated mucus which occur when there is obstruction to the outflow of the frontal sinuses. The obstruction may be due to congenital anomalies, infection, trauma, allergy, neoplasms or surgical procedures in the nose.
This article is available only as a PDF. Please click on “Download...
Others
Emerging Therapies for Sepsis and Septic Shock
Septic shock remains a major cause of morbidity and mortality among hospitalised patients despite advances in antimicrobial therapy and medical support.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Adjuvant Chemotherapy for Patients with Resected Dukes’ C and High-risk B2 Colon Cancer with Fluorouracil and Levamisole
Carcinoma of the large bowel is the second leading cause of cancer mortality in Singapore. Although the great majority of patients are discovered at a stage where resection with curative intent is possible, almost half of the patients afflicted will die of it.
This article is available only as a...
Others
Postanaesthetic Shivering—A Comparison of Thiopentone and Propofol
The incidence of shivering following general anaesthesia varies from 5% to 65%. Postanaesthetic shivering may increase tissue oxygen demand by as much as 500% and accompanied by increases in minute ventilation and cardiac output to maintain aerobic metabolism.
This article is available only as a PDF. Please click on “Download...
Commentary
Experience with a Nine-step Policy Dealing with Requests for Medically Inappropriate Interventions for Cancer
Although great strides have been made in treating cancers, a significant number of patients still reach the point at which no curative treatment is available. Physicians then face the difficult task of informing patients that, although palliation is always possible, cure is not.
This article is available only as a...
Commentary
Invasive Cancer after Treatment of Cervical Intraepithelial Neoplasia
The objective of a cervical screening programme is to prevent invasive cancer of the cervix by detecting and treating pre-invasive disease of the cervix. The impact of the programme depends both on the detection of women with cervical intraepithelial neoplasia (CIN) and upon their being treated effectively.
This article is...
Commentary
The Polarprobe—Emerging Technology for Cervical Cancer Screening
Cervical cancer is a preventable disease that affects nearly half a million women worldwide. The Papanicolaou smear has been used for screening for over fifty years and the test has the advantage of fast and relatively easy sample collection.
This article is available only as a PDF. Please click on...
Others
Occult Virilizing Ovarian Tumours in Postmenopausal Women: Problems in Evaluation with Reference to a Case
A remarkable variety of endocrinologic disorders may cause virilization syndromes. This can pose a diagnostic dilemma to even the most experienced clinicians.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Occult Virilizing Ovarian Tumours in Postmenopausal Women: Problems in Evaluation with Reference to a Case
A remarkable variety of endocrinologic disorders may cause virilization syndromes. This can pose a diagnostic dilemma to even the most experienced clinicians.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Pelvic Spleen Masquerading as an Ovarian Neoplasm
A 53-year-old Caucasian woman, a receptionist in a general practice, was referred to the gynaecology outpatient clinic with an 18-month history of heavy, irregular menses and a pelvic mass on an abdominal ultrasound arranged by her General Practitioner (GP). She was otherwise asymptomatic.
This article is available only as a...
Others
Repair of Complex Ureterovaginal and Vesicovaginal Fistulas with Ileal Cystoplasty and Ureteric Reimplantation into an Antireflux Ileal Nipple Valve—A Case Report
Urogenital fistulas are a known but uncommon complication of gynaecological surgery, especially those involving a malignant process. Its incidence does not exceed 2%.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
A Case Report—Delayed Vesicocutaneous Fistula After Radiation Therapy for Advanced Vulvar Cancer
To our knowledge this is the first reported case of an isolated vesicocutaneous fistula related to previous radiation therapy for recurrent vulvar cancer.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Review Article
Optimal Treatment in Gestational Trophoblastic Disease
Gestational trophoblastic diseases (GTD) encompass a spectrum of interrelated conditions:
Hydatidiform mole (HM)
Invasive mole (IM)
Choriocarcinoma (CC)
Placental site trophoblastic tumour (PSTT)
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Review Article
Fallopian Tube Carcinoma—A Review
Fallopian tube cancer is the least common of gynaecological malignancies. It was first described by Renaud in 1847.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Review Article
Current Management of Early Vulvar Cancer
Carcinoma of the vulva is an uncommon malignancy, but one that is amenable to early diagnosis if symptoms and signs are appropriately investigated. Although patient and physician delay remains common, an increasing number of patients are being diagnosed with early stage disease.
This article is available only as a PDF....
Review Article
Topoisomerase-I Inhibitors in Gynaecologic Tumours
Topoisomerases are essential nuclear enzymes with a multiplicity of cellular functions involving DNA replication, RNA transcription, mitosis, and chromosome condensation. Two classes have been identified: the class I topoisomerases, named “I” because they induce single-strand breaks and reunions of the DNA double helix, and the class II topoisomerases, named...
Review Article
Screening for Ovarian Cancer
Ovarian cancer is the most common gynaecological malignancy with over 5000 new cases diagnosed every year in the UK and 22 000 in the United States. Four thousand women die each year of ovarian cancer in England and Wales, and 13 000 die in the USA.
This article is available...
Review Article
Biomarkers in Carcinoma of the Cervix: Emphasis on Tissue-related Factors and Their Potential Prognostic Factors
Accurate staging is of utmost importance in determining the prognosis of carcinoma of the cervix. Demographic features such as race and socio-economic status have been demonstrated as not having significant influence.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full...
Review Article
The Management Dilemma of the Mildly Abnormal Smear: Fact or Fiction?
Carcinoma of the cervix is still a relatively common gynaecological malignancy. However, despite being potentially preventable it still claims the lives of many women even in those countries where organised screening programmes exist.
This article is available only as a PDF. Please click on “Download PDF” on top to view...
Review Article
Adenocarcinoma of the Cervix
It is clear from studies in Canada, Scandinavia, and more recently the United Kingdom, that routine Pap smear screening has not only reduced the incidence of squamous carcinoma of the cervix but indeed in the last 10 to 15 years has halved the mortality rate from this disease. In...
Original Article
Malignant Ovarian Germ Cell Tumours: Experience in the National University Hospital of Singapore
One of the most remarkable advances in the management of gynaecological cancers is in malignant ovarian germ cell tumours. Before the early 70s, some of the malignant ovarian germ cell tumours had a notoriously bad reputation in terms of aggressiveness and poor prognosis.
This article is available only as a...
Original Article
A Phase II Study of Combined CPT-11 and Mitomycin-C in Platinum Refractory Clear Cell and Mucinous Ovarian Carcinoma
Platinum resistance, either de novo or acquired, is a major obstacle in the treatment of advanced ovarian cancer. Platinum-resistance has been classified into the following three categories; (1) primarily (intrinsically) platinum-resistant disease: tumours showing no change (NC) or progressive disease (PD) while on initial platinum-based chemotherapy; (2) secondarily platinum-resistant...
Original Article
Single Agent Paclitaxel in Resistant and Relapsed Epithelial Ovarian Cancer After First-line Platinum-based Chemotherapy—Experience in an Asian Population
Ovarian carcinoma ranks fourth among causes of death in women and is the leading cause of death from gynaecological malignancies in Western countries. In Singapore, the incidence of this cancer has been rising for the last 25 years.
This article is available only as a PDF. Please click on “Download...
Original Article
Uterine Papillary Serous Carcinoma—The KK Hospital Experience
Endometrial carcinoma comprises a morphologically heterogeneous group of tumours. Several authors during the 1960s and 1970s described an unusual variant of endometrial cancer containing psammoma bodies.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Original Article
Radiotherapy as Local Adjuvant Treatment for Endometrial Carcinoma—A Review of 45 Patients
Radiotherapy as an adjunct to surgery has long been used in the management of endometrial carcinoma with the intent to improve local tumour control as well as to achieve excellent survival rates. Over the years, however, the specific role and relative benefit of postoperative radiotherapy for this particular cancer...
Original Article
Outcome of Obstructive Uropathy After Pelvic Irradiation in Patients with Carcinoma of the Uterine Cervix
Radiotherapy is the mainstay treatment for locally advanced carcinoma of the cervix. It is also administered as an adjuvant therapy to patients deemed at high risk for local recurrence after radical hysterectomy.
This article is available only as a PDF. Please click on “Download PDF” on top to view the...
Original Article
The Surgical Management of Colorectal Complications from Irradiation for Carcinoma of the Cervix
Radiation bowel injury is a significant clinical problem because of the technical difficulties of surgery. Among the more common causes is radiation of carcinoma of the cervix, because radiotherapy is the principle mode of treatment for this fourth most common malignancy in women in Singapore (after carcinoma of the...
Original Article
Adjuvant Chemotherapy in “High Risk” Patients after Wertheim Hysterectomy—10-year Survivals
Wertheim radical hysterectomy has today become an accepted method of management of stage IB and early stage IIA cervical carcinoma, particularly in young patients in whom preservation of ovarian and coital function cannot be achieved if they were subjected to radiotherapy instead. However, a group of patients undergoing radical...
Original Article
A Review of Patients with High-risk Carcinoma of the Cervix Treated with Combined Surgery and Postoperative Radiotherapy
It is generally accepted that early stage invasive carcinoma of the cervix, stage I to stage IIA disease, can be treated with equal effectiveness with either radical hysterectomy or radical radiotherapy. However a proportion of patients treated with surgery may be classified as having a significant risk of relapse...
Original Article
Outcome of Early Cervical Carcinoma Treated by Wertheim Hysterectomy with Selective Postoperative Radiotherapy
Cancer of the cervix is the fourth most common cancer in females in Singapore after breast, colorectal and lung cancers. It forms 7.8% of all cancers in females for the period 1988 to 1992.
This article is available only as a PDF. Please click on “Download PDF” on top to...
Editorial
Gynaecologic Oncology—The Next Lap
Cancer of the pelvic reproductive organs and external genitalia accounts for one in six cancers in women. It can occur in women of all age groups: rhabdomyosarcoma in young girls, germ cell tumours in teenage girls and young women, cervical cancer in the middle age women, and epithelial ovarian...
Letter to the Editor
Re: Haematuria in the Diagnosis of Urinary Calculi. SBS Ooi, NW Kour, A Mahadev. Ann Acad Med Singapore 1998; 27:210-4
The above article highlights the insensitivity of urine microscopy compared with the Combur 9 test for detecting haematuria associated with urinary calculi. In the article, the equivalent microscopic RBC values for the Combur 9 are given as 5/ml (typo? it should be 5/µl) and 10 /ml (?10/µl) for intact...
Others
Book Review
This book is a collection of 30 case studies, which were published in the Singapore Medical Journal from 1994 to 1997. They include interesting cases from all the major anatomical regions and organ systems.
This article is available only as a PDF. Please click on “Download PDF” on top to...
Others
The Sixth SGH Lecture—Singapore: A New Venice of the 21st Century
Venice is one of the legendary cities of the world. Its beauty and physical setting make Venice unique. For almost 800 years, from 1000 AD to 1797, the Venetians were a separate people.
This article is available only as a PDF. Please click on “Download PDF” on top to view...
Others
Citation on Professor Tommy Koh
Professor Tommy Koh was born on 12 November 1937 in Singapore. He was educated at Outram School from 1949 to 1951, followed by Raffles Institution from 1952 to 1957.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Sudden Profound Hypoxaemia in the Intensive Care Unit—A Case Report
Significant arterial hypoxaemia is defined as a partial pressure of oxygen (PaO2) that is less than 60 mmHg or a percentage of oxyhaemoglobin (% HbO2) that is less than 90%. The immediate response in acute situations is to rapidly exclude or treat common conditions such as airway obstruction, pneumothorax...
Others
Hyperthyroidism with Gynaecomastia as the Initial Complaint: A Case Report
Gynaecomastia is not a commonly recognised feature among the myriad symptoms and signs associated with hyperthyroidism. A review of the literature disclosed only eight reported cases of gynaecomastia as a presenting feature in thyrotoxicosis, and herein we describe an additional case.
This article is available only as a PDF. Please...
Others
Rosai-Dorfman Disease with Primary Cutaneous Manifestations—A Case Report
In 1969, Rosai and Dorfman first described a newly recognised benign systemic histioproliferative disease characterised clinically by bilateral striking cervical lymphadenopathy, fever, leukocytosis, and pathologically by enlarged lymph nodal sinuses containing large histiocytes with intact phagocytosed lymphocytes (emperipolesis). They dubbed the entity “sinus histiocytosis with massive lymphadenopathy” (SHML or...
Others
The Alien Hand Sign–Case Report and Review of the Literature
The alien hand sign or “strange hand sign”, first coined by Brion and Jedynak in 1972, refers to a feeling that the hand is foreign, together with autonomous activity which is perceived as independent of voluntary control, as if the hand is driven by an external agent.
This article is...
Others
Simultaneous Transcatheter Valvuloplasty and Amplatzer Septal Occlusion for Pulmonary Valvar Stenosis and Secundum Atrial Septal Defect
Congenital pulmonary valvar stenosis (PVS) and secundum atrial septal defect (ASD) are relatively common forms of congenital heart disease (CHD). Since the first successful clinical application of transcatheter balloon dilation of PVS in 1982, the latter has become the treatment of choice for children with PVS who have significant...
Others
A Case of Metastatic Nasopharyngeal Carcinoma in Benign Nasal Polyps
Our patient was a 39-year-old Chinese man with nasopharyngeal carcinoma (NPC) presenting initially with right upper cervical lymphadenopathy. He was treated primarily with a course of radiotherapy, following which he was examined three monthly and was found to be free of disease in the nasopharynx and the neck.
This article...
Others
A Case Report of Atasoy Antenna Procedure
The hook nail deformity is a relatively common problem after fingertip amputations. It is usually ignored but can be quite disabling.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
Thoracoscopic Thymectomy for Myasthenia Gravis: A Case Report
Total thymectomy is the established surgical therapeutic method for generalised myasthenia gravis. Several approaches are used for the surgical removal of the thymus and these include the transcervical approach, partial sternotomy, median sternotomy and a combination of the transsternal and transcervical approaches.
This article is available only as a PDF....
Others
Electrocardiographic Abnormalities in Combined Hypercalcaemia and Hypokalaemia—Case Report
The electrocardiographic abnormalities in isolated hypercalcaemia and hypokalaemia have been well documented in the literature. However, electrocardiogram (ECG) findings in combined hypercalcaemia and hypokalaemia have rarely been described.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Others
A Case Series of Ocular Disease as the Primary Manifestation in Sarcoidosis
Sarcoidosis is an idiopathic, systemic, non-caseating, granulomatous disease with protean clinical manifestations. Although the first description of sarcoidosis was attributed to Hutchinson, its ocular features received little attention until 1936 when Heerfordt’s syndrome of uveitis, salivary gland enlargement and cranial nerve palsies was recognised as a sign of sarcoidosis.
This...
Review Article
Bronchoscopy in the Intensive Care Unit (ICU)
Flexible fibreoptic bronchoscopy (FFB) has become an indispensable tool in the optimal management of intensive care unit (ICU) patients with both diagnostic and therapeutic goals. Its safety and usefulness, in well-trained hands with appropriate precautions, have led to its increasing use even in unstable and mechanically ventilated patients.
This article...
Review Article
Use of Atypical Neuroleptics in a State Mental Institute
Schizophrenia is the most severe of all mental disorders and affects about 1% of the population. The main disturbances of schizophrenia comprise positive symptoms, negative symptoms and disorganisation.
This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.
Review Article
Trends in the Pattern of Blindness and Major Ocular Diseases in Singapore and Asia
Singapore’s population has grown rapidly since 1965, the year in which it gained independence. The total population enumerated at its first census in 1970 was 2 074 507, compared to 3 103 500 in 1997.
This article is available only as a PDF. Please click on “Download PDF” on top...
Review Article
The Impact of Clinical Guidelines and Clinical Pathways on Medical Practice: Effectiveness and Medico-legal Aspects
Guidelines for the management of specified clinical conditions are increasingly being touted as a vital component of the future delivery of health care. However, there are many guidelines that have been drawn up which have remained in the closed shelves of many clinics and hospitals.
This article is available only...
Original Article
Electrophysiological Features in the Management of Meralgia Paraesthetica
Meralgia paraesthetica is a condition resulting from entrapment of the lateral femoral cutaneous nerve at the region of the anterior superior iliac spine, when the nerve angulates sharply over the inguinal ligament. It presents classically with pain, paraesthesia and sensory loss over the anterolateral surface of the thigh.
This article...
Original Article
Urinary Deoxypyridinoline is a Useful Biochemical Bone Marker for the Management of Postmenopausal Osteoporosis
Postmenopausal osteoporosis is the most common cause of osteoporosis. It is heralded by the cessation of oestrogen production by the ovaries resulting in at least 10% to 15% bone loss over the next 10 to 15 years from menopause.
This article is available only as a PDF. Please click on...