Related Articles

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...

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...

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...

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...

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...

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...

Minimal monitoring is a safe but underutilised strategy for hepatitis C virus treatment 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...

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...

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...

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...

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...

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....

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...

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...

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...

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...

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...

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...

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...

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.

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....

Childhood Leukaemia: Towards an Integrated Psychosocial Intervention Programme in Singapore

In the last two decades there has been a surge of interest concerning the psychosocial correlates of life-threatening illnesses. Research in this area has focused especially on cancer and the possible link between immunology and psychological factors. This article is available only as a PDF. Please click on “Download PDF”...

Are Antacids Necessary as Routine Prescriptives with Non-steroidal Anti-inflammatory Drugs?

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for their analgesic or anti-inflammatory properties in musculoskeletal pain. However, they are not without adverse effects, such as abdominal pain, diarrhoea, nausea and fluid retention, which are reported to occur in 30% of people taking NSAIDs. This article is available only as a...

9th Seah Cheng Siang Memorial Lecture: Gastric Cancer—Where are we now?

The last two decades have witnessed dramatic changes in the understanding of gastric cancer: a rapid decline in global incidence, its association with Helicobacter pylori gastritis, and the new information regarding its molecular biology. Nevertheless, gastric cancer remains the second commonest cancer in the world in terms of morbidity...

A Case Report of Adult T-Cell Leukaemia/Lymphoma (ATLL)

Our patient was a 71-year-old Chinese man who presented with a 6-year history of recurrent papular erythematous eruptions to the dermatologist. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Newer Thrombolytic Agents

First-generation fibrinolytic agents (streptokinase and urokinase) are effective thrombolytic drugs, but are not fibrin specific as they also have the property to convert circulating plasminogen to plasmin when given at therapeutic doses. Because the plasminogen in the thrombus is in equilibrium with the plasminogen pool in plasma, the plasminogen...

Diagnosing and Managing Faecal Incontinence

Faecal incontinence is the inability to control the passage of gas, liquid or solid through the anus. Its severity varies from infrequent passage of gas to persistent lack of control of solid stools. This article is available only as a PDF. Please click on “Download PDF” on top to view...

Magnetic Resonance Cholangiopancreatography: Value of Using the Half-Fourier Acquisition Single-Shot Turbo Spin-Echo (HASTE) Sequence

Direct cholangiopancreatography has long been considered the standard of reference for assessment of the biliary tree and is generally safe, reliable and widely available. However, these methods are operator dependant and have the potential for morbidity in some patients (3% to 5%) with complications such as acute cholangitis, pancreatitis,...

8th Seah Cheng Siang Memorial Lecture: New Antithrombotic Agents

The tremendous interest in finding new anti-aggregating agents stems from the preeminent role that platelets play, not only in haemostasis and thrombosis, but also in atherogenesis and, be it less definitive, in arterial spasm. Compelling data from large-scale trials have established the role of platelet inhibitors in reducing coronary...

Activated Protein C Resistance: A Study Among 60 Thromboembolic Patients in the Singapore Population

In 1993, Dahlback and colleagues described a new hereditary thrombophilia state-activated protein C resistance (AK-R). Further studies showed this to be the commonest genetic cause of thrombophilia. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Standard Oesophageal Manometry in Healthy Adults in Singapore

Although standard oesophageal manometry has been widely used in the West for many years, normal manometric values that have been well described for healthy volunteers in the West may not be applicable to this part of the world. Such normal values vary between investigators, even within the same study...

Gut Barrier Dysfunction in Experimental Acute Pancreatitis

Bacterial infections are devastating and potentially lethal complications of acute pancreatitis, responsible for up to 80% of deaths in the condition. Pathogenetic studies of acute pancreatitis imply that the disease is initially a non-bacterial insult and that secondary sepsis frequently occurs during the progression of pancreatitis, concomitant with the...

Experimental Models of Pancreatitis

From a historical perspective, the first experimental pancreatitis was induced by Claude Bernard in 1856 by the injection of bile and olive oil into the canine pancreatic duct, thus producing an acute necrotising pancreatitis. Since that time, acute experimental pancreatitis has attracted thousands of researchers, who employ animal models...

Experimental Models of Hepatic Fibrosis in the Rat

Hepatic fibrosis and cirrhosis of the liver are complex diseases which, in man, may be caused by such varied factors as alcohol, hepatitis, schistosomiasis, biliary atresia, malnutrition and exposure to carcinogens and hepatotoxins. Although hepatic fibrosis is characterised by the massive deposition of extracellular matrix components in the liver...

Development of the Human Intrahepatic Biliary System

The development of the human biliary system has been studied extensively. This knowledge is essential to the understanding of the pathogenesis of a spectrum of diseases termed “ductal plate malformation” (DPM). This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Experimental Study of Hypovolaemic Shock-Induced Gastric Mucosal Lesions in the Rat

Hypoxic tissue injury is not only caused by lack of oxygen as was previously believed. Now it is clear that tissue injury associated with hypoxia occurs to a large extent in the post-hypoxic reoxygenation period. This article is available only as a PDF. Please click on “Download PDF” on top...

The Role of Mast Cell Degranulation in Ischaemia-reperfusion-induced Mucosal Injury in the Small Intestine

Although a number of data support the notion that mast cell (MC) degranulation Is an important component of the tissue response elicited by ischaemia-reperfusion, the role of the gastrointestinal MC system in the pathophysiology of postischaemic mucosal barrier lesions is still poorly understood. The mucosal MCs (MMCs) of the...

Direct Mucosal Targeting of Colonic Receptors by Prokinetic Drugs in an Experimental Model

The direct intraluminal (IL) administration of drugs into the intestine may have an important regional action and therefore clinical implications in the effective management of functional bowel disorders. We have previously published findings in the anaesthetised in vivo pig, that cisapride and mebeverine when infused IL into the sigmoid...

Antineutrophil Cytoplasmic Antibodies (ANCAs) in Patients with Inflammatory Bowel Disease Show No Correlation with Proteinase 3, Lactoferrin, Myeloperoxidase, Elastase, Cathepsin G and Lysozyme: A Singapore Study

The diagnostic tests currently employed to diagnose inflammatory bowel disease (IBD) and to differentiate between Crohn’s disease (CD) and ulcerative colitis (UC) are both expensive and invasive. Serological markers that are easily applied which can distinguish between CD and UC with comparable sensitivity and specificity are lacking. This article is...

Pseudomembranous Tracheobronchitis Caused by Aspergillus in a Patient after Peripheral Blood Stem Cell Transplantation

Pseudomembranous tracheobronchitis caused by Aspergillus is a rare and lethal variant of invasive aspergillosis. It has been reported in a few series of immunocompromised patients. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Philadelphia Positive Acute Lymphoblastic Leukaemia (ALL): Clinico-Haematologic Characteristics, Molecular Analyses and 3-year Follow Up—A Single Institution Study

A number of specific chromosome abnormalities are associated with acute lymphoblastic leukaemia (ALL). The commonest in adults with B lineage ALL is the Philadelphia (Ph) chromosome t(9;22)(q34;q11). This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Pseudomembranous Colitis in a Patient Treated with Paclitaxel for Carcinoma of the Breast: A Case Report

Paclitaxel was discovered in 1963 as a crude extract from the bark of the pacific yew Taxus brevifolia. Since its development, a range of anticancer activity has been demonstrated. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Early Hepatocellular Carcinoma Presenting with Biliary Ductal Invasion—A Case Report

Hepatocellular carcinoma (HCC) is a common malignant tumour worldwide. The local incidence of HCC is 40 per 100,000 in males and 20 per 100,000 in females. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Survival of Colorectal Cancer Patients in Singapore by Anatomic Subsite: A Population-based Study

Colorectal cancer incidence rates rank second in most developed countries and have been rising rapidly in urban societies of East Asia. Despite much effort to detect early-stage disease and to explore more effective treatment methods, the overall 5-year survival rate has remained around 40% based on the reports from...

Thrombotic and Haemorrhagic Complications in Patients with Mechanical Heart Valve Prostheses Attending the Singapore General Hospital Anticoagulation Clinic

Patients with mechanical heart-valve prosthesis receive lifelong anticoagulation. The management of these patients taking oral anticoagulants is aimed at achieving and maintaining adequate levels of anticoagulation to prevent thrombotic manifestations and at the same time to keep the risk of severe haemorrhagic complications to the minimum. This article is available...

Shigella Septicaemia in Adults: Report of Two Cases and Mini-Review

Shigellosis is generally considered to be confined to the gastrointestinal tract. Septicaemic infections with Shigella species are extremely rare in adults. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Psychiatric Illness, Personality Traits and the Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder seen by gastroenterologists and has been found to account for 50% of referrals to a Gastroenterology clinic. It has an estimated prevalence of between 15% and 25% in the non-patient population. This article is available only as a PDF....

Clinical Update on Helicobacter pylori

Helicobacter pylori is one of the commonest infections in human, affecting 30% to 50% of people worldwide. It is associated with the development of peptic ulcer, chronic gastritis and gastric cancer and may play a role in a small subset of patients with non-ulcer dyspepsia. This article is available only...

Treatment of Acute Promyelocytic Leukaemia Using a Combination of All-trans Retinoic Acid and Chemotherapy

Acute promyelocytic leukaemia (APL), or acute myeloid leukaemia (AML)-M3 under the French-American-British (FAB) classification, is characterised by the following: a distinct expansion of promyelocytes and immature myeloblasts in the bone marrow; balanced reciprocal translocation between the long arms of chromosome 15 and 17, t(15;17) which results in apposition of...

Perioperative Treatment with Bactericidal/Permeability-Increasing Protein (rBPI21) in Major Liver Surgery: A Concise Summary

Primary and secondary hepatic malignancies constitute a major health problem. Hepatocellular carcinoma accounts for 90% of all primary hepatic malignancies in the world. While relatively uncommon in Western countries, it is the most prevalent malignant neoplasm in Southeast Asia, South Africa, and many other regions. This article is available only...

Book Review

The third edition of this manual of gastroenterology by regional experts from Malaysia and Singapore consists of 27 short chapters packaged in 2 sections entitled “Luminal gastroenterology and “Hepatobiliary & Pancreas.” In his preface, the editor, Dr Richard Guan, states that “our goal is to provide a resource for...

CD4 Lymphocyte Enumeration in Patients with Human Immunodeficiency Virus Infection Using Three-Colour and Four-Colour Dual-Platform Flow Cytometry: An Inter-Laboratory Comparative Evaluation

Clinical flow cytometry provides a precise technology for the multiparameter analysis of the morphological (scatter) and immunofluorescence properties of stained leukocyte populations, as well as their percentages and absolute counts, at the single-cell level. Flow cytometry is commonly used for the identification of human lymphocyte subsets, a process referred...

Deep Vein Thrombosis is Not Rare in Asia—The Singapore General Hospital Experience

Deep vein thrombosis (DVT), pulmonary embolism (PE), the postphlebitic syndrome and recurrent venous thromboembolism (VTE) are important and often preventable causes of early morbidity or death and of long-term disability in western populations. The reported annual incidence of VTE is about 2 per 10,000 persons in Scotland. This article is...

High-dose Therapy followed by Autologous Haematopoietic Stem Cell Transplantation in Multiple Myeloma

Multiple myeloma (MM) is a disorder in which malignant plasma cells accumulate in the bone marrow and produce an immunoglobulin, usually monoclonal IgG or IgA. The incidence of MM in Singapore is 1 to 2 per 100,000 per year with a median age of 65 to 70 years at...

New Aspects of the Blood Coagulation Cascade, Anticoagulants and Vein Thrombosis in Asia

Injury to blood vessels triggers haemostasis, a process that has evolved to achieve two superficially incompatible outcomes: arresting blood loss while protecting vessel patency and blood flow to distal organs. Contributors to haemostasis include subendothelial tissues and endothelial cells, blood platelets, tissue factor, plasma clotting factors and their physiological...

Four Pregnancies in Two Patients with Essential Thrombocythaemia—A Case Report

Essential thrombocythaemia (ET) is a rare myeloproliferative disease which manifests with an elevated platelet count. It presents predominantly in the middle-aged population, occurring slightly more frequently in women than men. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Idiopathic Thrombocytopenia in Pregnancy

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder in which platelets are sensitised with an antiplatelet autoantibody and then destroyed by the reticuloendothelial system.1 Hence, it is also known as primary autoimmune thrombocytopenic purpura. There are two forms of ITP—acute and chronic. This article is available only as a PDF....

Thrombophilia in Pregnancy

A clear understanding of thrombophilia is becoming increasingly important in the practice of high-risk obstetrics. In addition to their role in thromboembolic disease, there is increasing evidence linking thrombophilia and adverse pregnancy outcomes such as pre-eclampsia, intrauterine growth restriction, placental abruption and recurrent pregnancy loss. This article is available only...

Management of Haematologic Malignancies in Pregnancy

Malignancy complicates the course of about 1 in 1000 pregnancies and is the second leading cause of death in women of reproductive age. The most commonly diagnosed malignancies during pregnancy are breast cancer, cervical carcinoma, Hodgkin’s lymphoma and melanoma. This article is available only as a PDF. Please click on...

Pregnancy in Women with Idiopathic Thrombocytopaenic Purpura

Idiopathic thrombocytopaenic purpura (ITP) is the most common autoimmune haematological disorder in pregnancy. The pathophysiology of the disease is peripheral destruction of platelets mediated by antiplatelet antibodies. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Clinical Update on Deep Vein Thrombosis in Singapore

Deep vein thrombosis (DVT), and its acute complication–pulmonary embolism (PE), is one of the most important preventable causes of death in hospital patients. It also contributes to significant morbidity in terms of post-phleblitic syndrome and chronic venous ulcers. This article is available only as a PDF. Please click on “Download...

Case Report on Recombinant Coagulation Factor VIIa in the Treatment of Three Haemophilia A Patients with Inhibitors in Singapore

Development of inhibitors against factor VIII is one of the main complications in the treatment of haemophiliacs. Inhibitors block the procoagulant effects of factor VIII and prevent the successful arrest of bleeding episodes when administered to these haemophiliacs. This article is available only as a PDF. Please click on “Download...

Current Status in the Surgical Management of Adult Polycystic Liver Disease

Adult polycystic liver disease (APLD) is a rare benign condition that is characterised by the growth of multiple cystic lesions in the liver. More commonly, it occurs in close association with autosomal dominant polycystic kidney disease (ADPKD), where the prevalence increases from 25% in the third to 80% in...

Evaluation on the Use of a Portable Unit Versus the Laboratory for the Monitoring of International Normalized Ratio (INR) in Orally Anticoagulated Patients

Oral anticoagulation therapy is used for a number of conditions, namely deep venous thrombosis, pulmonary embolism, mechanical heart valves, embolic stroke as well as atrial fibrillation. Patients receiving this therapy are carefully monitored in order to maintain the intensity of anticoagulation in the appropriate therapeutic range. This article is available...

Boerhaave’s Syndrome Presenting as a Right-sided Pleural Effusion

A 79-year-old Chinese woman with no significant past medical history was admitted to another hospital with symptoms of abdominal pain and haemetemesis of approximately 200 mL of blood after a severe bout of vomiting. She declined a oesophago-gastro-duodenoscopy (OGD) and was clinically diagnosed to have Mallory-Weiss syndrome. This article is...

Modern Management of Colorectal Polyps: Are They All Premalignant?

Polyps of the colon and rectum are relatively common lesions. Most colorectal polyps are either adenomas or hyperplastic polyps. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Autoimmune Liver Disease in Children

Autoimmune liver disorders are inflammatory liver diseases characterised histologically by a dense mononuclear cell infiltrate, including plasma cells, in the portal tract (Fig. 1) and serologically by the presence of non-organ and liver-specific autoantibodies and increased levels of immunoglobulin G (IgG), in the absence of a known aetiology. They...

Trauma-induced coagulopathy: Mechanisms and clinical management

Globally, trauma accounts for the highest number of mortalities in adolescents and young adults up to 49 years old.1 Of these deaths, a large percentage is attributable to exsanguination.2 Trauma-induced coagulopathy (TIC) occurs in 25–35% of hospitalised severe trauma patients and is associated with increased incidence of bleeding, blood...

Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting

The practice of gastrointestinal (GI) endoscopy over the last 3 decades has seen both a rise in volume of routine procedures, and an increase in the breadth and complexity of procedures. Routine endoscopies have increased due to a growth in population size, and the introduction of guidelines is needed...

The impact of deprescribing interventions on oral proton pump inhibitor utilisation in a Singapore tertiary hospital: A quality improvement initiative

The established efficacy of proton pump inhibitors (PPIs) in the treatment of upper gastrointestinal (GI) disorders, coupled with their perceived safety, have led to PPI overutilisation.1,2 Prescription of PPIs in absence of evidence-based indication, also known as low-value prescribing, is prevalent across the spectrum of healthcare settings.1-4 Within Singapore,...

Coagulopathy related to trauma: Is it time for a goal-directed approach?

Trauma represents a leading cause of death globally, and post-traumatic haemorrhage accounts for 40% of early mortality in spite of recent improvements in modern trauma care.1 Post-traumatic haemorrhage occurs primarily from direct injury to blood vessels, leading to exsanguination and hypovolaemic shock depending on the type and calibre of...

Ensuring safe sedation during gastroendoscopy

Gastrointestinal (GI) endoscopy started in Singapore in 1968 with diagnostic endoscopic gastric examination, using flexible fibre-optics GI endoscopy. Fibre-optic flexible sigmoidoscopy and colonoscopy were introduced later. Most of these procedures were performed then without sedation. The patients needed to cooperate with the endoscopists and inability to complete the endoscopic...

Inflammatory Fibroid Polyp of the Caecum in a Patient with Neurofibromatosis

Inflammatory fibroid polyp is an uncommon nonneoplastic lesion found in the gastrointestinal tract. It is a benign, non-encapsulated submucosal lesion, composed mainly of loose connective tissues, vessels and with an eosinophilic inflammatory component. This article is available only as a PDF. Please click on “Download PDF” on top to view...

Clinico-pathological Analysis of Myelodysplastic Syndromes According to French-American-British Classification and International Prognostic Scoring System

Myelodysplastic syndromes (MDS) are a heterogeneous group of acquired clonal haemopoietic stem cell disorders characterised by ineffective haematopoiesis and peripheral cytopenia. The natural history ranges from the indolent forms spanning years to those with rapid evolution to blast transformation. This article is available only as a PDF. Please click on...

In vitro Biological Characteristics of Human Cord Blood-derived Megakaryocytes

Haematopoietic stem cell transplantation (HSCT) is now a well-established therapeutic modality for a broadening spectrum of medical problems. Umbilical cord blood (CB) has emerged as an alternative source of HSCT in recent years due to the lack of a human leukocyte antigen (HLA)-identical sibling donor in the majority of...

Unrelated Umbilical Cord Blood Transplantation in Children and Adults

Allogeneic haematopoietic stem cell transplantation (HSCT) is an established form of treatment for many high-risk haematological malignancies and marrow failure syndromes. The use of HSCT is still limited by the availability of human leukocyte antigen (HLA) matched donors, even though unrelated donor registries have markedly improved the chances of...

Haematopoietic Graft Engineering

Haematopoietic stem cell transplantation (HSCT) has become an established modality for the treatment of cancer and diseases of the bone marrow and immunological system. Such transplants effect their cures through 3 main avenues: namely, eradication of disease through intensive chemo/radiotherapy, replacement of defective blood-forming cells with normal haematopoietic progenitors...

Stem Cells: Current Usage and Future Potentials

In recent years, the term “haematopoeitic stem cell transplantation” has replaced “bone marrow transplantation”. It is more precise and emphasises the “haematopoeitic stem cell” as the key element. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Appropriateness of the Use of Parenteral Nutrition in a Local Tertiary-Care Hospital

Parenteral nutrition (PN) is an important supportive and often life-saving therapy for patients with gut failure. However, it is expensive and carries significant complications such as electrolyte disturbances, hyperglycaemia, hypertriglyceridaemia, hepatobiliary complications and line-related complications. This article is available only as a PDF. Please click on “Download PDF” on top...

A Rare Case of Porphyria

Porphyrias are a rare and intriguing group of metabolic disorders. We report a case of congenital erythropoietic porphyria, one of the infrequent forms of porphyria. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Extensive Calcinosis Cutis in Relapsed Acute Lymphoblastic Leukaemia

Calcinosis cutis is characterised by the aberrant deposition of calcium salts in the skin. In metastatic calcinosis cutis, calcium salts are precipitated in normal tissue as a result of an underlying defect in calcium and/or phosphate metabolism. This article is available only as a PDF. Please click on “Download PDF”...

A Bolt Out of the Blue: A Case of Unexpected Acute Liver Failure

Acute hepatitis could result from viral, autoimmune or drug-reaction causes, among others. In areas endemic with hepatitis B, acute exacerbations of chronic hepatitis B (CHB) are the commonest cause. Hence, in Singapore where 4% of the population are hepatitis B carriers, when faced with acute hepatitis in a patient...

Does the Advent of Endoscopic Ultrasound (EUS) Sound the Death Knell for Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Endoscopic retrograde cholangiopancreatography (ERCP) has been the primary method of diagnosing and treating many pancreatic and biliary diseases (PBD) over the last 3 decades. The development of endoscopic ultrasound (EUS) since its introduction in the early 1980s has added a new dimension to the treatment of PBD. This article is...

Clinical Experience with Three Combination Regimens for the Treatment of High-risk Febrile Neutropenia

Cancer patients who become severely neutropenic as a result of intensive myelosuppressive chemotherapy are at high risk for developing life-threatening infections, and unless they are treated at the first sign of infection, the rate of mortality is high. Because of the defect in the inflammatory response, the classic signs...

Hepatitis B Virus Infection and the Risk of Coronary Atherosclerosis

Coronary artery disease (CAD), also called coronary heart disease, is the leading cause of death for both men and women. CAD is usually caused by atherosclerosis. Atherosclerosis (the hardening of the arteries) is the most common form of arteriosclerosis, in which the walls of arteries become thicker and less...

Ceftriaxone-resistant Salmonella spp. in Singapore

The utility of ceftriaxone for the treatment of Salmonella typhi bacteraemia was first demonstrated in Singapore as early as 1985. Since then, ceftriaxone has become established as first-line treatment for typhoid fever and serious non-typhoidal Salmonella infections. This article is available only as a PDF. Please click on “Download PDF”...

Ten-year Series of Splenic Abscesses in a General Hospital in Singapore

Splenic abscess is an uncommon clinical problem. Fewer than 800 cases have been reported in the literature. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Charity Colonoscopy Event to Commemorate the 185th Anniversary of Singapore General Hospital

Colorectal cancer is now the cancer with the highest incidence in Singapore. Similar to many developed countries, individuals here have a moderate to high risk of developing colorectal cancer in their lifetime. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Use of Antibiotics in a Haematology Ward – An Audit

Rising rates of antibiotic resistance prompted a review of antibiotic use policies hospitalwide. The Department of Haematology established a new set of consensus guidelines in 2002 for antibiotic use in febrile neutropenia. We were tasked by the hospital’s Pharmacy and Therapeutics Committee to audit adherence to the guidelines. This article...

An Unusual Cause of Lymphadenopathy and Rash

A 38-year-old Chinese man who was previously well, presented with one month of fever and a non-pruritic rash involving the face, trunk and upper limbs. There was no oral, ocular or genital involvement. He denied weight loss, night sweats, fatigue or easy bruising and there was no history of...

Bone Marrow Cytogenetics Workup: Application of Lean Management System to Determine if Additional Cell Workup is Helpful and Necessary to Analysis

Cytogenetic studies are important to the diagnosis and monitoring of various haematopoietic disorders such as myelodysplastic syndrome (MDS), acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia (CLL), chronic myeloid leukemia (CML), lymphoproliferative disease (LPD), and multiple myeloma (MM). It can also provide a prognosis to a...

A Case of Congenital Haemolytic Anaemia and Thrombocytopenia

A 20-month-old boy came from Bangladesh to Singapore for medical consultation. He presented with progressive pallor, easy bruising, intermittent dark-coloured urine, and failure to thrive since birth. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Guidelines for Endoscopic Ultrasonography

This guideline addresses the use of endoscopic ultrasound (EUS) as part of the diagnostic evaluation of certain conditions. In addition, issues of training and credentialing in EUS and complications of this procedure are also dealt with, within these guidelines. EUS combines features of endoscopy and ultrasonography in order to...

Prospective Audit of Febrile Neutropenia Management at a Tertiary University Hospital in Singapore

Febrile neutropenia (FN) is considered a medical emergency and remains a major cause of morbidity and mortality in Oncology and Haematology units worldwide. A study analysing pooled FN data from 115 US academic medical centres between 1995 and 2000 showed that the overall in-hospital mortality was 9.5%, whereas pooled...

Diagnostic Challenge: A 79-Year-Old Woman with Calcified Lower Abdomen Mass

A 79-year-old woman presented with fever, diarrhoea, vomiting and abdominal pain for several hours. Her temperature was 39.2°C, pulse 102 beats/minute, respiratory rate 19 breaths/minute, and blood pressure 149/74 mmHg. A physical examination revealed diffuse abdominal tenderness. This article is available only as a PDF. Please click on “Download PDF”...

Laparoscopic Common Bile Duct Exploration: Our First 50 Cases

Since its introduction a few decades ago, endoscopic retrograde cholangiopancreatography (ERCP) has brought about a significant change in the management of choledocholithiasis. With continual improvement in the technology and expertise in laparoscopic techniques, laparoscopic common bile duct exploration (CBDE) is becoming more popular and may be the next paradigm...

Immunophenotypic, Cytogenetic and Clinical Features of 113 Acute Lymphoblastic Leukaemia Patients in China

Acute lymphoblastic leukaemia (ALL) is a heterogeneous disease with abnormal proliferation and accumulation of immature lymphoblasts within the bone marrow (BM), peripheral blood and lymphoid tissues, and is composed of different genetic, biological, and clinically relevant subtypes. Morphological and cytochemical methods were the main tools for diagnosis and classification...

Peutz-Jeghers Syndrome: Data from the Singapore Polyposis Registry and a Shifting Paradigm in Management

Peutz-Jeghers Syndrome (PJS) is an uncommon autosomal dominant hamartomatous polyposis syndrome associated with mucocutaneous melanocytic macules. Melanin deposition occurs most commonly in the perioral region and buccal mucosa, but these maccules may also be found on the hands, feet and perianal regions. This article is available only as a PDF....

Non-haem Iron-mediated Oxidative Stress in Haemoglobin E Beta-thalassaemia

Thalassaemia is a genetic haemoglobinopathy in which the production of normal haemoglobin is partly or completely suppressed because of a defective synthesis of 1 or more of its component globin chains. In haemoglobin (Hb) E beta-thalassaemia, an individual inherits 1 gene for Hb E from 1 parent and 1...

When Less is More: Can We Abandon Prophylactic Platelet Transfusion in Dengue Fever?

Dengue fever (DF) is the most common mosquito-borne human viral illness worldwide, and has rapidly spread to reach hyper-endemic proportions in the urban tropics over the last quarter of a century. With an estimated 2.5 billion people at risk and a global annual incidence of 50 million cases, DF...

Thyroid Dysfunction and Long-term Outcome during and after Interferon-alpha Therapy in Patients with Chronic Hepatitis C

Hepatitis C virus (HCV) infection is a major health problem, affecting more than 170 million people worldwide. Its prevalence rates range from 0.5% to 2% in the developed world with 6.5% in Africa. About 90% of the HCV infected patients proceed to the development of chronic liver disease with...

Fasting during Ramadan and Associated Changes in Glycaemia, Caloric Intake and Body Composition with Gender Differences in Singapore

Muslim individuals worldwide participate in obligatory abstinence from oral consumption of medications, food and liquid during the fasting month of Ramadan. Fasting during Ramadan is one of the 5 pillars of Islam. However, Islam exempts individuals whose health may be significantly affected from fasting. Despite this, up to 80%...

Assessment of Age in Ulcerative Colitis Patients with Ileal Pouch Creation—An Evaluation of Outcomes

A total proctocolectomy is considered the standard of care in patients with ulcerative colitis (UC). The indications for this operation in patients with UC include failure of medical treatment or dysplastic changes following endoscopic evaluation. The timing of the surgery could hence be highly variable among patients. This article is...

Medical management of PAD: Expand or consolidate?

In this issue of the Annals, a rapid review of adherence to evidence-based medical treatment highlights an important and underappreciated aspect of the management of patients with peripheral arterial disease (PAD). It is easy, upon meeting a patient, to prescribe appropriate medication in an outpatient setting and believe that...

Congenital adhesion band causing recurrent subacute intestinal obstruction in a virgin abdomen

Intestinal obstruction (IO) caused by malignancy and adhesion bands from previous surgery is common among adults. However, IO caused by congenital adhesion bands (CAB) in the elderly is rare. We report a case of a 63-year-old man who presented with acute-on-chronic intestinal obstruction due to CAB, which caused pseudointestinal...

Severe COVID-19 and coagulopathy: A systematic review and meta-analysis

Manifestations of the coronavirus disease 2019 (COVID-19) span a wide clinical spectrum, from asymptomatic carriers to critical illness with a wide range of complications. Our understanding of the pathophysiology of the disease process is still evolving. As part of the host response to viraemia, it has been postulated that...

Estimating the impact of COVID-19-induced coagulopathy

The current coronavirus disease 2019 (COVID-19) pandemic has exerted significant strain on healthcare worldwide. Mostly asymptomatic or mildly symptomatic, COVID-19 caused by SARS-CoV-2 is described as a thrombo-inflammatory syndrome,1 with severe respiratory illness occurring in about 13% of affected patients. This can rapidly transform into a life-threatening condition in...