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...

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...

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...

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)...

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...

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.

The study of poisoning has been relatively neglected in Singapore. A check through the Infogate database of the National University of Singapore Library revealed only seven papers on the epidemiology of poisoning since 1975 (the earliest year covered by the database) and none targeting those severe enough to require...

Cardiopulmonary resuscitation (CPR) is widely practised for cardiopulmonary arrests with variable success. The initial intention was to defibrillate patients with ventricular fibrillation after acute myocardial infarction, to save those with “hearts too good to die”. This article is available only as a PDF. Please click on “Download PDF” on top...

Singapore employs more than 350,000 foreign workers currently. With this influx of foreign workers into our city-state which has limited land and resources, it is not surprising that public services like the health service feel the impact of their presence. This article is available only as a PDF. Please click...

Drowning is defined as suffocation from submersion in a liquid with death within the first twenty-four hours. Near-drowning implies that recovery has occurred, at least temporarily, or that the victim has survived over twenty-four hours. This article is available only as a PDF. Please click on “Download PDF” on top...

The above is a textbook of medicine written by Singapore doctors and published in Singapore. It is difficult not to be over-enthusiastic about it as there are so few books of medicine written and published in Singapore. This article is available only as a PDF. Please click on “Download PDF”...

There is a trend in Asia towards a greater application of psychotherapeutic approaches in multidisciplinary settings to emotional and behavioural disturbances. The inaugural issue of Asian Psychologist announced landmarks in the education and training of clinical psychology in two major Asian communities. This article is available only as a PDF....

Of the approximately 15,000 deaths that occur in Singapore every year, about 25% are from cardiac causes; of which, some 30% to 40% occur suddenly, outside of a hospital. The mechanism of death is usually a fatal arrhythmia, most often ventricular tachycardia or fibrillation. This article is available only as...

BCG vaccines are live vaccines derived from a strain of Mycobacterium bovis that was attenuated by Calmette and Guerin at the Pasteur Institute in Lille, France. In Singapore, all newborn babies are given the vaccination at birth, and until recently, a second vaccination was given to children at the...

Total parenteral nutrition (TPN) may contribute to good outcome in selected groups of patients. Parenteral nutrition is highly effective in reversing effects attributable to simple starvation. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Acute coronary syndrome (ACS) refers to a continuum of clinical entities ranging from unstable angina pectoris (UAP) to Q-wave myocardial infarction. Mortality rates from acute myocardial infarction (AMI) have seen a worldwide decline in recent years. This article is available only as a PDF. Please click on “Download PDF” on...

Pulmonary thromboembolism (PE) has historically been considered a rarity in the Asian population. Although well studied in the West, Asian literature on this condition has been sporadic. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Livedoid vasculitis is a clinicopathological entity that has variously been referred to as atrophie blanche, livedoid vasculopathy or segmental hyalinising vasculitis. It presents with purpuric lesions and recurrent, painful ulcerations of the lower limbs which result in depressed, atrophic white scars. This article is available only as a PDF. Please...

It is projected that elderly persons will make up 18.4% of Singapore’s population by the year 2030. Currently, there are 5189 residents staying in nursing homes. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Increasing life expectancy and ageing of the “post-war baby boomer” generation have led to the rapidly ageing demographic of many Asian countries. Singapore’s elderly population above the age of 65 will rise from 7.5% in 2002 to 18.9% by the year 2030. This article is available only as a PDF....

Dear Editor, The COVID-19 pandemic has disrupted medical education1,2 and distressed clinicians.3,4 Understanding the impact of this pandemic on emergency medicine (EM) residents’ experience of stress will allow for more effective interventions to aid residents, while reducing attrition and its impact on pandemic response. We present our qualitative study, guided by...

A postnatal finding of intracranial haemorrhage carries potential medico-legal implications for the obstetrician. However, one cannot exclusively attribute this to birth trauma. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Pyriform sinus fistula is a developmental abnormality of the 3rd or 4th branchial pouch. It usually presents in childhood as acute inflammatory swelling of the neck and frequently involves the thyroid gland. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

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...

The Singapore shoreline has changed significantly over the last 30 years, but the stonefish (Synanceia sp.) continues to inhabit our native waters and human envenomation still occurs with relative frequency. In this paper, we document the clinical course, review our management experience and propose a treatment algorithm. This article is...

Acquired thoracic spinal canal stenosis is an uncommon condition compared to myelopathy and radiculopathy frequently seen in the cervical and lumbar spine, respectively. Because the rib cage restricts its movement, the thoracic spine is less prone to degenerative changes in the disc and facet joints, which result in loss...

Singapore has a resident population of 3.26 million and 0.53 million foreign workers. Of these half a million foreigners, 450,000 are work permit holders, typically working in lower skill industries and blue-collar sectors, e.g. construction industry. This article is available only as a PDF. Please click on “Download PDF” on...

Delusional parasitosis (DP), or delusional infestation, is a condition in which a person has the unshakeable and mistaken belief of being infested with parasites. Originally described in 1894, it has been previously referred to as dermatophobia, parasitophobic neurodermatitis, parasitophobia or entomorphobia. This article is available only as a PDF. Please...

Chickenpox (varicella) in adults can be severe. It is frequently associated with pneumonia and immunosuppression as well as increased mortality rates. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Central serous chorioretinopathy (CSCR) is an idiopathic disorder characterised by serous detachment of the macula, retinal pigment epithelial (RPE) detachment and areas of RPE atrophy that may represent sequelae of previous episodes. CSCR can arise secondary to chronic treatment with steroids. This article is available only as a PDF. Please...

Buprenorphine, more commonly known as Subutex (Reckitt Benckiser Pharmaceuticals), has been released in Singapore since 2002. Initially marketed as an opiate substitute to help addicts wean off their dependence, it has another formulation, Suboxone, which additionally contains naloxone as an active ingredient. This article is available only as a PDF....

Photodynamic therapy using verteporfin (Visudyne, Novartis Ophthalmics) has been proven safe and effective for the treatment of predominantly classic, age-related macular degeneration (AMD)-related subfoveal choroidal neovascularisation (CNV), pathologic myopia-related CNV, and subgroups of AMD-related occult CNV. Visual results following verteporfin treatment of subfoveal, non-AMD related CNV have been variable....

Paracetamol overdose is one of the most common drug overdose in both children and adults in Singapore. Doses of paracetamol exceeding 150 mg/kg in a patient can be life threatening. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Earthquakes and tsunamis can cause massive destruction over large areas, affecting the lives of many in areas hit by such disasters. The local health care system often gets disrupted and the health and well-being of the survivors may depend on disaster relief organisations from within the country as well...

Liver abscess has been recognised since the time of Hippocrates. The first report on liver abscess was published by Bright in 1836.1 However, reports pertaining to liver abscess in the neonatal period have been published only since the 1930s. Neonatal liver abscess is a rare entity. To our knowledge,...

Aspergillosis of the central nervous system (CNS) is an uncommon infection, mainly occurring in immunocompromised patients. It may present in several forms: meningitis, mycotic aneurysms, infarcts and the tumoral form (aspergilloma). This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Most patients with acute ischaemic stroke have arterial thrombi that occlude extra- or intracranial vessels. Intravenously administered tissue plasminogen activator (IV-TPA) induces thrombolysis and remains the only FDA-approved therapy for ischaemic stroke within 3 hours from symptom onset. This article is available only as a PDF. Please click on “Download...

Haemolysis of blood samples leads to inaccurate results and often necessitates a repeat sample. Escalating workloads and finite resources are an increasing problem in many Emergency departments (EDs), where many conditions have time-dependent outcomes, and accurate and quick blood results are thus important. This article is available only as a...

Children with obstructive sleep apnoea (OSA) may present with nocturnal and/or diurnal symptoms. The history is best obtained from parents, or siblings who share a bedroom, since the child is often unaware of what happens when he or she is asleep. This article is available only as a PDF. Please...

While the surgical procedure of placing dental implants may seem technically simple, it is not straightforward and requires careful preoperative planning. This article is available only as a PDF. Please click on "Download PDF" to view the full article.

Carcinoma of the oesophagus is a relatively uncommon malignancy in Singapore and incidence rates have been declining since 1968. A total of 506 cases were diagnosed from 1993 to 1997. The age-standardised rate for the same period was 5.8 per 100,000.1 The predominant histologic type is squamous cell carcinoma,...

Dissecting aneurysms of the vertebral artery often present with subarachnoid haemorrhage.1 A high mortality occurs with rupture.2 Currently, the treatment options for vertebral artery dissecting aneurysms presenting with subarachnoid haemorrhage (SAH) are still controversial and include trapping of the aneurysms with or without bypass as well as proximal occlusion,...

Pancreatic cancer is notoriously known to be diagnosed in the later stages and this carries with it a poor prognosis. In particular, tumours involving the head of pancreas are particularly difficult to diagnose early and computed tomography (CT) scanning often fails to detect an early tumuor at that site....

In a previous study,1 we reported that patients who had decreased proteinuria also had improvement in renal function. Three out of the 8 patients who had renal impairment prior to angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ATRA) therapy regained normal renal function after therapy with ACEI/ATRA, while the remaining 5...

Patients suffering from visual field defects caused by optic nerve or post-chiasmatic injury commonly experience many limitations in their daily activities. The generally accepted paradigm that nothing can be done leaves little hope for such patients as restoration was once considered impossible. This article is available only as a PDF....

Holoproscencephaly (HPE) is an uncommon congenital developmental defect of the forebrain structures to divide into separate hemispheres and ventricles during embryogenesis. The prevalence rate of HPE is estimated to be between 1 in 11,000 to 1 in 20,000 live births, and 1 in 250 during early embryogenesis. This article is...

Primary percutaneous coronary intervention (PCI) for patients with acute ST-elevation myocardial infarction (STEMI) has been shown to be superior to thrombolytic therapy in terms of its ability to achieve higher patency rates, minimise infarct size, improve left ventricular function and improve long-term survival, as well as lower rates of...

Thromboembolism is a well-known complication of mitral stenosis especially when it is associated with cardiac dysrhythmias. However, renal artery embolism is a disease that is easily missed due to its infrequent and non-specific presentations. This article is available only as a PDF. Please click on “Download PDF” on top to...

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder characterised by spinal and cortical motor neuron degeneration. Although electro myography, muscle biopsy and motor unit number estimation are useful for the evaluation of lower motor neuron (LMN) damage, there is at present no objective and quantitative technique to detect...

Critical limb ischaemia (CLI) is the most severe form of peripheral vascular disease where there is inadequate blood flow to a limb to maintain reasonable metabolic requirement of the tissues at rest. Eventual loss of limb is the feared sequelae of CLI. This article is available only as a PDF....

Slipped capital femoral epiphysis is the commonest hip problem in the adolescent age group. The goals of treatment are aimed at avoiding the complications of osteonecrosis and chondrolysis, preventing further slips, and promoting physeal closure. This article is available only as a PDF. Please click on “Download PDF” on top...

Neovascularisation of the iris is associated with many ischaemia retinal disorders and elevated levels of the vascular endothelial growth factor is found in patients with neovascular glaucoma. Inhibition of the vascular endothelial growth factor has been shown to prevent retinal ischaemia-associated neovascularisation of the iris. This article is available only...

The occurrence of an adrenal mass in patients with an underlying malignancy may represent distant metastases, precluding curative surgical resection of the primary malignancy. On the other hand, it may simply represent a benign adrenal adenoma with no prognostic implications. In a cohort of lung cancer patients, an isolated...

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease with an incidence of approximately 0.5/1000 live births (5% to 7% of congenital heart lesions). In Singapore with a live birth of over 37, 000 per year,1 the expected number of new TOF cases will be approximately...

Arteriovenous fistulae (AVF) are created for haemodialysis in patients with end-stage renal failure. While AVF is a lifeline for these patients, its creation is not without complications.1 One complication is that of aneurysmal dilatation, which can cause rupture and potentially fatal haemorrhage. This article is available only as a PDF....

In recent years, Singapore has seen a resurgence of dengue fever despite the seemingly successful implementation of a nationwide Aedes mosquito control programme,1 culminating in 9459 clinical and laboratory-confirmed dengue cases in 2004 and up to 13,653 cases in its 2005 dengue epidemic.2 This article is available only as a...

Since its advent in 1982, magnetic resonance imaging (MRI) has become an important component in the evaluation of multiple sclerosis (MS). MRI is a highly sensitive tool for MS, with 95% patients with clinically definite MS (CDMS) demonstrating brain abnormalities.1 However, MRI is also known to be low in...

Schwannomas, also known as neurilemmomas, neuromas, or neurinomas, are uncommon nerve sheath neoplasms that may originate from any peripheral, cranial or autonomic nerve of the body with the exception of the olfactory and optic nerve. Malignant change is unusual. Some 25% to 45%1 of schwannomas are located in the...

The auditory apparatus and vestibular part of the inner ear are often included in the radiation field treatment of patients with head and neck tumours.1-5 Radiation injury resulting in late-onset sensorineural hearing loss is a recognised complication, but the underlying pathological processes are poorly understood.4 Magnetic resonance imaging (MRI)...

We thank the authors for their interest in our study and their insightful comments. We agree that filling pressures such as the central venous pressure and pulmonary artery wedge pressures are inaccurate in predicting cardiac output or fluid responsiveness. This article is available only as a PDF. Please click on...

We would like to thank Dr Huck Chin Chew et al for sharing their findings and we are appreciative of their work, “Oesophageal Doppler Ultrasound in the Assessment of Haemodynamic Status of Patients Admitted to the Medical Intensive Care Unit with Septic Shock”. In their paper, Dr Chew and...

Snakes are present even in an industrialised country like Singapore. A bite from a venomous snake can inflict much morbidity and occasionally, it can be fatal. In many countries with a large agricultural base, it poses a significant economic burden. This article is available only as a PDF. Please click...

Out-of-hospital cardiac arrest (OHCA) is a substantial public health burden that has poor prognosis. Patients who receive “good” and “high-quality” cardio-pulmonary resuscitation (CPR) have better outcomes. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

In recent decades, medical advances and economic pressures have shifted medical student training from hospital inpatient to ambulatory settings such as hospital outpatient and primary care clinics. Most studies have found that patients are agreeable to seeing medical students and value the opportunity to interact with them. This article is...

Exercise-related cardiac arrest is uncommon, however it is devastating when it occurs in otherwise healthy adults. In young adults, vigorous physical exercise trigger cardiac arrest in those affected by silent congenital cardiovascular conditions. In older adults, sudden vigorous physical exercise increases the incidence of acute coronary events in those...

Our tertiary hospital has a 9-bed Surgical Intensive Care Unit (SICU) that caters to all surgical disciplines except Cardio-Thoracic and Vascular Surgery (which has its own dedicated Cardio-Thoracic Intensive Care Unit). This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Severe cases of influenza have traditionally generated much interest. The pandemic of 1957 provided instructive materials on the subject, with publications on the pulmonary complications and histopathologic features. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Complete atrioventricular block (AVB) develops in more than 5% of patients with myocardial infarction (MI). These patients have poorer outcomes compared to those without complete AVB. Thrombolysis has been demonstrated to improve the prognosis of such patients, especially those with inferior MI. This article is available only as a PDF....

Gambling has been defined as a wager of any type of item or possession of value upon a game or event of uncertain outcome in which chance, of a variable degree, determines the outcome. The failure to resist the impulse to gamble despite disruption to personal, family and vocational...

Chronic Achilles tendon rupture is a disabling condition resulting in ankle pain, weakened ankle plantarflexion and abnormal gait. Management of chronic ruptures is technically challenging with generally poorer outcomes and higher complication rates than that of acute repair. Current literature suggests this problem is still better tackled surgically although...

Simple cysts are commonly seen in neonatal ovaries. Majority of them are small and resolve spontaneously. Complications such as torsion and haemorrhage rarely occur, but when they do, they may cause symptoms due to mass effect such as bowel or urinary obstruction. Sonography plays an important role in diagnosis,...

Invasive fungal infections (IFI) are associated with a high mortality in liver transplant recipients. The incidence of fungal infections after liver transplantation ranges from 7% to 42%, with Candida sp. and Aspergillus sp. being the commonest pathogens. A prophylactic strategy against fungi is therefore attractive, and is practised in...

Mammogram has been the gold standard for breast cancer screening and Magnetic Resonance Imaging (MRI) has been advocated for screening of high- risk individuals. However, there is currently no recommendation for supplementary ultrasound scan in breast cancer screening. Moreover, it is known that dense breasts, which are common in...

Male breast cancer is a rare disease entity, traditionally said to represent <1% of all diagnosed breast cancers. Recent statistics, however, suggest that its incidence may be on the rise, although the clinical significance of this is unknown. This rarity has precluded large randomised controlled trials, and most treatment...

It was an unusually busy ward round. The newly promoted registrar was keen to review the patients handed over to him. But there were constant distractions from the other things he needed to attend to quickly. The patient, Madam Sumar was referred by her family doctor for chest pain with...

Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are performed for decompression of the spine when the primary compressive pathology lies anterior to the spinal cord – prolapsed intervertebral discs (PID), ossified posterior longitudinal ligament (OPLL), spondylodiscitis and retropulsion of fractured bony fragments. More...

It has been 4.5 years since the Accreditation Council for Graduate Medical Education (ACGME-I) accredited competency-based emergency medicine residency programmes were started in July 2010 in Singapore. The transit from a time-based curriculum to a competency-based curriculum, which centres on the 6 ACGME-I core competencies of ‘medical knowledge’, ‘patient...

Child sexual abuse (CSA) is a global public health issue with adverse short- and long-term repercussions. Formal definitions of CSA and the age for defining children differ around the world. In Singapore, CSA refers to any act where a child or young person below 16 years old is used...

The coronavirus disease 2019 (COVID-19) outbreak has impacted healthcare systems worldwide. Globally, visits to the emergency department have fallen as much as 25% during COVID-19-related lockdowns. Notably, there have been reports that patients with acute emergencies such as strokes and heart attacks are either not seeking treatment, or are...

Singapore employs a large foreign worker (FW) population, defined as non-Singapore citizens and non-permanent residents working locally. Holders of “work permit” (WP), the work pass issued to semiskilled workers, comprise 26.0% of Singapore’s entire labour force. Two other work passes held by FWs, “S pass” and “employment pass”, are...

Overweight and obesity continue to be one of the most critical public health issues worldwide. Body mass index (BMI) derived from height and weight has been directly linked to a number of debilitating diseases, including diabetes, heart disease and cancer, and has gained increased popularity as a measure of...

Carbamazepine (CBZ) has been used in Singapore since 19881 as an effective drug for the treatment of conditions such as epilepsy, neuropathy, neuralgia and psychiatric conditions. However, it is a high-risk drug for Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), particularly in Asians, and in 2004, a genetic marker human leukocyte...

In the past 2 decades, the management of chronic venous insufficiency (CVI) has been revolutionised by the introduction of minimally invasive endovenous techniques, which have replaced open surgical high tie and stripping as the treatment of choice. CVI is common in the Western population and is reported to affect...

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide, with a global incidence of 62 cases per 100,000 person-years. In addition, there are variations in the reported survival-to-hospital discharge rates among different regions in the world. In Singapore, OHCA incidence rate was 27.2 per 100,000 person-years, with...

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality and a significant public health problem globally. In Singapore, OHCA affected 11,061 adults between 2011 and 2016. Despite multiple pre-hospital and hospital-based interventions, survival rates remain low. Initiation of time-sensitive cardiopulmonary resuscitation (CPR) while waiting for emergency services arrival...

EQ-5D is a tool to measure and value health status. It is a standardised questionnaire that comprises 2 components: a Descriptive System (DS) on the first page and a hash-marked visual analogue scale (EQ-VAS) on the second page. Importantly, responses to the DS can be converted into a utility...

Health-seeking behaviour varies during a pandemic. Early reports have suggested reduced attendances at emergency departments (EDs), especially in paediatric patients and in patients with minor ailments, but these observations have yet to be evaluated in Singapore. We investigated ED attendances during the coronavirus disease 2019 (COVID-19) pandemic in Singapore. This...

Emergency airway management is a keystone of emergency medicine practice and critical skill in residency training. An accredited emergency attending is expected to handle difficult airways that may present unexpectedly with expertise. Flexible bronchoscopic intubation (FBI) technique is considered an important option in the management of predicted difficult airways....

Coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization (WHO) on 11 March 2020, with over 110 million cumulative cases worldwide to date and a case fatality rate of approximately 1%. In comparison, the 2003 outbreak of severe acute respiratory syndrome (SARS) had 8,422 cumulative...

Head injuries are common childhood injuries that present to paediatric emergency departments. Falls are the most common cause in young children, while contact sports and road traffic injuries are common causes in school-going children. Majority of paediatric head injury cases are mild traumatic brain injuries, defined as a Glasgow...

Emergency airways often present with little warning, and the need for airway management is necessary for a successful resuscitation. This is in contrast to most intubations performed in the operating room (OR). Additionally, difficult airways are more prevalent in emergency department (ED) populations due to acute conditions such as...

Asia faces an epidemic of diabetes. The prevalence of diabetes in Asia is projected to grow from 114 million in 2007 to 180 million by 2025, driven in part by marked economic and epidemiologic transition in recent decades.1 In China, the prevalence of diabetes rose from 1% in 1980...

Splenic artery aneurysms (SAAs) are uncommon and often asymptomatic. However, ruptured SAAs can be rapidly fatal. We reviewed the literature on SAAs and highlighted the management challenges faced in the emergency department (ED). This article is available only as a PDF. Please click on "Download PDF" on top to view...