Related Articles

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...

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...

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...

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...

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...

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...

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...

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.

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...

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...

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...

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...

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...

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.

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.

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...

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.

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.

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.

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.

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....

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...

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...

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...

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...

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...

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...

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...

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...

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.

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...

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...

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...

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...

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...

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...

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...

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...

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...

Management Training in Critical Care Medicine

Critical care medicine as a specialty has grown rapidly, both clinically and academically, over the past 25 years. In the USA, certification of competence has been awarded to graduates of the critical care medicine fellowship programmes since 1987. This article is available only as a PDF. Please click on “Download...

Combined High-frequency Ventilation (CHFV) in the Treatment of Acute Lung Injury—A Case Report

The role of ventilatory support in acute lung injury is supportive, whilst the damage to alveolar-capillary membranes resolves and alveolar stability is restored. The optimum mode of support varies with individual patients, but none can reliably prevent progression of acute lung injury and high frequency ventilation (HFV) has been...

Critical Care Medicine in the Western Pacific Region

The Western Pacific region includes a very diverse group of countries varying in their culture, economic development and per capita income, disease prevalence and medical traditions. The Western Pacific Association of Critical Care Medicine (WAPCCM) includes countries from Japan in the north to Australia and New Zealand in the...

Critical Care—The Worldwide Perspective

Although special areas for postoperative patients existed 50 years ago, the modern specialty of Critical Care began during the polio epidemic of the 1950s. Prolonged hand ventilation, and positive or negative pressure ventilation, enabled maintenance of oxygenation until some patients developed sufficient recovery or compensatory processes to enable separation...

Caudal Morphine in Paediatric Patients: A Comparison of Two Different Doses in Children after Major Urogenital Surgery

The use of caudal preservative-free morphine for postoperative analgesia in children has gained popularity since it was first described by Jensen. Several studies have reviewed its use for inguinal and genital surgery in children. This article is available only as a PDF. Please click on “Download PDF” on top to...

Predictors of Long-term Outcome in Severe Head Injury

Injuries form the fifth commonest cause of death locally. They accounted for 27 out of 100 000 deaths in 1993. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Audit of 2431 Admissions to the Surgical Intensive Care Unit, Singapore General Hospital

The Singapore General Hospital is a 1700-bedded tertiary hospital with subspecialty intensive care units (ICUs), i.e. Surgical ICU, Cardiothoracic ICU, Neurosurgical ICU, Medical ICU, Burns ICU, Medical ICU, Coronary Care Unit and Neonatal ICU. The SICU receives patients from various surgical disciplines (Table I). This article is available only as...

Intensivists for the Intensive Care Unit—Do They Make a Difference?

Does Critical Care Medicine exist and what defines its area of practice? Different countries have embarked on their own journeys of discovery, and have arrived at different paradigms—open versus closed models, specialty-based intensive care units (ICUs) versus general ICUs, internist versus pulmonologist or anaesthetist, and so forth. This article is...

A Case of Accelerated Development of Proliferative Diabetic Retinopathy in a Woman with Type 2 Diabetes Mellitus after Pregnancy

Diabetic retinopathy is the leading cause of blindness in persons between the age of 24 and 64 years both in the US and the UK. Peak fertility and childbearing years correspond to the first half of this period. This article is available only as a PDF. Please click on “Download...

Epidural Analgesia in Obstetrics

Most obstetric anaesthetists have their favourite epidural concoction for use in labour, This paper surveys the variation in techniques of drug delivery and types of drugs used in labour epidurals. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

An In vitro Evaluation of Epidural Catheters: Tensile Strength and Resistance to Kinking

In the current era of increasing economic and medicolegal pressures, it is imperative that equipment-related limitations and complications be reduced to a minimum. Epidural catheter breakage can result in the inconvenience of surgical extraction of catheter fragments, while kinking can lead to impairment or failure of drug delivery to...

The Use of Magnesium Sulphate in the Intensive Care Management of an Asian Patient with Tetanus

A 29-year old Thai construction worker, previously well, was admitted to our Orthopaedic Department for sudden onset of lower back pain. Physical examination showed severe tenderness in the lumbar region, limited straight leg raising but no neurological deficit. This article is available only as a PDF. Please click on “Download...

Re-expansion Pulmonary Oedema Following One-lung Ventilation —A Case Report

A 15-year-old female patient weighing 40 kg with asymptomatic but severe scoliosis was admitted for correction of a skeletal deformity via a thoracoscopic anterior release approach and posterior instrumentation. Preoperative assessment revealed good effort tolerance. This article is available only as a PDF. Please click on “Download PDF” on top...

Changing the Institutional Practice of Prolonged Mechanical Ventilation after Coronary Artery Bypass Graft Surgery to Early Extubation

In the past, cardiac patients in this institution were ventilated postoperatively for a prolonged period, frequently overnight. Since 1997 some of our cardiac anaesthetists have, whenever possible, adopted the practice of early extubation after cardiac surgery to improve the patient’s level of comfort and to allow an early return...

Rapid One-day Fluorescence In Situ Hybridisation in Prenatal Diagnosis Using Uncultured Amniocytes and Chorionic Villi

The most common chromosomal abnormalities in newborns are trisomy 21, trisomy 18, trisomy 13, and monosomy X, with incidences of 1/800, 1/8,000, 1/20,000, and 1/10,000, respectively. Conventional cytogenetic approaches traditionally employ foetal cells from amniotic fluid (AF) or chorionic villus (CV) grown in vitro and metaphase banding for chromosome...

Controversies in Anaesthesia—Designer Drugs

The discovery of new drugs in anaesthesia previously relied completely on chance. Chemical compounds produced by pharmaceutical companies were screened by a variety of different teams looking for effects of interest to their own area. This article is available only as a PDF. Please click on “Download PDF” on top...

A Preliminary Study of the Immunohistochemical Detection of a Novel Tumour Marker, 22-1-1 Antigen, in Gynaecological Cancer Specimens

Monoclonal antibodies expressed against specific tumour cells can play a useful role in the study and management of such cancers. Such antibodies have been useful in diagnosis and treatment of certain cancers (as tumour markers) and many such antibodies have now been described. This article is available only as a...

Radial Nerve Injury after Intravenous Cannulation at the Wrist—A Case Report

A 44-year-old male, right-handed and ASA 1 bus driver presented for elective mastoidectomy under general anaesthesia. Preoperative venous cannulation with a 20G cannula (Angiocath™) was first attempted on the dorso-lateral aspect of the right wrist at the base of the anatomical snuffbox. This article is available only as a PDF....

Prognostic Factors in Endometrial Carcinoma

In the United States of America, endometrial carcinoma is the most common cancer of the female genital tract and has an annual incidence of 72 per 100,000 women. In Singapore it is the third most common female genital tract cancer after cancer of the cervix and ovary. This article is...

Factors Affecting Success in an Embryo Cryopreservation Programme

The first pregnancy resulting from the thaw and transfer of cryopreserved pre-embryos was reported in 1983 by Trounson and his team, in Melbourne, Australia. This technological breakthrough in infertility treatment has been successfully repeated since then and cryopreservation of excess embryos now forms an integral part of any assisted...

Hyperlipidaemia during Normal Pregnancy, Parturition and Lactation

Increase in the plasma lipid fractions in normal pregnancy have been described but irregularity of sampling, difference in materials studied (whole blood, serum, and plasma) and the variations in the method of reporting precluded any comparison of results. In Western populations normal pregnancy leads to an increase in cholesterol...

Dissemination of Respiratory Secretions During Tracheal Tube Suctioning in an Intensive Care Unit

Tracheal tube suctioning is frequently performed in critically ill patients. This procedure often results in dissemination of droplets from the patient’s respiratory tract with potential spread of respiratory tract microorganisms from one patient to another. This article is available only as a PDF. Please click on “Download PDF” on top...

An Unusual Tumour Metastasis to the Cervix

A 55-year-old Chinese lady had a left mastectomy in April 1995 for an invasive lobular carcinoma of the breast. Axillary lymph node metastases were present. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Perioperative Wheezing—A Report of Three Cases

Perioperative “wheezing” can be due to upper or lower airway obstruction. The signs and sounds of upper airway obstruction are typically worse during inspiration, whereas those of lower airway obstruction are worse in expiration. This article is available only as a PDF. Please click on “Download PDF” on top to...

The Use of the Laryngeal Mask Airway in Post-Tonsillectomy Haemorrhage—A Case Report

A 53-year-old man with a history of hypertension and asymptomatic Wolff-Parkinson-White syndrome was admitted to the hospital for an elective uvulopalatopharyngoplasty, tonsillectomy and bilateral functional endoscopic sinus surgery for mild obstructive sleep apnoea and chronic sinusitis respectively. He weighed 109 kg, all his four upper incisors were missing and...

A Case Report of the Use of Magnesium Sulphate during Anaesthesia in a Patient who had Adrenalectomy for Phaeochromocytoma

Phaeochromocytomas are catecholamine-secreting tumours of the chromaffin cells of the body derived from neural crest tissue. They may secrete both adrenaline and noradrenaline in varying proportions. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Prophylactic Esmolol Infusion for the Control of Cardiovascular Responses to Extubation after Intracranial Surgery

Both intubation and extubation are processes associated with blood pressure and heart rate flux. While many studies have been carried out on the changes associated with intubation, the frequency and magnitude of the changes associated with extubation are less well documented. This article is available only as a PDF. Please...

Genetics of Male Infertility: Role of Androgen Receptor Mutations and Y-Microdeletions

Three to four per cent of men have severe defects in sperm production that result in infertility. Most of these men are healthy and the causes of depressed spermatogenesis are rarely identified with certainty. This article is available only as a PDF. Please click on “Download PDF” on top to...

Association or Agreement

Association and agreement between two factors are very different concepts, although the methods used to describe them appear similar. For example, the association between levels of aflatoxin serum albumin adducts and dietary aflatoxin intake can be demonstrated in a bivariate scattergram; the agreement between two methods of measuring aflatoxin...

Transurethral Surgery and the Adductor Spasm

Bladder tumours frequently arise from the posterolateral wall of the bladder1 over the course of the obturator nerve. It is during transurethral resection of these tumours that direct electrical stimulation of the obturator nerve occurs. This article is available only as a PDF. Please click on “Download PDF” on top...

Subcutaneous Emphysema and Pneumomediastinum after Endotracheal Anaesthesia

Pneumomediastinum is a well-recognised clinical entity. It may present either intraoperatively or postoperatively from a number of possible causes. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Microdochectomy for Single-duct Nipple Discharge

Nipple discharge is a common disturbing symptom for many women and often leads to a surgical referral. It accounts for 3% to 5% of all breast symptoms. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Total Intravenous Anaesthesia Using 3-in-1 Mixture of Propofol, Alfentanil and Mivacurium

Total intravenous anaesthesia (TIVA) implies achieving the 3 components of anaesthesia (hypnosis, analgesia and muscle relaxation) by the administration of anaesthetics via the intravenous (IV) route without the use of inhalation agents. The main advantages of TIVA are avoidance of both volatile agent and nitrous oxide exposure and reduction...

The Predictive Value of Intraoperative ST-segment Monitoring as a Marker of Myocardial Injury

Patients with ischaemic heart disease have a high incidence of perioperative ischaemia resulting in an increased risk of cardiac events in the post-surgical period.1 Goldman et al2 formulated the “cardiac risk index”, implicating previous myocardial infarction (MI), heart failure and unstable angina as major determinants of postoperative cardiac events. This...

Fibre-optic Aided Bougie (FAB) for Simulated Difficult Tracheal Intubation

Difficult intubation remains a key problem1 and the value of a flexible introducer (gum elastic or wire) as a first approach is well recognised in the UK and USA. It is the simplest method, effective for all grade 2 laryngoscopies, where at least the arytenoids are visible and most...

A Case Report on the Treatment of Intractable Anal Pain from Metastatic Carcinoma of the Cervix

Unremitting pain remained a primary therapeutic challenge in cancer patients. Both opioids and non-opioids are often the main stay of therapy for many. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Intravenous Regional Anaesthesia Using Lignocaine and Tramadol

Intravenous regional anaesthesia (IVRA) has a reported success rate of between 94% and 98% for upper limb surgery. Limitations to its use include the quality of intraoperative anaesthesia, tourniquet pain and lack of adequate postoperative analgesia. This article is available only as a PDF. Please click on “Download PDF” on...

Catheter-related Infection: Diagnosis, Prevention and Treatment

Intravascular catheters are indispensable for patient care. Despite advances in catheter technology and patient care, catheter infection remains a significant clinical problem. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Prevention of Human Immunodeficiency Virus (HIV) Transmission from Mother to Child—A Cohort Study in Singapore

Since the onset of the acquired immunodeficiency syndrome (AIDS) epidemic in the mid-1980s, the number of HIV-infected cases has risen sharply throughout the world. Globally, 5.8 million new HIV infections have been diagnosed in 1998 with 1.2 million being diagnosed in Southeast Asia. This article is available only as a...

Book Review

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”...

Book Review

This handbook serves an important function for Intensive Care Units in Singapore. It is a collective effort of 35 specialists in 5 different institutions in Singapore. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Intra-abdominal Hypertension—Implications for the Intensive Care Physician

Although the detrimental effects of raised intra-abdominal pressure have been known for over 100 years, it is only in the last two decades that the clinical importance of these changes are being recognised.1-7 This coincides with the increasing availability of intensive care, which allows many more patients to survive...

Anaemia in the Critically Ill—The Optimal Haematocrit

The function of haemoglobin (Hb) is to transport oxygen to the tissues. Approximately 97% of oxygen is transported via Hb, while 3% is transported dissolved in the plasma. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Quality of Life in Long-Term Survivors of Intensive Care

Intensive care has undergone rapid technological advancement in recent years enabling complex treatment of patients of advanced age and/or with advanced chronic diseases underlying their acute medical problems. New interventions have been introduced with success determined by their ability to save lives. This article is available only as a PDF....

Limitation of Life Support in the Critically Ill: The Hong Kong Perspective

Technological advances over the last 30 years have had an enormous impact on the way in which medicine is delivered today. This is particularly so in the specialty of intensive care where intensivists possess the necessary knowledge and tools to prolong life in many situations where patients would previously...

Simulation-based Training at the University of Pittsburgh

In the domain of medical education of both the general public and healthcare professionals, the next decade will present both challenges and opportunities centred on training issues and technologies. Since the introduction of external cardiopulmonary resuscitation in 1960 through to the establishment of International Guidelines for Cardiopulmonary Resuscitation and...

Retinol Palmitate Counteracts Oxidative Injury During Experimental Septic Shock

Gram-negative bacteria induced septic shock, a condition with high mortality, is frequently seen in critical care medicine. The wall of gram-negative bacteria consists of endotoxin, which is chemically composed of lipopolysaccharide, and is extremely biologically active. This article is available only as a PDF. Please click on “Download PDF” on...

Obstetric Admissions to the Intensive Therapy Unit of a Tertiary Care Institution

Pregnancy is associated with physiological changes in various organ systems and complications arising from the interaction between these changes and disease processes may be severe enough to require admission to the intensive therapy unit (ITU) for management. The purpose of this study was to review all obstetric patients admitted...

Pulse Dye Densitometry: A Novel Bedside Monitor of Circulating Blood Volume

The monitoring of circulating blood volume (CBV) is important in the care and management of critically ill patients. Progressive blood volume depletion, if unmonitored and uncorrected, can result in tissue ischaemia, acidosis and systemic inflammatory response syndrome. This article is available only as a PDF. Please click on “Download PDF”...

Case Report: Catheter-Related Epidural Abscess

Epidural abscess complicating epidural catheterisation was first reported in 1974. Two recent studies indicated a local infection incidence of epidural catheters of 4.3% to 12% and about 0.7% are reported to have central nervous system infection e.g. epidural abscess or meningitis. This article is available only as a PDF. Please...

A Case of Pulmonary Haemorrhage Following Jet Ventilation for Vocal Cord Surgery

Laryngospasm occurring at extubation is not an uncommon complication seen with use of endotracheal tubes and laryngeal mask airway. We report a case of laryngospasm on extubation of a Benjamin jet tube resulting in pulmonary haemorrhage. This article is available only as a PDF. Please click on “Download PDF” on...

Subdural Block—From a Spinal? A Case Report

There have been multiple reports of accidental subdural blocks published in the last 20 years. Majority of these have been the result of an epidural gone astray, and the lowest reported volume of local anaesthetic used was 3.5 mL. This article is available only as a PDF. Please click on...

Problems Related to Epidural Analgesia for Postoperative Pain Control

Epidural analgesia has been shown to provide excellent pain relief following thoracotomy, abdominal and other surgery. Studies have shown improvement in specific variables with epidural analgesia; and effective postoperative pain relief is a prerequisite to attain improved postoperative outcome. This article is available only as a PDF. Please click on...

Management of Premalignant Lesions of the Cervix

Cervical cancer is one of the most common female cancers worldwide. It is ranked second only to breast cancer and in many underdeveloped countries, it is the most common female cancer. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

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.

The Course of Pregnancy in a Patient with Nail-Patella Syndrome

The nail-patella syndrome (NPS) is a rare autosomal dominant disorder defined by the association of nail dysplasia, bone abnormalities and, frequently, renal disease. We report the course of pregnancy in a patient with such a condition. This article is available only as a PDF. Please click on “Download PDF” on...

Rheumatic Heart Diseases in Pregnancy

Rheumatic heart disease comprises acute rheumatic fever following group A beta-haemolytic streptococcal infection of the tonsillopharynx, and its long-term sequelae of heart valve fibrosis causing chronic valvular lesions. Severe myocardial and pericardial involvements are much less common. This article is available only as a PDF. Please click on “Download PDF”...

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...

Current Understanding of Pre-eclampsia

Pre-eclampsia is a major cause of adverse obstetric outcome. It remains one of the leading causes of maternal mortality1 and continues to contribute significantly to perinatal morbidity and mortality. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Management of Thromboembolic Disease in Pregnancy

Venous thromboembolism (VTE) refers specifically to 2 related entities: deep vein thrombosis (DVT) and pulmonary embolism. The management of arterial thrombo-embolism, in particular that of women with artificial heart valves, is beyond the scope of this paper. This article is available only as a PDF. Please click on “Download PDF”...

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...

Thyroid Diseases in Pregnancy

Abnormalities of thyroid function associated with pregnancy encompass both hyperthyroidism and hypothyroidism. These may have been present before the onset of pregnancy, or occurred only during or after pregnancy. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Outcome of Pregnancy in Asian Women with Systemic Lupus Erythematosus: Experience of a Single Perinatal Centre in Singapore

Systemic lupus erythematosus (SLE) is a chronic systemic connective tissue disease with a reported prevalence of 5 to 100/100,000. Women are affected much more commonly than men (ratio 9:1), particularly those in the child-bearing age (15:1). This article is available only as a PDF. Please click on “Download PDF” on...

Pregnancy after Renal Transplantation: Experience in Singapore General Hospital

Successful renal transplantation significantly improves the sexual and reproductive functions of women with end-stage renal disease and offers the best hope for those who wish to have children. Conception rate has been reported to improve dramatically from 1 in 200 dialysis patients to 1 in 50 women with a...

Gestational Diabetes Mellitus: A Call for Systematic Tracing

The prevalence of diabetes is increasing worldwide. In Singapore, the prevalence of diabetes has increased dramatically from 4.7% in 1984 to 8.6% in 1998. Diabetic complications lead to a significant number of patients with blindness, amputations and end-stage renal failure annually. This article is available only as a PDF. Please...

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.

Are Maternal Deaths on the Ascent in Singapore? A Review of Maternal Mortality as Reflected by Coronial Casework from 1990 to 1999

It is said that, worldwide, over half a million maternal deaths occur annually. This might well be a conservative estimate, given the difficulties inherent in collecting the relevant data, compounded by the under-reporting and misclassification of such deaths. This article is available only as a PDF. Please click on “Download...

Medical Disorders in Pregnancy—The Challenges Ahead

Nowhere is the fate of two individuals more closely intertwined than that of the mother and her fetus. Pregnancy is a unique state where the physiology of the mother is greatly altered to accommodate the newly developing “organ”—the fetus. This article is available only as a PDF. Please click on...

Clinical Update on Managing the Obstructed Airway

Maintaining a patent upper airway is the first principle in resuscitation and acute care. This is usually carried out by anaesthesiologists, emergency medicine physicians and intensivists. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Anaesthetic Considerations for Lung Volume Reduction Surgery—A Case Report

Only until a few years ago, the only surgical alternative for patients with severe emphysema was lung transplantation. However, with transplantation, there are problems of rejection, infection, immunosuppression and declining donor pools. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Osteoporosis in Relation to Menopause

Singapore has a rapidly ageing population. In 1990, only 6% of the population was above the age of 65 years but this percentage of elderly citizens will rise rapidly to 17% by the year 2030. As Singaporean women achieve longer life expectancy and live a greater portion of their...

Remifentanil in the Management of Laparoscopic Resection of Phaeochromocytoma – Case Reports

The perioperative management of surgery for laparoscopic resection of phaeochromocytoma presents a significant challenge. Many different anaesthetic techniques and drugs have been used to control the haemodynamic fluctuations during phaeochromocytoma resection. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Burch Colposuspension: Review of Perioperative Complications at a Women’s and Children’s Hospital in Singapore

Genuine stress incontinence (GSI) is the most common cause of female urinary incontinence. When conservative treatment fails, surgery is indicated. Open Burch colposuspension is an established surgical procedure1 and remains the gold standard upon which the efficacy of newer surgical options is evaluated. This article is available only as a...

A Prospective Audit of Critical Incidents in Anaesthesia in a University Teaching Hospital

Despite the highest standards of training, practice and equipment, morbidity and mortality due to anaesthesia still occur. These risks are difficult to quantify, and medicolegal considerations may limit any comprehensive study of anaesthetic mishaps. This article is available only as a PDF. Please click on “Download PDF” on top to...

Endometrioid Adenocarcinoma of the Uterus: Surgico-Pathological Correlations and Role of Pelvic Lymphadenectomy

Endometrial cancer is the most common female genital malignancy in industralised countries today. Despite the overall favourable prognosis in this neoplasia, survival is associated with several prognostic factors. In endometrial cancer, one of the most potent prognostic factors is nodal metastasis. This article is available only as a PDF. Please...

FIGO Stage 1B2 Cervical Carcinoma – The KK Women’s and Children’s Hospital Experience

Important prognostic factors in stage 1B cervical carcinoma include primary tumour diameter, nodal metastases, depth of stromal invasion, lymph-vascular invasion, microscopic parametrial extension and status of surgical margins.1 In 1994 FIGO addressed the significance of tumour diameter by designating stage 1B into 1B1 (clinical lesions no greater than 4.0...

Bowel Surgery for Epithelial Ovarian Cancer – An Early Case Series

Epithelial ovarian cancer is the leading cause of death in patients with gynaecological malignancies in Singapore and developed countries, the main reason being the advanced stages of the disease (stage III or IV) at diagnosis. This is largely due to the lack of an effective screening tool to detect...

Pregnancy Following Embolisation of Uterine Arteriovenous Malformation – A Case Report

Arteriovenous malformations (AVMs) of the uterus are rare but potentially life-threatening lesions. The common presentation is vaginal bleeding and, if not diagnosed correctly, can result in torrential bleeding, especially following dilatation and curettage. This article is available only as a PDF. Please click on “Download PDF” on top to view...

A Case Series of Gastrointestinal Abnormalities in Fetuses with Echogenic Bowel Detected During the Antenatal Period

Although the presence of fetal echogenic bowel (EB) has been largely regarded as benign, it has been viewed as a soft marker for various congenital anomalies. To date, no studies have been conclusive and the importance of antenatal EB amongst the low-risk population has remained confusing. This article is available...

Audit of ‘Crash’ Emergency Caesarean Sections Due to Cord Prolapse in Terms of Response Time and Perinatal Outcome

Umbilical cord prolapse is an uncommon intrapartum event with a reported incidence of 1 in 160 to 714 deliveries. Predisposing factors include fetal malpresentation, prematurity, small fetal size, multiple gestation, polyhydramnios and membranes rupture prior to head engagement. This article is available only as a PDF. Please click on “Download...

Quality Control Assurance in National Screening Programmes for Cervical Cancer

The National Health Service (NHS) was established in the United Kingdom (UK) in 1948, against a post-war background of poverty and ill health. The aim was to provide healthcare based on need to all citizens of the UK, free at the point of delivery. This article is available only as...

The Combined Oral Contraceptive Pill in Women Over Age Forty

In the 1970s, several studies appeared to suggest that users of oral contraceptives (OCs) were at increased risk of cardiovascular events. More recently following newer studies on lower dose OCs and re-analysis of the old studies, it was concluded that the risk of cardiovascular accidents was attributable primarily to...

Contemporary Management of Fibroids

Fibroids are the most common, solid benign pelvic tumours occurring in about 30% of women beyond the age of 30. They are asymptomatic in most women. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Investigating the Infertile Couple

Infertility is defined as the inability to conceive after 1 to 2 years of unprotected intercourse. In general, an estimated 84% of all women would conceive after a year of intercourse. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Use of Hormone Replacement Therapy in the Asymptomatic Postmenopausal Woman: What is the Current Evidence?

The understanding of hormone replacement therapy (HRT) for postmenopausal women has undergone dramatic change since the publication of the results of the Women’s Health Initiative (WHI) study in July 2002. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Fetal Cells in Maternal Blood: State of the Art for Non-Invasive Prenatal Diagnosis

Without prenatal diagnosis, 1 in 50 babies are born with serious physical or mental handicap, and as many as 1 in 30 with some form of congenital malformation. These may be due to structural or chromosomal abnormalities, or single gene disorders. This article is available only as a PDF. Please...

Human Papillomavirus Triage of Patients with Atypical Squamous Cells of Undetermined Significance on Cervical Papanicolaou Smear

Cervical cancer affects >400,000 women a year worldwide, and represents a significant health issue for women. In the United States (US) however, screening programmes have reduced the incidence to 8.3 cases per 100,000 women with only 14,000 cases and 5000 deaths annually. This article is available only as a PDF....

Screening for Chromosomal Anomalies: First or Second Trimester, Biochemical or Ultrasound?

A chromosome abnormality contributes significantly to fetal loss during pregnancy, and perinatal morbidity and mortality. The contribution of chromosomal abnormalities to fetal loss decreases as pregnancy progresses; an estimated 50% of first-trimester spontaneous abortions are due to chromosomal abnormalities. This article is available only as a PDF. Please click on...

Should Doctors Perform an Elective Caesarean Section on Request?

Caesarean sections performed without medical indication, better known as maternal request caesarean sections, have generated intense debate in recent times. While uncommon in the past, a recent national audit in the United Kingdom (UK)1 revealed that 7% of all elective caesarean sections were performed for precisely this reason. This article...

Recent Advances in Obstetrics and Gynaecology

The science and art of providing quality health care to women has made tremendous strides in recent years. In the subspecialties of Obstetrics and Gynaecology, recent advances in laboratory techniques and in clinical diagnostic, surgical and laparoscopic skills have improved the prevention and early detection of disease. This article is...

MR Imaging of the Fetal Brain and Spine: A Maturing Technology

The introduction of a new diagnostic test into a clinical arena goes through a number of stages. The first stage is technical development. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The Use and Abuse of Steroids in Perinatal Medicine

Preterm birth, delivery prior to 37 weeks of gestational age, accounts for a major and disproportionate amount of infant and neonatal morbidity and mortality. Despite advances in medical technology, the prevalence of preterm birth in Singapore has increased, secondary to an increase in multiple gestations and obstetric interventions. This article...

Changing Trends in Indications for Caesarean Sections in a Tertiary Hospital

Increasing rates of caesarean deliveries have received widespread attention in recent years and has increased widespread discussion in the public domain. The ideal caesarean section rate has never been defined and national rates of caesarean delivery vary from country to country. This article is available only as a PDF. Please...

Obstetric Cholestasis: Current Opinions and Management

Obstetric cholestasis (OC) is a pregnancy-specific liver disorder. It is also known by other names, such as pruritus gravidarum, recurrent intrahepatic cholestasis of pregnancy and obstetric hepatosis. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Advances in Imaging in Prenatal Diagnosis and Fetal Therapy

Technology in sonography has advanced tremendously in recent years, contributing to improvements in clinical applications for prenatal diagnosis and fetal therapy. These include transvaginal scanning, harmonic imaging, Doppler imaging, 3-dimensional (3D) ultrasonography and magnetic resonance imaging (MRI) ultrafast sequences. This article is available only as a PDF. Please click on...

Factors Influencing Fetal Growth

Birth weight remains one of the most important measures we have of the health status of a population, being a strong predictor of both mortality and morbidity, and reflecting nutritional status and growth rates. Yet, the estimation of the normal growth potential — and hence the definition of growth...

Improving the Uptake of Human Immunodeficiency Virus (HIV) Antenatal Screening in a Primary Healthcare Setting

Since the acquired immunodeficiency syndrome (AIDS) was first diagnosed in Singapore in 1985, its incidence rose from 15 cases in 1988 to 226 in 2000. There has also been a change in the profile of AIDS patients over this period. This article is available only as a PDF. Please click...

Labour epidural practice in a tertiary training centre

Dear Editor, Labour analgesia provided through the central neuraxial approach is offered for parturients who are in their active stage of labour, usually after 2–4cm of cervical dilatation. Lumbar epidural, the gold standard for labour analgesia, is recently recommended over other alternative methods of analgesia such as pressurised gaseous nitrous...

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...

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...

Evaluation of a Bedside Test for Phosphorylated Insulin-like Growth Factor Binding Protein-1 in Preterm Labour

The diagnosis of preterm labour poses a problem. Preterm labour accounts for about 50% of preterm births; however, most data reveal that only about 20% of women presenting with suspected preterm labour actually deliver preterm. This article is available only as a PDF. Please click on “Download PDF” on top...

Inaugural College of Obstetricians & Gynaecologists Lecture: Recent Developments in Obstetric Care and Maternal Fetal Medicine in Singapore

Has it done any good to pregnancy outcome as promised? This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The Importance of High Resolution Chromosome Analysis in the Diagnosis of Birth Defects: Case Reports of Holoproscencephaly and Cystic Hygroma

Optimal chromosome preparation is a function of many factors. These include cell density culture initiation, optimal time for harvest, concentration and exposure duration to a mitotic arrestant, appropriate hypotonic treatment and adequate fixation with modified Carnoy’s fixative. This article is available only as a PDF. Please click on “Download PDF”...

Tailoring the Field and Indication of Adjuvant Pelvic Radiation for Patients with FIGO Stage Ib Lymph Nodes-Negative Cervical Carcinoma Following Radical Surgery Based on the GOG Score – A Pilot Study

Although no significant survival difference exists between primary surgery and radiotherapy (RT) for the treatment of FIGO stage Ib cervical cancer, radical surgery is the preferred modality of treatment as conservation of the ovarian and vaginal function is of prime importance. It also allows the study of prognostic histopathological...

A Case of Cystic Leiomyoma Mimicking an Ovarian Malignancy

Uterine leiomyomas are the most common gynaecological tumour. Typical appearances of leiomyomas are easily recognised on imaging. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Abnormal Liver Function Tests in the Symptomatic Pregnant Patient: The Local Experience in Singapore

The diagnostic work-up of abnormal liver function tests (LFT) in pregnancy is challenging, as the conditions peculiar to pregnancy have to be considered in addition to the causes affecting the non-pregnant population. The spectrum of disease is varied and the abnormal LFT can be mild with no long-term consequence,...

Twin Births in Singapore: A Population-Based Study Using the National Birth Registry

Twin studies are regarded as one of the better ways to study the effects and significance of gene, environment and interactions of both. The study of monozygotic (MZ) and dizygotic (DZ) twins allows for an estimation of the relative importance of genes and environment. This article is available only as...

Transmission of Tuberculosis from Patient to Healthcare Workers in the Anaesthesia Context

Tuberculosis poses a very real problem to healthcare workers (HCWs). In Singapore, the prevalence of tuberculosis in the general population remains high at 44 per 100,000 in the year 2001. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The Effectiveness of Transvaginal Anterior Colporrhaphy Reinforced with Polypropylene Mesh in the Treatment of Severe Cystoceles

Using the Baden-Walker halfway system, Grade 4 cystoceles are defined as extrusions of the bladder base beyond the vaginal introitus with patient straining maximally and represent the extremes of anterior vaginal wall prolapse (Table 1). They result from increased laxity and weakness of the urethrovesical supporting system comprising the...

Book Review

This handbook is written by 3 obstetricians and gynaecologists based at the KK Women’s & Children’s Hospital, Singapore. It is an excellent book that answers the everyday questions that general practitioner (GP) will ask in their clinical practice. This article is available only as a PDF. Please click on “Download...

An Unexpected Left Hydrothorax after Left Internal Jugular Venous Catheterisation for Total Parental Nutrition and Antibiotics

Percutaneous indwelling central venous catheters are commonly used for a variety of medical and surgical indications. There are various complications associated with the insertion of central venous lines despite the advances made in the design, material of the catheter and the technique of insertion. This article is available only as...

Recurrent Non-immune Fetal Hydrops: A Case Report

The incidence of non-immune hydrops (NIH) has been reported to be 1/10001 and is associated with high perinatal morbidity and mortality at all gestational ages with an overall perinatal mortality rate (PNMR) of 86.6%. If the diagnosis is made before 24 weeks’ gestation, the PNMR is 95%, with 30%...

The Impact of Experiential Learning on NUS Medical Students: Our Experience With Task Trainers and Human-patient Simulation

The realisation that students have different cognitive and learning styles has had major implications on medical curriculum design efforts. If the student’s learning style is mismatched with the teaching style or the teaching environment, the student may spend considerable effort to adapt, and this may negatively impact the student’s...

Socio-demographic Profile and Help-seeking Behaviour of Buprenorphine Abusers in Singapore

Opiate dependence is a major health and social concern in many countries across the world. The burden of disease is considerable, with surveys indicating that up to 2% of the population had used opiates for non-medicinal reasons. This article is available only as a PDF. Please click on “Download PDF”...

Right Atrial Isomerism – Preponderance in Asian Fetuses. Using the Stomach-distance ratio as a Possible Diagnostic Tool for Prediction of Right Atrial Isomerism

Atrial isomerism is a disorder of lateralisation characterised by symmetric development of normally asymmetric cardiac atria and organ systems. The synonyms for these defects include heterotaxy syndrome, polysplenic/ asplenic syndrome, right/left isomerism, isomerism of the atrial appendages and situs ambiguous. This article is available only as a PDF. Please click...

Assessment of Medical Graduates Competencies

Medical professional proficiency comprises a set of skills, knowledge, and attitudes necessary to efficiently accomplish the practice of medicine. The major aim of undergraduate medical education in the region is to produce doctors who are competent and able to meet the health needs of the community while also being...

Chylous Ascites in Recurrent Gynaecological Malignancies

Chylous ascites is an unusual phenomenon where there is accumulation of chyle in the peritoneal cavity. It is especially rare following treatment of gynaecological cancers. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Placental Calcification in Pseudoxanthoma Elasticum

Pseudoxanthoma elasticum (PXE) is an inherited multisystem disorder of the elastic tissue leading to skin disease as well as ocular and cardiovascular complications. Although earlier literature on pregnancy in PXE contained reports of severe complications, most patients show no serious complications during pregnancy. This article is available only as a...

Holoprosencephaly: An Antenally-diagnosed Case Series and Subject Review

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...

Laparoscopic Heller’s Cardiomyotomy for Achalasia of the Cardia in a Pregnant Patient

Laparoscopy was first used for the evaluation of acute abdominal pain in pregnancy by gynaecologists in 1980. The most commonly reported laparoscopic procedure during pregnancy is laparoscopic cholecystectomy. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Spontaneous Vaginal Expulsion of a Filshie Clip

Laparoscopic sterilisation is a common method of permanent contraception. The Filshie clip system is a safe and effective method of female sterilisation. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Care of Women in Menopause: Sexual Function, Dysfunction and Therapeutic Modalities

Menopause is a life change described by biological alterations occurring in the context of important social changes. There is an increasing appreciation for the role of sexual function in menopause and its importance for a woman’s health and well-being. This article is available only as a PDF. Please click on...

An Unexpected Presentation of Endometriosis – A “Parasitic” Cyst of the Bowel in a Menopausal Woman on Hormone Therapy

Endometriosis commonly affects women during their reproductive years and may involve any organ. Although rare, endometriosis has been reported in postmenopausal women and is often associated with hormone replacement or tamoxifen. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Menopause, Hormone Therapy and Cardiovascular and Cerebrovascular Disease

Cardiovascular disease is a major cause of morbidity among postmenopausal women. Up to the age of 50 years, the prevalence of coronary artery disease (CAD) among women is lower than among men, but the incidence rises significantly after the menopause. This article is available only as a PDF. Please click...

Tetanus in an Injecting Buprenorphine Abuser

Problems with parenteral drug abuse with opioids and infectious complications have been well-described in medical literature.1-3 Substitution drugs such as buprenorphine (Subutex) have been used as an adjunct to manage intractable opioid dependence. Buprenorphine, a partial opioid agonist, has been shown in previous trials to reduce heroin use, with...

Reply from Author: Intrathecal Analgesia for Cancer Pain: Externalised Intrathecal Catheters

We thank Dr Nicholas Chua et al for their interest in our review article. We agree and appreciate the experience and comments by the authors regarding the usage of externalised intrathecal catheter for analgesia in cancer pain. This article is available only as a PDF. Please click on “Download PDF”...

Intrathecal Analgesia for Cancer Pain: Externalised Intrathecal Catheters

We thank the authors for a comprehensive review on the role of interventional pain therapies used in cancer pain as well as a informative local audit using the intrathecal catheter (PORT-A-CATH® IT) implantable system (Deltec Inc, USA). This article is available only as a PDF. Please click on “Download PDF”...

The Influence of Maternal Ethnic Group and Diet on Breast Milk Fatty Acid Composition

Human milk is the ideal food which provides the complete nutritional requirements for infants during the first 6 months of life. The lipids accumulated in an infant represent the majority of all energy retained in the growing tissues during this crucial period of rapid growth and development. This article is...

A Clinicopathologic Study of Uterine Smooth Muscle Tumours of Uncertain Malignant Potential (STUMP)

Smooth Muscle Tumours of Undetermined Malignant Potential or STUMPs are interesting tumours from both the standpoint of histological diagnosis and classification as well as clinical management mainly because, as a group, its natural history is poorly understood. Prognostic criteria of how STUMP tumours will behave have been studied and...

Embolised Injection Needle Fragment to the Heart, Mimicking a Subcutaneous Charm Needle

Embolisation of a fragmented injection needle to the heart is rare, even in intravenous drug abusers. The presence of an embolised needle fragment to the heart can serve as a nidus for infective endocarditis. This article is available only as a PDF. Please click on “Download PDF” on top to...

Obstetric Outcomes of Influenza A H1N1 (2009) Infection in Pregnancy – Experience of a Singapore Tertiary Hospital

Influenza A H1N1 (2009) is a new viral strain containing gene segments from human, swine and avian lineages. Soon after reports of human cases of the infection in April 2009, the World Health Organization declared the situation a public health emergency of international concern. This article is available only as...

Inadvertent Use of Bevacizumab to Treat Choroidal Neovascularisation During Pregnancy: A Case Report

The recognition that vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of neovascular age-related macular degeneration (NVAMD) has led to the development of several intravitreal anti-angiogenic therapeutics. Ranibizumab (Lucentis, Genentech, San Francisco, USA) and pegaptanib (Macugen, OSI/Eyetech Pharmaceuticals, New York, USA) have been FDA-approved for...

Emerging Trends in Breastfeeding Practices in Singaporean Chinese Women: Findings from a Population-based Study

The health benefits of breast milk have been well documented, with positive implications for infants’ metabolic, immunologic, respiratory and digestive health. The World Health Organization (WHO) and the American Academy of Pediatrics recommend exclusive breastfeeding for 6 months and partial breastfeeding thereafter for at least 12 or 24 months....

Dilemmas in Management of Brain Tumours in Pregnancy

Brain tumours in pregnancy are rare with an incidence of 15 per 100,000 and previous reports have shown variable outcomes. We present a case of glioblastoma multiforme (GBM) in pregnancy in which the patient underwent emergency craniotomy and adjuvant radiotherapy before delivering a healthy baby with good outcome. This article...

A Unique Pair of Monozygotic Twins with Concordant Clear Cell Renal Cell Carcinoma: A Case Report

Studies of monozygotic and dizygotic twins represent an important approach in estimating the relative contributions of genes and environment to the development of various cancers and disease in general. However, remarkably and almost curiously, there has been no monozygotic twin-pair concordant for clear cell renal cell carcinoma (ccRCC) reported...

Clinical Outcomes of High-risk Labours Monitored Using Fetal Electrocardiography

Intermittent auscultation (IA), cardiotocography (CTG), amniotic fluid colour and fetal scalp capillary blood gas analysis are currently accepted standards for intrapartum fetal monitoring. According to the results of recent randomised clinical trials, intrapartum CTG monitoring is a very sensitive method; however, its very low specificity seems to be strongly...

Microsurgical Reversal of Sterilisation – Is This Still Clinically Relevant Today?

Different contraceptive options are available today; however, tubal sterilisation is still one of the most prevailing contraceptive alternatives. Locally, many prefer mechanically occluding the tubes with Filshie clips. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Recommendations for standards of neuromuscular monitoring during anaesthesia

Dear Editor, We presented recommendations for neuromuscular monitoring during anaesthesia, which were approved by the Council of the College of Anaesthesiologists, Singapore in September 2019 and the Council of the Academy of Medicine, Singapore in May 2021. Neuromuscular blocking drugs (NMBDs) are used to facilitate tracheal intubation and mechanical ventilation;...

Evidence-Based Guidelines on the Use of Opioids in Chronic Non-Cancer Pain—A Consensus Statement by the Pain Association of Singapore Task Force

Studies show that the incidence of chronic pain is approximately 18% in Australia and developed countries in Europe. In Asia, data from Hong Kong and Singapore indicate that chronic pain is experienced by about 10% of adults, with chronic pain being more common in women and older adults. In...

The Use of Complementary and Alternative Medicine in Chronic Pain Patients in Singapore: A Single-Centre Study

Chronic pain is a prevalent disease that is often diffi cult to manage. According to a World Health Organisation survey, the worldwide prevalence of chronic pain is in the range of 20% to 30%. Chronic pain disease has an impact not only on the individuals’ general health and psychological health,...

Management Plan to Reduce Risks in Perioperative Care of Patients with Obstructive Sleep Apnoea Averts the Need for Presurgical Polysomnography

A significant proportion of patients with underlying obstructive sleepapnoea (OSA) remain undiagnosed when they present for surgery. Epidemiologic data have placed the prevalence in the general adult Western populations with a diagnosis of OSA at up to 5%,3 with a higher incidence in certain subpopulations such as males and obese...

Neonatal Outcome of the Late Preterm Infant (34 to 36 Weeks): The Singapore Story

Neonatologists were caught looking the other way in the early part of the millennium. While they were keenly following the progress of extreme preterms and their travails, preterms born at the other end of the spectrum were being quietly ignored as “well babies”. In July 2005, the National Institute...

Are Pregnant Women Adequately Equipped for Autonomy in Pregnancy Screening?

The concept of first trimester screening (FTS) to evaluate the risk of fetal aneuploidies was first introduced in 1997 by Orlandi et al. The Fetal Medicine Foundation, London, has refined and populated this screening test that uses a combination of maternal age, nuchal translucency (NT) thickness and biochemical markers,...

Prenatal Diagnosis of Chromosomal Abnormalities—Shifting Paradigm

It is very likely that in 10 years time, invasive prenatal diagnostic tests like amniocentesis and chorionic villus sampling (CVS) will join the club of forgotten obstetric procedures like vaginal breech delivery and rotational forceps delivery. In 1968, Henry Nadler1 and his team were the first to report prenatal...

Prevalence of vitamin D deficiency and insufficiency in Malaysian infants

Vitamin D deficiency, a worldwide health problem, is also prevalent in tropical countries. It is estimated that 15% of the world’s population are either vitamin D deficient or insufficient. In a study on the state of Kelantan in Malaysia (2010–2012), 60% of pregnant women were vitamin D deficient. Maternal...

A survey of Singapore anaesthesiologists for practice and prevention of peri-operative hypothermia in adult surgical patients

Core temperature is the temperature of blood and internal organs; influenced by biorhythm, metabolism, activity and hormones. It is regulated within a narrow range, but this is impaired during general and/or neuraxial anaesthesia. Inadvertent peri-operative hypothermia is defined as a core temperature of <36C, the prevalence of which can...

Maternal obesity and risk of adverse obstetric outcomes in Malaysia

Obesity during pregnancy is associated with increased risk of adverse health outcomes such as gestational diabetes mellitus (GDM), hypertension and preeclampsia. Unlike the well-known association between maternal hyperglycaemia and pregnancy outcomes, the effect of obesity in pregnancy has drawn some controversial conclusions.1Data are even scarcer in Southeast Asia countries....

Uterine rupture in Singapore: Trends and lessons learnt

Uterine rupture is arguably one of the most dreaded acute obstetric complications in obstetrics. Synonymous with significant maternal and perinatal morbidity and mortality risks, uterine rupture is usually encountered in the context of vaginal births after previous caesarean section (VBAC). This article is available only as a PDF. Please click...

Cervical screening in foreign domestic workers in Singapore

Cervical cancer is the most common gynaecological cancer in many countries in Southeast Asia, with a cumulative age-standardised incidence rate (ASRI) of 17.2 per 100,000 and a corresponding mortality rate (ASMR) of 10 per 100,000. In Singapore, cervical cancer is the 10th most common cancer in women with an...

Risk factors and outcomes of uterine rupture in Singapore: Emerging trends

Uterine rupture is a catastrophic life-threatening complication of pregnancy with associated high maternal and neonatal morbidity and mortality. The incidence of uterine rupture varies with geographical location and obstetric practice. With the changes in obstetric practice over the years, caesarean section rates have increased in our population with undesirable...

Use of EMLA Cream or Alfentanil for Analgesia during Ophthalmic Nerve Blocks

Cataract surgery is performed mainly as day-case surgery, with the majority performed under regional anaesthesia. Retrobulbar block, combined with facial nerve block, provides good operating conditions, with the facial nerve block preventing blepharospasm and providing lid akinesia. This article is available only as a PDF. Please click on “Download PDF”...

A Pilot Study of the Efficacy and Tolerability of Intralesional Recombinant Human Beta-Interferons in Cervical Intraepithelial Neoplasia

Cervical intraepithelial neoplasia (CIN) is a neoplastic disorder in which infection with sub-types of the human papillomavirus appears to play an important aetiological ro1e. The interferons are a family of proteins which possess anti-viral action, inhibit cell proliferation and modulate the natural immune response2 and which therefore may be...