Dear Editor, Artificial intelligence (AI) is viewed as the most important recent advancement in radiology with the potential to achieve Singapore’s objective of delivering value-based patient-centric care.1 We have developed and implemented a deep-learning model using bidirectional long short-term memory (Bi-LSTM) neural network to enable automated triage of unstructured free-text...

Dear Editor, Various neurological manifestations associated with coronavirus disease 2019 (COVID-19) have been described,1 conditions which left a significant proportion of patients with permanent disability. Continued vigilance is crucial with emergence of new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants that cause the disease. Vaccination against COVID-19 remains the...

A 52-year-old woman of Indian ethnicity with a history of well-controlled hypertension, hyperlipidaemia and recurrent transient ischaemic attacks presented with altered mentation and slurred speech. Physical examination revealed generalised weakness. Initial blood tests showed raised total white cell count, raised erythrocyte sedimentation rate at 35mm/h and fasting low-density lipoprotein...

The electroencephalographic pattern is distinctive in many but not in all patients with Creutzfeldt-Jakob disease (CJD). Often, it is one of diffuse and non-specific slowing in the background with stereotypical generalised periodic high-voltage slow and sharp wave complexes. This article is available only as a PDF. Please click on “Download...

Prevalence studies in various parts of the world have shown that Parkinson’s disease (PD) is relatively common among the aged in all countries. Crude prevalence rates range from 10 to 450 per 100 000 population. This article is available only as a PDF. Please click on “Download PDF” on top...

The alien hand sign or “strange hand sign”, first coined by Brion and Jedynak in 1972, refers to a feeling that the hand is foreign, together with autonomous activity which is perceived as independent of voluntary control, as if the hand is driven by an external agent. This article is...

Meralgia paraesthetica is a condition resulting from entrapment of the lateral femoral cutaneous nerve at the region of the anterior superior iliac spine, when the nerve angulates sharply over the inguinal ligament. It presents classically with pain, paraesthesia and sensory loss over the anterolateral surface of the thigh. This article...

Genetic susceptibility and environmental factors influence the prevalence and clinical manifestations of multiple sclerosis (MS). Since MS is rare in Southeast Asia, descriptions of this disease particularly as it occurs in Singapore have been sparse. This article is available only as a PDF. Please click on “Download PDF” on top...

Transient ischaemic attacks (TIA) are commonly seen in neurologic practice. They are most commonly associated with cerebrovascular insufficiency, either from a thrombotic or embolic occlusion of a cerebral artery. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Palatal myoclonus is a rare movement disorder characterised by rhythmic recurring jerky movements of the soft palate, pharynx, larynx and rarely diaphragm, trunk and limb muscles. It usually develops secondary to brainstem or cerebellar disease (symptomatic palatal myoclonus) interrupting the central tegmental tract or dentato-olivary fibres. This article is available...

It is known that exposure of animals and humans to heavy metals such as lead can result in neurological dysfunction. Pharmacodynamic effects of lead (Pb++) on tension of smooth muscles, interaction with catecholaminergic function and neuromuscular transmission have been described. This article is available only as a PDF. Please click...

A 24-year-old man was referred for hyperhidrosis of more than 15 years duration. It affected both hands, feet and axilla. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Hemifacial spasm (HFS), characterized by intermittent twitching of muscles supplied by one facial nerve is commonly due to compression of the facial nerve by blood vessel(s) adjacent to its root exit zone (REZ). The facial nerve REZ refers to the part where facial nerve exits from the pons. This article...

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

The Alzheimer’s Disease Assessment Scale (ADAS) is a 21-item scale designed to assess the severity of cognitive and non-cognitive impairment in patients with Alzheimer’s disease (AD). This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

It was Charcot (1868) who first made the formal pathological correlation between lesions in the central nervous system (CNS) and a disorder termed, ‘la sclérose en plaques’. Today, a number of other immune-mediated, demyelinating CNS diseases have been recognised and hence, classical multiple sclerosis (MS) is now specified as...

Epilepsies are one of the most common neurological disorders, affecting about 3% of individuals at least once in a lifetime. It thus represents a major health care problem. Socio-economical and educational issues are well known. This article is available only as a PDF. Please click on “Download PDF” on top...

Humans have primarily been active/awake during the day and inactive/asleep at night. The discovery of artificial light and introduction of electric power generator have made available a continuous and reliable source of light throughout day and night. This article is available only as a PDF. Please click on “Download PDF”...

Delirium is a disturbance of consciousness characterised by an acute onset and fluctuating course of inattention, accompanied by either a change in cognition or a disorganised thinking, resulting in an impaired ability of the patient to receive, process, store and recall information. Delirium develops over a short period of...

The general experience of local physicians and available data suggest that listerial infections of the central nervous system (CNS) are uncommon among adults in Singapore. This situation may change. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Rathke’s cleft cysts are non-neoplastic cystic epithelial lesions of the sellar and suprasellar region which are thought to originate from the remnants of Rathke’s pouch and are characteristically lined by a single layer of ciliated cuboidal or columnar epithelium with goblet cells. However, foci of squamous epithelium in Rathke’s...

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”...

Neurointensive care has come into being in the past decade as a recognised subspecialty. Pioneering neurointensivists in the United States, such as Allan Ropper and Dan Hanley, have led in demonstrating the specialised expertise that neurointensivists offer to critically ill patients. This article is available only as a PDF. Please...

The first step in the evaluation of sudden visual loss is to determine if the visual loss is monocular or binocular. The first diagnostic pitfall to avoid is the assumption that what is one-sided is one-eyed. This article is available only as a PDF. Please click on “Download PDF” on...

The neuronal cells of the central nervous system are especially susceptible to various forms of insult such as trauma and ischaemia. Once the ischaemic cascade is set into motion by the initiating injury, the resultant damage is traditionally considered to be unavoidable, untreatable and permanent. This article is available only...

Parkinson’s disease (PD) affects 1% of adults above the age of 65 years. It is characterised histologically by the loss of neurons in the substantia nigra pars compacta and the presence of Lewy bodies within the degenerating neurons. This article is available only as a PDF. Please click on “Download...

Huntington’s disease (HD) is an autosomal dominantly inherited disease, affecting 1 in 10,000 individuals of European origin. The incidence in the Asian population is much lower, and the estimated prevalence in Singapore is 3 to 15 per million. This article is available only as a PDF. Please click on “Download...

Aseptic meningitis is a common diagnosis among infants admitted for fever without an obvious source. In cases where the aetiologic agent could be identified, more than 90% were due to enteroviruses. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Stroke is the fourth leading cause of death and a leading cause of morbidity in Singapore. The number of hospital admissions for cerebrovascular disorders has been rising dramatically over the last few years, exceeding 10,400 in 2001. This article is available only as a PDF. Please click on “Download PDF”...

When the practice of orthopaedic surgery first began in Singapore, it was not a specialty in itself. There are no records as to when the first orthopaedic cases were managed, but it must have been when modern medicine was introduced into Singapore, at the beginning of the twentieth century...

Disease management (DM) is an approach to patient care that coordinates medical resources for patients across the entire healthcare delivery system. It requires a shift in focus from viewing patient care as discrete episodes or fragmentary encounters with different parts of the healthcare system, to provision of high-quality care...

Stroke is the fourth principal cause of death in Singapore, and the leading cause of long-term disability amongst developed countries. Due to the spiralling increase in healthcare expenditure in recent years, many countries have implemented cost-containing measures in healthcare financing. This article is available only as a PDF. Please click...

Functional brain imaging refers to a set of non-invasive imaging techniques that are used to infer linkages between brain structure and function. In this review, blood flow functional magnetic resonance imaging (fMRI) is specifically discussed. This article is available only as a PDF. Please click on “Download PDF” on top...

From September 1998 to June 1999, there was an outbreak of viral encephalitis in several pig farming villages in Malaysia. The outbreak, which started in Ulu Piah, Tambun and Ampang near Ipoh in the state of Perak, later involved Sikamat, Sungai Nipah, Kampong Sawah and Bukit Pelanduk areas in...

A 6-year-old Chinese boy presented at the Oral and Maxillofacial Surgery clinic with gingival bleeding due to poor oral hygiene, odontogenic pain due to multiple dental caries, phenytoin-induced gingival hyperplasia and severely worn-down and eroded dentition. He is under regular follow-up by the Paediatrics Department of the National University...

Creutzfeldt-Jakob disease (CJD) is the commonest human transmissible subacute spongiform encephalopathy. It has a worldwide distribution with an estimated annual incidence of 0.5 to 1.0 per million population. However, the incidence of CJD in the Singaporean population is not known. With a population of 4 million, an estimated 2...

Hemifacial spasm (HFS) is a movement disorder characterised by intermittent involuntary contractions of the facial muscles. It begins with contractions of the orbicularis oculi, gradually spreading to involve the rest of the ipsilateral facial muscles. This article is available only as a PDF. Please click on “Download PDF” on top...

The Guillain-Barré syndrome (GBS) is an acute, frequently severe evolution of a demyelinating inflammatory polyradiculopathy with an autoimmune pathogenesis. In developed countries, GBS is the most common cause of acute neuromuscular paralysis. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

The purpose of these guidelines is to provide a broad framework for clinicians considering the use of positron emission tomography (PET) scanning for their patients. PET imaging is a rapidly evolving field, with ongoing developments in imaging technology, radiochemistry, isotope production, animal research and clinical applications. This article is available...

Contemporary medical imaging is progressing towards quantification of tissue function in addition to merely providing anatomical information, as illustrated by the rising use of such modalities as functional magnetic resonance imaging (fMRI), magnetic resonance spectroscopy (MRS) and positron emission tomography (PET). As far back as 1951, positron-emitting radiotracers have...

The spinocerebellar ataxias (SCAs) are a rare group of neurodegenerative disorders that are clinically and genetically heterogeneous. Almost all SCAs are due to trinucleotide repeat expansions and 16 types of SCAs have been described. This article is available only as a PDF. Please click on “Download PDF” on top to...

For diseases with complex inheritance, the age-old debate regarding the relative contribution of gene-environment interaction never fails to generate interest, discussion and hypothesis within the scientific community. The unraveling of the human genome project brings hope and great optimism that a verdict on such debates may be in the...

Seminal studies in the 1960s, using -thymidine autoradiography, reported that neurogenesis occurs in discrete areas of the adult mammalian brain, in rodents. Studies in the 1970s and 1980s confirmed that neurogenesis occurs in hippocampus and subventricular zone (SVZ) of rodents. This article is available only as a PDF. Please click...

Sarcoidosis remains an enigmatic disease with protean manifestations. It is a multi-system disorder of unknown cause characterised by an accumulation of T-lymphocytes, mononuclear phagocytes and non-caseating epithelioid granulomas in affected organs. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Since time immemorial, generations of medical students and physicians have always been taught that a thorough and detailed history and examination is the foundation of the practice of good clinical medicine. This is particularly so in Neurology, in which the detection of an absent reflex or of focal weakness...

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...

Most adults have experienced sleep deprivation at some stage of their lives, be it in the context of work, illness or play. Sleep deprivation can be both total, taking place over 1 to 2 nights, or chronic partial, as characterised by insufficient restorative sleep over days, months and even...

In humans, the daily pattern of consolidated sleep and wake is strongly influenced by the timing of exposure to light and darkness. In the absence of environmental time cues, cycles of sleep-wake, physiology, and gene expression continue to exhibit a near-24-hour circadian rhythm (derived from the Latin phrase “circa...

The sleep-wake cycle, with its characteristic intervals of activity alternating with restfulness that recur with a periodicity approximating the 24-hour day-night cycle, is the prototypical example of a behaviour that demonstrates a circadian rhythm. Circadian (from the Latin “circa diem” – “about a day”) rhythms are also discernible in...

A 58-year-old Chinese man was admitted because of increasing lethargy and confusion over 4 days. He had been taking hydrochlorthiazide for hypertension and regularly consumed ethanol in moderation. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

We present a patient with limb-shaking transient ischaemic attack (TIA) associated with extracranial carotid occlusion and suggest that the pathophysiological mechanism is hypoperfusion, as evidenced by impaired cerebrovascular reactivity. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Neuropsychiatry can be described as the interface between neurology and psychiatry – the intersecting field of enquiry for both the brain and the mind. In more practical terms, it often, though not necessarily, narrows down to psychiatric comorbidities of neurologic diseases (e.g. depression in a patient with stroke) and...

More than 100 years ago Alois Alzheimer first presented the clinical and pathological features of an unusual brain disease at his seminal lecture in Tübingen. The patient, Auguste Deter, suffered memory loss, disorientation, hallucinations and died at an early age of 55. This article is available only as a PDF....

Sir Gordon Arthur Ransome was born in Salop, England, in 1910.1 He came to Singapore in 1938, where he taught and practised medicine for 33 years before his retirement in 1971. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

The core of the Family Medicine (FM) vision is patient-centred care, requiring specific education and vocational training. Modern day FM began its existence as a “counterculture” to the disease-and-body-part focus of the hospital specialties in the 1960s. This article is available only as a PDF. Please click on “Download PDF”...

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...

Alzheimer’s disease (AD) is the most prevalent form of age-related dementia in the modern society. Other than symptomatic treatment with acetylcholinesterase inhibitors at its earlier stages, no disease-modifying strategies are currently known. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Transcranial Doppler (TCD) is routinely performed to assess the blood flow in patients with cerebral ischaemia and provides important real-time information about cerebral haemodynamics. TCD can aid in the diagnostic work-up by detecting, localising and grading the severity of intracranial arterial obstruction. This article is available only as a PDF....

Cerebral venous thrombosis (CVT) is an infrequent but potentially deadly disease. The mortality rate of CVT is 10% to 20%, and surviving patients may suffer significant morbidity such as seizures or neurological deficits. This article is available only as a PDF. Please click on “Download PDF” on top to view...

Although levodopa is currently a well-endorsed form of treatment for Parkinson’s Disease (PD), the search for a safe, long-term and dyskinesia-free treatment remains an agenda for many clinicians and scientists alike. Amongst others, restorative cell therapies are considered a potential treatment for this debilitating disease. This article is available only...

Cerebrovascular disease (CVD) is Singapore’s fourth leading cause of death, comprising 9% of all deaths, a crude death rate of 40.4/100,000, an age- and sex-standardised prevalence of 3.65% among adults aged ≥50 years, and an incidence of 1.8/1000 patient-years. It is among our top 10 causes of hospitalisation. With...

Neuroleptic malignant syndrome (NMS) is characterised by the impairment of consciousness, high fever, rigidity and autonomic instability. Although originally described in patients taking neuroleptic drugs, this syndrome may also occur in patients with Parkinson’s disease (PD) during withdrawal or reduction of levodopa therapy or other dopaminergic drug therapy and...

Traumatic injury to the brain (TBI) can lead to multiple medical, cognitive and functional issues, both in the acute care setting as well as over the much longer term. Much knowledge has been gained from relevant research in this area for adults, and the goals, guidelines and outcome for...

Intravenously administered tissue plasminogen activator (IV-TPA) induces thrombolysis and remains the only FDA-approved therapy for acute ischaemic stroke (IS) within the therapeutic time-window according to the current guidelines. However, significantly low recanalisation rates have been demonstrated with intravenous thrombolysis alone. This article is available only as a PDF. Please click...

Dystonia is a movement disorder characterised by sustained muscle contractions, repetitive twisting movements, and abnormal postures of the trunk, neck, face, or arms and legs. Classification of this condition may be based on topography, age at onset, cause, or by the presence of genetic markers. This article is available only...

Intravenous tPA is a proven treatment for acute ischaemic stroke. However as it has to be given in a narrow time window from symptom onset, utilisation is limited by delayed arrival of most patients to hospital. This article is available only as a PDF. Please click on “Download PDF” on...

Alzheimer's disease (AD) is the most common form of dementia which refers collectively to syndromes of progressive deterioration of memory along with other cognitive domains such as language, praxis and executive function. More than 70 million people worldwide have dementia currently and AD accounts for over 50% of all...

Young adults are frequently presented with headaches due to various causes. Atypical facial pain, renamed as persistent idiopathic facial pain (PIFP) is a poorly understood condition with the pain described as a persistent facial pain that does not have the characteristics of cranial neuralgias and which is not attributable...

Genetic testing is an important means to confirm the diagnosis of an inheritable disease. For this to be feasible, genes that are associated with the disease need to be identified. Hunting for the genes that cause or are associated with a particular disease is a challenging task. This article is...

World Epilepsy Day falls on 26 March 2013. As we observe this important date in Singapore, it is perhaps instructive to take a step back to review epilepsy as a disease, to reflect on progress made, and as yet unresolved challenges. Epilepsy is a fairly common disease affecting 5 to...

The rising cost of health care and the burden of chronic illness are perennial concerns. Remarkably, there exists a measure that around 30% of city dwellers can implement to reduce their risk of accidents, coronary artery disease, diabetes, cancer and all-cause mortality while improving their cognitive performance. Unlike costly supplements...

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...

Dear Editor, Chorea is a well-recognised albeit rare neuropsychiatric manifestation of systemic lupus erythematosus (SLE). We describe here a case of a 67-year-old woman presenting with chorea, which affected her left lower limb and both upper limbs after phototherapy. Chorea is an extrapyramidal movement disorder characterised by non-repetitive, abrupt, involuntary jerky...

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...

Little is known about the genetics of Parkinson’s disease (PD) in Southeast Asian populations.1 We extended knowledge of the Southeast Asian monogenic PD landscape by describing a Malaysian Malay family with early-onset PD (EOPD), defined as onset at <50 years of age and a rarely reported homozygous PRKN exon...

Stroke is a major cause of death and disability globally, with 6.55 million deaths (95% uncertainty interval 6.00–7.02 million), 101 million prevalent cases (95% UI 93.2–111 million) and 143 million disability adjusted life years lost (DALYs) (95% UI 133–153 million) in 2019. The impact is even higher in...

Cerebral palsy (CP) is a common, lifelong disorder of movement and posture resulting from an insult or maldevelopment of the developing brain. The movement disorders of CP are often accompanied by other associated sensory and cognitive impairments. For the majority of children (about 95% in high income countries), the...

The cost of rehabilitation for children post-traumatic brain injury (TBI) is significant. The annual total healthcare cost of TBI had been estimated to range from USD5.9 billion–76.5 billion. Studies performed in the adult population reported that the direct cost of acute rehabilitation had been relatively similar over a 10-year...

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...

Behçet’s disease (BD) is a chronic multisystem inflammatory disease with a classic triad of painful oral ulcers, genital ulcers and uveitis. Neurological manifestations, though uncommon, can affect both central and peripheral nervous system; producing parenchymal, non-parenchymal and mixed forms of the disease. Ophthalmic findings include ocular inflammation and other...