Dear Editor, Acute lower respiratory infections (ALRIs) are a leading cause of under-5 mortality globally—two-thirds could be attributable to respiratory viral infections (RVIs).1,2 The burden of paediatric RVIs in settings of tropical climate with year-long virus circulation is relatively underreported.3,4 Previous studies in these areas have estimated that around 8–11%...

Early inpatient rehabilitation therapy has been known to have beneficial impact on physical function and mobility, psychological status and cognitive function of patients following an acute medical event requiring hospitalisation.1 Following an acute hospital care, those who have been identified to have potential for functional improvements are often transferred...

Intravenous heparin therapy is used in the management of angina and myocardial infarct with increasing frequency in recent years. Those patients who have been on heparin therapy for several days may exhibit resistance to heparin given before cardiopulmonary bypass. This article is available only as a PDF. Please click on...

Following the rapid advances in medical therapy and critical care technology over the past 30 years, coupled with the spiralling cost of medical care, outcome analysis including mortality risk prediction has become a challenge for the modern day intensivists. During the early 90s, the focus has shifted from the...

Total thymectomy is the established surgical therapeutic method for generalised myasthenia gravis. Several approaches are used for the surgical removal of the thymus and these include the transcervical approach, partial sternotomy, median sternotomy and a combination of the transsternal and transcervical approaches. This article is available only as a PDF....

Children undergoing chemotherapy for cancer are especially vulnerable to infection because of immunosuppression related to their underlying illness, the effects of chemotherapy and radiotherapy. Empiric antimicrobial chemotherapy is the mainstay of therapy for febrile neutropenic episodes pending the culture results. This article is available only as a PDF. Please click...

Malaria is an important and common infectious parasitic disease globally. It is associated with significant morbidity and mortality, especially in endemic areas. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Diabetes insipidus (DI) is a syndrome characterised by the excretion of abnormally large volumes of dilute urine. It occurs uncommonly in neurosurgical patients, but is an important complication. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Critical care is costly as it is labour intensive and involves expensive life support technology. In the United States, the intensive care units (ICUs) use about 15% of the total hospital cost or about 1% of the gross national product. This article is available only as a PDF. Please click...

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...

Breast cancer is the most common cancer among women in Singapore with age-standardised incidence rates increasing markedly from 26.8 to 38.7 per 100 000 per year over the last decade. While many recognised risk factors exist for the development of breast cancer such as demographic factors (personal and family...

Data on infections in paediatric surgical patients are few in the literature. Although there are many studies on infection in adult surgical and paediatric medical patients, paediatric surgical patients are a special group in their spectrum of diseases and treatment requirements. This article is available only as a PDF. Please...

Lupus nephritis is a common manifestation of lupus associated with significant morbidity and mortality. The use of cytotoxic agents has resulted in improved renal outcomes but is associated with considerable morbidity, and their role in the management of lupus nephritis is not universally accepted. This article is available only as...

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...

Community-acquired pneumonia (CAP) is a common illness with nearly 4 million adults diagnosed each year in USA with more than 600,000 hospita1isations. The associated cost of hospitalisation is enormous and approaches nearly US$4 billion per year. This article is available only as a PDF. Please click on “Download PDF” on...

Rising trends in mortality in asthma have been reported from many countries, including Asian countries such as Hong Kong. Asthma deaths have been associated with a number of avoidable factors such as deficiencies in personal and professional management that can potentially be remedied if identified. This article is available only...

Children with complex congenital heart disease and a functional single ventricle may not be ideal candidates for a Fontan procedure. A staged approach to Fontan’s operation has been undertaken in an effort to reduce the volume load of a single ventricle as early as possible and to minimise the...

Retinopathy of prematurity (ROP), which could lead to visual impairment and blindness, is a recognised serious morbidity amongst surviving premature infants. The inverse relationship between the risk of this disease with birth weight and gestational age had been well-documented, in particular, in infants with birth weight ≤1500 g (very...

Despite the recent developments of minimally invasive surgery, most cardiac surgery procedures still include ischaemic cardioplegic arrest and cardiopulmonary bypass. For decades the efforts of many researchers aimed at improvement of cardioplegic solutions to minimise ischaemic injury of the myocardium. This article is available only as a PDF. Please click...

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...

Tumours of the chest wall are uncommon and are usually sarcomatous in nature. Primitive neuroectodermal tumours (PNETs) are rare and are thought to arise from neuroepithelial cells, possibly derived from the peripheral intercostal nerves. They could also arise from the neural crest cells, which have migrated alongside the peripheral...

Atrial septal defect (ASD) forms the commonest grown up congenital heart diseases seen in cardiac surgical practice. Repair of this has become so safe that the emphasis now is on cosmetic outcome. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Cancer is the most common cause of death in Singapore. Although there is a gradual decline in incidence of stomach cancer over the years, it is the third (10.1%) most common cancer in males and the fifth (6.5%) most common cancer in females in Singapore. This article is available only...

The association between congenital complete heart block (CHB) and maternal autoimmune disorders has been described for many years. Maternal systemic lupus erythematosus (SLE) is the commonest of these disorders, and a leading cause of heart block in newborns. This article is available only as a PDF. Please click on “Download...

Congestive heart failure (CHF) is a leading cause of cardiovascular morbidity and mortality. This syndrome tends to run a chronic course with a wide spectrum of compensatory physiological and neurohormonal mechanisms that may be maladaptive in the terminal phase of the illness. This article is available only as a PDF....

The management of aortoiliac occlusive disease has been evolving in the past few decades. Surgical options include aortofemoral bypass, endarterectomy, extraanatomical bypass and endovascular intervention. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Western literature reports a very high incidence of deep vein thrombosis in its population especially after orthopaedic surgery. In total knee replacement without prophylaxis, its incidence is quoted between 46% and 84% in various studies. This article is available only as a PDF. Please click on “Download PDF” on top...

Although there has been a significant decline in elective surgery for peptic ulcer disease with the introduction of H-2 blocker, the incidence of peptic ulcer perforation has remained relatively unchanged over the years. The mortality rate from perforated peptic ulcer remains high as more perforations occur in the elderly...

Voiding dysfunction is a relatively common problem in hospitalised older patients. Up to one-third of hospitalised elderly were reported to have post-void residual urine volume (PRUV) of more than 50 mL. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

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.

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....

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...

Studies on the foregoing of life support (FLS) in North America, Europe and Australia have shown diversity in terms of the incidence, decision-making process and outcome. However, they have not specifically looked into such practice in the elderly. This article is available only as a PDF. Please click on “Download...

Bladder carcinoma is the tenth most common cancer affecting men in Singapore. It is more common in men with an age-standardised incidence rate of 6.9 per 100,000 per year for men and 1.7 per 100,000 per year for women in Singapore. This article is available only as a PDF. Please...

Minimally invasive techniques are increasingly being used in cardiac surgery. In particular, coronary artery bypass grafting (CABG) and mitral valve surgery are now often done using a limited approach to the heart. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Rapid urbanisation and increasing affluence have improved the socioeconomic status of Asians. This, however, has brought with it new socioeconomic and medical problems resulting from the urbanised lifestyles entrenched in these newly industrialised economies. This article is available only as a PDF. Please click on “Download PDF” on top to...

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

Influenza is a major cause of morbidity and mortality worldwide. Morbidity in the working age group gives rise to frequent doctor visits and considerable sickness absence from work. Influenza in the elderly population and in high-risk groups results in hospitalisations and deaths due to complications of pneumonia. This article is...

Human isolates of group G streptococci (GGS) that form large colonies are similar to group A streptococci (GAS) in terms of virulence and cause a range of serious infections. These included infective endocarditis which had been emphasised in older reports1 but was found to be uncommon in later studies. This...

Singapore is facing a rapidly ageing population. Osteoporosis, which is an age-related illness, will become an increasing problem. Osteoporotic hip fracture, because of the need for hospitalisation and surgery, represents an important economic burden to society, in addition to its medical morbidities and social implications upon the patient and...

Cardiac and pericardial lipomas are very rare tumours. They remain asymptomatic for a long time and produce symptoms, if at all, by the virtue of their size. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

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

One of the significant milestones in the perinatal care in Singapore is the birth of the Perinatal Society of Singapore in March 1989. This signaled the beginning of increased collaboration between the obstetricians and neonatologists in the management of high-risk pregnancies through multidisciplinary birth defect clinics and high-risk perinatal...

The most common causes of morbidity in adolescence often have behavioural or social determinants, and can have enormous social and economic consequences for adolescent and future adult health and well being. Adolescent substance use and abuse is an example of this. This article is available only as a PDF. Please...

Diaphragmatic rupture is a recognised consequence of high-velocity blunt trauma to the abdomen and chest and also has been reported in 0% to 5% of thoracoabdominal trauma patients. The diagnosis is often difficult and delay in diagnosis is implicated in increased morbidity and mortality. This article is available only as...

The clinical syndrome of heart failure is recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses. Heart failure is the end-stage of all heart diseases. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Atrial fibrillation is the most common sustained cardiac arrhythmia. The overall prevalence of atrial fibrillation is 0.4%. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Fourteen years ago, an editorial in the Annals announced the coming of age of cardiology in Singapore. Among the issues raised in that editorial were the impact of changing demographics and disease patterns, the importance of optimising resources, and the need for structured training and sub-specialisation. This article is available...

The use of deep hypothermic circulatory arrest (DHCA) as a method of cerebral protection during aortic surgery was first described in 1975. Its use is based on 2 fundamental concepts. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Compared to in-hospital patients, patients treated in an intensive care unit (ICU) have the highest risk of contracting an infection. The risk correlates well with underlying and accompanying diseases and invasive monitoring. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

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

The heart is difficult to image because of its complex wall motion and variability of the cardiac cycle. Recent advances in 16 and 64-slice computed tomography (CT) technology such as thin detector collimation and fast gantry rotation allow the heart to be scanned in a single breath-hold. This article is...

Hospitalisation is a stressful event for the older person. The physiological changes associated with ageing, such as decreased muscle strength and aerobic activity, reduced bone density, altered appetite and tendency towards urinary incontinence, predispose older patients to complications during hospitalisation. Studies have shown that about one-third of older persons...

This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Streptococcus pneumoniae infection is the most common cause of community-acquired pneumonia worldwide.1 It has been associated with an approximately 10% rate of bacteraemia.2-4 Despite the advances in antibiotics, pneumococcal bacteraemia still carries a significant mortality rate.2-6 This article is available only as a PDF. Please click on "Download PDF" to...

Pulmonary artery catheter is widely used in cardiovascular surgical practice. Various complications of the Swan-Ganz catheter during insertion, its long-term placement, or removal are well known since its introduction. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The first case of human immunodeficiency virus (HIV) infection was detected in Singapore on 16May 1985. The number of newly diagnosed HIV/acquired immuno-deficiency virus syndrome (AIDS) infections has been increasing since 1985, and a total of 1599 cases were detected as of December 2001. In a known cohort of...

In the last few years, hundreds of papers exploring the issue of postoperative nausea and vomiting (PONV) have been published. It has been estimated that the overall incidence of PONV for all surgeries and patient populations is between 25% and 30%, with severe, intractable PONV estimated to occur in...

Thyroid eye disease (TED) is a visually and socially disabling condition. Newly diagnosed patients are often fearful of sight-threatening complications that include optic nerve compression or restrictive strabismus. Although the current literature has pointed to age (>60 years), gender (male), abnormal thyroid function (both hyper- and hypo-thyroidism), smoking and...

Coronary artery disease (CAD) is the leading cause of mortality following ischaemic stroke. The annual risk for myocardial infarction following ischaemic stroke is approximately 2.2%. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Pulmonary hernia is a rare and uncommon clinical entity that has been defined as a protrusion of pleural membranes or lung parenchyma through the defect in the thoracic enclosure. According to aetiology, pulmonary hernias can be congenital (due to rib or intercostal hypoplasia or agenesis) or acquired (traumatic, pathological...

Radiofrequency ablation (RFA) intended to produce complete thermal necrosis of unresectable primary or secondary hepatic malignancies have gained widespread availability and acceptance over the past 5 years. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

In order to commit to their mission and placement requirement efficiently and effectively, policy-makers need to decide which types of students their training units should recruit, what type of curriculum they should design and what kinds of support mechanisms they should implement. This article is available only as a PDF....

Laparoscopic cholecystectomy has become a routine surgical procedure in general surgical units all over the world. Its implementation has expanded dramatically and is considered a feasible and safe approach even for acute cholecystitis.1,2 Laparoscopic management of acute cholecystitis may still be associated with increased risks of complications such as...

Cardiovascular complications account for the highest rate of morbidity and mortality in patients with diabetes mellitus (DM), type 1 and type 2, respectively. The Copenhagen City Heart Study, carried out in 13,105 subjects followed up prospectively for 20 years, reported that in patients with type 2 DM, the risk...

Percutaneous coronary intervention (PCI) is the preferred therapy strategy for revascularisation in the case of an acute coronary syndrome (ACS) or acute myocardial infarction (AMI). This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Peripheral arterial disease (PAD) is a significant complication of diabetes mellitus and accounts for the majority of amputations among these patients with diabetes. In addition, PAD is a manifestation of systemic atherosclerosis and is associated with increased risk of death and ischaemic events. This article is available only as a...

Urinary tract infection (UTI) is one of the most common types of nosocomial infections encountered in the inpatient settings including intensive care unit (ICU). Amongst patients admitted to ICU, studies have revealed the incidence of nosocomial UTIs to range from 9% to 29%. This article is available only as a...

The first cases of infection with a novel influenza A (H1N1) strain were reported in 6 cases in California and 2 cases in Texas in the United States in late April 2009. This was linked to outbreaks of influenza in Mexico, which included reports of large numbers of cases...

Obesity is a condition characterised by an excess of body fats. According to the World Health Organization (WHO), there were about 1.6 billion overweight adults aged 15 years and above and at least 400 million adults worldwide in 2005. Obesity poses a serious health burden as it is associated...

Non-alcoholic fatty liver disease (NAFLD) is increasing recognised as one of the most important causes of chronic liver disease in Western countries. It encompasses a spectrum of diseases ranging from simple hepatic steatosis to non-alcoholic steatohepatitis (NASH). Hepatic steatosis is a common clinical and histological finding and it is...

To date, the major part of routine cardiac surgery is performed using extracorporeal circulation with cardioplegic arrest. Regardless the technique of cardioplegia, temporary renal dysfunction can be observed frequently. Renal dysfunction requiring dialysis occurs in less than 5% of the patient undergoing cardiac surgery with cardiopulmonary bypass. This article is...

The advent of the highly active antiretroviral therapy (HAART) era has greatly reduced the mortality and incidence of new diagnoses of acquired immune deficiency syndrome (AIDS)-defining illnesses (ADIs) in individuals infected with human immunodeficiency virus (HIV) in many countries. This has led to a paradigm shift in the management...

Pseudomonas aeruginosa (PA) is a virulent nosocomial pathogen and PA bacteraemia is associated with high mortality ranging from 18% to 59%. It is ranked among the top 3 gram-negative bacteria associated with bacteraemia. It is commonly reported in patients with cancer and in intensive care units (ICUs). PA bacteraemia...

The World Health Organization (WHO) has divided violence into 3 categories: interpersonal violence, self-directed violence, and collective violence. Violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has...

Dear Editor, Reoperation for mitral valve re-replacement in patients with patent coronary bypass grafts can be a formidable task in the elderly. We report a patient that was successfully treated using a novel minimally invasive approach via the apex of the left ventricle. This article is available only as a PDF....

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...

Cirrhosis is the common end result of chronic damage to liver parenchyma caused by a variety of liver diseases. It results in replacement of liver tissue by fibrotic scar tissue and regenerating nodules, leading to progressive liver dysfunction and clinical complications such as portal hypertension, hepatocellular carcinoma (HCC), liver...

According to the National Health Survey, the percentage of Singapore residents with diabetes mellitus (DM) aged between 18 and 69 years has risen from 8.2% in 2004 to 11.3% in 2010. DM can lead to a myriad of long-term health complications such as coronary heart disease, kidney failure and...

Although coronary angiography has been used as the “gold standard” imaging technique for the diagnosis of coronary artery disease, it is essentially a lumenogram that offers no information on the functional significance of a coronary lesion. It is difficult to define the haemodynamic significance of a stenosis from the...

Over the past 30 years, different versions of severity of illness scoring systems and prognostic models have been developed for prediction of patient outcomes in critical care. These physiological-based systems and models allow patients to be stratified according to their severity of illness and provide prediction of in-hospital mortality....

  Atrial fibrillation (AF) is the most common and severe cardiac arrhythmia. It affects 0.4% to 1% of the general population, and the prevalence of AF,1 which increases with age, is 8% in people aged over 80. About three-quarters of the cases are non-valvular AF. The risk for stroke in...

Bronchiectasis is a chronic lung disease of significant morbidity and mortality. The pathological hallmarks of the disease are abnormal dilatation of airways resulting from recurrent inflammation, airway obstruction and mucous plugging. The past 2 decades have seen a significant increase in its prevalence, exceeding the threshold of 5 per...

Paravalvular leaks (PVLs) are not uncommon after surgical valve replacement. The need for re-operation for clinically significant leaks is between 1 and 3%. Percutaneous PVL closure has become increasingly performed and is an alternative to surgery.1 PVLs occur more frequently after transcatheter aortic valve implantation (TAVI), as the transcatheter...

Coronavirus disease 2019 (COVID-19) has spread rapidly from China to other countries around the world, with the World Health Organization characterising it as a global pandemic on 12 March 2020. The number of fatalities owing to COVID-19 is escalating rapidly. COVID-19 is caused by the Severe Acute Respiratory Syndrome...

Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is established that increasing age and comorbidities such as cardiovascular diseases are associated with risk of infection, more severe disease and adverse outcomes. Obesity is an epidemic globally, causing...