Achieving optimal fluid balance for a patient undergoing major surgery, especially transplant surgery, has always been the lofty goal of peri-operative care,1 which often proves to be an elusive target. While keeping the patient well hydrated improves organ perfusion, being too generous with fluids can result in morbidity, such...

Dear Editor, The standard of care for endometrial cancer is a total hysterectomy with bilateral salpingo-oophorectomy, and pelvic lymph node dissection (THBSO-PLND). Obesity is a known risk factor for endometrial cancer, and obese patients are challenging to operate on due to their anatomy and comorbidities. A recent database search showed...

Dear Editor, Breast-conserving surgery (BCS) followed by radiation therapy for breast cancer offers improved cosmetic results and comparable long-term survival rates as mastectomy.1 However, BCS is associated with a higher risk for local recurrence, and published literature has reported re-excision rates as high as 20–70% due to positive resection...

Dear Editor, Peripheral artery disease (PAD) is characterised by the debilitating atherosclerotic occlusion of arteries in the lower extremities, with chronic limb threatening ischaemia (CLTI) representing the most advanced stage of this disease process. Left untreated, these sequelae will invariably progress to major lower extremity amputation (LEA) and premature death....

An 81-year-old man who had been fully vaccinated against COVID-19 was admitted to the medical intensive care unit on day 5 of his COVID-19-induced pneumonia for high flow nasal oxygen treatment. He had hypoxaemic respiratory failure secondary to acute respiratory distress syndrome (ARDS) from the COVID-19-induced pneumonia. He had...

Diabetes mellitus (DM) is a common comorbidity worldwide with global prevalence among adults above 18 years of age increasing from 4.7% in 1980 to 8.5% in 2014.1 DM has been shown to be a common comorbidity in heart failure (HF) patients ranging from 4.3–28%2 and when present, portends a...

Dear Editor, Transseptal access to the left heart is increasingly performed for electrophysiological procedures and for structural heart disease interventions such as balloon mitral valvuloplasty (BMV), left atrial appendage closure (LAAC) and transcatheter mitral valve repair (TMVr). Most of the iatrogenic atrial septal defects (iASDs) close spontaneously, and for those...

Dear Editor, End-stage renal disease (ESRD) patients have higher mortality, hospital admissions and invasive procedures towards the end of life.1 However, many of them (82%) prioritise minimising suffering over life prolongation. Although twice as many patients prefer dying at home and inpatient hospice (65%) compared to hospital (27%), hospice utilisation...

End-stage renal disease (ESRD) is a challenging and growing health issue, with number of patients increasing globally. The use of dialysis has greatly improved the survival and life expectancy of ESRD patients. Haemodialysis (HD) and peritoneal dialysis (PD) are 2 broad dialysis modalities used for ESRD. Despite the advancement...

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....

Traumatic dislocation of the testes is uncommon. The first case was reported by Claubry in 1818 in Paris, when a 20-year-old soldier was run over by a wagon resulting in bilateral suprapubic dislocation of his testes. This article is available only as a PDF. Please click on “Download PDF” on...

Liver abscess traditionally has been treated by open surgical drainage, mortality rates being as high as 80% to 100% if left untreated. However, with the advent of modern non-invasive imaging techniques, percutaneous techniques performed under imaging guidance have, over the recent years, become increasingly acceptable as a suitable alternative...

Multiple segment osteotomy (MSO) orthognathic surgery serves to combine total or segmental maxillary and mandibular correction of dentofacial deformities with concurrent diastematic procedures to provide immediate repositioning of dental-osseous elements. In addition, splitting the palate may often be necessary to correct a functionally poor relationship of the maxilla to...

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

Diabetes mellitus affects some 9% of Singaporeans. Studies had shown that virtually all insulin dependent diabetes mellitus (Type 1) and 85% of non-insulin dependent diabetes mellitus (Type 2) patients would develop retinopathy after 20 years of disease. This article is available only as a PDF. Please click on “Download PDF”...

A 57-year-old woman was admitted to our hospital for perforated left tubo-ovarian abscess and found to have newly diagnosed diabetes with an admission blood glucose of 23 mM and glycated haemoglobin value of 12% (reference range 4.6% to 6.4%). She denied past symptoms of thirst, polyuria or polydipsia. This article...

The spectrum of pulmonary aspergillosis includes saprophytic colonisation, hypersensitivity syndromes and invasive lung disease. There has been a tendency to classify these syndromes as separate entities but clinical overlap occurs. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The “gold standard” for the diagnosis of diabetes mellitus has all along been the oral glucose tolerance test (OGTT). As diabetes mellitus defines a group of individuals at high risk for macrovascular and microvascular disease, it is essential that the diagnosis be made promptly. This article is available only as...

Traditional medicine includes the knowledge and practices that rely exclusively on practical experience and observations handed down from generations to generations, either verbally or in writing. Traditional systems of medicine in India are culturally acceptable and usually inexpensive. This article is available only as a PDF. Please click on “Download...

Dear Editor, More than 2 years since the start of the COVID-19 pandemic, cases continue to climb despite global efforts at viral control. This is largely driven by the emergence of viral variants. In the later part of 2021, the Delta variant was the predominant variant circulating globally, and was...

Dear Editor, The coronavirus disease 2019 (COVID-19) pandemic has impacted global healthcare including paediatric solid organ transplantation (SOT). We report our experience of resuming paediatric living-donor SOT during COVID-19, which took into account safety considerations for living donors, paediatric recipients and the transplant healthcare team. The US Centers for Disease...

Hypoglycaemia is a common medical emergency. It presents either with symptoms of neuroglycopaenia, such as episodes of visual blurring, confusion, convulsions and sometimes coma or with symptoms caused by excess of counterregulatory hormones like catecholamines, such as palpitations, sweating and tremulousness. It is most commonly seen in patients with...

Unlike in Caucasians, primary malignant melanoma is an uncommon skin malignancy in Singapore. There have been little published data on cutaneous melanoma in Southeast Asia. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Type 2 diabetes mellitus is now recognised as a metabolic syndrome and although the treatment paradigm has shifted from one that focuses solely on glycaemic control to one addressing global cardiovascular risk factors in a particular individual, glycaemic control remains one of the key challenges that the physician faces...

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...

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...

Diabetes mellitus (DM) is a common and growing healthcare problem in Singapore with a prevalence of 9% in 1998. Since the 1990s, the Ministry of Health, Singapore has identified DM as a priority condition for disease control. This article is available only as a PDF. Please click on “Download PDF”...

Diabetes mellitus (DM) is a common and growing global health problem. It is highly prevalent in Asian communities. Hong Kong, Pakistan, and Singapore are among the countries with the highest prevalence of diabetes in the adult population. This article is available only as a PDF. Please click on “Download PDF”...

The epidemic of type II diabetes mellitus is now recognised worldwide. In India, it has been estimated that the population with type II diabetes would increase by 150% in 2025. As the population with type II diabetes increases, so does the prevalence of diabetic retinopathy and other microvascular complications. This...

The management of necrotising pancreatitis has improved significantly over the last 2 decades, with a corresponding improvement in mortality rates. This improvement is largely attributed to advances in supportive therapy, diagnostic radiology and a better understanding of the pathophysiology of necrotising pancreatitis. This article is available only as a PDF....

By 2010 there will be more than 2 million patients worldwide on maintenance dialysis, a 400% increase in 20 years.1 This increase, occurring predominantly in developing nations, is being driven especially by a worldwide increase in the incidence of diabetes, and is too great to be offset by increased...

Hip fractures constitute a major health concern for older persons and are associated with significant morbidity and mortality, with 1-year mortality rates ranging from 14% to 36% in spite of advancements in anaesthesia, surgical techniques and nursing care.1,2 In addition, epidemiological studies have shown that the incidence of hip...

Lung cancer is the leading cause of cancer mortality in Singapore. The age standardised incidence rate is 45 per 100,000/year. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Teaching, training, appraising and assessing doctors and students are important for the care of patients now and in the future.1 In most hospitals, trainee surgeons play a substantial role in providing healthcare and surgical services, under the supervision of a consultant. The Departments of Hand Surgery and Orthopaedic Surgery...

Public health education is a cornerstone in the primary prevention of chronic diseases. In the United States, for example, studies have shown that cardiovascular public health education contributed to increased hypertension detection and control as well as a decline in smoking, thus contributing significantly to the major reduction in...

Cervical spondylosis is an extremely common condition managed by both physicians and surgeons in daily clinical practice. Cervical spondylotic myelopathy (CSM), resulting from longstanding degenerative impingement of the spinal cord and nerve roots by osteo-cartilagineous elements, is managed by conservative or surgical methods.1 While surgery is often performed in...

The delivery of good medical care and the safety of patients are of utmost importance in all healthcare systems. Indeed, healthcare providers need to rely on one anothers’skills to minimise risk and decrease the number of medical errors.1 This is of particular concern in the practice of obstetrics and...

Undergraduate medical education is considered a continuum leading into postgraduate training and ultimately medical practice.1 To this effect, it has been suggested that measures of performance of medical students and practising doctors should be aligned and the transition should be a smooth one. However, studies show a poor correlation...

High-grade glioma (malignant glioma) is the most common primary intra-axial tumour of the central nervous system (CNS). Despite recent therapeutic advances in glioma treatment, the outcome for high-grade glioma has been disappointing. The first reported case of glioma resection was performed by Rickman Godlee in 1884.1 More than a...

The incidence and prevalence of diabetes mellitus (DM) worldwide is increasing, due almost exclusively to an increase in non-insulin-dependent (type 2) DM, which represents more than 90% of all cases of diabetes.1 Presently, there is a global pandemic of type 2 DM and its clinical sequelae. The World Health...

A 36-year-old woman presented with a 4-month history of right neck lump. She had mild shortness of breath, but no dysphagia or voice changes. Clinical examination found a firm right thyroid mass that moved with swallowing, consistent with a right thyroid lesion. Ultrasound evaluation of the lump revealed a...

Dear Editor, Mohs micrographic surgery (MMS) has become the treatment of choice for high-risk non-melanoma skin cancers (NMSC) worldwide.1 Unlike wide local excision, MMS enables precise microscopic removal of tumour foci while allowing maximal tissue preservation, thereby maintaining cosmesis and anatomical function.1 The MMS service in Singapore started in...

Dear Editor, Over the past decade, the utilisation of peritoneal dialysis (PD) among end-stage kidney disease (ESKD) patients in Singapore has been persistently low (<20%).1 Difficulty in accessing PD catheter insertion services is considered one of the main obstacles to the growth of the PD population.2 Traditionally, PD catheter insertion...

Diabetes Mellitus (DM) is a serious chronic illness that imposes significant morbidity and mortality and has a major impact on the quality of life of the individuals suffering from this illness. Singapore, a multi-ethnic country in Southeast Asia, with Chinese, Malay and Indian as the three main ethnic groups,...

The training of surgeons composed of two aspects: (1) Clinical skill and competence; (2) The ‘soft’ skill and ‘art’ of surgery. With the gradual introduction of residency programme into the surgical discipline, hopefully our clinical training will be more systematic, closely supervised, monitored, assessed and reassessed, and structured. This article...

Hand infections are common in the general population, and their management is usually uncomplicated. Several papers have noted that patients with diabetes mellitus have more severe infections, a different spectrum of bacteriology and a worse outcome. In our experience, of all patients with upper limb infections, those with end-stage...

The prognosis of patients with stage IV melanoma or recurrent melanoma is poor with an estimated median survival period of 6 months. The recent revised version of the American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma has further sub-divided melanoma metastatic sites to 3 specific categories;...

Obstructive calculous disease of the kidney often results in infectious complications such as pyelonephritis and perinephric abscesses. Renojejunal fistula formation may occur as the inflammation becomes chronic. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Patients with diabetes mellitus (DM) have higher incidence of cardiovascular morbidity and mortality compared with non-diabetic patients. The underlying mechanism is due to the more diffuse and accelerated form of atherosclerosis and endothelial dysfunction which lead to diffuse coronary lesions, small vessel disease, multi-vessel involvement, larger plaque burden as...

Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. The Framingham Risk Score (FRS) was derived from the Framingham Heart Study (FHS) cohort and was designed to predict 10-year risk of hard coronary events, including mortality due to coronary heart disease and non-fatal myocardial infarction (MI)...

Metabolic syndrome describes a constellation of interrelated metabolic risk factors, in which components coexist more frequently in a given individual than could be expected by chance alone. These risk factors include hypertension, hyperglycaemia, dyslipidaemia and obesity. The underlying pathophysiology is as yet unclear, but has been closely linked to...

Submandibular masses are common presenting complaints in the outpatient setting. The differential diagnosis of a submandibular mass lesion can be salivary gland pathology, lymph nodal disease or soft tissue conditions. The more common submandibular gland pathologies include sialadenitis, sialolithiasis, pleomorphic adenoma, lymphoma and carcinomas. This article is available only as...

Type 2 diabetes mellitus is a major chronic disease globally. With increasing life expectancy, long-term complications of diabetes mellitus leading to significant morbidity and mortality have great impact on each patient’s health. Health-related quality of life refers to a person’s self-perceived functioning and well-being, and is increasingly used to...

The development of new-onset diabetes after transplantation (NODAT) is a serious metabolic complication of kidney transplantation that predisposes patients to graft dysfunction, cardiovascular disease and death. Although NODAT has been recognised for many years, the true incidence has been difficult to establish due to inconsistencies in the definition of...

Emergency gastrectomy has been associated with high morbidity and mortality rates. These complications arise as a direct consequence following the procedure, such as duodenal stump leak and intra-abdominal collections, or more frequently, because of the resultant systemic complications. This article is available only as a PDF. Please click on “Download...

In the planning of a tuberculosis prevalence survey in Singapore in 1975, it was decided to include a urine examination of the respondents using Labstix (Ames Company, Elkhart, Indiana, USA). Respondents found to have proteinuria, haematuria or both in the examination centres were then referred to the Department of...

The prevalence of diabetes mellitus (henceforth referred to as diabetes) has increased significantly in the last decade and it is reaching epidemic levels worldwide due to ageing population, urbanisation, obesity and sedentary lifestyles. In Singapore, the National Health Survey 2004 revealed that 8.2% of the population aged 18 to...

Dear Editor, The buccal space is an infrequently addressed fascial space of the head and neck region. Intrinsic tumours of the buccal space are rare and hence present a management challenge. In a recent systematic review of 217 patients, 4 main surgical approaches were identified (intraoral, extended parotidectomy/rhytidectomy, transcutaneous...

Kidney cancer accounts for 3% to 4% of all cancers. In a systematic review by Mathew and et al,2 the incidence of kidney cancer was the highest in France (16.1 per 100,000 man-years) and the lowest in India (0.9 per 100,000 woman-years) during 1988 to 1992. A trend analysis in...

Hysteroscopy is an important surgical component of any training programme in gynaecology. Traditionally, surgical training in hysteroscopy occurred in the operating room where trainees first observe their senior performing the procedure, and then take on increasing roles in surgical cases under direct supervision. Often, hysteroscopic skills are acquired via a...

  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...

A 55-year-old Chinese woman presented to the ear, nose and throat clinic with a 6-month history of left-sided blood-stained mucus. It was dark brown with no epistaxis. There was no mucopus, nasal obstruction, facial pain or fever. She denies any history of hypertension, trauma, head and neck cancer, anticoagulation...

A fit and well 78-year-old woman with no significant past medical history presented to the Emergency Department with large painless perianal ulcers. It started as an erythematous patch that developed into pruritic perianal blisters, and rapidly evolved into a necrotic ulcer over 2 days. She denied any prior injury...

Dear Editor, Osteoarthritis of the big toe (hallux rigidus) is a common arthritic condition of the first metatarsophalangeal joint (MTPJ), beginning with stiffness, pain and inflammation. This subsequently progresses to restriction of movements especially dorsiflexion.1 Articular surface degeneration and formation of periarticular osteophytes may be seen on radiographs.2 Common...

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...

Radiofrequency ablation (RFA) has been shown to be safe and efficacious in the treatment of benign thyroid nodules. Ion agitation during RFA generates high temperatures between 60 and 100 degree Celsius to cause tissue damage and size reduction.   This article is available only as a PDF. Please click on "Download...

Diabetic kidney disease remains a significant disease burden globally and is associated with increased medical costs once chronic kidney disease (CKD) ensues. Therefore, optimisation of CKD management through glycaemic control and albuminuria reduction are key strategies for retarding renal deterioration. Sodium glucose cotransporter-2 (SGLT-2) inhibitors are a new class...

Approximately one in ten patients admitted to an intensive care unit (ICU) develops acute kidney injury (AKI), an important complication of ICU patients, and requiring renal replacement therapy (RRT). It is well known that AKI contributes to mortality and chronic kidney diseases which result in health and economic burdens....

With improvements in device technology as well as increasing experience, transcatheter aortic valve implantation (TAVI) has replaced open surgical aortic valve implantation as the treatment of choice in severe symptomatic aortic stenosis (AS) patients who have prohibitive and high surgical risks. TAVI has also gained increasing uptake in patients...

As infrastructure and policies were being put in place to combat COVID-19, we recognised that specialty-specific policies and protocols had to be drawn up as well. Similarly, the Renal Medicine Unit at the Singapore General Hospital, an academic medical centre, acted quickly to modify our services to (1) protect...

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...

A 70-year-old man with poorly controlled type 2 diabetes mellitus (DM), hypertension, hypercholesterolemia and alcohol dependence presented intoxicated, with occipital scalp lacerations after a fall. A brain computerised tomography (CT) revealed occipital skull fracture with bilateral subarachnoid haemorrhages, subdural haemorrhages and parenchymal contusions. He was admitted for close observation...

Diabetes is a chronic disease characterised by elevated levels of blood glucose. The most common type of diabetes is type 2 diabetes mellitus (T2DM). This usually occurs in adults and arises through insulin resistance or an insufficiency of insulin production. Diabetes is one of the priority non-communicable diseases targeted...

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...

Membranous nephropathy is an organ-specific autoimmune disease and is the most common cause of adult-onset nephrotic syndrome. The diagnosis of membranous nephropathy mainly depends on pathological characteristics observed through various techniques such as diffuse thickening of the glomerular basement membrane and spike formation by light microscopy, granular deposition of...