Original Article
Long-term outcomes of subthalamic nucleus deep brain stimulation for Parkinson’s disease in Singapore
Parkinson’s disease (PD) is a chronic and progressive neurodegenerative disorder characterised by motor symptoms such as limb bradykinesia, rigidity and resting tremor.1 Non-motor symptoms, including mood disturbances, cognitive impairment, autonomic dysfunction, and sleep disorders, are also common. Disease progression often leads to motor fluctuations and dyskinesias, along with worsening...
Original Article
Trends in fluid overload-related hospitalisations among patients with diabetes mellitus: The impact of chronic kidney disease
Diabetes mellitus (DM) is a major global health problem, contributing to significant clinical disease burden, healthcare expenditure and societal costs.1 In Singapore, DM accounts for 2.9% of disability-adjusted life years and 4.3% of years lived with disability.2,3 By 2030, it is projected to cost approximately USD 1.89 billion in...
Letter to the Editor
A consensus survey of neurologists and clinical geneticists on spinal muscular atrophy treatment in Singapore
Dear Editor,
Just a decade ago, spinal muscular atrophy (SMA) was considered a debilitating, progressive neuromuscular disease that inevitably led to chronic disability and a shortened lifespan. Now, it is treatable with nusinersen, onasemnogene abeparvovec (OAV) and risdiplam—the 3 disease-modifying drugs approved by the US Food and Drug Administration, the...
Letter to the Editor
Comparing the effectiveness, safety and cost of teleconsultation versus face-to-face model of pharmacist-led anticoagulation clinic: A single institution experience
Dear Editor,
Teleconsultation-based (TELE) anticoagulation clinic (ACC) is an alternative modality, but its use in Singapore’s clinical setting has not been well studied. In Tan Tock Seng Hospital (TTSH), the TELE ACC service was established to enrol patients who (1) perform self-testing using a loaned point-of-care (POC) international normalised ratio...
Letter to the Editor
Preferences for oral anticoagulant medications for managing atrial fibrillation
Dear Editor,
Stroke prevention in patients with atrial fibrillation (AF) using anticoagulants involves weighing the benefits of reduced ischemic stroke1,2 against the elevated risks of serious bleeding events.3 Warfarin and direct oral anticoagulants (DOACs) are the available oral anticoagulants for this indication. We developed a discrete choice experiment (DCE) survey4...
Review Article
Through the eyes into the brain, using artificial intelligence
Neurological dysfunction is a leading cause of disability, affecting more than 276 million people worldwide.1 Over the last decades, the prevalence of neurological dysfunction has increased, particularly in the ageing population which is commonly affected by dementia, stroke and brain tumours.1,2 The increasing number of patients suffering from neurological...
Original Article
Concordance of self-reporting of diabetes compared with medical records: A comparative study using polyclinic data in Singapore
Approximately 422 million people worldwide have diabetes and 1.6 million deaths are attributed to diabetes each year,1 contributing to high economic costs worldwide. Diabetes education and awareness of the disease contribute significantly to minimising complications and reducing morbidity and mortality.2 In addition, there is also a strong impetus to...
Editorial
The eye as a window to the brain
Over the last 20 years, it has become evident that the age-old expression, “the eye is the window into the soul”, might in fact hold more truth than previously thought. We are currently able to distinguish a variety of systemic diseases by funduscopic inspection. Following the dawn of high-resolution...
Letter to the Editor
Association between self-care and chronic kidney disease in patients with type 2 diabetes mellitus
Dear Editor,
Chronic kidney disease (CKD) is one of the key complications occurring in 25–40% of patients with type 2 diabetes mellitus (T2DM).1 Our earlier study also showed that CKD was present in 53% of patients with T2DM recruited from a secondary care diabetes centre and primary care polyclinic...
Letter to the Editor
Implementation of an AI model to triage paediatric brain magnetic resonance imaging orders
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...
Original Article
Non-alcoholic fatty liver disease screening in type 2 diabetes mellitus: A cost-effectiveness and price threshold analysis
Non-alcoholic fatty liver disease (NAFLD) is a growing epidemic and has become a major cause of liver-related mortality and indication for liver transplantations globally. It is estimated that nearly 25% of the world’s population and more than 60% of type 2 diabetes mellitus (T2DM) patients have NAFLD. A prior...
Letter to the Editor
Safety and efficacy of combined antiplatelet and low-dose rivaroxaban in patients with chronic limb threatening ischaemia in Singapore
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....
Editorial
Different strokes for different folks
Atrial fibrillation (AF) remains the most common arrhythmia since William Harvey’s observation of fibrillating auricles in open chest animal models in 1628. Willem Einthoven first documented ECG tracing of AF in 1906. Fast forward several hundred years since its first observation, AF remains a mystery from its pathogenesis and...
Original Article
Interaction of sex and diabetes in Asian patients with heart failure with mildly reduced left ventricular ejection fraction
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...
Editorial
Impact of sex and diabetes in patients with heart failure with mildly reduced ejection fraction
With increasing global awareness of sex differences in the heart failure population and the new entity of heart failure with mildly reduced ejection fraction (HFmrEF), much has yet to be fully understood with regard to patient demographic, clinical presentation, response to guideline-directed heart failure therapies, and outcome across the...
Letter to the Editor
Neuralgic amyotrophy in COVID-19 infection and after vaccination
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...
Images in Medicine
A 52-year-old woman with beading of intracranial arteries
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...
Letter to the Editor
Previous history of hyperthyroidism in emergency department patients with atrial fibrillation does not increase the risk of thromboembolism and death
Dear Editor,
Atrial fibrillation (AF) is frequently encountered in the emergency department (ED) and is a major risk factor for thromboembolic events. The clinical decision for anticoagulation is guided by risk scoring systems that include factors such as age, sex and comorbidities.1,2 AF can sometimes occur in patients with active...
Others
Creutzfeldt-Jakob Disease Presenting with Visual Blurring, Diplopia and Visual Loss: Heidenhain’s Variant
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.
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Original Article
The Profile of Hospitalised Patients with Parkinson’s Disease
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.
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Others
The Alien Hand Sign–Case Report and Review of the Literature
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...
Original Article
Electrophysiological Features in the Management of Meralgia Paraesthetica
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...
Original Article
A Retrospective Review of Patients with Clinically Definite Multiple Sclerosis
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.
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Others
Chronic Subdural Haematoma Presenting with Transient Ischaemic Attacks— A Case Report
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.
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Others
Palatal Myoclonus—A Case Report
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...
Others
Bilateral Caudate Infarct—A Case Report
The head of caudate nucleus forms a prominent bulge in the lateral wall of the anterior horn of the lateral ventricle. Its blood supply is from the deep penetrators from the middle cerebral and anterior cerebral arteries.
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Review Article
Homocysteine and Atherosclerotic Disease: The Epidemiologic Evidence
Homocysteine is a thiol-containing amino acid formed during the metabolism of methionine. The metabolic fate of homocysteine may be influenced by the alterations in the activities of serum folate, pyridoxine and cobalamin.
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Original Article
Potentiation of Acetylcholine-induced Smooth Muscle Contraction in Rat Ileum by Lead
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.
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Others
Extensor Pollicis Longus Paralysis Following Thoracoscopic Sympathectomy
A 24-year-old man was referred for hyperhidrosis of more than 15 years duration. It affected both hands, feet and axilla.
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Original Article
Role of Magnetic Resonance Imaging and Magnetic Resonance Angiography in Patients with Hemifacial Spasm
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...
Review Article
Diabetic Retinopathy
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.
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Others
Hypoglycaemia from Islet Cell Hyperplasia and Nesidioblastosis in a Patient with Type 2 Diabetes Mellitus—A Case Report
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...
Original Article
The Reliability and Validity of the Alzheimer’s Disease Assessment Scale Cognitive Subscale (ADAS-Cog) among the Elderly Chinese in Hong Kong
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).
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Original Article
Long-Term Outcome of Aortofemoral Bypass for Aortoiliac Occlusive Disease
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.
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Others
The Current State of Multiple Sclerosis Genetic Research
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...
Others
The Genetics of Human Epilepsies
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.
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Others
A Case Report of Aspergillus Hypersensitivity Syndrome with Obstructing Bronchial Aspergillosis
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.
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Original Article
A Rational Alternative for the Diagnosis of Diabetes Mellitus in High Risk Individuals
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...
Review Article
Sleep/Wake Cycle and Circadian Disturbances in Shift Work: Strategies for Their Management—A Review
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.
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Others
Traditional Indian Systems of Medicine
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.
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Original Article
Incidence and risk factors of delirium in post-anaesthesia care unit
Post-anaesthesia care unit (PACU) delirium is defined as a disorder in thought processes that affect cognition in terms of memory, comprehension and attention.1 It has a strong association with postoperative delirium, which is present in up to 45% of patients after surgery.2-5 PACU is a wide-reaching problem, and especially...
Editorial
Delirium in patients following general anaesthesia
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...
Others
Listeria Meningoencephalitis: Two Cases and a Review of the Literature
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.
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Others
Panhypopituitarism due to Pituitary Cyst of Rathke’s Cleft Origin—Two Case Reports
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...
Others
A Rare Cause of Syncope in a Patient with Diabetes Mellitus—A Case Report
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...
Original Article
Malignant Melanoma Seen in a Tertiary Dermatological Centre, Singapore
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.
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Others
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.
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Review Article
Advances in Neurointensive Care
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.
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Review Article
The Eye in Neurology: Evaluation of Sudden Visual Loss and Diplopia—Diagnostic Pointers and Pitfalls
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.
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Review Article
Neuroprotection in Acute Stroke
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...
Review Article
Current and Emerging Treatments in Parkinson’s Disease
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.
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Original Article
Trinucleotide Repeat Analysis of Huntington’s Disease gene in Singapore
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.
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Original Article
Aseptic Meningitis in Children—The Singapore Experience
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.
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Others
Current Therapeutic Strategies for Type 2 Diabetes Mellitus
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...
Others
Update in the Management of Stroke
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.
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Others
Stroke Disease Management—A Framework for Comprehensive Stroke Care
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...
Original Article
Variance Analysis Applied to a Stroke Pathway: How This Can Improve Efficiency of Healthcare Delivery
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.
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Review Article
Seeing How We Think About Words Using BOLD Contrast fMR Imaging
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.
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Review Article
Nipah Encephalitis Outbreak in Malaysia
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...
Others
MELAS: A Case Report
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...
Others
Case Reports of Two Biopsy-proven Patients with Creutzfeldt-Jakob Disease in Singapore
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...
Review Article
Axoglial Interaction via the Notch Receptor in Oligodendrocyte Differentiation
Oligodendrocytes (OLs) derived from the common neural progenitor cells in the central nervous system (CNS) ensheathe the nude axon to form the myelin that not only effects saltatory conduction but also protects and maintains the axonal structure. It is the last type of cells that appear in the CNS....
Original Article
How Much do Diabetic Patients Know About Diabetes Mellitus and its Complications?
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.
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Original Article
Hemifacial Spasm in Singapore: Clinical Characteristics and Patients’ Perceptions
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.
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Original Article
Characteristics and Acute Rehabilitation of Guillain-Barré Syndrome in Singapore
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.
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Others
Clinical Indications for Positron Emission Tomography (PET) Scanning
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...
Editorial
Positron Emission Tomography – A Vital Component of Molecular Imaging
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...
Others
Spinocerebellar Ataxia Type 2 with Focal Epilepsy – An Unusual Association
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.
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Commentary
Identification of a Common Genetic Risk Variant (LRRK2 Gly2385Arg) in Parkinson’s Disease
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...
Review Article
Neural Progenitor and Stem Cells in the Adult Central Nervous System
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.
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Review Article
Diabetes as a Risk Factor for Periodontal Disease: Current Status and Future Considerations
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.
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Original Article
Diabetic Retinopathy in Type II Diabetics Detected by Targeted Screening Versus Newly Diagnosed in General Practice
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...
Others
Concurrent Intermediate Uveitis and an Enhancing Intracranial Lesion as the Initial Manifestation of Sarcoidosis
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.
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Editorial
Re-defining Neurological Syndromes: The Genotype Meets the Phenotype
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...
Others
Ultrasound Assisted Thrombolysis in Acute Ischaemic Stroke: Preliminary Experience in Singapore
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.
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Review Article
Functional Neuroimaging of Sleep Deprived Healthy Volunteers and Persons with Sleep Disorders: A Brief Review
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...
Review Article
Treatment of Circadian Rhythm Sleep Disorders with Light
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...
Review Article
Basic Science Review on Circadian Rhythm Biology and Circadian Sleep Disorders
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...
Images in Medicine
Delayed and Extra-pontine Myelinolysis after Osmotic Dysregulation
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.
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Letter to the Editor
Limb-Shaking Transient Ischemic Attack with Distal Micro-Embolic Signals and Impaired Cerebrovascular Reactivity Using Transcranial Doppler
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.
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Commentary
Neuropsychiatry – An Emerging Field
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...
Editorial
Alzheimer’s Disease – Towards More Patient-centred and Meaningful Clinical Outcomes
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.
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Commentary
Sir Gordon Arthur Ransome (1910-1978) – His Teaching Style and His Legacy
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.
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Others
Corticospinal Tract Degeneration in Amyotrophic Lateral Sclerosis: A Diffusion Tensor Imaging and Fibre Tractography Study
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...
Review Article
Biomarkers of Mild Cognitive Impairment and Alzheimer’s Disease
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.
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Original Article
Validation of Transcranial Doppler with CT Angiography in Cerebral Ischaemia: A Preliminary Pilot Study in Singapore
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.
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Original Article
Superior Sagittal Sinus Thrombosis: Subtle Signs on Neuroimaging
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.
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Editorial
Embryonic Stem Cells and Parkinson’s Disease: Cell Transplantation to Cell Therapy
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.
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Commentary
Bridging the Gap Between Primary and Specialist Care – An Integrative Model for Stroke
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...
Letter to the Editor
Malignant Syndrome of Two Parkinson Patients due to Withdrawal of Drugs
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...
Review Article
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.
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Commentary
Should Beta-Blockers Still be Used as Initial Antihypertensive Agents in Uncomplicated Hypertension?
Beta-blockers have been widely prescribed to treat hypertension over the years.1 While the benefits of these agents in reducing cardiovascular events in people with pre-existing heart disease are clear,2 their clinical benefits in individuals with uncomplicated hypertension are less well-defined. Questions have been raised about beta-blockers as first-line treatment...
Commentary
Sociodemographic Factors Influencing the Effectiveness of Public Health Education – A Comparison of Two Studies in Singapore
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...
Others
Neurogenic Pulmonary Oedema Misdiagnosed as Acute Myocardial Infarction in a Comatose Patient
Neurogenic pulmonary oedema (NPO) is a well recognised complication of subarachnoid haemorrhage (SAH) and severe traumatic brain injuries (TBI).1 The incidence of NPO was reported to be 6% in a series of 457 patients with SAH.2 However, the diagnosis of NPO can be challenging when it occurs without abnormal...
Original Article
Timing of Hospital Presentation After Acute Cerebral Infarction and Patients’ Acceptance of Intravenous Thrombolysi
Intravenous thrombolysis in acute cerebral infarction has been proven to be efficacious in improving functional outcome if given within 3 hours from stroke onset.1 Singapore recently received national licensing for the use of intravenous thrombolysis for this indication. Delay in hospital presentation is an important hindrance to the administration...
Original Article
Diabetes and Associated Cardiovascular Risk Factors in Iran: The Isfahan Healthy Heart Programme
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...
Review Article
Emerging Therapies in Stroke Rehabilitation
Stroke is the fourth leading cause of death in Singapore since 1998.1 While mortality due to stroke has steadily declined over the years with better care, stroke remains the leading cause of long-term disability in adults and the most common reason patients are referred for rehabilitation.
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Review Article
Botulinum Toxin for Post-stroke Spastic Hypertonia: A Review of its Efficacy and Application in Clinical Practice
Botulinum toxins (BTX) have revolutionised the management of focal spastic hypertonia in a variety of neurologic diseases. Prior to the introduction of BTX for this purpose in the early 1990s, clinicians were limited to oral spasmolytic agents and nerve blocks using phenol or alcohol. All these interventions are effective...
Others
Residual Neurovascular Function and Retinotopy in a Case of Hemianopia
Homonymous hemianopia is one of the most common forms of acquired visual field defects.1 It is typically produced by head injury, tumours or stroke that damage the occipital cortex, postgeniculate pathways or both.1 This leads to the impairment in basic functions, such as reading, visual search and navigation. Thus,...
Original Article
Impact of Depression on Health Related Quality of Life in Patients with Diabetes
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,...
Letter to the Editor
Multimodal Therapeutic Approach in Acute Ischaemic Stroke with Real-time Neurovascular Monitoring
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.
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Letter to the Editor
Chewing-induced Facial Dystonia
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.
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Original Article
Epidemiology and Management of Surgical Upper Limb Infections in Patients with End-stage Renal Failure
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...
Original Article
Timing of Arrival to a Tertiary Hospital after Acute Ischaemic Stroke – A Follow-up Survey 5 Years Later
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.
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Editorial
Alzheimer’s disease–The Inexorable Epidemic
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...
Letter to the Editor
Unusual Cause for Unilateral Headache: A Quadrigeminal Cistern Arachnoid Cyst
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...
Original Article
Eighteen-Month Clinical Safety and Efficacy Outcomes of Sirolimus-, Paclitaxel- and Zotarolimus-drug Eluting Stents in Diabetic Patients Undergoing Percutaneous Coronary Intervention for Complex Coronary Artery Stenosis
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...
Original Article
Framingham Risk Score Inadequately Predicts Cardiac Risk in Young Patients Presenting with a First Myocardial Infarction
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)...
Review Article
The Relevance of the Metabolic Syndrome
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...
Editorial
Genome-wide Association Studies: Promises and Pitfalls
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...
Original Article
Health-related Quality of Life is Associated with Diabetic Complications, but not with Short-term Diabetic Control in Primary Care
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...
Original Article
Incidence and Risk Factors for Development of New-onset Diabetes after Kidney Transplantation
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...
Original Article
Geriatric Syndromes and Depressed Mood in Lower-income Singaporeans with Diabetes: Implications for Diabetes Management and Health Promotion
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...
Original Article
Kidney Cancer and Diabetes Mellitus: A Population-Based Case-Control Study in Taiwan
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...
Editorial
Epilepsy: Looking Beyond Seizures
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...
Editorial
Sleep, Public Health and Wellness: The Elephant in the Room
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...
Letter to the Editor
Single-level Anterior Corpectomy with Fusion versus 2-level Anterior Cervical Decompression with Fusion: A Prospective Controlled Study with 2-year Follow-up Using Cages for Fusion
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...
Letter to the Editor
Chorea precipitated by phototherapy as initial presentation of systemic lupus erythematosus
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...
Letter to the Editor
Attendance for ischaemic stroke before and during COVID-19 lockdown in Singapore
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...
Letter to the Editor
Rare homozygous PRKN exon 8 and 9 deletion in Malay familial early-onset Parkinson’s disease
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...
Letter to the Editor
Adipsic diabetes insipidus and SGLT2 inhibitor: A perplexing conundrum
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...
Editorial
The Singapore Cerebral Palsy Registry: An important new resource for cerebral palsy research
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...
Original Article
Cost of inpatient rehabilitation for children with moderate to severe traumatic brain injury
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...
Original Article
Long-term outcomes of ischaemic stroke patients with diabetes in a multi-ethnic cohort in Singapore
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...
Letter to the Editor
Neuro-Behçet’s disease presenting as isolated intracranial hypertension
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...