bluuebunny/crossref_metadata_2025 huggingface dataset:
The Hazards of Total Knee Arthroplasty: A Case Report in Illustration
Authors: Puah Ken Lee , Chin Pak Lin , Lo Ngai Nung
Published: July 2015

Infections and periprosthetic fractures are uncommon but dreaded complications of total knee arthroplasty which carry attendant morbidity and prolonged hospitalization and necessitate repeat surgery. We present a patient with a total knee arthroplasty who had both intra-operative and post-operative periprosthetic fractures who subsequently developed infection of the prosthesis necessitating revision surgery. This was complicated too by positive intra-operative tissue cultures. The clinical course, presentation and management are discussed. Total knee arthroplasty is a frequently performed and successful operation and its complications are challenging to address and require early recognition by the surgeon with appropriate referral to a dedicated arthroplasty surgeon as needed.
Effectiveness of Symptom Guided Therapeutic Approach in Treating Discogenic Pain with Radiculopathy Using a Combination of Directional Preference Exercises, Mobilisation and Neural Mobility Exercises — A Case Report
Authors: Joshua Devasahayam Augustine
Published: July 2015

Researchers have reported various therapeutic approaches to treat patients with low back pain. The mechanical diagnosis and therapy as proposed by McKenzie, has been shown to be effective in diagnostic, therapeutic and prognostic inference. Most often, the treatment options considered in these studies was directional preference exercises and manual procedures utilising movement and positions. But the effectiveness of symptom guided therapeutic approach in treating discogenic low back pain with radiculopathy using directional preference exercises, mobilization and neural mobility exercises is unknown.

A case of a forty three-year-old male presenting with discogenic low back pain along with radiculopathy was assessed with McKenzie approach. Appropriate treatment strategy was selected and prescribed based on the initial assessment. The patient was re-evaluated each session, and treatment modification was made according to his symptom presentation during each visit. He proved to be symptom free after seven visits. This could have been due to disc regression and enhanced neural mobility obtained due to treatment. This case report demonstrates the effectiveness of symptom guided therapeutic management to treat patients with discogenic low back pain along with radiculopathy using appropriate treatment strategies. Finally, the report summarizes the treatment offered and discusses the possible explanation of the specific treatment strategies implemented.
Clinical Audit on Hypoglycaemic Symptoms in Type 2 Diabetic Patients in SingHealth Polyclinics
Authors: Quah Hui Min Joanne , Teo Swee Hong Stephanie , Yap Hui Bee Gladys , Lim Hwee Boon , Chow Mun Hong
Published: July 2015

Introduction:

Hypoglycaemia is an important complication of type 2 diabetes mellitus treatment, because it causes recurrent physical and psycho-social morbidity, and it is sometimes fatal. Achieving target glycaemic goals while avoiding hypoglycaemia is a major challenge in the management of patients with type 2 diabetes mellitus. Awareness of hypoglycaemia is a function of the knowledge and experience of an individual, as well as the physiological responses to low glucose concentrations. Our team conducted an audit to identify the prevalence and underlying causes of hypoglycaemic symptoms among type 2 diabetes mellitus patients seen in SingHealth Polyclinics. This data was collected as part of our efforts to improve diabetes care and increase awareness.

Methods:

Audit in the form of nurse-administered interviews were carried out on 120 type 2 diabetic patients seen in the Family Physician Clinic; they were 20 consecutive patients seen in each of 6 polyclinics. The questionnaire included both patient and nurse components, identifying hypoglycaemic symptoms, causes, related hospital admissions, self-management, current treatment and control.

Results:

Of the 120 patients audited, 31 (26%) reported hypoglycaemic symptoms. These patients with hypoglycaemic symptoms were more likely to be on insulin treatment than those without symptoms (p=0.000). Majority of patients with symptoms did not use the glucometer when they experienced these symptoms (19/31). The cause of hypoglycaemic symptoms was often meal-related. For patients not on insulin, those with hypoglycaemic symptoms were more likely to own a glucometer than those without symptoms (p=0.033).

Conclusion:

Hypoglycaemia is a common complication of diabetic treatment, and efforts should be focused especially on insulin-treated patients to prevent hypoglycaemia, including education on hypoglycaemia awareness, self-monitoring of blood glucose and dietary advice.
Assessing the Performance of Operating Rooms: What to Measure and Why?
Authors: Oh Hong Choon , Phua Tien Beng , Tong Shao Chuen , Lim Jeremy Fung Yen
Published: July 2015

There are multiple indicators that measure different aspects of operating room (OR) performance such as OR productivity, satisfaction of patients and staff involved. The choice of these indicator(s) used for monitoring the performance of ORs often impacts how the processes of ORs are organised and managed. However, there is still no consensus in literature on which indicator(s) should be used for monitoring OR performance. In an effort to promote consensus within the healthcare community, this paper discusses potential performance metrics which may be employed for evaluation of ORs, their rationale and their limitations, and explains why a multidimensional approach is critical in assessment of OR performance.
Streptococcus Gallolyticus Endocarditis: A Case Report Contrasting the Response in Frail and in Strong Elderly Patients
Authors: Surrun Soondal Koomar , Cheah Kee Leong
Published: July 2015

The elderly are at increased risk of developing Streptococcus gallolyticus endocarditis. The infection is easily controlled by antibiotics but a valvular replacement may be needed for gross valvular dysfunction. Some patients may have associated colonic or hepatic lesions needing surgical intervention that increase morbidity, mortality and costs. We describe a 71-year-old patient with Streptococcus gallolyticus endocarditis and discuss the differences of response between the strong and the frail elderly.
Radiological Findings of a 62-Year-Old Male with Loss of Weight and Appetite
Authors: Ng Matthew
Published: July 2015

Plain X-rays are still important basic first-line investigations for the family physician practising in the private and public sectors. They are useful in the detection of pathology in the skeletal system as well as some disease processes in the soft tissues. Notable examples include chest X-rays which can be used to identify diseases such as pneumonia, carcinoma of the lung or pulmonary oedema. The chest X-ray presented here is of a 62-year-old man presenting with a 3-month history of loss of weight and appetite as well as a chronic cough.
Arterial Blood Gases
Authors: Yap Clementine YF , Aw Tar Choon
Published: July 2015

Arterial blood gases (ABG) results reflect underlying pathology and interpretation of the results are often compounded by ongoing disease processes and clinical interventions. While ABG specimens should be analysed immediately for optimal results the Clinical and Laboratory Standards Institute (CLSI) has recommended a window of 30 minutes at room temperature from blood collection to ABG analysis. A fresh and simple approach to interpreting ABG is provided.
The Value of the Hearing Education Arcade in Educating Caregivers of Hearing-Impaired Patients
Authors: Low Wong Kein , Phua Mandy
Published: July 2015

Introduction:

Although technological advancements have improved the treatment outcomes of hearing-impaired patients, challenges still exist as caregivers are not able to fully appreciate patients' difficulties in communication. An effective education programme is deemed important, including an experiential learning component where people in contact with the patient could experience the sounds actually heard by the patient. This led to the setting up of the Hearing Education Arcade (HEAR), an interactive gallery which contains information about various aspects of hearing loss. This pilot study aims to assess the usefulness of HEAR as an educational tool for caregivers of hearing-impaired patients.

Methods:

Two separate surveys were carried out. The first survey sought to find out if HEAR had been informative and educational. The second, a focus-group survey on caregivers of hearing impaired children and adults, gauged knowledge levels before and after experiencing HEAR.

Results:

Most respondents found HEAR to be very informative (86.4%) and highly educational (75.8%). The respondents in both focus groups recorded improvement in knowledge scores after going through HEAR.

Conclusion:

This study supports the belief that HEAR is a useful tool in the education of caregivers of hearing-impaired patients about hearing, its disorders, the treatment and the needs of the hearing-impaired. When the family and caregivers are properly educated on matters of hearing loss, it can have a positive effect on management outcomes.
Modular Endoprosthesis for Mandibular Reconstruction — A Thematic Research Study at the National Dental Centre Singapore
Authors: Goh Bee Tin , Lee Shermin , Chanchareonsook Nattharee , Tideman Henk
Published: July 2015

Introduction:

A thematic research project was undertaken by the National Dental Centre Singapore to study the feasibility of using a novel modular endoprosthesis for reconstruction of the mandible. Successful application of this technique potentially eliminates the need for a donor site.

Methods:

Three sub-projects done in a monkey model are presented. In the first two sub-projects, a titanium modular endoprosthesis was inserted in surgically created defects for reconstruction of the ascending ramus and condyle; and body of the mandible respectively. In the third sub-project, a polycaprolactone scaffold with calcium phosphate (CaP) surface coating modular endoprosthesis was used for reconstruction of the body of the mandible. The animals were sacrificed at three to six months. Microcomputed tomographic and histologic analyses were done.

Results:

At the time of sacrifice, signs of infection were present in a few animals treated either with the titanium or the polycaprolactone endoprosthesis for replacement of the body of the mandible. None of the animals who received the ascending ramus and condyle titanium endoprosthesis had an infection. New bone formation was noted around the stems of the titanium devices and inflammatory reaction was much reduced from three to six months. For the polycaprolactone device, more de novo bone formation was seen in the group using Human-BMP-2.

Conclusion:

The use of a modular endoprosthesis for mandibular reconstruction seemed to result in a physiologic replacement of the lost part of the mandible, although the biomechanics of the system need further evaluation so as to improve its long term stability.
Uses of Botulinum Toxin a in Ophthalmology
Authors: Teo Livia , Chee Elaine
Published: July 2015

Introduction:

Botox® (serotype A) is currently available and used to treat various ophthalmological conditions. The aim of our study was to review the current indications, side-effects and updates on the clinical use of botulinum toxin- A (Btx-A) in the field of ophthalmology.

Methods:

A literature search using the keywords “Botulinum Toxin”, “Botulinum Toxin A”, “Botox” and “Ophthalmology” was performed using Pubmed. Articles describing the use of botulinum toxin A were selected and reviewed.

Results:

The uses of Btx-A in ophthalmology can be broadly classified into four categories: eyelid, strabismus, cosmetic and others. In the eyelid, it can be used to treat blepharospasm, hemifacial spasm, apraxia of lid opening or induce ptosis in lid retraction and exposure keratopathy. In strabismus management, it can be injected into overacting muscles to realign the eyes. For cosmesis, it can be used to relax facial muscles to reduce wrinkles while other indications include treatment of chronic dry eye, lacrimal hypersecretion and pain relief in acute angle closure attack. Complications of the injection include local effects like ecchymosis, pain or infection and spillover effects like ptosis, diplopia, lagophthalmos, mid facial weakness and dry eyes.

Conclusion:

The clinical application of botulinum toxin A in ophthalmology is extensive. When considering its application in clinical practice, one should be mindful of the indications, risks and benefits of the procedure. When properly delivered, its potential as an efficacious, minimally-invasive treatment modality can be maximised in patient management.
The Development of Neonatology as a Paediatric Subspecialty in Singapore
Authors: Ho Lai Yun
Published: July 2015

Singapore ranks amongst the very few countries with the lowest neonatal and infant mortality rates in the world in the last decade. Advance in obstetric care and the development of neonatal intensive care are important contributory factors, built upon a solid foundation of socio-economic improvements and sound primary maternal and child health services. Riding on the waves of global technological advances in neonatal care, the development of neonatal-perinatal medicine in Singapore has reached a crucial stage when the challenge is to achieve further reduction of our perinatal mortality without a concomitant increase in long-term mortality of the survivors. The journey of neonatology in Singapore mirrors that in other developed countries venturing into neonatal intensive care over the past half-century. Rarely have the processes and products of scientific medicine been as heralded and harangued, as lauded and condemned, as publicised and misunderstood as they have in the context of neonatology. We have overcome major challenges and neonatology is now recognised as the first paediatric subspecialty in Singapore. Our vision is to continue to develop neonatology as a scientific art and an artistic science in medicine.
Eight-Year Developmental Follow-up in Children with Birthweights 1,251–1,500g in KK Women's and Children's Hospital
Authors: Choo Winnie Li Chuen , Lourdes Mary Daniel
Published: July 2015

Background:

Children of very low birth weight (VLBW, birth weight <1,500g) are at risk of developmental disability and learning difficulties. Regular follow-up to a school-going age allows timely diagnosis and intervention.

Methods:

The duration, developmental assessment and service utilisation of 41 VLBW children with birth weights between 1,251–1,500g born in 2001 were retrospectively analysed.

Results:

The median follow-up duration was 5 years 11 months. 56% were followed-up till preschool entry. Gross motor, fine motor and language domains were assessed in more than 95% of children. Information on behavioural and learning problems was only sought for in approximately 50% of children.

Conclusions:

A significant proportion of these high-risk children were either not followed-up long enough or were not adequately assessed for learning and behavioural problems, thus justifying the development of a new standardised follow-up program for larger VLBW children.
Nested Case-Control Study of Children Presenting with First Afebrile Seizure at KKH: Seizure Recurrence and Comorbidities
Authors: Chan Derrick Wei Shih , Long Melody , Kumar Praveen , Kao Martha
Published: July 2015

Introduction:

First afebrile seizures are common in Singapore (incidence 24 per 100,000 person-years). We determined the seizure recurrence risk after first afebrile seizure, the risk factors at presentation and evaluated the quality of life of these children.

Methods:

Nested case-control study of children presenting with their first afebrile seizure from 2002 to 2004. Risk factors were measured at initial presentation. This follow-up study administered standardised telephone questionnaires to patients/caregivers seven years later. Subjects with only one afebrile seizure (1AS) were compared to those with recurrent afebrile seizures (RAS) for birth history, risk factors, developmental delay, school status, initial electroencephalogram (EEG), neuroimaging and initial seizure episode using Fisher's exact test. Quality of life was screened with a questionnaire.

Results:

Of 103 eligible subjects, 54 responded with seizures recurring in 21 (38.9%). Initial seizure frequency was yearly at 57.9%. The RAS group had more risk factors ( P=0.013) and greater frequency of abnormal initial development ( P <0.005), abnormal neurological examination in this population ( P=0.033) and abnormal current development ( P=0.028). Quality of life differed in behavioural changes ( P=0.022) and parental relationship with spouses ( P=0.004). EEG and neuroimaging were not predictive. Number of initial seizure episodes showed a significant difference between 1AS and RAS groups ( P=0.037).

Conclusion:

Abnormal development and neurological examination are risk factors for seizure recurrence after the first afebrile seizure. Children with more than four seizures during the initial seizure presentation may be at an increased risk of seizure recurrence. Recurrent seizures affect quality of life of both the affected child and the family.
Diagnosis and Management of Iron Deficiency Anaemia in Children — A Clinical Update
Authors: Chew Elaine Chu Shan , Lam Joyce Ching Mei
Published: July 2015

Iron deficiency anaemia (IDA) remains an important public health problem even in developed countries like Singapore. This clinical update covers recent developments in the knowledge of iron metabolism, which aids in the approach towards the diagnosis, management and prevention of IDA in children. Besides IDA, iron deficiency (ID) has several non-haematological consequences including effects on neurocognition and immune function as suggested by several animal and clinical studies. Thus paediatricians and other health care providers should work towards the prevention and elimination of IDA in children.
Mild Encephalopathy with Reversible Splenial Lesion in Children
Authors: Chow Cristelle , Ling Simon
Published: July 2015

Mild encephalopathy with reversible splenial lesion (MERS) is a recently described clinico-radiological syndrome. It is characterised by acute mild encephalopathy and changes in the splenium of the corpus callosum on brain magnetic resonance imaging (MRI). MERS has been described mainly in East Asian populations. Infection, particularly influenza, is the most common association. The prognosis is generally favourable with spontaneous resolution of clinical and radiological abnormalities. We report two cases of non-influenza MERS in children, one associated with varicella, and discuss their differing clinical presentations.
Childhood Stroke after Influenza Vaccination
Authors: Thoon Koh Cheng , Chan Derrick Wei Shih
Published: July 2015

Neurological complications following influenza vaccination are rare in children, with the most common being seizures, and less commonly encephalopathy and Guillain-Barré syndrome. We report here a 10-year-old child who developed cerebellar stroke one day after receiving the seasonal trivalent influenza vaccine; to our knowledge this is the first reported case in literature. The child presented with acute-onset vertiginous giddiness, blurred vision, headache and non-bilious vomiting. Clinical examination revealed marked ataxia with past pointing worse on the right. Laboratory investigations did not reveal any thrombophilic tendency and there was no suggestion of embolic phenomena from a distant site. Magnetic resonance imaging (MRI) of the brain showed two areas of restricted diffusion in the left cerebellar hemisphere. She was commenced on aspirin and underwent rehabilitation before being discharged six days after admission in good health. She recovered completely by outpatient review and aspirin was discontinued eight months after presentation.
Adult-Onset Still's Disease: A Review
Authors: Fong Weng Seng , Lui Nai Lee
Published: July 2015

Adult-onset Still's disease (AOSD) is an uncommon inflammatory condition characterised by high fever, leukocytosis with neutrophilia, arthralgia and skin rash. Diagnosis is often clinical, and it is always necessary to exclude common disease mimics such as infections, malignancies and other rheumatic diseases. Ferritin and glycosylated ferritin are useful adjuncts to aid in the diagnosis of AOSD. Important complications to consider include fulminant hepatitis, disseminated intravascular coagulopathy and hemophagocytic syndrome. Mainstay treatment of AOSD is often with glucocorticoids. Other agents that can also be used include methotrexate, and biologic therapy, such as tumor necrosis factor-α (TNF-α) blockers and interleukin-1 (IL-1) inhibitors. A retrospective review of patients diagnosed with AOSD admitted to Singapore General Hospital (SGH) was performed, and their disease characteristics and laboratory findings were compared with that of previous published cohorts.
The Rheumatology Monitoring Clinic in Singapore — A Novel Advanced Practice Nurse-/Pharmacist-Led Clinic
Authors: Chew Li-Ching , Yee Sow Ling
Published: July 2015

Due to the increasing demand for healthcare services worldwide, there is a need for innovative changes in the provision of healthcare. The introduction of advanced practice nurse (APN)- and/or pharmacist-led outpatient clinics is an emerging trend in many countries. The Rheumatology Monitoring Clinic (RMC) started in Singapore General Hospital (SGH) in 2009, as a new healthcare delivery service model, led by APNs and pharmacists. The aim of the RMC is to ensure that stable patients with rheumatoid arthritis and spondyloarthritis on disease modifying anti-rheumatic drugs (DMARDs) are monitored regularly and appropriately for drug toxicity. The benefit of having such a model of care in a local tertiary centre is to deliver right-siting of care for stable patients, hence allowing more clinic slots for rheumatologists to see new patients, and those with complex diseases. A survey conducted on the RMC showed that it received positive feedback from patients, with an overall high degree of satisfaction. We thus established the acceptability of a non-physician-led clinic in our local setting. Based on the success of the RMC, the scope has been extended to monitor patients on newly initiated DMARDs and escalation therapy. Additionally, an APN-led telephone clinic (the Virtual Monitoring Clinic [VMC]) has been introduced, offering cost-effective healthcare, personalised service, and convenience to patients. This review aims to summarise the role and model of care of a novel RMC in Singapore, discuss the key roles of APNs/pharmacists, and describe the outcomes of the RMC audit and survey.
Haematopoietic Stem Cell Transplantation in Systemic Lupus Erythematosus: A Case Report and Review of the Literature
Authors: Fong Weng Seng , Loh Yvonne , Yoong Jon
Published: July 2015

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with a relapsing and remitting course, which is often treatable with immunosuppressive therapy. However, we describe a patient with severe and refractory thrombotic thrombocytopaenic purpura (TTP) secondary to SLE that did not respond to high dose corticosteroids, cyclophosphamide (CyC), vincristine, rituximab, and plasmapheresis. She eventually required haematopoietic stem cell transplantation (HSCT) to bring the disease under control. She is in disease remission three years post-stem cell transplantation. HSCT is a possible treatment option for severe and refractory SLE when conventional therapy has failed. HSCT for other rheumatologic diseases is also reviewed.
Antiphospholipid Syndrome Antibodies — Snippets from the Laboratory
Authors: Tan Justin Hung Tiong , Ngan Cecilia , Arkachaisri Thaschawee
Published: July 2015

Antiphospholipid (aPL) antibodies refer to antibodies associated with the clinical syndrome of vascular thrombosis and/or pregnancy morbidity, termed as aPL syndrome (APS). aPL antibodies include lupus anticoagulants (LA), anticardiolipin (aCL) antibodies and anti-β2-glycoprotein 1 (anti-β2GP1). aCL antibody is more sensitive than LA and anti-β2GP1 even though the latter are more specific for APS. Interpretation of aPL results should be done collectively together with the clinical presentation of each individual. The latest recommendations and consensus on aPL antibody testings should be closely adhered to by laboratories in order to achieve an accepted standard and to ensure accuracy of test results.
The Effects of Parkinson's Disease on Caregivers and People with Parkinson's Disease: A Literature Review
Authors: Bee Tan Siok , Allison Williams
Published: July 2015

Parkinson's disease (PD) is a complex, slowly progressive, neurodegenerative, neurological condition characterised by a wide range of motor problems such as movement disorders, issues with gait and balance, and difficulty with swallowing and speech. In addition, sufferers also experience non-motor symptoms such as disorder of sleep, postural hypotension, mood alterations, lethargy, and cognitive dysfunction. As PD progresses to an advanced stage, people experience periods of debilitating physical and neurological problems and their caregivers face increasing complexity of care. Many people with PD require the support of a caregiver to attend to activities of daily living. This paper will review the literature on the effects of Parkinson's disease on both the patient and caregiver. Findings highlight the progressive nature of the disease affecting both functional and affective domains, and the need for caregiver support to enable the delivery of quality of care to this group throughout the disease trajectory.
Phenytoin: A Guide to Therapeutic Drug Monitoring
Authors: Wu Melissa Faye , Lim Wai Hing
Published: July 2015

Therapeutic drug monitoring of phenytoin is carried out to ensure effective and safe levels. Some of the factors complicating phenytoin dosing include a narrow therapeutic window, high degree of protein binding, and nonlinear pharmacokinetics. However, serum drug levels should only be taken when there is a clear indication to guide patient management. Scenarios where monitoring levels may be clinically useful include: (1) establishing an individual therapeutic concentration, (2) aiding in diagnosis of clinical toxicity, (3) assessing patient compliance, and (4) guiding dosage adjustments in patients likely to have greater pharmacokinetic variability. This paper aims to provide an overview on of the correct timing and interpretation of phenytoin levels. It will also address phenytoin dosing, other monitoring parameters, and management of phenytoin adverse effects.
A Review of Endoscopic Treatment of Hydrocephalus in Paediatric and Adult Patients
Authors: Ling Ji Min , Tiruchelvarayan Rajendra
Published: July 2015

Endoscopic treatment for hydrocephalus started in the early 20th century, but could not thrive due to poor illumination and magnification of the scope. In the 1950s, ventriculoperitoneal (VP) shunt became widely acceptable as standard treatment for hydrocephalus owing to the invention of well-designed valves and discovery of silicone, a biocompatible material for manufacturing shunt catheters. However, shunting is still far from being an ideal treatment because of its associated complications such as catheter malposition, blockage, and over- or under-drainage of cerebrospinal fluid. The shunt revision rates remained high in recent series. At the same time, endoscopy has undergone tremendous improvement in the latter half of the century and has emerged as an attractive alternative since the early 1990s. The article described the usage of endoscopy in the treatment of hydrocephalus, such as endoscopic third ventriculostomy, fenestration of multi-loculated hydrocephalus, and fenestration of septum pellucidum prior to VP shunting.
Comparing the Effectiveness of Green Tea versus Topical Metronidazole Powder in Malodorous Control of Fungating Malignant Wounds in a Controlled Randomised Study
Authors: Lian Siew Bee , Xu Yi , Goh Seow Lin , Aw Fung Chee
Published: July 2015

Aim:

To test the efficacy of green tea with that of conventional topical metronidazole powder by comparing the rate of malodorous score reduction using the verbal numeric scale (VNS).

Methods:

This was a prospective randomised experimental study comparing two types of odour control agents used for treating malodorous fungating malignant wounds in a tertiary hospital in Singapore. Patients were randomised to either control (metronidazole power) or treatment (green tea) group and was follow-up with a daily dressing for a week by a designated nurse. Both patient and designated nurse would rate the malodorous score daily on a VNS of 0 (no smell) to 10 (worst smell that one can imagine).

Results:

Thirty cancer patients with malodorous fungating wounds were randomised into either treatment (n=15) or control group (n=15). The location of wounds were breast (n=24), neck (n=2), groin (n=2), spine (n=1) and anus (n=1). All patients in both groups showed improvement in odour control by Day 7. Treatment group was as effective as control group and there was no statistical significance (p>0.05) to demonstrate which treatment is more superior.

Conclusion:

Green tea dressing is as effective as conventional topical metronidazole powder in controlling odour. Green tea is cheap, easily available and has no risk of drug resistance over long term use. Alternatively, it can also be used interchangeably with metronidazole powder to reduce the risk of drug resistance.
Parotid Gland Surgery for Benign Tumours: Have We Come Full Circle?
Authors: Chua Dennis Yu Kim , Goh Christopher Hood Keng
Published: July 2015

Parotid gland surgery has been described for over two centuries. The surgical philosophies in management of parotid gland tumors started off in the 18th century from a conservative approach of simple enucleation so as to minimize post-operative facial nerve palsy rate. This occurred, as there was a lack of understanding of surgical anatomy of the parotid gland and facial nerve. However unacceptably high recurrence rates ensued and this encouraged the further study of parotid gland anatomy till the 1950s when, deriving from a better understanding of the surgical anatomy, superficial parotidectomy with facial nerve identification and preservation became the new standard of care. This method then evolved to a partial superficial parotidectomy as this slightly more conservative approach allowed adequate parotid tumour resection with low recurrence rates and yet minimising post-operative complication such as Frey's syndrome. Over the last two decades, a more conservative approach known as an extracapsular dissection of parotid tumour emerged in certain high-volume centers as an alternative to a partial superficial parotidectomy. These centers published better post-operative results with lower postoperative facial nerve palsy rates, less Frey's syndrome and faster patient recovery. Dissection of parotid tumours via this technique involves following a plane close to the tumour and is similar to enucleation in terms of its conservative approach with very significant differences post-operatively. This article presents a summary on the surgical philosophies pertaining to parotid gland surgery since its inception two centuries ago.
Smoking Behaviour of Asthmatic Patients in Primary Care: A Cross-Sectional Study
Authors: Teo Stephanie Swee Hong , Tan Ngiap Chuan , Ngoh Agnes Soh Heng , Swah Teck Sin , Chen Zhaojin , Tai Bee Choo
Published: July 2015

Introduction:

One-third of adult asthma patients smoke cigarettes despite smoking being a known trigger of asthma exacerbation. This study aims to describe the behaviour of asthmatic patients who smoke and explore the reasons why they continue to smoke cigarettes even when unwell.

Methods:

A cross-sectional questionnaire survey was conducted on adult asthma patients at primary care clinics in Singapore. One hundred and seventy-four asthmatic smokers (AS) of four ethnic groups, both genders, aged 21–50 years were recruited. Demographic data and smoking characteristics, reasons for smoking, and experiences during their attempts to quit were collected and analysed using the statistical software STATA version 12.

Results:

The median age of AS was 30 years. Seventy-five percent were males and mostly Malays (58%). Seventy-one percent had at least secondary education. Eighty-six percent started smoking before 20 years old. Ninety-eight percent smoked less than 10 sticks per day and 51% smoked ≤5 pack-years. Thirty-eight percent smoked within 5 minutes of awakening. AS cited reasons such as stress relief (79%), peer pressure (36%), influence from family members who smoke (40%), think better (35%), staying alert (57%), and relaxed (53%). Although 77% believed smoking worsened their asthma, they continued to smoke. Restlessness (43%), mood swings (27%), difficulties in concentration (25%) and irritability (24%) were common symptoms encountered in those who attempted to quit. About 44% did not refrain from smoking even when they were ill.

Conclusion:

Adult asthmatic smokers continued cigarette smoking to relieve stress, maintain mental alertness and avoid withdrawal symptoms. Implementing a programme to address smoking behaviour and withdrawal symptoms is paramount towards successful smoking cessation.
Effectiveness of Medication Review in Improving Medication Knowledge and Adherence in Primary Care Patients
Authors: Goh Bandy Qiuling , Tay Adeline Hsu Peng , Khoo Rachel Shu Yuen , Goh Boon Kwang , Lo Pauline Fei Ling , Lim Christina Jit Fan
Published: July 2015

Introduction:

Medication review by pharmacists can be an important educational intervention to improve adherence rates as it can potentially address many of its barriers. Medication review may also directly improve the patient's knowledge and understanding of his or her drug regimen. This study aims to assess the effectiveness of medication review as an intervention to improve a patient's knowledge and adherence to their chronic medications.

Methods:

Two hundred and forty patients from four polyclinics, who were referred by their prescribers for pharmacist-conducted medication review, were recruited for this prospective study. The effectiveness of medication review in improving their knowledge of and adherence to chronic medications was evaluated using a two-part questionnaire, which was applied before intervention and upon follow-up. The data collated was then analysed using Student's paired t-test, Chi-square and Pearson's correlation test.

Results:

Of the 195 patients who completed follow-up, 93.8% demonstrated medication knowledge deficits. Medication review conducted by the polyclinic pharmacists had improved the patients' overall understanding of their medications' dosage, frequency, indication, storage and administration method (p<0.01). Seventy point three percent of study patients had issues with medication adherence. Of these, half reported an improvement after medication review. There was significant correlation between the patients' knowledge and adherence scores (p<0.001).

Conclusion:

Medication review was found to be an effective intervention for improving patient's medication knowledge and reported adherence to chronic medications in this preliminary study. Further study demonstrating the effectiveness of medication review in cultivating knowledge retention and sustained adherence in the longer term is warranted.
A Unique Case of Spontaneous Secondary Pneumothorax (SSP) Occurring during an Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)
Authors: Low Lian Leng , Vasanwala Farhad Fakhrudin
Published: July 2015

Spontaneous secondary pneumothorax (SSP) is a known complication and can occur during an acute exacerbation of chronic obstructive pulmonary disease (COPD) to confuse an unsuspecting physician. These patients have limited cardiopulmonary reserve, so can deteriorate quickly and require urgent management. We describe a unique case of SSP that occurred during an acute exacerbation of COPD, to remind physicians of this possibility and to re-examine their patients who are not improving as expected with nebulisation therapy.
Simultaneous Orthognathic Surgery and Rhinoplasty for the Repaired Unilateral Cleft Lip and Palate Patient: A Case Report
Authors: Seah Tian Ee
Published: July 2015

Patients with repaired cleft lip and palate often require orthognathic surgery and rhinoplasty to achieve better aesthetics and function. Conventionally, rhinoplasty is performed as a staged procedure after orthognathic surgery. An online search by the author through PubMed and Google Scholar revealed one article describing simultaneous Lefort I osteotomy and rhinoplasty for a bilateral cleft lip and palate patient. This paper reports on a case of simultaneous Lefort I osteotomy, mandibular bilateral saggital split, genioplasty and rhinoplasty for a repaired unilateral cleft lip and palate patient. It also touches on certain operative considerations for the surgeon performing this operation.
Posterior Reversible Encephalopathy Syndrome and Anti-Angiogenic Therapy
Authors: Lam Justina Yick Ching , Ng Matthew Chau Hsien
Published: July 2015

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity first described in 1996 by Hinchey et al, most commonly associated with hypertensive encephalopathy, eclampsia in pregnant women, immunosuppressants and cytotoxic agents. In recent years, anti-angiogenic agents as a novel class of anti-cancer therapies have become a standard of care for certain tumours. Correspondingly, there have been an emerging number of case reports documenting PRES associated with these anti-angiogenic therapies. As the manifestations of PRES are often non-specific, but could rarely lead to permanent neurological disability or even death, it is crucial that physicians are aware of PRES in relation to anti-angiogenic therapy to promptly institute appropriate management to achieve the best outcomes for patients.
Abnormal Liver Function Test in a Patient with Polymyalgia Rheumatica
Authors: Ng Choon Ta , Khoo Ivan Yi , Boo Ho Chin , Tulsidas Haresh
Published: July 2015

Polymyalgia rheumatica is characterised by pain and stiffness of neck muscles, shoulder and pelvic girdles that is worse in the morning, generally accompanied by constitutional symptoms and an elevated erythrocyte sedimentation rate. Abnormal liver function is uncommonly associated with polymyalgia rheumatica. We describe a case of an elderly lady with polymyalgia rheumatica who presented with a history of early morning stiffness and pain in the lower limbs and markedly deranged liver function. She responded remarkably well to corticosteroid therapy with rapid improvement in her symptoms and normalisation of her liver function test.
Awake Craniotomy with Intraoperative MRI: Description of a Sedation Technique Using Remifentanil and Dexmedetomidine
Authors: Sim Eileen Yilin , Tan Tong Khee
Published: July 2015

We describe the anaesthetic management of a patient requiring intra-operative MRI and awake neurological testing during neurosurgical resection of a frontal tumour. This tumour involved her motor and speech areas. The anaesthetic drugs administered during awake craniotomy should be safe and allow appropriate changes in the level of sedation, so that the patient is adequately sedated during periods of intense surgical stimulus, yet awake, comfortable and cooperative during functional testing and tumour resection. We report the novel and successful use of a sedative — dexmedetomidine in combination with a narcotic, remifentanil. There has not been much experience with this combination locally. Dexmedetomidine, a selective alpha-2 agonist with sedative, analgesic and anaesthetic-sparing effect does not suppress ventilation. Patients are sedated, but can be easily roused verbally. Remifentanil is a useful choice in this surgery as it can be rapidly titrated according to level of surgical intensity and has a reliable context sensitive half life. Potential problems associated with awake craniotomy such as impaired ventilation during sedation, nausea, vomiting and seizures are discussed. These anaesthetic challenges are compounded by the challenges posed by the iMRI environment. Emphasis is placed on patient selection and preparation peri-operatively. This is crucial to the success of the operation.
Rabies Post-Exposure Prophylaxis (PEP) in a Major Tertiary Hospital in Singapore
Authors: Chua Ying Ying , Ang Wan Chen , Low Jenny Guek Hong , Wijaya Limin
Published: July 2015

Rabies is one of the most feared human diseases as it is almost uniformly fatal once clinical symptoms set in. The majority of deaths were due to a lack of rabies post-exposure prophylaxis (PEP). We review the profile of travellers to Southeast Asia (SEA) seeking rabies PEP in Singapore General Hospital (SGH). Thirty-seven patients visited our travel clinic for rabies PEP from Dec 2010 to Dec 2013. Their mean age was 27.0 years. Twenty-four (65%) received rabies PEP within 24 hours of exposure. Rabies immunoglobulin (RIG) was indicated in 28 cases (76%) but only half were administered; two-thirds were given in our clinic. Only two received rabies pre-exposure prophylaxis and both were non-residents. There is an urgent need to increase the awareness of potential rabies infection amongst Asian travellers.
Interventional Echocardiography: Current Role and Progress
Authors: Hamid Nadira , Ewe See Hooi
Published: July 2015

Advances in cardiovascular interventional techniques have enabled percutaneous treatment for a wide spectrum of non-coronary cardiovascular diseases, also known as ‘structural heart diseases (SHD)’. As these therapies are performed without an open-heart surgery, the use of echocardiography is crucial for detailed visualisation of cardiac anatomy, and to provide guidance for optimal success of these catheter-based interventions. This review will describe the key role of the echocardiographic techniques and imaging protocols that are currently used in different catheter-based SHD interventions.
The Appropriate Use of Percutaneous Coronary Intervention in Contemporary Clinical Practice
Authors: Chin Chee Tang , Wong Aaron Sung Lung
Published: July 2015

Percutaneous coronary intervention (PCI) is common and generally low risk. Although shown to be of significant benefit in certain clinical situations, especially in the context of acute coronary syndromes, there exist clinical scenarios where PCI has not been shown to be helpful. In these cases, the risk of periprocedural complications as well as longer term issues such as bleeding or stent thrombosis mean that PCI may potentially be harmful. To inform best clinical practice, we now have published recommendations with regards to the Appropriate Use Criteria (AUC) for coronary revascularisation. The goal of the AUC is to guide physician decision-making and future research as well as to label coronary revascularisation more clearly for patients and payors in regards to its expected benefits in certain situations. In this review, we summarise and discuss the more clinically relevant of these AUC, either because they are contentious or of particular relevance to the local context or practice. We conclude that there continue to be situations whereby inappropriate PCIs are performed, and these represent opportunities for quality improvement.
A Descriptive Study on Registered Nurses' Continuing Educational Needs in Research from Three Different Health Care Institutes in Singapore
Authors: Ang Shin Yuh , Kwan Xui Ling , Aloweni Fazila Abu Bakar , Aw Ai Tee , Tan Ai Meng , Chua Alice Foong Sin , Tay Rosaline Lee Hua
Published: July 2015

Introduction:

Nurses are encouraged to engage in research activities in order to stay abreast with the current nursing practice. However, limited knowledge about the research process may influence their level of involvement and utilisation of research in their daily nursing practices. This study examines Singapore nurses' perceived knowledge and educational needs in research as well as to explore their preferred mode and duration of education delivery.

Methods:

This is a multi-site, cross-sectional study that recruited 2248 registered nurses working in Singapore. A self-administered tool was used to examine nurses' perceived knowledge and educational needs in research. Descriptive statistics were used to present the nurses' demographic data; the Kruskal-Wallis and chi-square tests were used to examine the relationship between the nurses' education level and their perceived knowledge and educational needs in research.

Results:

Nurses in this study perceived low levels of knowledge in research. Majority of those who were involved in research activities had a bachelor's degree. There were statistically significant differences between education level and perceived knowledge (p=0.001). However, there was no significant difference between education level and perceived educational needs. Younger nurses (19–35 years old) preferred shorter duration when attending workshops compared to older nurses (36 years old and above). Skill-based workshop and tutorial or seminar that last no longer than a week was the most preferred educational mode and duration.

Conclusion:

Nurses with high level of education perceived a higher level of research knowledge and thus reported lower educational needs in research. The results showed the need for continual training programs, even for nurses with bachelor's and master's degrees, in order to better prepare them for evidence-based practice. Understanding the demographic of the nurses and their learning styles is important when devising strategies to teach research.
Peri-Anaesthetic Dental Injury in Children: A Retrospective Audit in a Tertiary Paediatric Centre
Authors: Tan Tracy Yi Shuen , Lim Suan Ling , Teo Pei-Fen , Ong Say Yang , Toh Siew Luan
Published: July 2015

Introduction:

Dental injury is one of the most common adverse events related to anaesthesia with a reported incidence of 0.04–0.1%. It is a frequent cause of anaesthesia-related medico-legal claim. To date, there is a lack of data in the literature on paediatric peri-operative dental injury. Accidental aspiration of the avulsed teeth into the bronchus is potentially life-threatening. Dental injury of permanent teeth in children also carries significant implications. The aim of this study is to determine the incidence, risk factors and outcomes of peri-anaesthetic dental injury in children following 80,811 general anaesthetics over a twelve-year period in our tertiary paediatric institution. This will aid in the prevention and management of peri-operative dental injury.

Methods:

A retrospective audit of our department audit database for incidents of dental injury was conducted from 1 January 2000 to 30 June 2011.

Results:

The incidence of dental injury was 42 out of 80,811 anaesthetics (0.05%). Incidence is highest in children aged 5–8 years old. The majority of dental injuries (83.3%) occurred during elective surgeries. Ninety-two per cent of the intubated patients had a grade 1 Cormack-Lehane larynx at laryngoscopy. Sixty-two per cent of the dental injuries occurred in patients with an inaccurate history. Six patients with dental injuries detected in the recovery had an inaccurate dental history.

Conclusion:

The incidence of dental injury in our paediatric centre is 0.05% and is comparable to that widely reported in the adult population. An accurate pre-operative dental assessment and documentation in the anaesthesia record should be obtained by the attending anaesthesia team. History from the child is vital. Better communication, minimal handover between staff and continuing education are important measures. A high index of suspicion of injury and knowledge of the patient's dentition state are critical for early intervention and minimising adverse events when dental injury occurs.