bluuebunny/crossref_metadata_2025 huggingface dataset:
Non-Alcoholic Fatty Liver Disease
Authors: Tan Hui-Hui , Chang Jason Pik-Eu
Published: July 2015

Non-alcoholic fatty liver disease (NAFLD) comprises a disease spectrum ranging from benign hepatic steatosis to non-alcoholic steatohepatitis with inflammation (NASH) and liver cirrhosis. NAFLD is now recognised as the hepatic manifestation of the metabolic syndrome. Simple steatosis is benign, whereas NASH can progress to cirrhosis with its resultant complications. Liver biopsy remains the gold standard in the diagnosis of NAFLD/NASH. Lifestyle and dietary modifications to achieve sustained weight loss is the cornerstone of NAFLD/NASH treatment.
Innovative Proven Clinical-Research Strategies for Participant Recruitment and Retention
Authors: Tong Shao Chuen , Tin Aung Soe , Lim Jeremy Fung Yen , Chow Wai Leng
Published: July 2015

The ability to successfully recruit and retain research participants is an important precursor to conducting a successful clinical trial. With respect to participant recruitment, we discuss potential strategies used in well-known and successful research studies to reach out to the targeted populations, including public education on the importance of clinical trials and the use of new media in reaching out to a wider population. The measures used by research studies to engage their participants and their healthcare providers to optimise participant retention are also examined. We conclude by discussing how these strategies may be adapted for use in Singapore.
An Uncommon Cause of Abdominal Pain and Vomiting in a 55-Year-Old Woman
Authors: Chang Jason Pik-Eu , Cheng Lionel Tim-Ee , Low Albert Su-Chong
Published: July 2015

Abdominal pain is a symptom that is commonly encountered in clinical practice. Evaluation of abdominal pain involves the exclusion of a myriad of possible diagnosis. This case illustrates an uncommon cause of abdominal pain and vomiting in a 55-year-old female with diagnostic radiological features.
Neonatal Seizures: When to Consider and How to Investigate for an Inborn Error of Metabolism
Authors: Chan Derrick Wei Shih , Tan Ee Shien , Cleary Maureen Anne
Published: July 2015

Seizures occur more frequently in the neonatal period than in the remainder of childhood. Neonatal seizures can have different aetiologies. Inborn errors of metabolism are rare causes of seizures in the newborn. However, they are an important cause of intractable neonatal seizures, accounting for 30% of cases. Diagnosis is necessary for timely institution of appropriate treatment and is important in determining clinical outcome. As these are genetic conditions, it allows for appropriate genetic counselling. We describe the clinical presentation of neonatal seizures and the investigation findings in symptomatic neonatal seizures and epilepsy syndromes that arise in the neonatal period. The approach in diagnosis and investigation of an underlying inborn error of metabolism is described and inborn errors of metabolism that are important causes of neonatal seizures are reviewed.
Procedural Sedation and Analgesia in Children: Perspectives from Paediatric Emergency Physicians
Authors: Tham Lai Peng , Lee Khai Pin
Published: July 2015

Procedural sedation and analgesia in children is now widely practised in many emergency departments internationally. In this article, we address the general principles, indications, guidelines, medications, adverse events and future research in paediatric procedural sedation and analgesia in the Emergency Department.

Procedural sedation and analgesia is the use of sedative, analgesia and dissociative drugs to provide anxiolysis, analgesia, sedation and motor control during painful or unpleasant diagnostic and therapeutic procedures. It is a continuous spectrum from mild, moderate, deep sedation and then general anaesthesia. Dissociative sedation from ketamine is also commonly used.

Internationally, major clinical guidelines have been issued and revised since the 1980s. The guidelines should include the following components and documentation: pre-sedation assessment, intra-procedural monitoring and post-procedural monitoring and discharge criteria. The pre-sedation assessment involves assessing suitability of patient as candidate for sedation, any contraindications, fasting time, ensuring that the necessary equipment and drugs are available and the personnel providing the sedation are skilled in sedation and resuscitation.

The common medications for sedation in the emergency departments include ketamine, midazolam, fentanyl, morphine, oral chloral hydrate and nitrous oxide inhalation. Propofol and etomidate are used widely in some of the paediatric emergency departments internationally.

Procedural sedation has been documented to be safe and effective when performed by trained emergency physicians. The overall incidence of complications was 5.3% in a large prospective study, including airway and respiratory events (laryngospasm, apnoea, desaturations) and emesis. Aspirations are rare complications. Though the risks of adverse events are not high, emergency physicians need to have core competencies in sedation and resuscitation skills. The future of procedural sedation and analgesia will focus on enhancing training, safety and effectiveness.
Elderly Fallers: What Do We Need to Do?
Authors: Lim Si Ching
Published: July 2015

Falls are very common among the elderly. Furthermore, the incidence of falls increases as the age increases. As clinicians, we encounter elderly fallers very frequently in the outpatient clinics, accident and emergency departments as well as the inpatients. The approach to managing elderly fallers is often complex and time consuming. The inpatient fallers carry with them the possibility of complaints from family members and often cause a lot of fear and guilt among the hospital staff.
Use of Recombinant Factor VIIa in Gastrointestinal Bleeding in Children with Malignancies: A Case Series
Authors: Lee Jan Hau , Ng Heng Joo , Chan Mei Yoke
Published: July 2015

Recombinant factor VIIa (rFVIIa) may be useful in management of severe bleeding in paediatric oncology patients. We described our experience and outcomes in a form of a case series. In all cases, indication was massive gastrointestinal bleeding with haemodynamic instability, persistent thrombocytopenia and coagulopathy despite correction. The range of doses used was 88–102 mcg/kg/dose. Each patient received at least 3 doses. The use of rFVIIa resulted in a reduction in blood product support requirement. rFVIIa was effective in 2 out of 3 patients in stopping the bleeding. There were no drug-related complications. rFVIIa has a critical role to play in the early management of severe bleeding in critically ill paediatric oncology patients.
Low Back Pain in Changi General Hospital: An Observational Study
Authors: Goh Ming Rong , Po Ivy Yee Yeung , Olafsdottir Karolina
Published: July 2015

Aims:

The aim is to study the profile of local low back pain (LBP) patients and their physiotherapy management in an outpatient physiotherapy clinic.

Methods:

A retrospective study was done with records of LBP patients attending the Musculoskeletal Physiotherapy Clinic at Changi General Hospital from January to June 2009. Age, LBP onset, occupation, time off work, investigation results, and functional outcomes were obtained.

Results:

Ninety-four records were screened. Majority of patients (59.6%) were aged between 30–50 years old. Sixty-six percent were engaged in occupations that involved sustained postures. Majority of patients (91.5%) had minor/no trauma in association to the onset of their symptoms. Although majority of patients (64.9%) did not take any time off work to manage their LBP, a total of 640 days were lost off work due to LBP. Majority of patients (93.6%) underwent radiological investigations. There was no significant correlation between radiating symptoms and presence of nerve root compression on MRI (p = 0.144). In addition, pathology did not significantly impact on rehabilitative outcome in our sample (p = 0.397, p = 0.602). A review of clinical practice with regards to ordering radiological investigations may be required to minimise radiation exposure and increase cost effectiveness. Patients improved from a mean of 4.00 to 9.10 on the Patient Specific Functional Scale (PSFS) within an average of 3.65 sessions. There was a significant relationship between earlier onset of therapy and better functional improvement on the PSFS (r= −0.299, p = 0.026). Starting a physiotherapy service in our accident and emergency department may be a good consideration to implement in our hospital.

Conclusions:

Sustained postures may contribute to LBP in local patients. Disability and time lost off work as result of LBP appears to be a significant problem locally. Radiology has no correlation with symptoms, nor rehabilitative outcomes. Pathology may have only limited value in determining treatment or prognosis in nontraumatic LBP. A tailored physiotherapy approach towards education, manual therapy and exercises may be effective in improving functional capabilities in local LBP patients. Earlier onset of physiotherapy is associated with better functional recovery in LBP patients.
The Role of Resistance Training in Distance Running
Authors: Tan Philip
Published: July 2015

The main determinants of distance running performance include V̇O2max, lactate threshold (LT), and running economy (RE). The conventional way to achieve improvements in these areas is through endurance training due to the principle of training specificity. Some physiologists believe that the addition of resistance training is beneficial to distance running in the form of injury prevention and preparing runners for pace surge and sprint finishes. To date, it is consistent among findings that resistance training does not improve nor compromise V̇O2max in trained distance runners while LT improvements are only found in untrained individuals. RE has been shown to improve significantly post resistance training possibly due to neuromuscular changes including a shortening of the stretch-shortening cycle and an increase in muscle stiffness. The primary purpose of this review is to understand the impact of resistance training on the various factors known to affect distance running performance and to recommend resistance training guidelines for the distance runner to adhere to.
Inguinal Hernias: A Current Review of an Old Problem
Authors: Chiow Adrian Kah Heng , Chong Chee Keong , Tan Su-Ming
Published: July 2015

The repair of groin hernias are amongst the most commonly performed procedures by the general surgeon today, with almost as many types of repairs as there are hernias.

Inguinal hernias account for 75% of all abdominal wall hernias with a lifetime risk of 27% in men and 3% in women1. Repair techniques have evolved from open suture methods to mesh repairs done either open or laparoscopically, translating to improved patient care and decreasing complications associated with hernia repair.

This article is intended to provide an overview of the presentation and latest evidence based guidelines for the management of inguinal hernias.
Dietary Supplements Used in Osteoarthritis
Authors: Bee Tan Ai , Liew Angeline
Published: July 2015

Osteoarthritis (OA) is the most common form of arthritis and is associated with a high economic burden. Conventional pharmacologic agents are limited by their inability to alter disease progression and are associated with an adverse safety profile. A number of dietary supplements are marketed for treatment of OA. Glucosamine is one of the most commonly used supplements for OA and most research suggests that glucosamine sulfate can improve symptoms of pain related to OA, as well as slow disease progression in patients with OA of the knee. Chondroitin sulphate (CS) also appears to reduce OA symptoms and there is some evidence that CS may have a role as a structure-modifying agent in the management of patients with knee OA. Several other supplements are promoted for treating OA, such as methylsulfonylmethane, Perna canaliculus (green-lipped mussel), Zingiber officinale (ginger), Harpagophytum procumbens (devil's claw), Curcuma longa (turmeric), and Boswellia serrata (frankincense), but more evidence regarding long-term efficacy or safety are required.
Factors Influencing Costs of Inpatient Ischaemic Stroke Care in Singapore
Authors: Chow Wai Leng , Tin Aung Soe , Meyyappan Amutha
Published: July 2015

Introduction:

Stroke is a major public issue in Singapore, accounting for almost 10,000 admissions annually and the burden of disease is set to increase with an ageing population. We therefore seek to examine the factors influencing the cost of acute stroke care in Singapore.

Methods:

This is a retrospective analysis of 2,087 discharges with a primary discharge diagnosis of stroke from a tertiary hospital in Singapore from 1 January 2007 to 31 December 2008. Data including age, gender, length of hospital stay, components of direct cost and discharge disposition were obtained. A generalised linear model with a log link function and gamma distribution was used to determine the predictors of total hospital cost.

Results:

Mean age was 67.8 ± 12.4 years and 54.5% were males. Mean length of stay was 12.3 ± 16 days and mean total overall cost was S$6,783. Ward costs accounted for 48% of total cost. Length of stay strongly correlated to total cost. Being discharged to step-down facilities, death, receiving inpatient rehabilitation and length of stay significantly incurred higher total cost in multivariate analysis. However, there was an inverse relationship between age and total cost, possibly as a result of higher costs incurred for radiological, laboratory investigations and expert care.

Conclusion:

Further research is needed to examine factors influencing the cost of treatment particularly for those being discharged to step-down facilities and receiving inpatient rehabilitation as they have been found to incur higher total cost. This would impact on the planning of the continuum of healthcare facilities for stroke management.
Making Sense of Kleptomania: Clinical Considerations
Authors: Chee Kuan Tsee , Sim Kang , Lee Tih Shih , Ng Beng Yeong
Published: July 2015

An understanding of the historical roots, clinical features and current diagnostic criteria of kleptomania would help in a better appreciation and assessment of this condition. One of the few psychiatric conditions that is defined by an illegal activity, kleptomania has been classified as one of the impulse control disorders under ICD-10 and DSM IV-TR. In terms of assessment, it is not sufficient merely to look at the operational criteria. One should take a complete history and probe for predisposing factors including childhood development and behaviour, previous relationships, losses, and habits. It is also necessary to detect current stressors and concomitant symptoms or disorders that may precipitate and perpetuate the condition. Some of the diagnostic criteria are based on subjective claim or report which may be unreliable. The use or value of the articles stolen is relative but may be easier to assess. As a guide, kleptomania should be a diagnosis by exclusion of other contributing disorders. When other contributing symptoms/disorders such as depression are present, care should be exercised before a diagnosis of kleptomania is made.
Revisting Cerebrospinal Fluid (CSF) Examination
Authors: Yap Clementine YF , Aw Tar Choon
Published: July 2015

Routine cerebrospinal fluid (CSF) examination bears re-visiting as the body of knowledge has expanded and numerous new analytes touted as potential markers of CNS (central nervous system) diseases have emerged. Currently, visual assessment of CSF, microscopic examination for pathologic cells, and biochemical analysis for protein and glucose form the basis for routine CSF analysis. Further investigations that may be warranted include microbiology work-ups for CNS infections and immuno-detection for oligoclonal bands for multiple sclerosis. European guidelines for CSF analyses are available. CSF testing for other neurologic disorders (e.g. Parkinson's disease, Alzheimer's disease, and amyotrophic lateral sclerosis) while promising are not ready for prime time.
Evidence-Based Medicine for Traditional Chinese Medicine: Exploring the Evidence from a Western Medicine Perspective
Authors: Linn Yeh Ching
Published: July 2015

This article reviews the evidence of clinical efficacy of Traditional Chinese Medicine (TCM). Extracts from single herbs have been studied by the conventional path of drug discovery to become useful drugs in Western Medicine (WM), testifying to the pharmacological activity of herbs used in TCM formulations. Complex formulations prescribed in accordance to the principles of TCM have been in use for centuries. Much effort has been made in proving its efficacy by the criteria of Evidence Based Medicine (EBM). Problems peculiar to adopting such an approach for TCM is discussed, including issues inherent to TCM as well as the lack of well conducted randomised controlled trial to provide robust evidence. As a result the purported efficacy of TCM treatment for many conditions could not be validated by EBM criteria. A selection of studies and meta-analyses providing convincing evidence to the efficacy of some TCM treatment is cited in this review. Improved methodology and reporting in TCM clinical trials will be essential in establishing the role of TCM in the management of certain defined diseases and complementing current Western medical treatment.
Putting Health Services Research into Practice
Authors: Chow Wai Ling , Lim Jeremy Fung Yen
Published: July 2015

Health services research (HSR) seeks to shed light on healthcare as a system, focusing on the cost of, the quality of and access to health services. While there is recognition that the practice of medicine should be evidence-based, there has been limited progress in implementing evidence-based healthcare management. This review proposes a conceptual framework of putting HSR into practice through culture change; human capability capacity building and sustaining change via a supportive environment and reinforcing infrastructure
Should Chemotherapy Be Administered for Essential Thrombocythemia (ET) Patients with Leukemic Transformation?
Authors: Wong Gee Chuan
Published: July 2015

Introduction:

Essential Thrombocythemia (ET) is a clonal myeloproliferative disease presenting predominantly with thrombocytosis. One of its rare complications is leukemic transformation (LT). Once leukemic transformation occurs, prognosis is dismal. We aim to determine the disease profile of LT in our ET patients and evaluate if chemotherapy can alter prognosis.

Methods:

Clinical data of all patients diagnosed and treated with ET from 1999 to 2008 in the Department of Hematology, Singapore General Hospital, were captured in the Myeloproliferative Disease(MPD) Registry. ET patients with LT were selected. Patient characteristics, disease profile, including ET treatment, duration from ET diagnosis to LT, prior myelofibrosis (MF) history, type of chemotherapy, response and eventual survival were recorded.

Results:

Two hundred and thirty ET patients were diagnosed and treated from 1999 to 2008. Six patients had LT (2.6%). All were Chinese. Four were females. Age range was 47–70 years (mean 61.2 years). Transformation to acute myeloid leukemia (AML) was seen in 5 patients, after a latency period of 3–28 years. Acute biphenotypic leukemia was diagnosed in 1 patient 4 years after ET diagnosis. All patients had received hydroxyurea. There was no prior evolution to MF. Complex cytogenetics were seen in all cases. Three patients treated conservatively died within 1 month. The other 3 patients did not go into durable complete remission despite chemotherapy and succumbed within 9 months.

Conclusions:

Leukemic transformation in ET, though rare, is associated with grave prognosis. Outcome with chemotherapy is dismal. More studies are needed to evaluate if alternative treatment can improve survival.
Do We Have the Right Prognostic Index for Diffuse Large B Cell Lymphoma (DLBCL) in the Era of Rituximab?
Authors: Tai WM , Tang PL , Koo YX , Hou X , Tay KW , Quek R , Tao M , Lim ST
Published: July 2015

Introduction:

Whilst the addition of rituximab, a humanized monoclonal antibody to standard CHOP chemotherapy (R-CHOP) has improved the outcomes of DLBCL, the validity of the previously identified prognostic index based on clinical parameters is questioned. It is conceivable that prognostic model may alter with introduction of new therapeutics with differing efficacy and mechanisms of action.

Methods:

We conducted a retrospective analysis comparing the relevance of International Prognostic Index (IPI), Age-adjusted IPI and Revised International Prognostic Index (R-IPI) in 320 consecutive patients with DLBCL from 2003–2008 treated with R-CHOP chemotherapy with curative intent. We evaluated the prognostic factors determinant of survival in our group of patients.

Results:

Patients were followed up for a median of 2.70 years. IPI was only able to stratify patients into 3 main risk groups instead of 4. In addition, among patients <60, aa-IPI no longer seem a robust prognostic model. We showed that R-IPI was able to separate patients into 3 different prognostic groups and perhaps most relevant in the era of chemo-immunotherapy. Significant prognostic factors identified in multivariate analysis were performance status (P=0.004) and bone marrow involvement (P=0.026).

Conclusion:

The most robust prognostic index for patients with DLBCL in the era of rituximab remains uncertain. Incorporation of molecular markers into clinical parameters should be evaluated, a study we are embarking on.
A Missing C-Spine Link: Mind the Gap
Authors: Tan Wu Meng , Ng Quan Sing , Soh Lay Tin
Published: July 2015

A woman presented with metastatic breast cancer, having extensive lytic bony involvement of C2 vertebra and limited symptoms. We present the radiologic findings and case history.
Free Kappa and Lambda Light Chains in Plasma Cell Dyscrasias
Authors: Yap Clementine YF , Wong Pey Wah , Aw Tar Choon
Published: July 2015

Automated serum kappa (κ) and lambda (λ) free light chain (FLC) immunoassay may be used as a rapid screening tool for multiple myeloma and other light chain diseases as it is more sensitive and robust than serum protein electrophoresis (SPE) and urine immunofixation electrophoresis (IFE). Serum FLC enables earlier diagnosis and evaluation of tumour response to therapy. Serum FLC testing has been incorporated into an international guideline for all newly diagnosed plasma cell cancers for diagnosis, prognosis, monitoring and assessing treatment.
Thyroid Function Tests
Authors: Aw Tar Choon , Yap Clementine YF
Published: July 2015

A thyroid panel consisting of thyroid stimulating hormone (TSH) and free thyroxine (fT4) should form the first line of diagnostic tests; tri-iodothyronine (T3) — total or free may be needed occasionally. A TSH assay capable of detecting levels below 0.02mIU/L is required to differentiate the suppressed TSH levels typical in Graves' disease from subnormal levels seen in some geriatric patients, non-thyroidal illness, and patients on medications. Additional tests including thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TgAb), and TSH receptor antibody (TRAb) may be ordered to enable differential diagnosis when indicated. Serum thyroglobulin (Tg) may serve as a tumour marker for monitoring patients with differentiated thyroid cancer.
Threatening Airway Obstruction by Mediastinal Masses: The Experience of a Medical Intensive Care Unit
Authors: Hsu Anne Ann Ling , Phua Ghee Chee
Published: July 2015

Objective:

Life-threatening airway obstruction is a dreaded complication of mediastinal masses. The acute management is difficult and catastrophic outcomes have been reported. We describe our experience in a Medical Intensive Care Unit (ICU) and discuss the management options.

Design:

Retrospective observational study.

Setting:

1,600-bed tertiary-care hospital.

Patients and Participants:

13 patients were treated between January 1996 and February 2010.

Interventions:

All patients were mechanically ventilated. Three received emergent chemotherapy, 10 underwent airway stenting and 2 underwent surgery.

Measurements and Results:

The median age was 51 years (range 13 to 64). In 5 patients (36%), the diagnosis was only made after ICU admission. Two had benign pathologies (retrosternal goitre and bronchogenic cyst) and 3 had lymphoma. The remaining 8 had metastatic mediastinal lymphadenopathy. All were successfully weaned off the ventilator (range 0 to 5 days). All patients with benign pathologies and lymphoma were still alive with a mean follow-up of 2.8 years (range 1 to 7 years). All patients with metastatic disease died, with a mean survival of 3.8 months (range 1 to 9 months).

Conclusion:

In the management of life-threatening airway obstruction by mediastinal masses, we reported the heterogeneous nature of this group of conditions. Therefore in the intensive care setting, a definitive diagnosis needs to be established urgently, as treatment and prognosis are highly dependent on the underlying etiology. We propose categorising patients into subgroups and combining various therapeutic modalities.
A Pilot Study of the Effects of Music Listening for Pain Relief among Burns Patients
Authors: Kahar Noor Ahsikin Binte Ab , Kanageswari  , Tay Yong Bee , Koh Khee Xuan
Published: July 2015

Introduction:

The aim of this pilot study was to assess the effects of music listening for pain relief among burns patients during the change of dressings.

Methods:

Quasi-experimental study was conducted to evaluate if music helps in reducing the intensity of pain experienced by burns patients during wound dressing procedures. A convenience sample of 30 dressing changes were involved. Each dressing change was alternatively assigned to control (not listening to music) and treatment (listening to music) groups. Three assessment tools were used, namely: numeric pain scale, pain behavioural tool, and physiological monitoring. Patients who were given music to listen to were also asked about their experience at the end of the dressing change.

Results:

Most of the patients experienced little or no pain before dressing change, moderate pain during dressing change and lesser pain thereafter. There were no statistically significant differences in the pain experienced between wound dressing changed with no music listening and wound dressing changed with music listening. Despite a greater proportion of patients being distressed during wound dressing changes without music listening, there was no statistical evidence that music listening had an effect on the patient's distressed status. For wound dressing changes with music listening, patients experienced a lesser degree of change in mean blood pressure and heart rate (not statistically significant) as compared to wound dressing changes without music listening.

Conclusion:

Preliminary results from this pilot study demonstrated that listening to music might have a positive effect on patient's experience of pain. Large studies are needed to evaluate the impact of music. However many patients verbalised that the soothing music helped to distract them from the pain experience during the dressing changes.
The Use of Individual Performance Metrics to Reduce Prescription Errors in the Emergency Department
Authors: Tiah Ling , Lee Wee Yee , Tiruchittampalam Mohan
Published: July 2015

Introduction:

The study emergency department (ED) receives a new cohort of junior doctors every 6 months as part of the national manpower allocation to meet health service needs. An approach to effect a consistent reduction in prescribing errors by these doctors during their 6-month postings at the study ED was introduced in May 2009.

Methods:

Monthly broadcasting of prescribing error counts by individual doctors allowed performances to be openly benchmarked against one another while providing a reference for self-improvement. The monthly tally of absolute counts were computed into a pre-determined formula and translated into monetary rewards for the junior doctors. Control charts of total count per month, mean count per doctor per month and highest individual count per month were plotted based on a total of 48 data points for 8 cohorts over 4 years from May 2007 to April 2011.

Results:

There was a shift towards fewer absolute counts and lower mean count of prescribing errors per month in the post-intervention phase, suggesting a positive impact of the intervention on the doctors as a cohort. The intervention's impact on individual performances, however, was less convincing with minimal change in variation in the highest individual count per month over the 4 years.

Conclusion:

The use of metrics has helped to drive and sustain a reduction in prescribing errors among junior doctors as a cohort during their 6-month postings in the study ED.
Heparinised Saline versus Normal Saline in Maintaining Patency of Arterial and Central Venous Catheters
Authors: Goh Ling Jia , Teo Hui Sin , Masagoes Masayu
Published: July 2015

Introduction:

Heparin has been used in flush solutions in attempts to prolong the patency of arterial and central venous pressure monitoring lines. Its use however is not without risks such as hypersensitivity reactions and heparin-induced thrombocytopenia. Recent studies suggest that non-heparinised solutions may be as effective in maintaining catheter patency. Our aim is to determine if there is any difference in maintaining patency of arterial and central venous pressure monitoring lines using normal saline as compared to heparinised saline.

Methods:

In this randomised controlled trial, patients were randomised to receive either heparinised saline or normal saline flush solutions. Randomisation was achieved using sealed opaque envelopes. Only nurses who had been specially trained in the care of catheters cared for the lines. Data was collected at 8-hour intervals for up to 120 hours post-insertion on acceptability of arterial waveform and presence of backflow of blood in the arterial and central venous lines.

Results:

A total of 70 patients were enrolled, with 36 in the normal saline group and 34 in the heparinised saline group. There were no differences between the groups in functionality of the arterial catheters as determined by waveform and backflow at 72 hours (p=0.578) and 120 hours (p=0.328) as well as for the venous catheters at 72 hours (p=0.063) and at 120 hours (p=0.173) based on presence of backflow.

Conclusion:

Normal saline is as effective as heparinised saline as flush solutions. Eliminating heparin use in flush solutions will result in fewer potential adverse events and cost savings.
Mind Your Back
Authors: Chan Shaun , Tan Suan Cheng , Ong Keh Oon , Chan Ling Ling
Published: July 2015

Spinal fractures can be potentially unstable and they may result in significant morbidity. Appropriate and prompt imaging plays an important role in the management of these patients by delineating the anatomy, extent of injury and associated complications. We present a simple case of a vertebral burst fracture to illustrate the role of imaging.
Managing Cardiovascular Incidents in the Intra-Operative Magnetic Resonance Imaging (iMRI) Environment: Lessons from Three Case Studies
Authors: Zheng Jin Xi , Tan Tong Khee
Published: July 2015

In recent years, the use of magnetic resonance imaging (MRI) has extended into the operating theatre, especially in the field of neurosurgery. By providing real-time images during surgery, intra-operative MRI (iMRI) facilitates safer and more complete brain tumour resection. However, the iMRI environment poses additional challenges to the anaesthetist when managing intra-operative cardiovascular events. Through three case examples, this article will discuss the issues of cardiovascular resuscitation, cardiac pacing and cardiovascular monitoring in the iMRI environment.
Assessment and Management of Dry Eye Patients for Non-Ophthalmic Healthcare Practitioners
Authors: Tong Louis , Petznick Andrea , Lee Sze Yee , Tan Jeremy
Published: July 2015

Dry eye is a very common condition in many parts of the world. Both ophthalmologists and other healthcare professionals, such as optometrists and general practitioners, are often involved in the care of these patients. The main thrust of dry eye management is over-the-counter tear lubricants. There is a wide range of tear lubricants available today. These lubricants vary in viscosity, duration of action, type of preservatives, osmolarity/osmolality and pH. This article aims to educate healthcare professionals on 1) how to assess and manage patients with mild to moderate dry eyes and 2) how to identify patients who may need a referral to an ophthalmologist. Strategies on the use of available treatments and their limitations, as well as factors that may affect patient compliance will be discussed.
Ocular 'Roid Rage
Authors: Ho Henrietta , Perera Shamira A , Aung Tin
Published: July 2015

Corticosteroids use can cause raised intraocular pressure (IOP), leading to glaucoma. We present a case report of steroid induced glaucoma in a young male with keratoconjunctivitis (VKC). Our patient was uncompliant with instructions to stop steroid use, initially started for VKC treatment, and required aggressive medical and surgical intervention for IOP control. He eventually progressed to severe glaucomatous optic neuropathy and eventual tunnel vision. Steroid induced glaucoma is an important and frequently encountered condition in ophthalmology clinics. This report serves to remind all physicians of the dangers of steroid eye drop usage.
Case Series of Single Stage Immediate Implant Placements into Fresh Extraction Sockets of Mandibular Molars
Authors: Yong Loong Tee
Published: July 2015

Immediate implant placement into fresh extraction sockets of mandibular molars requires good case selection, detailed clinical and radiographic examination as well as adequate clinical experience and judgement. This paper describes a standard protocol adopted by a single Oral and Maxillofacial Surgeon from the Department of Oral and Maxillofacial Surgery, National Dental Centre Singapore, as applied to a series of four cases.
Ten-Year Outcomes of Kidney Transplants at the Singapore General Hospital
Authors: Mok Irene Yanjia , Kee Terence , Goh Angeline
Published: July 2015

Renal transplantation is the treatment of choice for kidney failure. This study analyses the outcomes of kidney transplant recipients whose transplant was performed at the Singapore General Hospital from January 2000 to 31 December 2010, and who have had at least a year of follow-up in the hospital. Patient demographics, recipient and donor characteristics, graft and patient outcomes were extracted from patients' electronic and hard copy medical records. Graft and patient survival were calculated by Kaplan-Meier analysis until return to dialysis or patient death.

There are 332 deceased donor (DD) and 118 live donor (LD) kidney transplants included in this study. Majority of our transplant recipients were Chinese males, and the most common etiology of renal failure was chronic glomerulonephritis. DD recipients were significantly older than LD recipients (45.3+8.2 years vs. 36.9+11.7 years, respectively, P <0.001), and also had a significantly longer duration of dialysis (8.6+2.6 years vs. 2.3+3.5 years, respectively, P <0.001). Majority were on haemodialysis prior to transplantation. DD were significantly older than LD (45.7+8.2 years vs. 37.1+11.8 years, respectively, P <0.001); 73.2% of our DD were standard criteria donors. Graft survival at 5 years was 80.8% and 96.5%, and 65.9% and 79.4% at 10 years for DD and LD transplants, respectively. Patient survival at 5 years was 91.5% and 82.7%, and 99.1% and 84.7% at 10 years for DD and LD transplants, respectively. LD recipients had improved graft and patient survival compared to DD recipients, reinforcing LD kidney transplantation as the treatment of choice for patients with end-stage renal failure.
An Introduction to Extracorporeal Blood Purification in Critical Illness
Authors: Lim Cynthia Ciwei , Tan Han Khim
Published: July 2015

Critical care nephrology is an emerging sub-specialty with rapid technological advancement and a growing body of dedicated literature in blood purification techniques. Their applications have been extended to improve morbidity and survival in multiple organ dysfunctions. Novel techniques have also allowed us to push the frontiers in transplant medicine, giving high-immunological risk patients a chance at a kidney transplant where this was previously precluded by hyperacute antibody-mediated rejection. We aim to review the myriad extracorporeal blood purification techniques now available for treating various critical illnesses in our clinical practice. Some of these techniques will still require further clinical research to determine the optimal timing and dose in order to achieve significant improvement in clinical outcomes.
An Unusual Cause of Mediastinal Mass — A Case Report and Literature Review of Intrathoracic Kidney
Authors: Chong Siew Le , Chao Sing Ming
Published: July 2015

Posterior mediastinal mass is not an uncommon condition seen in clinical practice. It often generates anxiety among healthcare providers, as the most common cause of a posterior mediastinal mass is a neurogenic tumour which potentially can be malignant and carries serious consequences. A very rare but generally benign cause of such a mass is an intrathoracic ectopic kidney. Due to its rarity, literature on the intrathoracic kidney, its management, prognosis and complications is sparse and confined to case reports. We report a rare case of a two-month old baby who had a chest x-ray done for a prolonged cough and was found to have a posterior mediastinal mass, which was later diagnosed to be an intrathoracic ectopic kidney. The approach to mediastinal mass and literature review of an intrathoracic ectopic kidney and its complications are also discussed.
Clinical Use and Measurement of Cardiac Troponin (cTn)
Authors: Yap Clementine YF , Phua Soon Kieng , Aw Tar Choon
Published: July 2015

Cardiac troponins are cardio-specific and are widely used for the early diagnosis and triage of patients with acute coronary syndromes in conjunction with clinical history, electrocardiographic changes and imaging. Troponin is also useful for the prediction of outcomes in acute coronary syndromes, renal failure, sepsis, and critically ill patients. New developments in assay technology, designated as high sensitivity troponins, permit detection of lower levels of troponin in most healthy individuals, earlier diagnosis of myocardial infarction, and prognosis of stable coronary disease in the community.
Knowledge and Attitudes of Junior Medical Doctors towards Gastric Cancer
Authors: Goh Boon Bee George , Tan Meng Yew Damien , Ling Khoon Lin
Published: July 2015

Introduction:

Gastric cancer (GC) has considerable morbidity and mortality in Singapore. As doctors play an important part in persuading patients to undergo screening, and as screening may have an important role in diagnosing early GC, we sought to determine the knowledge and attitudes of doctors towards GC and GC screening.

Methods:

Self-administered questionnaires were distributed to a cohort of junior doctors in Singapore General Hospital.

Results:

There were a total of 104 respondents; 82.5% of respondents felt that GC is common in Singapore. While most risk factors (RF) were identified correctly, knowledge of dietary RF was deficient, with only 34.3% and 36.5% realising that a high salt diet and low vegetable/fruit intake were RF, respectively. 95.1% knew that GC can be asymptomatic, but if detected early, is potentially curable (97.1%). Majority of respondents felt that GC was best diagnosed by endoscopy and the best time to diagnose it was when asymptomatic. However, only 52% of the respondents felt that screening gastroscopy was worthwhile. For those willing to pay for screening gastroscopy, the mean cost they were willing to pay was S$243.

Conclusion:

Our results show that while most RF of GC are well recognised, knowledge of dietary factors is deficient. There is ambivalence towards screening gastroscopy despite knowing that GC is common in Singapore and can be asymptomatic. This may be a barrier to tackling the problem of GC in Singapore. Before we recommend any GC screening programmes in the future, it may be important to optimise knowledge and change the mindsets of doctors in Singapore towards GC.
Current Status of Direct Endoscopic Necrosectomy
Authors: Ang Tiing Leong
Published: July 2015

The management of pancreatic necrosis has evolved. Sterile necrosis is now managed conservatively. Intervention is generally required for infected necrosis but is now deferred until four weeks after disease onset in order to permit encapsulation and demarcation of the necrotic collection. Demarcation facilitates necrosectomy and reduces complications related to the drainage and debridement procedures. The approach to pancreatic necrosectomy has evolved from primary open necrosectomy to minimally-invasive radiologic, surgical and endoscopic procedures. Direct endoscopic necrosectomy is a minimally-invasive technique that was introduced in recent years for the treatment of infected walled-off necrosis. A stoma is created endoscopically between the gastric lumen and the walled-off collection. An endoscope is then inserted directly into the cavity to perform endoscopic necrosectomy. This is followed by short-term placement of double pigtail transgastric stents and nasocystic catheter for post-procedural irrigation and drainage. This review will summarise the current status of direct endoscopic necrosectomy.
Killing Two Birds with One Stone: Subclavian Vein Bypass Graft for Relief of Venous Obstruction and Haemodialysis Access
Authors: Koh Kar Wee , Chanyaputhipong Jendana , Tan Seck Guan
Published: July 2015

Subclavian and brachio-cephalic vein stenosis or occlusion occurs, most commonly, as an iatrogenic complication of the placement of central venous catheter. This occurrence can cause ipsilateral arm swelling in a newly-created arteriovenous fistula (AVF). Critical central vein stenoses are often successfully managed by endovascular approach; occasionally, complete occlusion with symptomatic severe arm swelling and pain that does not respond to angioplasty requires ligation of the dialysis access. We report successful surgical management of an end-stage-renal-failure (ESRF) patient with symptomatic subclavian vein occlusion refractory to angioplasty in an ipsilateral arm with an existing functional brachio-basilic transposition arteriovenous fistula by performing a basilic to internal jugular vein (IJV) bypass graft, relieving both the arm swelling and salvaging the existing vascular access for future haemodialysis.
Gastric Pacing in a Child with Severe Gastroparesis and Review of the Literature
Authors: Ong Christina , Logarajah Veena
Published: July 2015

Gastroparesis is a disorder characterised by symptoms of and evidence for gastric retention in the absence of mechanical obstruction. Symptoms include nausea and vomiting, early satiety, postprandial fullness, regurgitation and abdominal pain. Common causes of gastroparesis are diabetes, post-surgical and idiopathic. In some patients, gastroparesis can be very severe and refractory to medical therapy including anti-emetics, anti-reflux and pro-kinetic medications. Gastric electrical stimulation represents a novel treatment for severe gastroparesis by regulating gastric electrical dysfunction with a neurostimulator. In adult studies, vomiting frequency has been reduced by up to 81% from baseline. We report a case of a 13-year-old girl with life-long severe idiopathic gastroparesis who was successfully treated by gastric pacing.
Obstructive Uropathy in a Child with Severe Chronic Constipation
Authors: Logarajah Veena , Phua Kong Boo , Yap Te Lu , Ong Christina
Published: July 2015

Urinary symptoms are well-described in children with chronic constipation which include enuresis, urgency and recurrent urinary infections. Renal tract obstruction is a rare complication of severe chronic constipation. We describe a case of a 10-year-old boy with a history of long-standing constipation who presented with obstructive uropathy. Treatment strategies involved intensive medical therapy, parental education, behaviour modification strategies and close follow-up in a specialised constipation clinic. The obstruction was reversed and medications were discontinued after six months. Successful management of children with chronic constipation involves a multi-disciplinary approach in a specialised constipation clinic.
Evaluation of the Hanen it Takes Two to Talk Intervention Programme
Authors: Fong Nikki Wen Yan , Ho Selina Kah Ying , So Brian Jian Wei , Lian Wee Bin
Published: July 2015

Introduction:

It Takes Two to Talk (ITTT) – The Hanen Programme is a family-focused programme for parents of young children with speech and language delays (SLD). It aims to equip parents with the skills to help their child learn to communicate and use language. This programme is widely used overseas, but there is little evidence about its effect on the Singapore population. The aim of this study was to investigate the effectiveness of ITTT in improving a child's speech and language abilities, and in equipping parents with the skills necessary to teach their children.

Methods:

Parents of four children aged 26–41 months with a diagnosis of SLD participated in the study. The child's language was evaluated pre- and post-ITTT by a parent report communicative development inventory. Parental perceptions were evaluated with a knowledge, attitudes and perceptions questionnaire.

Results:

Improvement was seen post-program in expressive vocabulary for all participating children, with an increase in the median vocabulary age-equivalence of the child, beyond that of the chronological time that had elapsed. All parents achieved a pass rate in scores on knowledge-based questions. While 2/3 of parents felt ill-equipped to handle their child's SLD, all were interested to attend training in this area as they saw a need to implement changes in the way they helped their children.

Conclusion:

Results suggest that ITTT may be a useful tool in helping children with SLD. However, more research needs to be done on a larger population locally to determine the effectiveness of the programme.
Knowledge, Attitudes, and Practices regarding Chickenpox Disease and its Prevention in Singapore: Comparison between Parents and Medical Students
Authors: Ho Ernest Weisheng , Ereno Imelda Lustestica , Ibrahim Masitah , Yeo Cheo Lian
Published: July 2015

Introduction:

The incidence of chickenpox in Singapore is steadily increasing despite the availability of effective preventive measures. To address the need for improvement in public education, a survey was conducted to establish if differences exist amongst parents and medical students with regards to their knowledge, attitudes, and practices regarding chickenpox and its prevention.

Methods:

Over a six-week period in 2010, an online survey involving parents who attended a paediatric clinic, and medical students from the National University of Singapore, was conducted.

Results:

Parents had a significantly greater lack of knowledge compared to medical students ( P <0.001). Family and friends were the main source of information for parents and junior medical students, unlike senior medical students who learnt more from physicians. A large majority of responders (85.2%) favoured vaccination for varying reasons, with parents and junior students being more concerned about the spread of disease and favouring its avoidance, and senior students fearing life-threatening complications. Parents who would not recommend the vaccine considered chickenpox a rite of passage and believed the vaccine lacks long-term benefits, while a perception that the disease is mild was more prevalent among medical students. A better understanding of the disease and vaccine was the most influential factor for changing decisions against vaccination.

Conclusion:

Greater efforts to disseminate information about chickenpox disease and its prevention are needed to address important deficits in public health and medical school education. Being aware that chickenpox can be more than just a mild disease with serious complications may increase the uptake of chickenpox vaccination.