Characteristics of electroencephalogram changes and correlation with seizures in hospitalised patients.

INTRODUCTION: Electroencephalogram (EEG) is an important investigational tool that is widely used in the hospital settings for numerous indications. The aim was to determine factors associated with abnormal EEG and its clinical correlations in hospitalised patients. MATERIALS AND METHODS: Patients with at least one EEG recording were recruited. The EEG and clinical data were collated. RESULTS: Two hundred and fifty patients underwent EEG and 154 (61.6%) were found to have abnormal EEG. The abnormal changes consist of theta activity (79,31.6%), delta activity (20, 8%), focal discharges (41,16.4%) and generalised discharges (14, 5.6%). Older patients had 3.481 higher risk for EEG abnormalities, p=0.001. Patients who had focal seizures had 2.240 higher risk of having EEG abnormalities, p<0.001. Low protein level was a risk for EEG abnormalities, p=0.003. CONCLUSION: This study emphasised that an abnormal EEG remains a useful tool in determining the likelihood for seizures in a hospital setting. The risk factors for EEG abnormality in hospitalised patients were age, focal seizures and low protein level. The EEG may have an important role as part of the workup in hospitalised patients to aid the clinician to tailor their management in a holistic manner.

Outcome of acute ischaemic stroke patients after intravenous alteplase in Hospital Universiti Sains Malaysia.

INTRODUCTION: Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) is effective in treating acute ischaemic stroke. Our primary objective is to assess the outcome of these acute ischaemic stroke (AIS) patients after IV alteplase with the modified Rankin scale (mRS). METHODS: This is a cross-sectional study in which patients receiving IV alteplase in Hospital Universiti Sains Malaysia, from January 2017 to April 2020 were recruited. Demographical data, National Institutes of Health Stroke Scale (NIHSS) scores, door-to-needle time were recorded. Modified Rankin scale (mRS) scores were evaluated at 90 days after initial therapy. Good and poor functional outcomes were defined as 0-2 and 3-6, respectively. RESULTS: A total of 30 patients were included in the study with a mean age of 59±11.47 years old. 76.7% of them were male and the rest were female. From the study, onset-toneedle time was 197.47±51.74 minutes, whereas door-toneedle time was 120.93±53.63 minutes. Seventeen (56.3%) patients achieved a favourable score of 0-2 on the mRS at 90 days after treatment. Haemorrhagic transformation occurred in eight (26.7%) of the patients with a mortality rate of 13.3%. CONCLUSION: 56.7% of our patients showed improvement in the mRS at 90 days post thrombolysis for AIS. Higher baseline NIHSS scores and diabetes mellitus were associated with poorer functional outcomes after thrombolysis.

An unusual case of primary melioidotic prostatic abscess complicated by perianal abscess.

Burkholderia pseudomallei is recognized to cause severe and fatal infections. Most of the infections caused by this facultative intracellular gram-negative bacterium are pneumonia, soft tissue, genito-urinary and central nervous system infection. We report an unusual case of primary prostatic abscess complicated by perianal abscess caused by Burkholderia pseudomallei. Melioidosis related anorectal infections have not been previously reported in the literature.

Should general physicians or subspecialists undertake acute medical care in public hospitals?

Acute medical care in public hospitals may be handled differently in different countries. As general physicians in Singapore are trained to deal with undifferentiated clinical problems and run most of the admitting wards, they are suited to take care of patients with acute medical problems. The exceptions to this rule are made for patients accurately diagnosed with stroke and acute coronary syndrome, who have better clinical outcomes if admitted directly to stroke units and coronary care units respectively. In the diagnostic workup, general physicians are trained to practise probabilistic medicine, and thus to order more focused investigations to rule in or rule out certain diagnoses. The subspecialist is more inclined to exclude possible diagnoses in his or her field. Once there is a clear-cut diagnosis, for primary care, it is up to the patient to decide if his primary doctor should be a generalist or subspecialist. An important role for the general physicians who manage patients with multiple diseases is constant medication review to shorten the list of drugs.

Postgraduate medical education and specialist training in Singapore.

The Singapore Medical School celebrates its Centenary in 2005. This historical review is presented on Singapore's postgraduate medical education and specialist training programmes. The special informal role of the Alumni Association and its members during the early years and soon after World War II is highlighted. Postgraduate education and specialist training was more formalised only during the challenging years when Singapore became more autonomous and politically independent with the establishment of the Academy of Medicine, the School's postgraduate medical studies, the Singapore Medical Association, specialist societies and, more recently, the College of Family Physicians. Specialist training programmes and the process of specialist accreditation are also outlined. While Singapore has gone far towards developing a comprehensive programme of postgraduate medical education and specialist training, the process is still evolving and can be improved upon. As long as we keep pace with relevant and realistic strategies, the future for postgraduate medical training and specialist training should be assured.

Health care services for the elderly--a Singapore perspective.

Singapore is greying at a phenomenal pace as well as in a markedly disproportionate manner. By the year 2030, the elderly will comprise around 25% of the total population; at the same time the numbers of younger and economically active persons will decline. The reasons for this process are varied and its implications disturbing. An important consequences is the urgent need for careful and comprehensive planning to meet the elderly's needs. The needs are best addressed when the elderly are looked at as either being well or frail. A guiding principle is that most of them prefer and should remain within community (and not be institutionalised). Efficient and appropriate community services must be developed so as to support the elderly's stay in the community.

The natural history of dengue illness based on a study of hospitalised patients in Singapore.

AIM OF STUDY: To study the clinical features of dengue illness in hospitalised patients in Singapore. METHODS: One-hundred and thirty hospitalised patients with serologically confirmed dengue illness, from 1 April 1992 to 31 October 1992, were analysed retrospectively. RESULTS: Teenagers and young adults between 15 to 30 years of age were most commonly affected. The male to female ratio was 1.3:1. The mean duration of fever and rash prior to admission were 5.2 +/- 1.5 (mean +/- SD) days and 1.7 +/- 1.7 days respectively. Petechiae were present in 52.3% of the patients. Three-quarters of the patients with petechiae had platelet counts (PCs) of 100 x 10(3) ul-1 or less. Thrombocytopenia (PCs of 100 x 10(3) ul-1 or less) was first documented 5.8 +/- 1.4 days after the onset of illness. The nadir of thrombocytopenia occurred on the 6.4 +/- 1.6 day of illness. The mean duration of thrombocytopenia was 3.6 +/- 1.6 days. Nineteen patients (14.6%) had non life-threatening clinical bleeding or coagulopathy, namely bleeding gums (9 patients), epistaxis (5), vaginal spotting/menorrhagia (4) and prolonged PTT (3). Six patients (4.6%) required platelet transfusion because of severe thrombocytopenia (PCs less than 30 x 10(3) ul-1) and clinical bleeding. There was no secondary fall in the PCs over 2 or more consecutive days when the PCs were in the recovery phase. It took 1 more day to reach PCs of 100 x 10(3) ul-1, the "safe" level commonly used in Singapore to decide discharge of patients, as compared to 80 x 10(3) ul-1. At PCs of 80 x 10(3) ul-1 or more, 2 patients had bleeding gums, 1 each had epistaxis and vaginal spotting. No transfusion was required for these 4 patients. The mean hospital stay was 4.2 +/- 1.5 days. There was no mortality in this study. CONCLUSION: Dengue illness is a relatively benign self-limiting illness. When the PCs are on the rising trend and in the absence of clinical bleeding, it is reasonably safe to discharge patients when the PCs reach 80 x 10(3) ul-1, instead of 100 x 10(3) ul-1. This will shorten each patient's stay by 1 day, resulting in cost saving and more efficient use of hospital beds.

Comparison of platelet counts in simultaneous venous and capillary blood samples using an automated platelet analyser.

Platelet counts (PC) obtained simultaneously from capillary blood (CB) are generally lower than those from venous blood (VB). We quantified this difference in 17 patients with low platelet counts (LPC) and 18 healthy volunteers with normal platelet counts (NPC). The reproducibility of the counts in these 2 groups of subjects was also evaluated. The mean venous platelet count (VPC) and the mean capillary platelet count (CPC) were 67 +/- 30 x 10(3)/ul (+/- SD) and 61 +/- 23 x 10(3)/ul (p = 0.012) in the LPC, and 264 +/- 44 x 10(3)/ul and 234 +/- 45 x 10(3)/ul (p = 0.00016) in the NPC respectively. The mean difference (d) in the PC between VB and CB were 9.4 +/- 13.1 x 10(3)/ul and 19.4 +/- 17.6 x 10(3)/ul in the LPC and NPC respectively. The coefficients of variation (CV) of double counts for VB and CB were 8.1 +/- 8.3% and 9.8 +/- 8.6% for LPC, and 2.3 +/- 1.6% and 2.5 +/- 2.2% for NPC respectively. In conclusion, VPC was frequently (82.9% or 29/35 cases) higher than CPC. In addition, in patients with LPC, the agreement between VPC and CPC was poor and the counts were less reproducible.

Small cell carcinoma of lung: a prospective clinical study.

Seventeen patients with small cell carcinoma of the lung diagnosed on sputum cytology, bronchial biopsy/aspirate or lymph node biopsy, were prospectively followed up for 33 months. Four patients who had no or inadequate treatment survived an average of 10.5 months. Ten treated patients survived 10.6 months. Three patients are still alive receiving chemotherapy with no local irradiation. All patients were Chinese; all smoked cigarettes; two patients were women; all patients were older than 50 years. Four patients had no chest complaints but presented with Superior Vena Caval obstruction (two cases), dermatomyositis and the Eaton Lambert syndrome. Two patients had the syndrome of inappropriate antidiuretic hormone secretion. None was hypercalcaemic. Twelve patients had right sided lung lesions. The majority of patients underwent combined radiotherapy and chemotherapy, the latter consisting of three weekly cyclical methotrexate, adriamycin, cyclophosphamide and CCNU (MACC regime).

Tuberculous lymphadenitis in Singapore.

An analysis of patients diagnosed as having tuberculous lymphadenitis (the second commonest form of tuberculosis after respiratory tuberculosis) in 1980, was carried out to ascertain the pattern of disease and methods of diagnosis. Of 114 cases so notified, 97 were available for this purpose. Diagnosis was on lymph node biopsy with histological examination and/or bacteriological culture confirmation. Patients with tuberculous lymphadenitis tended to be young (more than 60% below 31 years old), and to have cervical involvement (88.6% of cases). A female preponderance (as in other studies) and a disproportionate number of Indians and Malays (thrice and twice that expected on the basis of their ethnic proportion of the Singapore population) were noted. Only 25 out of 97 biopsied glands were sent for mycobacterial culture by the surgeons and 16 grew niacin positive Mycobacteria tuberculosis. This 64% culture-positive rate is more sensitive and specific than the histological demonstration of acid-fast bacilli (13.4%) in the diagnosis. It must be stressed that the pathologist can only report a picture consistent with or supportive of a diagnosis of tuberculosis and be more confident if acid-fast bacilli are seen microscopically. The diagnosis cannot be absolute except on a positive culture which also identifies typical or atypical mycobacteria and allows drug sensitivity testing. Surgeons removing lymph nodes in patients suspected to have tuberculous lymphadenitis must send these to both the bacteriologist and pathologist, the tissue to the former not being suspended in formalin but saline.

Blood glucose levels in non-diabetics on intravenous dextrose infusions.

Does a 5% dextrose infusion of up to 3 litres per 24 hours in a patient cause significant hyperglycemia if the patient is not a known diabetic? This small study showed that in 15 patients on such a drip not on steroids, the blood glucose level at least two hours postprandially did not rise above 140 mg%. On the other hand, another two patients on steroids had blood glucose levels above this value but below 180 mg%.

Refining clinical practice: transforming science research into the art of medicine.

This article traces the development of modern day breast cancer treatment from 1896 when observations were made on the positive response of patients to oophorectomy. The oestrogen receptor was defined and tamoxifen was discovered to be an effective anti-oestrogen. The genes related to breast cancer, BRCA1 and BRCA2, were found to confer high risks of breast and ovarian cancer on women with these genes. The application of functional genomics to breast tumours would result in a more accurate classification of cancers and hopefully more specific therapy and better clinical outcomes. An important off-shoot of anti-oestrogen research has resulted in a new class of drugs called selective oestrogen receptor modulators for treatment of osteoporosis and dyslipidemia.

1st college of physicians lecture: the role of internal medicine as a specialty in the era of subspecialisation.

This paper is divided into 4 parts. The first deals with the definition of specialties and traces its roots from the early 20th century in the United States of America with the formation and growth of Specialty Boards. The second is a reflection on the scene in Singapore from the 1960s to the present, describing the change from public healthcare institutions run by the civil service to the autonomous restructured public service hospitals towards the end of the 20th century. The third section deals with what the 4ps have expressed about changes necessary to the Singapore system in the 21st century. The 4ps are the politicians, the payers, the patients and the public. It is about value for money, better coordination and better communication. Finally, just what is Internal Medicine - its competencies and its practice. A review of the systems in Australia, New Zealand, and the USA is presented. The idea of the "hospitalist" is discussed. Concluding remarks deal with the viability of Internal Medicine because of low reimbursement, administrative burdens and brief patient visits.

Quality assurance in the training of primary health care doctors and specialists.

Training of doctors is expensive as it requires at least six years of supervision while on the job plus sponsorship for courses, examination and even overseas training. Quality assurance of training is essential to ensure maximum throughput of the required number of specialist doctors for national needs. First, there is competition for training posts at basic (three years) and advanced (three years) levels. Basic training prepares doctors to sit and pass the relevant postgraduate examinations. Fifty percent of each cohort of doctors are selected as Basic Trainees but 40% finally complete Advanced Training. Second, trainees complete a training programme under supervision and record their clinical and learning experience in log books which are checked and certified by appointed supervisors who are consultants in government and restructured hospitals or institutions. Third, supervisor reports are submitted six monthly to the respective bodies: Academy of Medicine, School of Postgraduate Medical Studies or the Ministry of Health and Training Committees which vet these with the aim to continue the training or to terminate the training. Fourth, Parts I and II of relevant examinations must be passed within stipulated time frames. By these measures, there is quality assurance in the postgraduate training of our doctors.

Lupus erythematosus cell preparation, antinuclear factor and antideoxyribonucleic acid antibody incongruity in systemic lupus erythematosus.

'Total antinuclear antibody' (ANF) is detected by the fluorescent antinuclear antibody technique which is a screening test, positive in 99% of systemic lupus erythematosus (SLE) sera. The LE factor (positive in 75% of SLE sera), like the anti-DNA antibody, is an antinuclear antibody but directed against DNA-histone. ANF-negative SLE is a clinical entity with absence of these antibodies. A false negative ANF, in the presence of high titre anti-DNA antibody and/or LE cells, is illustrated in two cases of SLE. Postulated mechanisms for this phenomenon are interference in ANF detection by rheumatoid factor, and the prozone effect on the immunofluorescent tests.

General medicine--revisited, rejuvenated, revitalized and reemphasized.

INTRODUCTION: The swing of the pendulum towards medical subspecialties, which are mainly organ-based, was inevitable. Over 30 years ago, this problem surfaced in the United States (US). The fragmentation of medicine had its advantages and disadvantages. However, as lifespan lengthens and there are more elderly sick with multiorgan dysfunction and failure, the patient is asking for the one doctor who can manage him as a whole patient rather than the ten specialists, each focused on one body part. METHODS: Revisit--A search of the recent literature revealed that changes are underway in the US and the United Kingdom (UK). RESULTS: Rejuvenate--Diagnosis Related Group (DRG) funding for inpatients based on the length of stay means referrals to specialists (if any) should be concurrent rather than consecutive. This, in turn, means the general physician should assess the whole patient from the outset and be in charge of the management plan. Also, the patient prefers this to being passed from one specialist to another. Revitalized--We are short of doctors in Singapore and if one patient could be properly managed by fewer specialists, then we will need fewer specialists in Singapore. Their role is to manage the more difficult patients, rather than every patient that happens to have a problem within that organ specialty. Internists should be allowed to have a wider training in Singapore, with dual accreditation in general medicine and another medical speciality made available from this year onwards. The duration of this training will be 5 years. Reemphasized--A full chair in general medicine was established at Harvard Medical School in 2000. The UK Royal Colleges of Physicians are revamping their advanced specialty training programme to include more time in general medicine and the Renaissance School of General Medicine may become a reality. CONCLUSION: Whole patient medicine is what patients want, not medicine in bits and pieces. The general physician has a vital role to play in meeting this need.

The development of postgraduate training programmes in Singapore.

Singapore is a small country compared to Pakistan. Being an urban modern developed nation with a high population density, adequate doctors (& specialists), and good infrastructure, it has one medical school enrolling 200 students annually, one Graduate School of Medical Studies (GSMS) responsible for entry postgraduate examinations (the M Med) and one Academy of Medicine (AM) responsible (jointly with the Graduate School) for exit certification/examinations (FAMS) into 35 specialties. There is also one College of Family Physicians with a significant role in the training of Family Physicians jointly with the Graduate School. The Aga Khan University runs 14 residency (3 to 4 years) and 2 fellowship programmes. It has the College of Physicians and Surgeons of Pakistan, which awards fellowships to trained postgraduate doctors. Formal postgraduate education in Singapore began in the 1960s with the help of the Australasian Royal Colleges. The Graduate School of Medical Studies was born in 1969 to conduct Master of Medicine courses and examinations, either alone or jointly with overseas colleges. Over the years up till 1996, the M Med covered 11 disciplines. Programmes are set up based on local needs for a specialty, subspecialty, skill or expertise. Both the GSMS and AM have heavy responsibilities under the Specialists Accreditation Board (SAB) of the Ministry of Health, to administrate the 35 Specialist Training Committees. Syllabus, log books, registers, supervisors, mentors, interviews and exit certification/examinations are essential components of the specialist training programmes which last 6 to 7 years. As new specialties and subspecialties develop internationally, they will be introduced locally at the appropriate time. Through the local training programmes, doctors become specialists in their early thirties. The challenge is to develop systems to ensure that for the next 30 years of their practice, they remain up-to-date, competent and effective doctors.

Infection in the elderly.

One hundred and eleven patients with pyogenic infections were studied. Of these, 32 patients (28.8%) were diabetic, and 33 patients (30%) had positive cultures obtained. Fifty-eight patients (52.3%) had fever (T degrees greater than 37.2 degrees C) while 69 patients (62.2%) had leucocytosis. Forty-one patients (36.9%) had nosocomial infections. It was found that patients older than 75 years-old did not respond to infection by a febrile response as often as those younger than 75 years-old. Mortality rate was increased in those whose T degrees greater than 38.2 degrees C and in those with more than one source of infection. Age and the presence of diabetes was not found to increase the mortality rate, though diabetics tend to have more than one source of infection. A positive blood culture was also associated with a higher mortality rate. There were also more deaths among patients with nosocomial infection than the community acquired group. The three most common sources of infection were lung, urinary tract and skin respectively. The most common group of organisms cultured was gram negative bacilli, of which Klebsiella species was most frequently isolated. Of these, 57% of the Klebsiella sp cultured came from the nosocomial group. Staphylococcus aureus was the next most frequently cultured bacteria, and all these isolates (100%) came from the nosocomial group. Though antibiotics were started within 48 hours of suspicion of infection in majority of patients (101 patients or 91%), and all of these received appropriate initial antibiotics, mortality rate remained high (26 deaths or 23.4%).

Ergotism and vascular insufficiency: a case report and review of literature.

We report a case of ergot-induced peripheral vascular insufficiency of the lower limbs and review the vascular complications, angiographic findings and the different modalities of treatment. The following case report highlights the clinical features and course of ergot toxicity, and the difficulty in early diagnosis.

Drug treatment of hypercholesterolaemia.

We review the current drug treatment of hyperlipidaemia at our specialist out-patient clinics between October 1995 and December 1995. During this period, 523 patients received one or more lipid-lowering drugs. Each patient was assessed for his vascular risk, the number of lipid measurements before and after treatment and the type, duration and outcome of drug treatment. Only 30% patients achieved the low-density lipoprotein cholesterol (LDL-C) targets recommended by the National Cholesterol Education Program II: 14%, 37% and 71% of the high, moderate and low risk patients achieved the targets respectively. Most patients (62.7%) were treated after only one lipid measurement and less than 50% of patients had a post-treatment lipid measurement within 3 months. Although the majority of patients did not achieve the recommended LDL-C targets, their LDL-C was significantly reduced by 20%. A greater reduction of LDL-C (32%) was achieved by simvastatin monotherapy.