Venous thromboembolism at the National Healthcare Group, Singapore

<p><b>INTRODUCTION</b>Venous thromboembolism (VTE), including its most serious clinical subtype, pulmonary embolism (PE), is a potentially preventable disease. While current assessment tools do not include ethnicity as a risk factor, studies suggest that Asians have lower risk of VTE compared to Caucasians. This study aims to describe 2006 in-hospital and projected population based incidence rates of VTE and PE in Singapore.</p><p><b>MATERIALS AND METHODS</b>Data on 2006 admissions at 3 major NHG hospitals, cases of VTE and their demographics were obtained from the ODS, a large administrative database of the National Healthcare Group (NHG). Demographic characteristics of the 2006 Singapore resident population were obtained from the 2006 Singapore Statistics website.</p><p><b>RESULTS</b>In 2006, there were 860 cases of VTE out of 98,121 admissions in these 3 hospitals. Overall and secondary VTE age adjusted in-hospital burden was 73 and 54 per 10,000 patients, respectively. Caucasians and Eurasians had VTE rates in excess of 100 per 10,000 while Chinese, Malays and Indians each had rates below 100 per 10,000. Assuming that 42.5% of the 2006 Singapore population was served by NHG, the estimated population-based incidence of VTE and PE is 57 and 15 per 100,000, respectively.</p><p><b>CONCLUSIONS</b>As patterns across ethnic groups point to lower VTE rates among Asians compared to Caucasians and Eurasians, analytic studies should be considered to test this hypothesis. There may be a need to develop locally applicable risk assessment tools which can be used to support local guidelines for VTE prophylaxis, thus leading to more acceptable and cost-effective care.</p>

Ultrasound assisted thrombolysis in acute ischaemic stroke: preliminary experience in Singapore

<p><b>BACKGROUND AND AIM</b>Intravenously-administered tissue plasminogen activator (IV-TPA) induces thrombolysis and remains the only FDA-approved therapy for acute ischaemic stroke. IV-TPA thrombolysis has been approved recently in Singapore for acute stroke. Continuous exposure of clot to 2-MHz pulsed-wave transcranial Doppler (TCD) ultrasound during IV-TPA infusion is known to augment thrombolysis. We aimed to determine the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore.</p><p><b>SUBJECTS AND METHODS</b>Consecutive patients with acute ischaemic stroke due to intracranial arterial-occlusions were treated with standard IV-tPA and continuously monitored with 2-MHz TCD according to the CLOTBUST-trial protocol. Arterial recanalisation was determined with Thrombolysis in Brain Ischemia (TIBI) flow-grading system. Safety and efficacy of ultrasoundassisted thrombolysis were assessed by rates of symptomatic intracranial haemorrhage (sICH) and functional recovery at 1 month, respectively.</p><p><b>RESULTS</b>Five consecutive patients (mean age 58 years, 3 men and 3 of Chinese ethnicity) were included. Mean time elapsed between symptom onset and presentation to emergency room was 98 minutes (range, 50 to 135 minutes) while the mean time interval between symptom onset to IV-TPA bolus was 144 minutes (range, 125 to 180 minutes). Partial or complete recanalisation with reduction in the stroke severity was noted in 4 out of the 5 patients during IV-TPA infusion (mean change in NIHSS = 4 points; range 2 to 8 points). None of our patients developed sICH while 4 patients demonstrated good functional outcome at 1 month.</p><p><b>CONCLUSIONS</b>Our preliminary study demonstrates the feasibility, safety and efficacy of ultrasound-assisted thrombolysis in acute ischaemic stroke in Singapore. Continuous TCD-monitoring during IV-TPA infusion provides real-time information, enhances thrombolysis and improves functional outcomes in acute ischaemic stroke.</p>

Is there a place for placebo in management of psychogenic movement disorders?

<p><b>INTRODUCTION</b>The management of psychogenic movement disorders is fraught with difficulties. Empathy and a non-judgmental manner are essential in dealing with patients, and a neurobiological explanation of the symptoms may help to foster trust, acceptance, understanding and recovery.</p><p><b>CLINICAL PICTURE</b>We report a 17-year-old Chinese girl with psychogenic blepharospasm. Her parents refused psychotherapy and pharmacotherapy.</p><p><b>TREATMENT AND OUTCOME</b>Placebo therapy (with parental consent) was prescribed with favourable results.</p><p><b>CONCLUSION</b>We examine the ethical considerations for and against placebo therapy, and explore the role of placebo therapy in the management of psychogenic movement disorders.</p>

POEMS syndrome--a case for more aggressive treatment

<p><b>INTRODUCTION</b>Patients with POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal or M-protein and skin changes) syndrome exhibit a wide range of clinical manifestations and are often seen by a variety of specialists prior to diagnosis.</p><p><b>CLINICAL PICTURE</b>We describe a case of POEMS syndrome that first presented with significant neuropathy but progressed to develop further manifestations of the condition, including marked gastrointestinal symptoms.</p><p><b>TREATMENT</b>The patient was commenced on localised radiotherapy and chemotherapy in addition to immunomodulatory therapy for the neuropathy.</p><p><b>CONCLUSION</b>We highlight several learning points that may benefit physicians from varied specialties. This case is also unique for its marked gastrointestinal manifestation. To our knowledge, this is the second reported case in the literature with this feature.</p>

Computer-based versus pen-and-paper testing: students' perception

<p><b>BACKGROUND</b>Computer-based testing (CBT) has become increasingly popular as a testing modality in under- and postgraduate medical education. Since 2004, our medical school has utilised CBT to conduct 2 papers for the third- and final-year assessments - Paper 3, with 30 multiple choice questions featuring clinical vignettes, and the modified essay question (MEQ) paper.</p><p><b>AIMS</b>To obtain feedback from final-year students on their preferred mode of testing for Paper 3 and MEQ components of the Medicine track examination, and the reasons underlying their preferences.</p><p><b>METHODS</b>An online survey was carried out on 213 final-year undergraduates, in which they were asked to provide feedback on Paper 3 and MEQ papers. Students were asked if they thought that the CBT format was preferable to the pen-and-paper (PNP) format for Paper 3 and the MEQ, and why.</p><p><b>RESULTS</b>One hundred and fourteen out of 213 (53.5%) students completed the online survey. For Paper 3, 91 (79.8%) felt that CBT was preferable to PNP, 11 (9.6%) preferred the PNP format and 12 (10.5%) were unsure. For the MEQ, 62 (54.4%) preferred CBT over PNP, 30 (26.3%) preferred the PNP format and 22 (19.3%) were unsure. Reasons given to explain preference for CBT over PNP for Paper 3 included independence from seating position, better image quality (as images were shown on personal computer screens instead of projected onto a common screen) and the fact that CBT allowed them to proceed at their own pace. For the MEQ, better image quality, neater answer scripts and better indication of answer length in CBT format were cited as reasons for their preference.</p><p><b>CONCLUSIONS</b>Our survey indicated that whereas the majority of students preferred CBT over PNP for Paper 3, a smaller margin had the same preference for the MEQ.</p>