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.

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.

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.

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.

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.

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.

Long-term outcome and disease control in near-fatal asthma.

Patients who have survived an episode of intubation and mechanical ventilation for acute respiratory failure due to a severe and unresponsive asthmatic attack are considered to have experienced a near-fatal asthma (NFA) attack. Such patients are at a higher risk of similar severe attacks and hence of death in the future. The aims of the study were to: (i) evaluate the outcome; (ii) identify any persistent deficiencies in asthma management, and (iii) assess self-management knowledge in survivors of NFA. Ninety-three consecutive patients who had been treated for NFA in the Intensive Care Unit of an urban teaching hospital in Singapore from 1992 to 1997 were studied. All hospital records were reviewed retrospectively. Survivors were then invited to attend a questionnaire interview and to have lung function tests performed. Of the original cohort (OC) of 93 patients with NFA (mean age 55.2 years), 18 (19% OC) patients (mean age 64 years) had died while in hospital and 75 (81% OC) patients survived the initial episode of NFA and were discharged home (DH). The long-term outcome of this DH group was: 13 patients had died (17% DH) and 62 (83% DH) survived. Of these survivors, 35 were interviewed while 27 declined or were not contactable. This interview yielded the following information: (i) Hospitalisation in the past year: 66% had no hospital admission; of the 31.4% who had 2 or more admissions, most had a further NFA attack. (ii) Health care: The majority of patients (71.4%) were monitored by a single doctor. (iii) Patient knowledge of disease management was deemed good to fair for trigger avoidance (77%), for appropriate drug usage (97%). (iv) Satisfactory inhaler skill (80%). NFA is associated with a high intrahospital and long-term mortality. Although most survivors of NFA appeared to have satisfactory care and a fair understanding of medication usage, a significant minority continue to pose much morbidity and risk for death.

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.

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.