Initiation of insulin therapy is challenging in the primary care setting without nursing support. Doctors have to prepare their practices to deal with these challenges in order not to delay insulin therapy when needed.

Central venous catheterisation is a common procedure performed for emergency dialysis. It is usually carried out without any cardiac monitoring. Cardiac arrhythmias with associated conduction blocks are rare complications. The underlying pathogenesis is trauma to the endocardium by the guide wire or catheter. It occurs more frequently in patients with acute renal failure and azotaemia than patients with established end stage renal disease. Disturbances in acid base balance and electrolyte abnormalities are contributing factors. Fortunately, most are benign but occasionally can lead to potentially fatal arrhythmias. We report a case of a 46-year-old lady with end stage renal failure secondary to diabetes mellitus who developed runs of transient ventricular ectopics and right bundle branch block during internal jugular catheterisation. This spontaneously resolved 12 hours later.

General Surgery ; history ; History, 20th Century ; History, 21st Century ; Humans ; Poverty ; Singapore ; Surgery Department, Hospital ; history

Ligamentous injuries of the lower limb are a common entity sustained during sports activities and military training. Magnetic resonance (MR) imaging of the knee and ankle is playing an increasingly important role in the detection, diagnosis and prognosis of these injuries and their associated complications. MR imaging with its exquisite soft tissue contrast resolution and multiplanar capability is increasingly seen as the modality of choice for evaluating ligamentous injuries of the knee and ankle. Representative knee and ankle MR studies from a tertiary referral hospital are used to illustrate both the normal appearance and typical radiological features of common ligamentous injuries of the knee and ankle. A thorough understanding of the MR appearances of these injuries is crucial to the radiologist and clinicians involved in the management of these patients.
Ankle Injuries ; diagnosis ; Athletic Injuries ; Humans ; Knee Injuries ; diagnosis ; Ligaments, Articular ; injuries ; physiopathology ; Magnetic Resonance Imaging

INTRODUCTIONSplenic abscess is an uncommon clinical problem. Traditionally, the "gold standard" treatment has been splenectomy. However, there is increasing use of non-operative treatments worldwide.

MATERIALS AND METHODSA 10-year (1996-2005) retrospective review of case records from a single centre (an 800-bed general hospital) was performed. Information regarding demographics, clinical presentation, aetiological agents and management was gathered and analysed.

RESULTSThere were 21 cases from 1996 to 2005. Nineteen (90%) had multiple abscesses. Disseminated melioidosis was the most common aetiological agent (15 cases, 71%). Only 3 patients underwent splenectomy. The remainder were treated conservatively with antibiotics. Almost all the patients (19, 90%) also suffered from diabetes mellitus.

CONCLUSIONSThe most common aetiological agent encountered was Burkholderia pseudomallei. Diabetes mellitus may be an important co-factor in the pathogenesis of splenic abscesses. The majority of our patients were managed conservatively and splenectomy was only occasionally required.

Abscess ; drug therapy ; epidemiology ; etiology ; Adult ; Aged ; Anti-Bacterial Agents ; therapeutic use ; Bacteremia ; complications ; drug therapy ; Female ; Hospitals, General ; statistics & numerical data ; Humans ; Male ; Melioidosis ; complications ; epidemiology ; Middle Aged ; Retrospective Studies ; Singapore ; epidemiology ; Splenic Diseases ; drug therapy ; epidemiology ; etiology

Introduction Chronic kidney disease in Brunei Darussalam is a growing problem. The number of patients reaching end stage kidney failure has increased dramatically in the last ten years. Currently, most are managed with haemodialysis while a smaller proportion is managed with continuous ambulatory peritoneal dialysis (CAPD). Automated peritoneal dialysis (APD) is a form of peritoneal dialysis and has been used in Brunei Darussalam since May 2008. Materials and Methods Eight patients participated in this prospective clinical trial. As all APD patients were previously on CAPD, comparisons are made between the outcomes of APD against CAPD. Results The median and mean age of APD patients were 42 and 45.5 ± 12.73 years respectively. After switching to APD, the serum haemoglobin and albumin improved from 10.56 ± 1.95 gm/L and 27.88 ± 7.71 gm/dL to 12.26 ± 1.82 gm/L and 33.63 ± 6.89 gm/dL respectively (p values <0.05). This corresponded to improvements in seven (87.5%) and six (75%) patients respectively in both parameters. Erythropoietin requirement was reduced in six (75%) patients, including three (37.5%) patients who were able to stop erythropoietin completely. There was no peritonitis encountered. All patients reported improved quality of life with better sleep, appetite and general well-being. Conclusions Our study showed that APD was as good as CAPD with improvement seen in both laboratory and quality of life parameters. There was also reduction in erythropoietin requirement. Based on these findings, we will actively encourage and promote APD usage as oppose to CAPD usage in our population.

INTRODUCTIONDyslipidaemia leads to atherosclerosis and is a major risk factor for cardiovascular diseases. In clinical trials, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, or statins, have been shown to effectively reduce dyslipidaemia. Despite the availability and accessibility of statins, myocardial infarctions and cerebrovascular accidents remain among the top causes of mortality in developed countries, including Singapore. This enigma could be attributed to suboptimal adherence to statin therapy. The present literature review aimed to evaluate patients' perceptions of statin therapy.

METHODSWe searched PubMed and other databases for articles published in English from October 1991 to May 2012 containing keywords such as 'patient', 'views', 'perceptions', 'adherence', 'statin' and 'dyslipidaemia'. Of the 122 eligible studies retrieved, 58 were reviewed. The findings were categorised and framed in accordance with the Health Belief Model.

RESULTSPatients with dyslipidaemia appeared to underestimate their susceptibility to dyslipidaemia-related complications, partly due to their demographic profiles. Failure to appreciate the severity of potential complications was a major hindrance toward adherence to statin therapy. Other factors that affected a patient's adherence included lack of perceived benefits, perceived side effects, the cost of statins, poor physician-patient relationship, and overestimation of the effectiveness of diet control as a treatment modality.

CONCLUSIONExisting evidence suggests that the cause of poor adherence to statin therapy is multifactorial. The use of the Health Belief Model to present the results of our literature review provides a systematic framework that could be used to design a patient-centric approach for enhancing adherence to statin therapy.

Attitude to Health ; Cardiovascular Diseases ; drug therapy ; Diet ; Dyslipidemias ; drug therapy ; Health Education ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors ; therapeutic use ; Medication Adherence ; Myocardial Infarction ; drug therapy ; Patient Acceptance of Health Care ; Physician-Patient Relations ; Risk Factors ; Singapore ; Stroke ; drug therapy

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INTRODUCTIONAsthma control varies in different clinical settings because of its multidimensional and heterogeneous nature, and variability over time. The revised asthma management guidelines indicate that the goal of treatment should be maintaining asthma control for long periods. The aims of this study were to explore: (i) difference in asthma control test scores in patients at different clinical practice settings; (ii) assess if patients were overestimating the level of their asthma control and (iii) assess the relationship of the derived Asthma Control Test (ACT) score to cost of inpatient stay and length of stay (LOS).

MATERIALS AND METHODSThe Asthma Control Test (ACT) is a 5-item questionnaire that assesses the multidimensional perspective of asthma control from activity limitation, shortness of breath, night symptoms, use of rescue medication and self-perception of asthma control. The score ranges on a scale from 1 (poorly controlled) to 5 (well controlled). ACT was administered to 447 patients diagnosed with asthma from the in-patient and out-patient settings (new and follow-up cases).

RESULTSThree hundred and ninety-nine (92%) patients completed the ACT questionnaire. The analysis only included patients who had completed the ACT questionnaire. The analysis showed that all the 5 items in the ACT questionnaire were significantly associated with different clinical settings (P <0.001). When we correlated the ACT question 5 (patients' self-rating of asthma control) in the ACT with Question 3 and Question 4 individually, it showed that most patients did not overestimate their asthma control (P <0.001). However, there was no correlation between the derived ACT score and cost (P = 0.419), LOS (P = 0.373), and the number of comorbid medical history (P = 0.055).

CONCLUSIONOur results reinforce the usefulness of ACT for clinicians to identify patients with poorly controlled asthma and to optimise their level of control in different clinical settings.

Adult ; Asthma ; physiopathology ; therapy ; Female ; Hospitalization ; Humans ; Length of Stay ; Male ; Middle Aged ; Outcome Assessment (Health Care) ; classification ; Primary Health Care ; Prospective Studies ; Surveys and Questionnaires ; Young Adult