The discovery of antibiotics had been one of the most significant events in the history of medicine. Antibiotics had saved countless number of lives and had contributed significantly to the health of mankind. The emergence of resistance is however a major threat to the continued usefulness of antibiotics. There are now strains of bacteria which are resistant to virtually all available antibiotics and these strains are increasingly being encountered in clinical practice. The development of new agents had not kept pace with resistance and it is unlikely that there will be major breakthroughs in the near future. The world needs to conserve and prolong the useful lives of the existing agents. This can only be achieved through good antibiotic stewardship programmes. As antibiotic resistance is a global threat all major stakeholders have to work together to meet this challenge.

Consent is defined as the “voluntary agreement to or acquiescence in what another person proposes or desires”. In the context of medical practice it is now universally accepted that every human being of adult years and of sound mind has the right to determine what shall be done with his or her own body. Informed consent is now a central part of medical ethics and medical law. There has been a change in the public’s expectations of their role in medical decision making. The paternalistic approach by doctors is no longer acceptable. Today the patient has the right to receive and the doctor the obligation to give sufficient and appropriate information so that the patient can make an informed decision to accept or refuse a treatment option. This has led to higher standards of practice in the process of informed consent taking. Consent taking is both a legal and moral requirement. Failure to comply with standards of practice can result in criminal prosecution, civil litigation or disciplinary action by the relevant professional authority. Consent taking is a process and not merely a one-off affixation of the patient’s signature on a consent form. It involves a continuous discussion to reflect the evolving nature of treatment from before the treatment is given to the post-operative or discharge period. The regulatory authorities in many countries have established standards for consent taking which would include the capacity of the patient, the person who should seek consent, the information to be provided and the necessary documentation.
Informed Consent

An emerging infection is defined as an infection that has newly appeared in a population while a re-emerging infection would be one that has existed in the past but its incidence has increased in recent times. The reasons for the emergence or reemergence of an infection are not completely understood but they are multifactorial and complex in the nature of their interactions. These factors may be related to the etiological organism, the host or the environment. Human activity appears to be a major driver. Malaysia had to deal with outbreaks of several emerging infections over the last two decades. They include Nipah virus infection, SARS and avian influenza. Infections like dengue, tuberculosis and leptospirosis are re-emerging in Malaysia. Both human activity and climatic changes appear to be key factors in the emergence and reemergence of infections in Malaysia. Our country needs to put in place a comprehensive plan to meet the challenge of emerging diseases. A multidisciplinary approach is required and the strategies involved should not merely confined to medical and health strategies.

Medical Education research is a relatively new field but one that is progressing rapidly worldwide. This article is an attempt to take stock of the current status of Medical Education research in International Medical University and to explore the various factors that have influenced its direction. It also shares some of the initiatives that have been instituted or intended to be instituted at our university.

A 44-year-old Malay gentleman was seen at the polyclinic on the advice of a medical social worker. He was noted to have coarse facies, extensive skin peeling, and nail deformities in all 4 limbs. He was suspected to have leprosy and referred to the National Skin Centre (NSC) which confirmed the diagnosis of Lepromatous Leprosy by histology. He has shown good progress since starting on a course of treatment. A brief review is presented here as a reminder of the challenges faced in the care of a condition largely forgotten in our highly urbanised setting: Hansen’s disease.

Aged ; Anemia, Sickle Cell ; complications ; pathology ; Arthritis, Rheumatoid ; complications ; Female ; Hemoglobin E ; Hemoglobin, Sickle ; Humans

Abdominal Pain ; etiology ; Adult ; Appendectomy ; Appendicitis ; complications ; diagnostic imaging ; pathology ; surgery ; Female ; Humans ; Schistosomiasis mansoni ; complications ; diagnostic imaging ; pathology ; surgery ; Tomography, X-Ray Computed

INTRODUCTION: We aimed to investigate the intergrader and intragrader reliability of human graders and an automated algorithm for vertical cup-disc ratio (CDR) grading in colour fundus photographs. MATERIALS AND METHODS: Two-hundred fundus photographs were selected from a database of 3000 photographs of patients screened at a tertiary ophthalmology referral centre. The graders included glaucoma specialists (n = 3), general ophthalmologists (n = 2), optometrists (n = 2), family physicians (n = 2) and a novel automated algorithm (AA). In total, 2 rounds of CDR grading were held for each grader on 2 different dates, with the photographs presented in random order. The CDR values were graded as 0.1-1.0 or ungradable. The grading results of the 2 senior glaucoma specialists were used as the reference benchmarks for comparison. RESULTS: The intraclass correlation coefficient values ranged from 0.37-0.74 and 0.47-0.97 for intergrader and intragrader reliability, respectively. There was no significant correlation between the human graders' level of reliability and their years of experience in grading CDR ( = 0.91). The area under the curve (AUC) value of the AA was 0.847 (comparable to AUC value of 0.876 for the glaucoma specialist). Bland Altman plots demonstrated that the AA's performance was at least comparable to a glaucoma specialist. CONCLUSION The results suggest that AA is comparable to and may have more consistent performance than human graders in CDR grading of fundus photographs. This may have potential application as a screening tool to help detect asymptomatic glaucoma-suspect patients in the community.

INTRODUCTIONThis study assesses the trends and predictors of mortality and morbidity in infants of gestational age (GA) <27 weeks from 1990 to 2007.

MATERIALS AND METHODSThis is a retrospective cross-sectional cohort study of infant deliveries between 1990 and 2007 in the largest perinatal centre in Singapore. This is a study of infants born at <27 weeks in 2 Epochs (Epoch 1 (E1):1990 to 1998, Epoch 2 (E2):1999 to 2007) using logistic regression models to identify factors associated with mortality and composite morbidity. The main outcomes that were measured were the trends and predictors of mortality and morbidity.

RESULTSFour hundred and eight out of 615 (66.3%) live born infants at 22 to 26 weeks survived to discharge. Survival improved with increasing GA from 22% (13/59) at 23 weeks to 87% (192/221) at 26 weeks (P <0.01). Survival rates were not different between E1 and E2, (61.5% vs 68.8%). In logistic regression analysis, higher survival was independently associated with increasing GA and birthweight, while airleaks, severe intraventricular haemorrhage (IVH) and necrotizing enterocolitis (NEC) contributed to increased mortality. Rates of major neonatal morbidities were bronchopulmonary dysplasia (BPD) (45%), sepsis (35%), severe retinopathy of prematurity (ROP) (31%), severe IVH/ periventricular leucomalacie (PVL) (19%) and NEC (10%). Although composite morbidity comprising any of the above was not significantly different between the 2 Epochs (75% vs 73%) a decreasing trend was seen with increasing GA (P <0.001). Composite morbidity/ mortality was significantly lower at 26 weeks (58%) compared to earlier gestations (P <0.001, OR 0.37, 95% CI, 0.28 to 0.48) and independently associated with decreasing GA and birth weight, male sex, hypotension, presence of patent ductus arteriosus (PDA) and airleaks.

CONCLUSIONIncreasing survival and decreasing composite morbidity was seen with each increasing week in gestation with marked improvement seen at 26 weeks. Current data enables perinatal care decisions and parental counselling.

Cross-Sectional Studies ; Female ; Gestational Age ; Humans ; Infant Mortality ; trends ; Infant, Extremely Premature ; growth & development ; Infant, Newborn ; Infant, Premature, Diseases ; classification ; diagnosis ; epidemiology ; Logistic Models ; Male ; Neonatal Screening ; methods ; Outcome Assessment (Health Care) ; statistics & numerical data ; Prognosis ; Risk Factors ; Singapore ; epidemiology ; Survival Rate ; trends

INTRODUCTION: Chronic kidney disease (CKD) is a significant comorbidity in aortic stenosis (AS) patients. We examined the impact of baseline CKD, postoperative acute kidney injury (AKI) and CKD progression on clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI). MATERIALS AND METHODS: Consecutive patients with severe AS who underwent TAVI were classified into CKD stages 1-2 (≥60 mL/min/1.72m), 3 (30-59 mL/min/1.73m) and 4-5 (<30 mL/min/1.73m or dialysis) based on estimated glomerular filtration rate (eGFR). Primary outcome was mortality and secondary outcomes included 1-year echocardiographic data on aortic valve area (AVA), mean pressure gradient (MPG) and aortic regurgitation (AR). RESULTS: A total of 216 patients were included. Higher eGFR was associated with lower overall mortality (adjusted hazards ratio [AHR] 0.981, 95% confidence interval [CI] 0.968-0.993, = 0.002). CKD 4-5 were associated with significantly higher mortality from non-cardiovascular causes ( <0.05). Patients with CKD 3-5 had higher incidence of moderate AR than those with CKD 1-2 ( = 0.010); no difference in AVA and MPG was seen. AKI patients had higher mortality ( = 0.008), but the effect was attenuated on multivariate analysis (AHR 1.823, 95% CI 0.977-3.403, = 0.059). Patients with CKD progression also had significantly higher mortality (AHR 2.969, 95% CI 1.373-6.420, = 0.006). CONCLUSION CKD in severe AS patients undergoing TAVI portends significantly higher mortality and morbidity. Renal disease progression impacts negatively on outcomes and identifies a challenging subgroup of patients for optimal management.