A case of rapid stabilization using electroconvulsive therapy (ECT) for a major depressive disordered (MDD) patient with life-threatening low body mass index (BMI) is reported. This case report focuses on a 55-year-old Malay housewife with underlying hyperthyroidism in a euthyroid state who presented with MDD with mood congruent psychotic features, which were precipitated by the death of her husband. Her BMI was only 11 kg/m2 due to severe anorexia, and she was highly suicidal. Peripheral total parenteral nutrition was started and ECT was commenced for rapid stabilization on top of tablet escitalopram 15 mg nocte. Full remission was achieved after nine ECTs and steady healthy weight gain was achieved throughout admission. The patient was discharged at BMI of 13 kg/m2 with good appetite. ECT was safe for very low BMI MDD patient.
Electroconvulsive Therapy ; Depressive Disorder, Major

Adult ; Erythema ; etiology ; Female ; Humans ; Leprosy ; complications ; diagnosis

: Multiparametric MRI (mpMRI) of the prostate is recently becoming more and more utilized in the detection of prostate cancer. Studies have shown that a higher PIRADS score correlated to a higher chance of obtaining a clinically significant prostate cancer but few studies have correlated PIRADS score to a specific Gleason score. OBJECTIVE: This study aimed to determine the concordance of PIRADS score to the Gleason score result of MRI ultrasound fusion-guided prostate biopsy. METHODS: All patients who had at least a PIRADS 2 lesion on mpMRI and underwent MRI ultrasound fusion-guided biopsy of the prostate from August 2018 up to November 2019 at St. Luke’s Medical Center, Global City were included in the study. An ambispective collection of data was done until the ideal sample size of greater than 100 positive lesions was obtained, in order to derive concordance rate. RESULTS: One hundred and sixty-two patients were included in the study with a total of 212 lesions analyzed. Forty three percent were benign while 57% were found to be malignant. PIRADS 2 lesions had zero high grade cancers, and the percentage steadily increased with 37.8% of PIRADS lesions considered high grade. Concordance was computed to be 0.38 showing a fair, direct concordance between PIRADS and Gleason score with significant result (p<0.05). CONCLUSION A result of PIRADS 4 or 5 lesion on mpMRI will have a higher urgency of doing a prostate biopsy and subsequent management to prevent unfavorable outcomes as opposed to PIRADS 3 lesions.

INTRODUCTIONSingaporeans are superstitious, and medical staff are no exception to the rule. We conducted a survey to determine the prevalence of superstitious beliefs and practices amongst doctors, nurses and medical students in Singapore.

METHODSInternet and face-to-face surveys of 68 respondents, all of whom completed the survey after being threatened with curses and hexes.

RESULTSSixty-eight doctors, nurses and medical students responded to our survey. Only 11 admitted to being superstitious, yet 31 believed in the ill-fortune associated with eating bao or meat dumplings, 6 in the nefarious powers of black (5) or red (1) outfits on call, and 14 believed that bathing (6 insisting on the powers of the seven-flower bath) prior to the onset of a call portended good fortune, in terms of busy-ness of a call. Twenty-four believed in "black clouds", i.e. people who attracted bad luck whilst on call, and 32 refused to mouth the words "having a good call" until the day after the event. We discovered 2 hitherto undescribed and undiscovered superstitions, namely the benefits of eating bread and the need to avoid beef, for the good and ill fortune associated with their ingestion.

DISCUSSIONSuperstitious practices are alive and well in modern-day Singapore, the practice not necessarily being restricted to the poorly-educated or foolish.

Attitude of Health Personnel ; Humans ; Singapore ; Superstitions

Escalating healthcare costs in Singapore have produced a significant movement of patients into ambulatory care, and the consequent dearth of clinical teaching materials. This deficiency has likewise prompted the creation of ambulatory teaching clinics and the use of standardised patients and simulators. In the last few decades, educators have utilised digital technology, for instance, digitally recorded heart and breath sounds, and digitised video vignettes, in medical education. We describe several pedagogical initiatives that we have undertaken at our university school of medicine.
Ambulatory Care ; Curriculum ; Diffusion of Innovation ; Education, Medical ; methods ; Humans ; Medical Informatics ; trends ; Singapore ; User-Computer Interface

INTRODUCTIONThis study aims to determine the attitudes of Asian elderly patients towards invasive life support measures, the degree of patient-surrogate concordance in end-of-life decision making, the extent to which patients desire autonomy over end-of-life medical decisions, the reasons behind patients' and surrogates' decisions, and the main factors influencing patients' and surrogates' decision-making processes. We hypothesize that there is significant patient-surrogate discordance in end-of-life decision making in our community.

MATERIALS AND METHODSThe patient and surrogate were presented with a hypothetical scenario in which the patient experienced gradual functional decline in the community before being admitted for life-threatening pneumonia. It was explained that the outcome was likely to be poor even with intensive care and each patient-surrogate pair was subsequently interviewed separately on their opinions of extraordinary life support using a standardised questionnaire. Both parties were blinded to each other's replies.

RESULTSIn total, 30 patients and their surrogate decision-makers were interviewed. Twenty-eight (93.3%) patients and 20 (66.7%) surrogates rejected intensive care. Patient-surrogate concurrence was found in 20 pairs (66.7%). Twenty-four (80.0%) patients desired autonomy over their decision. The patients' and surrogates' top reasons for rejecting intensive treatment were treatment-related discomfort, poor prognosis and financial cost. Surrogates' top reasons for selecting intensive treatment were the hope of recovery, the need to complete final tasks and the sanctity of life.

CONCLUSIONThe majority of patients desire autonomy over critical care issues. Relying on the surrogates' decisions to initiate treatment may result in treatment against patients' wishes in up to one-third of critically ill elderly patients.

Advance Directive Adherence ; Aged ; Aged, 80 and over ; Attitude ; Critical Care ; psychology ; Critical Illness ; psychology ; therapy ; Decision Making ; Dissent and Disputes ; Female ; Humans ; Male ; Personal Autonomy

INTRODUCTIONEfavirenz is an inducer of drug metabolism enzymes. We studied the effect of efavirenz and ritonavir-boosted darunavir on serum unconjugated and conjugated bilirubin, as probes for UGT1A1 and bile transporters.

MATERIALS AND METHODSHealthy volunteers were enrolled in a clinical trial. There were 3 periods: Period 1, 10 days of darunavir 900 mg with ritonavir 100 mg once daily; Period 2, 14 days of efavirenz 600 mg with darunavir/ritonavir once daily; and Period 3, 14 days of efavirenz 600 mg once daily. Serum bilirubin (conjugated and unconjugated) concentrations were obtained at baseline, at the end of each phase and at exit.

RESULTSWe recruited 7 males and 5 females. One subject developed grade 3 hepatitis on efavirenz and was excluded. Mean serum unconjugated bilirubin concentrations were 6.09 μmol/L (95% confidence interval [CI], 4.99 to 7.19) at baseline, 5.82 (95% CI, 4.88 to 6.76) after darunavir/ritonavir, 4.00 (95% CI, 2.92 to 5.08) after darunavir/ritonavir with efavirenz, 3.55 (95% CI, 2.58 to 4.51) after efavirenz alone and 5.27 (95% CI, 3.10 to 7.44) at exit (P <0.01 for the efavirenz phases). Mean serum conjugated bilirubin concentrations were 3.55 μmol/L (95% CI, 2.73 to 4.36) at baseline, 3.73 (95% CI, 2.77 to 4.68) after darunavir/ritonavir, 2.91 (95% CI, 2.04 to 3.78) after darunavir/ritonavir with efavirenz, 2.64 (95% CI, 1.95 to 3.33) after efavirenz alone and 3.55 (95% CI, 2.19 to 4.90) at exit (P <0.05 for the efavirenz phases).

CONCLUSIONEfavirenz decreased unconjugated bilirubin by 42%, suggesting UGT1A1 induction. Efavirenz also decreased conjugated bilirubin by 26%, suggesting induction of bile efflux transporters. Ritonavir-boosted darunavir had no effect on bilirubin concentrations. These results indicate that efavirenz may reduce concentrations of drugs or endogenous substances metabolized by UGT1A1 or excreted by bile efflux transporters.

Adult ; Aged ; Anti-HIV Agents ; therapeutic use ; Benzoxazines ; pharmacology ; Biological Transport ; Confidence Intervals ; Darunavir ; Dose-Response Relationship, Drug ; Drug Interactions ; Enzyme Induction ; drug effects ; Female ; Glucuronosyltransferase ; biosynthesis ; blood ; HIV Infections ; drug therapy ; HIV Protease Inhibitors ; Humans ; Incidental Findings ; Male ; Membrane Transport Proteins ; drug effects ; metabolism ; Middle Aged ; Ritonavir ; pharmacology ; Sulfonamides ; pharmacology ; Young Adult

Antimicrobial resistance to the extended-spectrum cephalosporins is increasingly reported worldwide. In the local setting, nosocomial infections with multi-resistant Gram-negative bacilli are not uncommon and are a growing concern. However, there is limited data on the carriage rates of such organisms in the local setting. In May 2001, a prospective study was carried out to determine the enteric carriage rates of ceftazidime-resistant Gram negative bacilli (CAZ-R GNB) among residents of nursing homes and from in-patients of the geriatric and adult haematology wards of University Malaya Medical Centre. Ceftazidime-resistant Gram-negative bacilli (CAZ-R GNB) were detected in 25 samples (30%), out of which 6 were from nursing home residents, 5 from geriatric in-patients and 14 from the haematology unit. A total of 28 CAZ-R GNB were isolated and Escherichia coli (10) and Klebsiella pneumoniae (7) were the predominant organisms. Resistance to ceftazidime in E. coli and Klebsiella was mediated by extended-spectrum beta-lactamases (ESBLs). Although the majority of the CAZ-R GNB were from patients in the haematology ward, the six nursing home residents with CAZ-R GNB were enteric carriers of ESBL-producing coliforms. Prior exposure to antibiotics was associated with carriage of ESBL organisms and to a lesser extent, the presence of urinary catheters.
seconds ; Upper case are ; Extended-spectrum beta lactamase ; Elderly ; Organisms (MeSH Category)

INTRODUCTIONOsteosarcoma treatment has experienced a renaissance in the last 3 decades with the institution of multimodality treatment involving multiagent chemotherapy and surgery. Yet globally, treatment success has stagnated at about 70% survival at 5 years in most single institution series. We performed survival analyses on 2 national databases in 2 countries and compared these with corresponding institution specific survival.

MATERIALS AND METHODSAll patients with the diagnostic code of non-metastatic intramedullary osteosarcoma in the long bones of the upper and lower limbs less than 30 years of age were selected from the Surveillance Epidemiology and End Result (SEER) database to ensure uniformity with respect to disease and treatment. We studied the factors: ethnicity, gender, age, grade, histology, size, site, surgery, compartmentalisation, number of primaries and venue of treatment for their contribution to survival. In addition, the data were stratified into 3 decades (seventies, eighties and nineties) to account for variations due to the evolution of treatment paradigms and imaging modalities.

RESULTSInstitution-specific survival was predictably better than national survival in the 4 databases. One thousand patients were selected from the SEER database. Oriental descent, state-specific treatment, female gender, treatment in the nineties, low-grade disease, intra-compartmental disease, small size, wide resections as opposed to forequarter or hindquarter amputations, and single primaries were good prognostic factors on univariate analysis as well as multivariate analysis (P <0.05). Survival was better in the more affluent states (P <0.05). Males were affected at an older age than females (P = 0.004). Blacks tended to have larger tumours although their overall survival was similar to whites. Orientals were more likely to be treated in the nineties with wide resections for smaller tumours and were located around states associated with good treatment. Orientals in Singapore and the United States had the same survival (P = 0.45). Survival in Orientals in Singapore was not significantly different from other races. The standard of healthcare for osteosarcoma varies greatly across the United States but is uniform in Singapore. Hence the observed differences in the United States were likely due to socioeconomic factors.

CONCLUSIONThis analysis confirms the importance of a number of prognostic variables in osteosarcoma and suggests the possibility of an ethnic and economic bias for good survival.

Adolescent ; Adult ; African Continental Ancestry Group ; Asian Continental Ancestry Group ; Bone Neoplasms ; epidemiology ; ethnology ; mortality ; Child ; Child, Preschool ; Databases, Factual ; European Continental Ancestry Group ; Female ; Humans ; Infant ; Infant, Newborn ; Internationality ; Kaplan-Meier Estimate ; Male ; Osteosarcoma ; epidemiology ; ethnology ; mortality ; Prognosis ; Registries ; Singapore ; epidemiology ; Young Adult