Acute Disease ; Diagnosis, Differential ; Humans ; Male ; Middle Aged ; Myocardial Infarction ; diagnosis ; pathology ; Pancreatitis ; diagnosis ; pathology

Blood Pressure Monitoring, Ambulatory ; COVID-19/therapy* ; Cardiac Rehabilitation ; Cardiovascular Diseases/therapy* ; Communicable Disease Control ; Contact Tracing ; Health Literacy ; Health Services Accessibility ; Healthcare Disparities ; Humans ; Internet Access ; Poverty ; SARS-CoV-2 ; Singapore ; Social Class ; Social Conditions ; Socioeconomic Factors ; Telemedicine ; Telerehabilitation ; Transients and Migrants

The causes of low voltage complexes on the electrocardiogram (ECG) are variable; however, they are not commonly discussed. An ECG with small QRS amplitudes may initially look unremarkable to the unwary, but some of the underlying conditions may be critical. Although imperfect, the ECG is still a useful, noninvasive and readily available tool for the screening of these underlying conditions. We present two cases with low voltage complexes in the ECG. The first case highlights how the findings on ECG and subsequent echocardiogram led to the diagnosis of a rare case of cardiac amyloidosis. In the second case, a screening electrocardiogram alerted the physicians to a life-threatening condition, that of a large pericardial effusion with cardiac tamponade.
Aged ; Cardiac Tamponade ; diagnosis ; etiology ; physiopathology ; Diagnosis, Differential ; Electrocardiography ; Female ; Heart Conduction System ; physiopathology ; Humans ; Male ; Middle Aged ; Pericardial Effusion ; diagnosis ; physiopathology

Background & Objective: Modulation of cortical excitability by low frequency repetitive transcranial magnetic stimulation (rTMS) has demonstrated therapeutic use in epilepsy. This study aimed to evaluate the efficacy of low-frequency rTMS on refractory epilepsy in a group of Malaysian subjects. Methods: Nine patients with refractory epilepsy completed the study. All patients received 10 sessions of 1Hz rTMS (1000 pulses per session) at 90% of resting motor threshold. Outcome measures included seizure frequency, Symptom Checklist-90 (SCL-90), Beck Depression Inventory II (BDI II) and Quality of Life in Epilepsy-31 (QOLIE-31). Responders were defined as having ≥ 50% seizure reduction. Results: The mean age was 33.8 years (SD 11.7), with 4 male. Three patients had mesial temporal sclerosis (MTS); 4 with focal cortical dysplasia (FCD) and two lesion-negative. Three patients achieved >50% seizure reduction at 8 weeks post-treatment, with 2 of them had improvement in the number of IED. All of the responders had FCD. The responders were younger (mean 24.7 vs. 38.3 years old), had shorter duration of illness (mean 15.7 vs. 30.5 years) and had less frequent seizure frequency prior to treatment (mean 5.5 vs. 10.8 attacks per week), as compared to the non-responders. Six patients had improvement in BDI-II scores, two in QOLIE-31 and four in SCL-90 post treatment, irrespective of seizure control. The mean scores in BDI-II improved significantly with treatment (p<0.01). Conclusion: rTMS is a potentially promising treatment for epilepsy, esp
Transcranial Magnetic Stimulation ; Epilepsy

INTRODUCTION: Pulmonary arterial hypertension (PAH) is associated with high medical and pharmaceutical costs. Phosphodiesterase type 5 (PDE5) inhibitors have been found to be beneficial but costly. They are not subsidised in Singapore except via the Medication Assistance Fund (MAF) Plus scheme. In this study, we described the help-seeking behaviour of patients and funding strategies for Singaporean patients on PDE5 inhibitors in our registry. METHODS: We consecutively recruited all patients with PAH who presented to our pulmonary hypertension specialty centre between 1 January 2003 and 29 December 2016. Singaporean patients on PDE5 inhibitors were included. Data recorded and analysed for this study included baseline demographics, whether the patients received MAF Plus funding, percentage of funding, and any additional source of subsidies. RESULTS: 114 (77.0%) of 148 patients in the registry were Singapore citizens on PDE5 inhibitors. 75 (65.8%) of these 114 patients had been seen by a medical social worker, of whom 16 were on MAF Plus funding. 14 of the remaining 59 patients were subsidised by MediFund, whereas the remainder were self-paying. 30 (26.3%) patients in total were on some form of subsidy, and 28 (24.6%) patients were on combination therapy. Of this group, nine were receiving MAF Plus subsidies. CONCLUSION Fewer than expected patients were found to be receiving drug subsidies for PAH. This was partly due to insufficient referrals and lack of requests for financial assistance. Patients on combination therapy had greater financial challenges. This study should spur us on to study funding gaps further and address them.

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Lipids to provide doctors and patients in Singapore with evidence-based treatment for lipids. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on Lipids, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.
Adult ; Cardiovascular Diseases ; complications ; therapy ; Child ; Coronary Artery Disease ; complications ; therapy ; Decision Support Systems, Clinical ; Dyslipidemias ; blood ; complications ; therapy ; Evidence-Based Medicine ; Female ; Humans ; Kidney Failure, Chronic ; complications ; therapy ; Life Style ; Lipids ; blood ; Lipoproteins, LDL ; blood ; Male ; Practice Guidelines as Topic ; Pregnancy ; Pregnancy Complications ; Risk Assessment ; Risk Factors ; Singapore

Right ventricle to pulmonary artery (RV-PA) conduits have been used for the surgical repair of congenital heart defects. These conduits frequently become stenosed or develop insufficiency with time, necessitating reoperations. Percutanous pulmonary valve implantation (PPVI) can delay the need for repeated surgeries in patients with congenital heart defects and degenerated RV-PA conduits. We presented our first experience with PPVI and described in detail the procedural methods and the considerations that are needed for this intervention to be successful. Immediate and short-term clinical outcomes of our patients were reported. Good haemodynamic results were obtained, both angiographically and on echocardiography. PPVI provides an excellent alternative to repeat open-heart surgery for patients with congenital heart defects and degenerated RV-PA conduits. This represents a paradigm shift in the management of congenital heart disease, which is traditionally managed by open-heart surgery.

INTRODUCTION: We aimed to describe the extrapulmonary manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, including their frequency, onset with respect to respiratory symptoms, pathogenesis and association with disease severity. METHODS: We searched the MEDLINE and Embase databases for SARS-CoV-2-related studies. Meta-analysis, observational studies, case series and case reports published in English or Chinese between 1 January 2020 and 1 May 2020 were included. Reports with only paediatric or obstetric cases were excluded. RESULTS: 169 articles were included. Early manifestations (preceding respiratory symptoms until Day 6 of onset) included olfactory and gustatory disturbance (self-reported in up to 68% and 85% of cases, respectively), gastrointestinal symptoms (up to 65.9%) and rash (up to 20.4%). From Day 7 onwards, hypercytokinaemia, paralleled multi-organ complications including acute cardiac injury (pooled incidence of 17.7% in 1,412 patients, mostly with severe disease and 17.4% mortality), kidney and liver injury (up to 17% and 33%, respectively) and thrombocytopenia (up to 30%). Hypercoagulability resulted in venous thromboembolic events in up to 31% of all patients. Uncommon disease presentation and complications comprised Guillain-Barré syndrome, rhabdomyolysis, otitis media, meningoencephalitis and spontaneous pneumomediastinum. CONCLUSION Although the systemic manifestations of SARS-CoV-2 infection are variegated, they are deeply interwoven by shared mechanisms. Two phases of extrapulmonary disease were identified: (a) an early phase with possible gastrointestinal, ocular and cutaneous involvement; and (b) a late phase characterised by multiorgan dysfunction and clinical deterioration. A clear, multidisciplinary consensus to define and approach thromboinflammation and cytokine release syndrome in SARS-CoV-2 is needed.
Humans ; Asian People ; COVID-19/complications* ; Inflammation/complications* ; SARS-CoV-2 ; Thrombosis