Humans ; COVID-19 ; Antibodies, Monoclonal, Humanized/adverse effects* ; Pneumonia ; Lung Neoplasms/drug therapy*

Diagnostic Imaging ; Humans ; Lung/diagnostic imaging* ; Lung Diseases, Interstitial/diagnosis*

Aged ; Feasibility Studies ; Health Status ; Humans ; Mobile Applications ; Treatment Outcome

Evidence-based medicine is the foundation of current medical practice. Suitable evidence is needed to support the holistic approach in clinical practice. Quantitative research produces some evidence needed for disease treatment based on probabilities or averages. However, the practice of evidence-based medicine should be personalised to individual patients without relying solely on an average perspective. Beliefs, values and expectations are unique for each individual and may differ significantly from the average. Therefore, understanding individual differences requires evidence from qualitative research. This is particularly important in family medicine practice, which focuses on holistic care for the person, family and community. Findings from properly conducted qualitative research can offer in-depth and comprehensive accounts on healthcare issues from patient and practice perspectives. Qualitative research also provides explanatory power and analytical transferability, which can be applied into daily family medicine practice. In conclusion, evidence from qualitative research should be rightfully equally acknowledged in family medicine and healthcare.
Family Practice ; Evidence-Based Medicine ; Qualitative research

INTRODUCTION: Treatment of pain is an important component of prehospital care. Inhalational analgesia agents have attractive strengths, but there is a paucity of studies comparing these with more conventional agents. We aimed to compare inhalational methoxyflurane and intramuscular (IM) tramadol as first-contact analgesia in the Singapore national ambulance service. METHODS: Ambulances were randomised to carry either methoxyflurane or IM tramadol for the first six months and crossed over to the other arm after six months. Patients aged ≥ 16 years, with acute pain arising from musculoskeletal trauma with Numerical Rating Scale (NRS) score ≥ 3 were enrolled. Variables included NRS reduction, time variables, adverse effects, Ramsay Sedation Scores, and patient and paramedic satisfaction scores on a Likert scale. RESULTS: A total of 369 patients were enrolled into this study, but 26 patients were excluded due to missing data. The methoxyflurane arm had a shorter median time taken from arrival at the scene to drug administration (9.0 [interquartile range 6.0-14.0] minutes vs. 11.0 [interquartile range 8.0-15.0] minutes). For patients who achieved reduction in NRS ≥ 3 within 20 minutes, those in the methoxyflurane arm took a shorter time. However, the methoxyflurane (46.7%) arm experienced lower proportion of patients not achieving NRS reduction ≥ 3 when compared to the tramadol (71.6%) arm after over 20 minutes. The methoxyflurane arm had significantly higher paramedic and patient satisfaction scores. CONCLUSION For the doses of medication used in this implementation study, methoxyflurane was superior in efficacy, speed of onset and administration, but had more minor adverse effects when compared to IM tramadol.

INTRODUCTION: It is vital to diagnose and treat pulmonary tuberculosis (PTB) early, in the interests of the patient and public health. At the Singapore Tuberculosis Control Unit (TBCU), it was not uncommon to discover abnormal chest radiographs (CXRs) predating their PTB diagnosis by months to years in the electronic medical records (EMRs) of sputum acid-fast bacilli smear-positive patients. Our study explored this observation. METHODS: The EMRs of sputum smear-positive PTB patients treated at the TBCU from January to July 2014 were viewed for abnormal CXRs preceding their PTB diagnosis. Information in the EMRs pertaining to the indication for the CXRs, radiological reports (including whether the possibility of PTB was stated) and action taken was captured. RESULTS: Of the 254 sputum smear-positive patients, 108 had previous CXRs in their EMRs, of whom 39 (36.1%) had previous CXRs compatible with PTB. Most of these were performed in tertiary institutions and for reasons unrelated to PTB. No action was taken in response to these CXRs in 24 (61.5%) patients. 27 (69.2%) patients had abnormal CXRs dating back more than six months, with 12 (30.8%) dating back more than 30 months before the PTB diagnosis. Patients aged ≥ 55 years were significantly more likely to have previous CXRs that were compatible with PTB. CONCLUSION PTB patients may be asymptomatic or have chronic indolent disease and remain undiagnosed for years. There is a need for vigilance within our healthcare system to seize opportunities for early diagnosis and treatment to prevent the spread of this infectious disease in Singapore.

Aim: To examine the trend of youth depression diagnosed in a healthcare group in Singapore over a 6-year period. Methods: This is a retrospective analysis of the medical records of patients who had been diagnosed with depression from Jan 2013 to Dec 2018 in a healthcare group in Singapore. The yearly trend of depression diagnosis among the youths (10-24 years of age) was compared with adults (25-64 years of age) and the elderly (≥ 65 years of age). The mean age at diagnosis, distribution of gender, ethnicity and clinical care settings among the subgroup of youth patients were compared across the years using analysis of variance or Pearson’s chi-square test. Results: A total of 4701 youths, 15243 adults and 6908 elderly patients were included in the analysis. Between 2013 and 2018, the rise in depression diagnosis in the youth was greater than in the adult and elderly populations, and the mean age at diagnosis decreased from 49.7 ± 0.3 (mean ± SE) years in 2013 to 39.6 ± 0.3 years in 2018. Among the youths, more females had been diagnosed with depression than males and females displayed a larger increase in diagnosis of depression. There was also a larger increase in the diagnosis of depression in primary care compared to emergency departments, outpatient specialist clinics and in-hospital wards. Conclusion Youth depression is a major health problem in Singapore. There is a need for the expansion of resources in a variety of avenues for depressed youths to seek help.

The coronavirus disease 2019 (COVID-19) is typically diagnosed by specific assays that detect viral nucleic acid from the upper respiratory tract; however, this may miss infections involving only the lower airways. Computed tomography (CT) has been described as a diagnostic modality in the COVID-19 diagnosis and treatment plan. We present a case series with virologically confirmed COVID-19 pneumonia. Variable CT features were observed: consolidation with ground-glass opacities, ground-glass opacities with subpleural reticular bands, and an anterior-posterior gradient of lung abnormalities resembling that of acute respiratory distress syndrome. Evolution of CT findings was observed in one patient, where there was interval resolution of bilateral lung consolidation with development of bronchiolectasis and subpleural fibrotic bands. While sensitive for detecting lung parenchymal abnormalities in COVID-19 pneumonia, the use of CT for initial diagnosis is discouraged and should be reserved for specific clinical indications. Interpretation of chest CT findings should be correlated with duration of symptoms to better determine the disease stage and aid in patient management.
Aged ; Betacoronavirus ; Coronavirus Infections ; diagnosis ; Diagnosis, Differential ; Female ; Humans ; Lung ; diagnostic imaging ; Male ; Middle Aged ; Pandemics ; Pneumonia, Viral ; diagnosis ; Tomography, X-Ray Computed ; methods

We characterize the clinical and laboratory characteristics of 5 patients with Graves’ thyrotoxicosis whose serum free thyroxine (fT4) concentration decreased unexpectedly to low levels on conventional doses of carbimazole (CMZ) therapy. The initial fT4 mean was 40.0 pM, range 25-69 pM. Thyroid volume by ultrasound measured as mean 11 ml, range 9.0-15.6 ml. Initial TSI levels measured 1487% to >4444%. Serum fT4 fell to low-normal or hypothyroid levels within 3.6 to 9.3 weeks of initiating CMZ 5 to 15 mg daily, and subsequently modulated by fine dosage adjustments. In one patient, serum fT4 fluctuated in a “yo-yo” pattern. There also emerged a pattern of low normal/low serum fT4 levels associated with discordant low/mid normal serum TSH levels respectively, at normal serum fT3 levels. The long-term daily-averaged CMZ maintenance dose ranged from 0.7 mg to 3.2 mg. Patients with newly diagnosed Graves' hyperthyroidism who have small thyroid glands and markedly elevated TSI titres appear to be “ATD dose sensitive.” Their TFT on ATD therapy may display a “central hypothyroid” pattern. We suggest finer CMZ dose titration at closer follow-up intervals to achieve biochemical euthyroidism.
carbimazole ; Thyroid Stimulating Immunoglobulin ; Immunoglobulins, Thyroid-Stimulating ; Immunologic Tests ; Graves disease

In this paper, we aim to provide professional guidance to clinicians who are managing patients with chronic liver disease during the current coronavirus disease 2019 (COVID-19) pandemic in Singapore. We reviewed and summarised the available relevant published data on liver disease in COVID-19 and the advisory statements that were issued by major professional bodies, such as the American Association for the Study of Liver Diseases and European Association for the Study of the Liver, contextualising the recommendations to our local situation.
COVID-19/epidemiology* ; Carcinoma, Hepatocellular/therapy* ; Chronic Disease ; Hepatitis B, Chronic/therapy* ; Hepatitis C, Chronic/therapy* ; Humans ; Liver Cirrhosis/therapy* ; Liver Diseases/therapy* ; Liver Neoplasms/therapy* ; Liver Transplantation ; Singapore/epidemiology*