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Teaching biochemistry to medical students in Singapore--from organic chemistry to problem-based learning.

The medical faculty in the National University of Singapore started in 1905 but the Chair in Biochemistry was only established in 1927. For many years the biochemistry course consisted of the teaching of the organic chemistry of substances of physiological importance, nutrition, metabolism and hormones. In 1961, clinical biochemistry was introduced and in the 1980s, genetics and molecular biology were included. By then, most of the organic chemistry content had been removed as greater emphasis was placed on clinical correlation. Laboratory classes consisted of mock glucose tolerance tests and the measurement of various enzymes. By the 1990s, students were no longer interested in such practical classes, so a bold decision was made around 1995 to remove laboratory classes from the curriculum. Unfortunately, this meant that the medical students who might have been interested in laboratory work could no longer do such work. However, the new curriculum in 1999 gave the department an opportunity to offer a laboratory course as an elective for interested students. This new curriculum adopted an integrated approach with Genetics being taught as part of Paediatrics, and a new module (Structural and Cell Biology) comprising aspects of cell biology and biochemistry was introduced. This module is currently taught by staff from Anatomy, Physiology and Biochemistry. Some biochemistry content is now incorporated into the clinical problem scenarios of problem-based learning such as jaundice, diabetes mellitus, anorexia nervosa, etc. So the evolution of teaching biochemistry to medical students in Singapore has paralleled worldwide trends and moved from the didactic teaching of organic chemistry of biomolecules to problem-based learning using clinical cases.

Biochemistry↗

One hundred years of the teaching of medicine in Singapore.

The Medical School was founded in 1905 in response to the need to train doctors for Singapore. In 2005, this School, now the Faculty of Medicine in the National University of Singapore, will celebrate her 100th year. This brief review attempts to chronicle the way in which the medical course has been designed over the years to address the principal aims of undergraduate medical education. From the inception of the Straits and Federated Malay States Government Medical School to the present, strong clinically based teaching was the key element, although there was some distinction between the foundational preclinical years and the clinical phases of training. Initially, this was necessitated by the fact that students were too poorly equipped in the sciences to have a more integrated curriculum. Over time, the structure of the course, learning objectives and teaching pedagogy and techniques became better developed. Of late, many of these elements have been revised and better articulated by the Faculty following a review. The method, frequency and emphasis of student evaluations have also changed as medical knowledge grows and the population becomes developed, with attendant disease pattern changes. The clinical relevance of the course and the need to train competent doctors remain the main mission of the Faculty of Medicine even in this age of molecular medicine and a technology-enhanced practice setting. Competency alone is, however, incomplete without good role models in the art of the practice of medicine. It is heartening to note that medical ethics and communications skills continue to be emphasised in the modern curriculum.

Curriculum↗

One hundred years of orthopaedic education in Singapore.

The Department of Orthopaedic Surgery at the University of Malaya (in Singapore) was established in 1952. Prior to this, the teaching of Orthopaedic Surgery at the University was undertaken by the Department of Surgery under the Professor of Surgery and Professor of Clinical Surgery. From a course consisting of 15 weekly classes on fractures for 18 undergraduates in the late 1930s, and the clinical postings in orthopaedic surgery for over 40 students in 1952, the programme now encompasses an exposure to musculoskeletal diseases and trauma in all 5 years of the undergraduate course. Over this time, the spectrum of clinical conditions has also changed, and with it the emphasis on the conditions to be taught; from that dealing primarily with tuberculosis of bones and joints, poliomyelitis, and childhood deformity, to those resulting from degenerative disorders, sports injuries, industrial and motor vehicle accidents, and cancer. The students are now taught orthopaedic surgery in all the major public hospitals. Local postgraduate training programmes for orthopaedic surgery started in the 1980s. From 1993, a more structured training and assessment programme was introduced for basic and advanced training in surgery and orthopaedics. Advanced trainees rotate through the various teaching hospitals to expose them to a wider range of orthopaedic problems as well as teachers. The postgraduate training programme is now well established, and Singapore is accredited by the Royal College of Surgeons of Edinburgh as an orthopaedic training centre for higher surgical training.

Education, Medical↗

Dental education in Singapore--from the past to the future.

Dental education in Singapore has come a long way since the founding of the Dental School in 1929. With an initial intake of 7 students, the Faculty has over the years produced more than 1700 graduates. Its early years were fraught with physical constraints and recruitment problems. With a dedicated core of leaders and good planning, the dental school has overcome many of these shortcomings. The King Edward VII College of Medicine played a significant role in the early years of the school's development. Many a student of the past era has pleasant memories that bind and bond them to the SGH Sepoy Lines campus. Acquiring full Dental Faculty status in 1966, the progress of dental education took on a new urgency and stature. The basic medical science subjects were taught to the dental students by our medical colleagues at Sepoy Lines and now continue to be tutored at the Kent Ridge campus. With the shift of the Faculty in 1986 to Kent Ridge (NUS-NUH), together with the implementation of the changed curriculum in 1990 and 1997, the Faculty of Dentistry remains at the forefront of pedagogy and technology to train the future generation of dentists for Singapore.

Curriculum↗

After the Indian Ocean tsunami: Singapore's contribution to the international disaster victim identification effort in Thailand.

This paper describes the international disaster victim identification (DVI) response mounted in Thailand, with particular reference to Singapore's contribution to this process, in the wake of the Asian tsunami of 26 December, 2004, which devastated parts of more than 10 countries in and around the Indian Ocean and claimed more than 200,000 lives. Although Singapore was unscathed by this natural calamity, over 30 Singaporean visitors were counted amongst the thousands of deceased victims, mostly in Thailand. The systematic application of forensic pathology, forensic dentistry, DNA profiling, and fingerprinting to human identification, especially of the bodies of various nationalities that were in advanced states of putrefaction, was crucial to the entire DVI process. The authors perceive that the resource implications arising from such a disaster, which is unprecedented in both its scale and reach in the international history of DVI, are immense. Forward planning, adequate funding and international cooperation are essential to mounting an effective response to any major mass disaster of the future.

Bayes Theorem↗

Parotid abscess in Singapore.

INTRODUCTION: In most parts of the world, acute parotid abscess is a rare pathology. It occurs mainly in elderly debilitated patients and patients with oral sepsis. In Singapore, this lesion appears to be more common. METHODS: We retrospectively reviewed all patients admitted to our hospital over a three-year period with parotid abscess. RESULTS: Ten patients were treated for parotid abscess. Only two of these patients were elderly and debilitated. The remaining patients were atypical in that they were relatively young and fit with no history of oral sepsis. All the abscesses responded to simple drainage and antibiotic therapy without the need to resort to the radical drainage techniques reported historically. CONCLUSION: Parotid abscess is seen in an unusually young cohort of patients in Singapore. The cause for this is unclear but it may be a result of chronic oral dehydration as a consequence of our climate.

Abscess↗

Neuropsychological testing: how it can benefit clinical neuroscience in Singapore.

Neuropsychological testing is a relatively new field in the area of clinical neuroscience. It has proven to be an effective and essential aid in the diagnostic process of brain-injured patients, especially in lesions of the cerebral cortex. More advanced countries have incorporated neuropsychological assessments in their standard neurological examinations of the brain damaged. Clinical neuropsychology is only beginning to be used in Singapore. Research using neuropsychological methods have also shown to be useful in providing a greater understanding of the brain-behaviour relationship in humans. Problems confronting the use of neuropsychological testing in Singapore are identified and the possible solutions discussed.

Brain Damage, Chronic↗

Experience with ARRAY multifocal lenses in a Singapore population.

INTRODUCTION: To evaluate the clinical efficiency, safety and subjective visual outcomes of multifocal intraocular lenses (IOL) in the Singapore population. METHODS: This is a retrospective case series of 45 phacoemulsification with multifocal lens implantation performed in 27 patients for cataracts, over a two-year period. The efficacy, stability and safety of the lens were assessed up to six months of follow-up. A telephone interview enquiring about ratings of vision, spectacle independence, glare, driving difficulty and photic phenomena, was conducted and the results were compared with those published in the literature. RESULTS: The best corrected distance Logmar acuity was 0.1 (0.1 and near visual acuity was N5 (range N5 to N8) at six months. The distance visual acuity stabilised by one month whereas near vision remained unchanged from day one post-surgery. Posterior capsular opacification was seen in 17 patients (38.6 percent) of which two patients (4.55 percent) required YAG capsulotomy. Total spectacle independence was achieved in 12 patients (54.4 percent). Among those who required spectacles, 50 percent required spectacles more than 50 percent of the time. Five patients (22.7 percent) reported glare usually at night (80 percent) as compared with daytime glare (20 percent). The most common photic phenomena report after surgery was halo. CONCLUSION: The Advanced Medical Optics ARRAY multifocal IOL showed good efficacy, predictability, stability and safety. The subjective visual outcomes in the Singapore population were comparable to those of their Western counterparts.

Aged↗

Clinical characteristics of patients with multiple system atrophy in Singapore.

INTRODUCTION: Our study aimed to describe the clinical features of multiple system atrophy (MSA) in Singapore and verify its diagnosis using the consensus statement in the diagnosis of MSA. MATERIALS AND METHODS: All patients suspected to have MSA between 1995 and March 2005 were identified from the Movement Disorders database and the autonomic function testing results. The medical records were reviewed using a standardised data collection form. The diagnosis of MSA was verified using the consensus statement. Disease progression was evaluated using 2 pre-determined events: aid-requiring walking and wheelchair use. RESULTS: Seventy-two per cent (33/46) fulfilled the consensus statement. There were 85% Chinese, 9% Malays, and 6% Indians. The mean age at onset of the disease was 60 +/- 10 years. We found a predominance of males (M:F = 1.5:1) as well as MSA-C cases (67%). The most common initial presenting features were parkinsonism and cerebellar signs (27% each). Abnormal neuroimaging was seen in 29 patients (91%). Autonomic function testing was abnormal in 58% (7/12). The risk for aid-requiring walking and wheelchair use at 3 years from onset of the disease was 31% and 17%, respectively. By 5 years, this had increased to 45% and 30%, respectively. There was no difference in the events rate between MSA subtypes. CONCLUSIONS: The clinical characteristics of MSA in Singapore are presented. Our study revealed a predominance of MSA-C patients as well as a later age at onset of disease and longer median time to aid-requiring walking and wheelchair use compared to Japanese patients.

Adult↗

Carbon monoxide poisoning: a five year review at Tan Tock Seng Hospital, Singapore.

INTRODUCTION: Carbon monoxide poisoning (COP) is one of the leading causes of death from poisoning worldwide. There is no published study of COP in Singapore so far. MATERIALS AND METHODS: All patients admitted with the diagnosis of COP to Tan Tock Seng Hospital (TTSH) over 5 years from 1999 to 2003 were retrospectively reviewed. The diagnosis was based on a history of potential exposure to carbon monoxide (CO) and elevated levels of carboxyhaemoglobin (COHb). The causes, demographic data, clinical presentations, management and complications were analysed. RESULTS: There were 12 patients with COP. Their average age was 38.9 (+/-11.8) years, with a male-to-female ratio of 3:1. Accidental COP (58.3%) was more common than intentional COP (41.7%). The most common cause of accidental COP was smoke inhalation from a faulty vehicle. Gas stove was the most preferred source for intentional poisoning. Presenting features were headache (83.3%), confusion (83.3%), coma (12.7%) and agitation (8.3%). The mean COHb level on admission was 35.9% (+/-13.6). All were treated with 100% oxygen. All the patients achieved normal levels of COHb within 24 hours of admission. Two (16.7%) required intubation for airway protection as they were comatose on arrival, of which 1 presented with very high level of COHb (48.1%) and was the only patient to be treated with hyperbaric oxygen. Acute complications were globus pallidus infarction (16.6%), acute respiratory distress syndrome (8.3%) and myocardial ischaemia (8.3%). Most of the patients (91.7%) were discharged well from the hospital. One patient developed parkinsonism after a follow-up of 2 years. There were no deaths. CONCLUSION: COP is relatively uncommon in Singapore. It has a low rate of short- and long-term complications.

Adult↗

Emergence of community-associated methicillin-resistant Staphylococcus aureus in Singapore: a further six cases.

INTRODUCTION: The clinical features and molecular epidemiology of further cases of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection in Singapore are described. METHODS: Six cases of CA-MRSA infection that occurred between April and October 2004 are described. The bacterial isolates were tested for the presence of Panton-Valentine leukocidin (PVL) genes and typed via pulsedfield gel electrophoresis, staphylococcal chromosomal cassette mec (SCCmec) and multi-locus sequence typing. The results were compared with that of previously-reported local and international CA-MRSA isolates. RESULTS: There were four cases of cutaneous abscesses and one each of chronic osteomyelitis and endocarditis. CA-MRSA isolates from the last two cases tested negative for PVL genes. Three isolates were identical and related to the Oceanian clone, and one isolate to the predominant Taiwanese clone. The isolate causing osteomyelitis had a novel sequence type. CONCLUSION: CA-MRSA, though uncommon, is being isolated with increasing frequency in Singapore. A predominant clone (ST30- MRSA-IV) seems to be emerging locally.

Adult↗

Psychiatric aspects of homicide in Singapore: a five-year review (1997 - 2001).

INTRODUCTION: The association between mental illness and violent offenders is an important issue not just for psychiatrists but for the public as well. Several studies have linked an increased prevalence of psychiatric illness among offenders of violent crimes. This study seeks to update the psychiatric community in Singapore on individuals charged with murder from 1997 to 2001, all of whom received a psychiatric assessment. METHODS: 110 individuals were charged with murder from 1997 to 2001. Socio-demographical data, psychiatric diagnoses, offence and victim profiles and court outcomes were obtained from prison records and psychiatric files. RESULTS: There were 110 individuals charged with murder between January 1, 1997 to December 31, 2001, with a total of 113 victims. In 70 of the cases, one offender killed one victim. Offenders were mostly unmarried males in the 20-39 year age group who received a secondary school level of education or less. 57 of the remandees were found not to suffer from any mental illness. Alcohol abuse and dependence disorders accounted for the largest diagnostic group. Depressive disorders accounted for 9.1 percent of the accused persons and schizophrenia, 6.4 percent. Victim profiles and court outcomes are also described. A comparison is drawn between this study and the last large report on homicides in Singapore, published in 1985. No difference is detected when the rates of schizophrenia and depression are compared between the two eras. CONCLUSION: Perpetrators of murder have been shown to have an increased incidence of psychiatric disorders. Reduction of the rate of homicide in the country may be achievable via the reduction of controllable factors found to be linked to the aetiology of murder. Alcohol and other illicit substance use are frequently found to be associated with homicide. The authorities are encouraged to enhance campaigns to dissuade alcohol abuse.

Adolescent↗

A 24-year review on the epidemiology and control of measles in Singapore, 1981-2004.

The objective of our paper is to review the epidemiology of measles in Singapore and the impact of the measles vaccination program on the control of measles. Our review will form the basis for a critical appraisal of our future measles control program. We analyzed the trend of reported measles cases in relationship to measles vaccination coverage from 1981 to 2004 using routine measles notifications and measles vaccination data submitted to the Ministry of Health and the National Immunization Registry, respectively. We determined the measles vaccine efficacy using data from epidemiological investigations of reported institutional measles outbreaks. The herd immunity of the population against measles was accessed through three seroepidemiological surveys that we conducted in 1989/1990, 1993 and 1998. In addition, we collected blood specimens from every clinically diagnosed case of measles notified to the Ministry in 1998/1999 to for measles-specific IgM antibodies in order to evaluate the proportion of clinically diagnosed cases of measles that were laboratory confirmed. The incidence of measles has decreased significantly since 1981 as a result of increased vaccination coverage of 89-93% following implementation of compulsory measles vaccination in 1985. However, resurgences still occurred in 1992/1993 and 1997. With the implementation of the two-dose measles vaccination schedule, the annual number of laboratory confirmed cases of measles to date has been less than 150. Vaccine efficacy of the trivalent MMR vaccine based on institutional outbreak investigations was consistently above 92%. We also found that the overall seroprevalence of the population to measles has decreased from approximately 91.5% in 1989/1990 to 1993 to 77.9% in 1998 (mainly in children < 4 years old) and that only 7% of clinically notified cases of measles were serologically confirmed to be positive for measles. Achieving a vaccination coverage of more than 95%, tightening our MMR vaccine delivery system and strengthening surveillance of measles are essential components which must be addressed in order to interrupt measles transmission in Singapore.

Adolescent↗

Liver transplantation for hepatocellular carcinoma in Singapore.

INTRODUCTION: The prognosis of patients with hepatocellular carcinoma (HCC) is poor. Surgical resection offers the benefit of removal of the tumour but is associated with liver decompensation and tumour recurrence, even after successful surgery. Liver transplantation offers the benefits of complete tumour removal with prevention of both decompensation and recurrence post-operation. This paper aims to review results of liver transplantation for patients with HCC in Singapore. METHODS: All adult patients with HCC accepted on the waiting list for liver transplantation (based on the Milan criteria) from 1996 to 2004 in Singapore were reviewed. Patients' HCC were managed with either transarterial chemoembolisation or percutaneous radiofrequency ablation while they were on the waiting list. Post-transplant survival and factors associated with mortality were analysed by Cox regression analysis. RESULTS: 41 patients with HCC were accepted onto the waiting list over the nine-year period. 22 underwent transplantation and 19 did not, with a one-year survival of 91 percent versus 24 percent, respectively. (p-value is less than 0.001). Mean waiting time for transplant was 39 weeks. Post-transplant HCC recurrence was 2/22 (nine percent). Among all patients, mortality was significantly related to baseline white cell counts, prothrombin time, age, alpha-foetoprotein level, Child-Pugh score, and whether patients underwent transplant. CONCLUSION: Despite the relatively long waiting time of a mean of 39 weeks, post-transplant recurrence of HCC was relatively low at nine percent. Liver transplant is an effective treatment for patients with a HCC, with a reasonable long-term survival.

Carcinoma, Hepatocellular↗

MELD may not be the better system for organ allocation in liver transplantation patients in Singapore.

INTRODUCTION: The Model for End-Stage Liver Disease (MELD) score is a good predictor of mortality on the liver transplant waiting list and is the current system of organ allocation in the USA. However, a higher MELD may be associated with poorer outcome post-liver transplantation. The aim of this study was to determine if MELD should be implemented as the system for organ allocation for liver transplantation in Singapore. METHODS: There were 46 adult patients who underwent primary liver transplantation at the National University Hospital, Singapore from January 1996 to December 2002. We applied the MELD score to patients who were transplanted and looked for a correlation with survival post-transplant. Patients were followed-up until the most recent visit or death. Survival analysis was performed using Cox regression and Kaplan-Meier method. RESULTS: The mean age at transplant was 52.7 (SD 2.34) years. The majority of the patients transplanted had Hepatitis B (43 percent). The median MELD score at transplantation was 17 (7-42) and the median Child's score was 11 (6-15). There was a significant correlation between pre-transplant MELD and survival at six months (p-value is 0.037, 95 percent confidence interval [CI] is 1.004-1.13) but not at one year (p-value is 0.065, 95 percent CI is 0.99-1.12). There were no differences in the pre-transplant MELD (odds-ratio [OR] 1, 95 percent CI 0.9-1) as well as survival for patients with and without Hepatitis B (OR 0.72, 95 percent CI 0.22-2.35). CONCLUSION: MELD allows livers to be allocated to the patients with the greatest medical urgency but its influence on post-transplant survival should be further clarified so that post-transplant survival is not compromised.

Female↗

Referral patterns and waiting times for liver transplantation in Singapore.

INTRODUCTION: Referral patterns, waiting times, waiting list, and mortality provide information on how effectively a transplant programme deals with referred patients. This paper aims to review these parameters in the Singapore National Liver Transplant Programme. METHODS: Data of all patients referred to the Singapore National Liver Transplant Programme since its inception were captured and outcomes were retrieved and described. RESULTS: 562 patients were referred for liver transplant evaluation from 1990-2004, consisting of 457 adults and 105 children. The main indications for referral were hepatitis B liver disease and hepatocellular carcinoma in adults, and biliary atresia in children. Most patients were of United Network of Organ Sharing (UNOS) status 3 or 4 at the time of referral. 114 (20.28 percent) patients had transplants, consisting of 66 adults (14.44 percent) and 48 (45.71 percent) children. 138 adults and ten children were rejected for transplant, mainly for the reason of being "too early". The median waiting time for adults who had transplants was 3.3 months while adults still on the waiting list had been waiting for 16.2 months. The overall waiting list mortality was 44.3 percent, being 52.5 percent in adults and 23.2 percent in children. CONCLUSION: The overall transplantation rate is low and the waiting list mortality is high as a result of low availability of organs, particularly in adults. Paediatric liver transplant appears to have been better at dealing with referred patients but this is probably due to availability of living-related liver transplant. Improvement in these may result from the Human Organ Transplant Act.

Adult↗

Epidemiology and control of SARS in Singapore.

Severe acute respiratory syndrome (SARS) was imported into Singapore in late February 2003 by a local resident who returned from a holiday in Hong Kong and started an outbreak in the hospital where she was admitted on 1 March 2003. The disease subsequently spread to 4 other healthcare institutions and a vegetable wholesale centre. During the period between March and May 2003, 238 probable SARS cases, including 8 imported cases and 33 deaths, were reported. Transmission within the healthcare and household settings accounted for more than 90% of the cases. Factors contributing to the spread of infection included the failure to recognise the high infectivity of this novel infection, resulting in a delay in isolating initial cases and contacts and the implementation of personal protective measures in healthcare institutions; and the super-spreading events by 5 index cases, including 3 with co-morbid conditions presenting with atypical clinical manifestations of SARS. Key public health measures were directed at prevention and control within the community and hospitals, and the prevention of imported and exported cases. An isolated laboratory-acquired case of SARS was reported on 8 September 2003. Based on the lessons learnt, Singapore has further strengthened its operational readiness and laboratory safety to respond to SARS, avian flu and other emerging diseases.

Adolescent↗

SARS in Singapore--predictors of disease severity.

INTRODUCTION: Severe acute respiratory syndrome (SARS) affected 8096 individuals in 29 countries, with 774 deaths. In Singapore, there were 238 cases of SARS with 33 deaths. A retrospective analysis was performed to identify predictors of poor outcome in patients with SARS locally. MATERIALS AND METHODS: Clinical, laboratory and outcome data of 234 patients admitted to Tan Tock Seng Hospital and Singapore General Hospital were collected and analysed. Only data collected at the time of admission were used in the analysis for predictors of poor outcome. Adverse events were defined as admission to the intensive care unit or death. RESULTS: Clinical (temperature, FiO2) and laboratory [leukocyte, lymphocyte, neutrophil, platelet, lactate dehydrogenase (LDH), albumin] trends in groups with and without an adversarial event were presented. Fifty patients experienced an adverse event. On univariate analysis, male gender, advanced age, presence of comorbidities, neutrophilia, lymphopaenia, hyponatraemia, hypoalbuminaemia, transaminitis and elevated LDH or C-reactive protein were found to be significant predictors. On multivariate analysis, predictors of poor outcome were increased age [odds ratio (OR) 1.73 for every 10-year increase; 95% CI, 1.35 to 2.21], neutrophilia (OR 1.06 for every 1 x 10(9)/L increase; 95% CI, 1.02 to 1.11) and high LDH (OR 1.17 for every 100 U/L increase; 95% CI, 1.02 to 1.34). None of the 12 paediatric patients had an adverse event. CONCLUSION: Advanced age, neutrophilia and high LDH predict poor outcomes in patients with SARS.

Adolescent↗