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Medical Digest Jul-Sept 2011

Medical Digest Jul-Sept 2011

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Medical Digest Jul-Sept 2011
Medical Digest Jul-Sept 2011

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Published by: Tan Tock Seng Hospital on Jun 18, 2012
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CENTRAL APPOINTMENTTel:6357 7000Tel:6357 8000(for private appointments only)NHG PARTNERSDirect Access Hotline: 9666 6698 ARTIFICIAL LIMB CENTREProsthetic-Orthotic ServicesTel : 6259 4026Podiatry ServicesTel : 6259 2678HEALTH ENRICHMENT CENTREHealth Screening & AssessmentTel: 6357 2233 / 35
Important TTSH contact numbers
Tan Tock Seng Hospital 11 Jalan Tan Tock Seng Singapore 308433Tel: 6256 6011 Fax: 6252 7282 Website: www.ttsh.com.sg
LASIK CENTRETel: 6357 8000 (General Appointments)Tel:6357 2255 (Laser Hotline)MOBILE DIABETIC PHOTOGRAPHYSERVICE FOR GPsTel:9665 1034ONCOLOGY SERVICESTHE CANCER INSTITUTE@TAN TOCK SENG HOSPITALMedical OncologyTel:6357 2390Radiation OncologyTel:6357 1080REHABILITATION CENTRETel:6450 6181SMOKING CESSATION SERVICESTel:6357 8010THERAPY SERVICESPhysiotherapyTel:6357 8307DBC neck and back careTel:6357 8309Occupational TherapyTel:6357 8338Speech and Language TherapyTel:6357 8324 / 27TRAVELLERS’ HEALTH & VACCINATION CENTRETEL:6357 2222
HP-CCS-ED JUL-11-6K
M
edical
digest
* Pre-registration is required for all Public Forums and CME Programmes. **Please keep a lookout for the latest event updates on our website at www.ttsh.com.sg
Diary Dates
Public Forums and Continuing Medical Education (CME) Programmes @ TTSH
TITLE OF EVENT / ORGANISING DATE & TIME VENUEREGISTRATION FEESCMECOURSE TOPICDEPARTMENTPOINTS
CME PROGRAMME
Public Forum: Health for Life– Unleash Your TruePotential with Weight LossSurgeryDepartment of GeneralSurgery22 October 20119am - 11am Annex Building, Level4, L4-N-M007(Rotary), TTSHTo register, call Mr. DennisYeoh at 635 8266Free-Public forum: What’s Newin Breast Health?Department of GeneralSurgery29 October 20111:30pm - 4pmTheatrette, TTSH,Level 1To register, call Mr. Dennis Yeohat 635 8266 or email tobcam_forum@ttsh.com.sgFree- Annual Pathology Seminar- Lymph Node PathologyUnravelledDepartment ofPathology3-4 November 2011Theatrette, TTSH,Level 1visit www.ttsh.com.sg todownload registration formLocal participantsSGD$150Overseas participantsUSD$150-
Jul.Aug.Sep. 2011
MICA (P) 031/04/2010
contents
1 MRSA — DO WE KNOW THE DISEASE BURDEN IN SINGAPORE?4A CASE OF DENGUE HEMORRHAGIC FEVER WITH ENCEPHALOPATHY7MANAGEMENT OF PATIENTS SCHEDULED FOR CT SCANS12RADIOLOGY QUIZ13
ECG QUIZ
 
From The Editor
Dr Leong Khai PangEDITORMedical DigestYou wouldn’t expect a free-of-charge medical magazine to supply the key tobeing an über-doctor, would you? Read on.Beginners do not capture the likeness of objects they want to portray. Later, theirdrawings start to look like the real thing. As the artists further mature, paradoxically,the resemblance is again tenuous. Picasso’s works, in the museums in Barcelonaand Paris, showed that even he had to go through the three stages in turn.Usually, we talk of three levels of expertise: novice, competent and expert.Guidelines and rules are meant for people that straddle the competent and expertstages. Expertise is shown by consistently superior performance to that of theexpert’s peers, concrete results and measurable outcomes (Ericsson KA, PrietulaMJ, Cokely ET. Harv Bus Rev 2007; 85:114-21, 193).Training and practice bring us to the expert level. “It is probably self-evident toinitiate that growth in expertise is dependent upon experience. What is not soevident is that experience in itself is not sufficient ... For all but the few effortlessself-learners, changes in expertise need reflection and deliberation,” says AdvancedConsulting in Family Medicine (Radcliffe Publishing Ltd, UK 2009). Consequently,it is hard for us to become better after we have completed training becausemedical practice primarily consists of personal interactions between the patientand the doctor, usually with no external critique or audit.Can there be skill levels above the expert? What if the medical problem wandersinto areas of great uncertainty and risk (Innes AD, Campion PD, Griffiths FE.Complex consultations and the 'edge of chaos'. Br J Gen Pract 2005; 55:47-52)?How does the doctor diagnose and treatment an illness not in the radar?Some writers propose two extra levels: the master and the visionary(http://doc.utwente.nl/58083/1/levels_of_expertise.pdf). I quote: “The …‘visionary’consciously strives to extend the domain in which he/she works. The worlddiscloser develops new ways things could be, defines the issues, opens newworlds and creates new domains …operates more on the margins of a domain,paying attention to other domains as well, and to anomalies and marginal practicesthat hold promises for a new vision of the domain.”In my view, precision, economy and preternatural ability (seemingly) are a fewtraits of the crack medical practitioner. He or she is right most of the time,regardless of the complexity of the case. He or she may propose an unusualdiagnosis, but it is appropriate (it’s easy to do so and be wrong). He or she doesnot over-investigate or over-treat. Analogously, Yasujiro Ozu did not need dollyshots, fades, dissolves, voice-overs or special effects to make the greatest moviesever made. We make decisions with logic and also through intuition (perhapssomething very difficult to teach). The über-doctor knows the limits of each anduses them in the right proportion. On 10 September 2011, Djokovic beat Federerin the semi-finals of the US Open. After saving two match points, everything hungon one shot. Djokovic said, “The forehand return, I cannot explain to you becauseI don't know how it happened. I read his serve and I was on the ball and I hadto hit it hard, and it got in, luckily for me.” These doctors exist; we have colleagueswho make correct diagnoses that we could never make, and avoid problems thatwe could never see coming. What we need is not longer lists of differentialdiagnoses, but more incisive decision-making; not more investigations, but moreresoluteness; and not more knowledge, but deeper understanding.We can be better doctors. May we always be growing and learning and thinking.
Jul.Aug.Sep. 2011
While every endeavour is made toensure that information herein isaccurate at the time of publication,Tan Tock Seng Hospital shall not beheld liable for any inaccuracies. Theopinions expressed in this publicationdo not necessarily reflect those ofTan Tock Seng Hospital. The contentsof this publication may not bereproduced without writtenpermission from the publisher.
We value your feedback.Please email your questions,comments or suggestions to:med_digest@ttsh.com.sgPlease also contact us for notification ofchange of postal address orfor requests of additional copies.
EDITOR
Dr Leong Khai Pang
MEMBERS
Dr Jackie TanDr Jaideepraj RaoDr Lee Cheng ChuanDr Khian Chong YawDr David FooDr Gregory KawDr Nikolle TanDr Ernest KwekMs Lim Wan Peng
EDITORIAL ASSISTANT
Ms Michelle Lee
DESIGNER
Ms Zaonah Yusof
 
Review
MRSA – do we know the disease burden
in Singapore?
EPIDEMIOLOGY
How prevalent is MRSA in our localpublic hospitals? In a study conductedin Singapore General Hospital in 2007during an outbreak, MRSA wasdetected in 13% of patients admittedto the intensive care unit (ICU). Inaddition, 13.8% was found MRSA-positive at exit from ICU care.
4
Theauthors concluded that at least 21%of the patients had evidence of MRSA presence in their body during theepisode of ICU stay, although theycould only indentify active infection in1.8%. Interestingly and ratheralarmingly, 20.2% of healthcareworkers were found colonized withMRSA during the study period.
5
TheNational University Hospital inSingapore detected MRSA soon afterthe new hospital became fullyoperational in the late 1980s. A fewyears after operation, MRSA wasaccountable for 34-46% of all clinicalisolates of
Staphylococcus aureus
. Ina retrospective study of a year’ssurveillance data from 1998 to 1999,the MRSA incidence rate in the ICUs
1:
MEDICAL DIGEST
Methicillin-resistant
Staphylococcus aureus
(MRSA) today is no longer a name unfamiliar to many. But when it wasfirst introduced into Singapore in the early 80s, it caused quite a stir in the medical community.
1
 
Staphylococcus aureus
commonly colonizes the exterior of our body, including the mucosal areas that come into contact with externalenvironment. Given the right opportunity, it invades to cause illnesses ranging from mild superficial skin infectionto deep seated infection in almost any anatomical site of the human body. The mortality rate of bloodstream infectionby Staphylococcus aureus can reach as high as 30% despite appropriate treatment. Because
Staphylococcus aureus
frequently colonizes the exterior of human body, it is important to distinguish carrier state (colonization) from clinicaldisease (infection).How did MRSA come about? MRSA essentially is the product of microbial evolution under the pressure of antimicrobialagents, specifically semi-synthetic beta-lactamase-resistant penicillins such as methicillin and cloxacillin. MRSA requires the presence of mec-genes that alter the penicillin-binding protein 2a on the cell-wall that render the semi-synthetic beta-lactamase-resistant penicillins ineffective. The treatment of choice is vancomycin which was expensivewhen it was first introduced and is associated with drug toxicity. However, it is vital to note that microbes nevercease to evolve; instead, they strive to survive in the hardiest of environment. Following the wider use of vancomycin,new resistant strains such as vancomycin-intermediate
Staphylococcus aureus
(VISA) and heteroresistant VISA haveemerged. Of note, this widely accepted hospital-bound or nosocomial organism is now also identified in the community.For epidemiological purposes, we classify the likely sources of acquisition of the infection into community-associatedMRSA and hospital-associated MRSA. MRSA today has evolved into multiple clones with varying degrees ofantimicrobial susceptibility.
2,3

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