Background: The effects of polypharmacy and its related adverse outcomes are well documented among elderly patients. Deprescribing is now recognised as an important part of medication review in addressing polypharmacy. However, little is currently known about local practices in discontinuing medications as a means to improve quality of life. There are two aims in this study: first, to explore the attitudes and beliefs of deprescribing medications among doctors in the Department of Internal Medicine (DIM) in Singapore General Hospital (SGH), and second, to see if differences exist among junior and senior doctors in their attitudes towards deprescribing. Methods: A descriptive survey was designed to look at the attitudes and beliefs of doctors towards deprescribing. All doctors in the department were invited to complete the survey. Results: The majority of doctors (66%) believed that deprescribing is beneficial for patients. Commonly cited barriers towards deprescribing were unwillingness to stop medications prescribed by another doctor, lack of time and insufficient knowledge. Lack of a specific approach to deprescribing was noted among 73% of the participants. A third of the juniors (32%) stated that they were reluctant to deprescribe medications, which was in contrast to the responses by the seniors, most of whom (94%) indicated no reluctance in deprescribing medications. Conclusion: Most doctors believe that deprescribing is beneficial to patients. Specific measures to target the barriers faced by doctors in deprescribing medications are necessary to improve deprescribing rates and minimising polypharmacy.

Patient: Male, 65-year-old Final Diagnosis: Dengue encephalitis Symptoms: AMS Medication:— Clinical Procedure: — Specialty: Infectious Diseases Objective: Rare co-existance of disease or pathology Background: Dengue virus is a common arbovirus with uncertain neurotropism. Dengue encephalitis is a rare but fatal manifestation of severe dengue. Diagnosis requires high clinical suspicion. It should be routinely considered in patients with encephalopathy, especially in countries where dengue virus is endemic. Unlike other forms of severe dengue, the typical warning signs and biochemical derangements are not reliable markers for dengue encephalitis. Alternative biochemical markers of dengue encephalitis are needed. Case Report: We present a case of dengue encephalitis with distinctly raised procalcitonin (13.2 μg/L), in the absence of the typical warning signs and biochemical derangements of severe dengue. The patient was a 65-year-old man with fever and sudden loss of consciousness in the absence of other localizing signs/symptoms. Inflammatory markers were raised, with findings of leptomeningeal enhancement on brain computed tomography suggestive of meningoencephalitis. Septic workup was unremarkable (normal renal and liver functions, negative blood and urine cultures). The typical neurotropic microorganisms were not detected in the cerebrospinal fluid. On day 4 of admission, the patient reported abdominal pain and hematuria with a new onset of bicytopenia. Subsequent investigations for dengue infection were positive for serum dengue NS1 antigen and dengue RNA (type 2 strain) in cerebrospinal fluid, confirming the diagnosis of dengue encephalitis. The patient was managed supportively and experienced full clinical recovery. Conclusions: Dengue encephalitis is a rare condition with nonspecific biochemical and imaging abnormalities. We demonstrated that a raised procalcitonin level can occur in the setting of dengue encephalitis. In endemic countries, this finding may prompt further investigations for dengue encephalitis in patients with meningoencephalitis.

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Coral reef aorta (CRA) is a rare condition with potentially devastating complications. It is characterised by atherosclerotic calcification and stenosis of the visceral part of the aorta, usually occurring at the juxtarenal or suprarenal locations, and causing refractory hypertension and renal dysfunction. Surgical intervention, which is the recommended definitive treatment, is associated with significant morbidity and mortality. Endovascular stenting has been reported to be an alternative management option. To the best of our knowledge, this is the first case report to describe medical management of a patient with CRA with diuretics and angiotensin receptor blockade without surgical treatment.