High resolution front-side visualization of charge stored in EEPROM with scanning nonlinear dielectric microscopy (SNDM)

By exposing floating gates of EEPROM memory cells with frontside sample preparation, scanning nonlinear dielectric microscopy (SNDM) succeeded in reading back the data stored in the memory cells with a 250 nm node size. At an optimized voltage bias of AC = 3 V and DC = 1 V, a clear signal contrast between programmed and erased cells is obtained. The high resolution SNDM signal reveals the details of bowling-pin shape structure of memory cells, providing high confidence in data assignment during forensic applications. Such high resolution also makes SNDM a promising technique for newer generation devices with smaller node size.

No hospital is an island - emerging new roles of the acute general hospital in the Singapore healthcare ecosystem

General hospitals in Singapore are undergoing a process of transformation, from being siloed providers of acute care, into vital hubs of a regional health system that integrates community and hospital-based care to meet the health and social needs of the population. Collaborations between the acute hospitals and other community providers, such as primary care and nursing homes, have been strengthened through clinical leadership supported by government policies that enable the sharing of key hospital clinical resources throughout the community. These collaborations have enabled better use of hospital resources while strengthening the capabilities of regional healthcare providers. Successful collaborations are propagated through the use of an intermediary enabling national agency. This paper outlines the journey that has been undertaken thus far and provides a few examples of how acute hospitals have begun to refocus their attention towards a new paradigm of care. The initial experiences and key lessons will be useful in the planning of a new 'greenfield' hospital campus designed from the 'ground up' which will embody these key principles of the hospital of the future.

Demographic and lifestyle characteristics associated with non-willingness to participate in health promotion programmes among adults of a lower socioeconomic status in Singapore

INTRODUCTION/OBJECTIVE

Lower socioeconomic groups have been found to have poorer health outcomes and engage in fewer health promoting behaviours. Understanding the reasons behind adverse lifestyle habits and non-willingness to participate in health promotion programmes among lower socioeconomic groups will enable administrators to modify the programmes and increase participation in this population. This study aimed to determine reasons for non-exercise, smoking and non-willingness to participate, and characteristics associated with non-willingness to participate in health promotion programmes among residents in Singapore.

METHOD

A cross-sectional survey was conducted on a purposive sample of residents living in four housing developments of one- and two-room households in Singapore from June to October 2009. The patterns of exercise and smoking, receptiveness towards health promotion programmes and the reasons for non-willingness to participate were elicited. Chi-square tests and logistic regression analysis were performed to identify differences between groups.

RESULTS

Seven hundred and seventy-eight responses were analysed. Only 36.1% of respondents were willing to participate in at least one health promotion programme (health screening, talk or workshop). Older respondents aged 45-64 years and more than 65 years were less likely to participate than their younger counterparts (18-44 years). Malays were more likely than Chinese to participate, and respondents who do not exercise were less likely to participate than respondents who exercise (regularly/occasionally). Reasons for non-willingness to participate were 'not interested' and 'no time'.

CONCLUSION

Health promotion messages should adapt to the needs and situation of the disadvantaged, to increase participation.

Effectiveness of a national transitional care program in reducing acute care use

This study evaluated the effectiveness of a national transitional care program for elderly adults with complex care needs and limited social support. The Aged Care Transition (ACTION) Program was designed to improve coordination and continuity of care and reduce rehospitalizations and visits to emergency departments (EDs). Dedicated care coordinators provided coaching to help individuals and families understand the individuals' conditions, effectively articulate their preferences, and enable self-management and care planning. Participants were individuals aged 65 and older hospitalized and enrolled from five public general hospitals in Singapore between February 2009 and July 2010 (N = 4,132). The coordinators worked with participants during hospitalization and followed up with telephone calls and home visits for 1 to 2 months after discharge and coordinated placements with appropriate community service providers. Unplanned rehospitalization and ED visit (up to 6 months after discharge) rates were compared with those of a comparator group of individuals who did not receive care coordination using propensity score-based weighting. Participant and caregiver surveys on quality of life and self-rated health were also administered. Recipients of the ACTION program had fewer unplanned rehospitalizations and ED visits after discharge. Propensity score-adjusted odds ratios of participants versus control for number of unplanned rehospitalization and ED visits were 0.5 (95% confidence interval (CI) = 0.5-0.6) and 0.81 (95% CI = 0.72-0.90) 30 days after discharge and 0.6 (95% CI = 0.6-0.7) and 0.90 (95% CI = 0.82-0.99) 180 days after discharge. Quality of life and self-rated health were better 4 to 6 weeks after discharge than 1 week after discharge. These findings confirm the effectiveness of the ACTION program in improving the transition of vulnerable older adults from hospital to community. Such transitional care should be considered as an integral part of care integration.

Singapore Programme for Integrated Care for the Elderly (SPICE)—an integrated model of care to enable frail elderly to be cared for in the community

Purpose

Alternative models of care for the frail elderly are needed in Singapore in view of the rapidly ageing population, increased longevity and increase in the complexity of elderly care needs. The objective of the programme (SPICE) is to delay and avoid institutional care for the frail elderly by meeting their complex care needs in the community.

Theory

SPICE is modeled after the US-based Programme for All-Inclusive Care of the Elderly (PACE), which delivers comprehensive care for NH eligible individuals. Evidence has shown that the community-based, integrated and comprehensive programme decreases overall hospital re-admission, average length of stay in hospital and visits to the emergency department (ED), decreases caregiver stress and improves overall satisfaction with care arrangements [1, 2].

Method

In SPICE, an inter-disciplinary team (IDT) delivers an integrated suite of medical, nursing, rehabilitation, social and personal care services, both in the centre and at the participant’s home, dependent on the needs. A comprehensive assessment, regular re-evaluation and detailed individualised care plan (ICP) is tailored and implemented to enable these frail elderly to avoid institutional care.

Results

37 participants have been recruited for the programme since October 2010. Preliminary 6-month pre-post analysis showed that caregiver stress decreased by 42% and participants perception of their own health increased by 18%. The total number of hospital admissions also decreased by 66.6%, average length of stay in the hospital decreased by 47.8% and the number of visits to the ED decreased by 50% over the 6 months.

Conclusion

The results suggest that SPICE is effective in enabling the frail elderly to reduce and avoid institutional care and improving their overall satisfaction with care arrangements. Further investigations with matched controls are needed to study if the long-term results.

The Evolving Role of the Community Pharmacist in Chronic Disease Management - A Literature Review

Introduction: We appraised the roles and responsibilities assigned to community pharmacists internationally and in Singapore. Materials and Methods: A systematic search of international peer-reviewed literature was undertaken using Medline. Grey literature was identified through generic search engines. The search period was from 1 January 1991 to 30 July 2009. The search criteria were English language manuscripts and search terms "community pharmacist", “community pharmacy”, “disease management” and "roles” as a major heading. Boolean operators were used to combine the search terms. Identified abstracts were independently reviewed and the findings were presented as a narrative summary. Results: Overall, we reviewed 115 articles on an abstract level and retrieved 45 of those as full text articles for background information review and inclusion into the evidence report. Of the articles included in the review, 32% were from United Kingdom (UK). Literature highlights the multi-faceted role of the community pharmacist in disease management. Community pharmacists were involved in the management of asthma, arthritis, cardiovascular diseases, diabetes, depression, hypertension, osteoporosis and palliative care either alone or in the disease management team. Evidence of effectiveness for community pharmacy/ community pharmacist interventions exists for lipid, diabetes, and hypertension management and for preventive services such as weight management, osteoporosis prevention and flu immunisation services. Majority of the community pharmacists in Singapore play the traditional role of dispensing. Attempts by the private community pharmacies to provide some professional services were not successful due to lack of funding. Factors found to impede the growth of community pharmacists are insufficient integration of community pharmacist input into healthcare pathways, poor relationship among pharmacists and physicians, lack of access to patient information, time constraints and inadequate compensation. Conclusion: Evidence from observational studies points out the wide range of roles played by the community pharmacist and provides insights into their integration into chronic disease management programmes and health promotion. Key words: Community pharmacy, Interventions, Services, Roles

The evolving role of the community pharmacist in chronic disease management - a literature review

INTRODUCTION

We appraised the roles and responsibilities assigned to community pharmacists internationally and in Singapore.

MATERIALS AND METHODS

A systematic search of international peer-reviewed literature was undertaken using Medline. Grey literature was identified through generic search engines. The search period was from 1 January 1991 to 30 July 2009. The search criteria were English language manuscripts and search terms "community pharmacist", "community pharmacy", "disease management" and "roles" as a major heading. Boolean operators were used to combine the search terms. Identified abstracts were independently reviewed and the findings were presented as a narrative summary.

RESULTS

Overall, we reviewed 115 articles on an abstract level and retrieved 45 of those as full text articles for background information review and inclusion into the evidence report. Of the articles included in the review, 32% were from United Kingdom (UK). Literature highlights the multi-faceted role of the community pharmacist in disease management. Community pharmacists were involved in the management of asthma, arthritis, cardiovascular diseases, diabetes, depression, hypertension, osteoporosis and palliative care either alone or in the disease management team. Evidence of effectiveness for community pharmacy/ community pharmacist interventions exists for lipid, diabetes, and hypertension management and for preventive services such as weight management, osteoporosis prevention and fl u immunisation services. Majority of the community pharmacists in Singapore play the traditional role of dispensing. Attempts by the private community pharmacies to provide some professional services were not successful due to lack of funding. Factors found to impede the growth of community pharmacists are insufficient integration of community pharmacist input into healthcare pathways, poor relationship among pharmacists and physicians, lack of access to patient information, time constraints and inadequate compensation.

CONCLUSION

Evidence from observational studies points out the wide range of roles played by the community pharmacist and provides insights into their integration into chronic disease management programmes and health promotion.

Bridging the Gap Between Primary and Specialist Care – An Integrative Model for Stroke

Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system. Key words: Cerebrovascular disease, Chronic disease management, Family physician, Neurologist, Stroke nurse

Bridging the gap between primary and specialist care--an integrative model for stroke

Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system.

Phenolic Michael Reaction Acceptors: Combined Direct and Indirect Antioxidant Defenses Against Electrophiles and Oxidants

The implications of oxidative stress in the pathogenesis of many chronic human diseases has led to the widely accepted view that low molecular weight antioxidants could be beneficial and postpone or even prevent these diseases. Small molecules of either plant or synthetic origins, which contain Michael acceptor functionalities (olefins or acetylenes conjugated to electron-withdrawing groups) protect against the toxicity of oxidants and electrophiles indirectly, i.e., by inducing phase 2 cytoprotective enzymes. Some of these molecules, e.g., flavonoid and curcuminoid analogues that have phenolic hydroxyl groups in addition to Michael acceptor centers, are also potent direct antioxidants, and may therefore be appropriately designated: bifunctional antioxidants. By use of spectroscopic methods we identified phenolic chalcone and bis(benzylidene)acetone analogues containing one or two Michael acceptor groups, respectively, as very efficient scavengers of two different types of radicals: (a) the nitrogen-centered 2,2'-azinobis-(3-ethyl-benzothiazoline-6-sulfonic acid) (ABTS.+) radical cation, and (b) the oxygen-centered galvinoxyl (phenoxyl) radical. The most potent scavengers are those also bearing hydroxyl substituents on the aromatic ring(s) at the ortho-position(s). The initial reaction velocities are very rapid and concentration-dependent. In the human keratinocyte cell line HaCaT, the same compounds coordinately increase the intracellular levels of glutathione, glutathione reductase, and thioredoxin reductase. Thus, such bifunctional antioxidants could exert synergistic protective effects against oxidants and electrophiles which represent the principal biological hazards by: (i) scavenging hazardous oxidants directly and immediately; and (ii) inducing the phase 2 response to prevent and resolve the consequences of hazardous processes that are already in progress, i.e., acting indirectly, but with much more diverse and long-lasting effects.

Stroke disease management--a framework for comprehensive stroke care

Disease management is an approach to patient care that coordinates medical resources for the patient across the entire healthcare delivery system throughout the lifetime of the patient with the disease. Stroke is suitable for disease management as it is a well-known disease with a high prevalence, high cost, variable practice pattern, poor clinical outcome, and managed by a non-integrated healthcare system. It has measurable and actionable outcomes, with available local expertise and support of the Ministry of Health. Developing the programme requires a multidisciplinary team, baseline data on target populations and healthcare services, identification of core components, collaboration with key stakeholders, development of evidence-based clinical practice guidelines and carepaths, institution of care coordinators, use of information technology and continuous quality improvement to produce an effective plan. Core components include public education, risk factor screening and management, primary care and specialist clinics, acute stroke units, inpatient and outpatient rehabilitation facilities, and supportive community services including medical, nursing, therapy, home help and support groups for patients and carers. The family physician plays a key role. Coordination of services is best done by a network of hospital and community-based care managers, and is enhanced by a coordinating call centre. Continuous quality improvement is required, with audit of processes and outcomes, facilitated by a disease registry. Pitfalls include inappropriate exclusion of deserving patients, misuse, loss of physician and patient independence, over-estimation of benefits, and care fragmentation. Collaboration and cooperative among all parties will help ensure a successful and sustainable programme.

Implementing chronic disease management in the public healthcare sector in Singapore: the role of hospitals

The public health care delivery system in Singapore faces the challenges of a rapidly ageing population, an increasing chronic disease burden, increasing healthcare cost, rising expectations and demand for better health services, and shortage of resources. It is also fragmented, resulting in duplication and lack of coordination between institutions. A disease management approach has been adopted by the National Healthcare Group (NHG) as a critical strategy to provide holistic, cost-effective, seamless and well-coordinated care across the continuum. The framework in the development of the disease management plan included identifying the diseases and defining the target population, organizing a multi-disciplinary team lead by a clinician champion, defining the core components, treatment protocols and evaluation methods, defining the goals, and measuring and managing the outcomes. As disease management and case management for chronic diseases are new approaches adopted in the healthcare delivery system, there is a lack of understanding by healthcare professionals. The leadership and participation of hospital physicians was sought in the planning, design and outcomes monitoring to ensure their 'buy-in' and the successful implementation and effectiveness of the program. The episodic diagnosis related group (DRG)-based framework of funding and subvention for healthcare, and the shortage of step-care care facilities, have been recognized by the Ministry of Health as an impediments to the implementation, and these are currently being addressed.

Development and implementation of a clinical pathway programme in an acute care general hospital in Singapore

A critical or clinical pathway defines the optimal care process, sequencing and timing of interventions by doctors, nurses and other health care professionals for a particular diagnosis or procedure. Clinical pathways are developed through collaborative efforts of clinicians, case managers, nurses, pharmacists, physiotherapists and other allied health care professionals with the aim of improving the quality of patient care, while minimizing cost to the patient. The use of clinical pathways has increased over the past decade in the USA, the UK, Australia, and many other developed countries. However, its use in the developing nations and Asia has been sporadic. To the author's knowledge, there is to date, no published literature on the use and impact of clinical pathways on the quality and cost of patient care in the Asian health care setting. This paper provides a qualitative account of the development and implementation of a clinical pathway programme (using the example of patients with uncomplicated acute myocardial infarction) in an acute care general hospital in Singapore. The paper concludes that clinical pathways, when implemented in the context of an acute care hospital, can result in improvements in the care delivery process.

Clinical pathways: a direction forward in health care

As in many developed nations, health care consumers in Singapore are demanding better (and more costly) services. At the operational level, one way to address consumers' demands while ensuring cost-effectiveness is through the implementation of a clinical pathway program. This paper provides an overview of the program at Changi General Hospital (CGH), a regional general acute care hospital in the Republic of Singapore. The paper highlights the problems encountered during the planning, developing and implementing phases. It concludes by predicting what the future might hold for clinical pathways in Singapore and the South East Asian Region.

The structure of L-amino acid oxidase reveals the substrate trajectory into an enantiomerically conserved active site

The structure of L-amino acid oxidase (LAAO) from Calloselasma rhodostoma has been determined to 2.0 A resolution in the presence of two ligands: citrate and o-aminobenzoate (AB). The protomer consists of three domains: an FAD-binding domain, a substrate-binding domain and a helical domain. The interface between the substrate-binding and helical domains forms a 25 A long funnel, which provides access to the active site. Three AB molecules are visible within the funnel of the LAAO-AB complex; their orientations suggest the trajectory of the substrate to the active site. The innermost AB molecule makes hydrogen bond contacts with the active site residues, Arg90 and Gly464, and the aromatic portion of the ligand is situated in a hydrophobic pocket. These contacts are proposed to mimic those of the natural substrate. Comparison of LAAO with the structure of mammalian D-amino acid oxidase reveals significant differences in their modes of substrate entry. Furthermore, a mirror-symmetrical relationship between the two substrate-binding sites is observed which facilitates enantiomeric selectivity while preserving a common arrangement of the atoms involved in catalysis.

Clinical pathways--an evaluation of its impact on the quality of care in an acute care general hospital in Singapore

A critical or clinical pathway defines the optimal care process, sequencing and timing of interventions by healthcare professionals for a particular diagnosis or procedure. It is a relatively new clinical process improvement tool that has been gaining popularity across hospitals and various healthcare organisations in many parts of the world. It is now slowly gaining momentum and popularity in Asia and Singapore. Clinical pathways are developed through collaborative efforts of clinicians, case managers, nurses, and other allied healthcare professionals with the aim of improving the quality of patient care, while minimising cost to the patient. Clinical pathways have been shown to reduce unnecessary variation in patient care, reduce delays in discharge through more efficient discharge planning, and improve the cost-effectiveness of clinical services. The approach and objectives of clinical pathways are consistent with those of total quality management (TQM) and continuous clinical quality improvement (CQI), and is essentially the application of these principles at the patient's bedside. However, despite the growing popularity of pathways, their impact on clinical outcomes and their clinical effectiveness remains largely untested and unproven through rigorous clinical trials. This paper begins with an overview of the nature of clinical pathways and the analysis of variances from the pathway, their benefits to the healthcare organisation, their application as a tool for CQI activities in direct relation to patient care, and their effectiveness in a variety of healthcare settings. The paper describes an evaluation of the impact of a clinical pathway on the quality of care for patients admitted for uncomplicated acute myocardial infarction (AMI) through an analysis of variances. The author carried out a one year evaluation of a clinical pathway on uncomplicated AMI in Changi General Hospital (CGH) to determine its effectiveness and impact on a defined set of outcomes. A before and after nonrandomized study of two groups of patients admitted to the Hospital for uncomplicated AMI was done. A total of 169 patients were managed on the clinical pathway compared to 100 patients in the control (historical comparison) group. Outcomes were compared between the two groups of patients. Restriction and matching of study subjects in both groups ensured that the patients selected were comparable in terms of severity of illness. The results showed that the patients on the clinical pathway and the comparison group were similar with respect to demographic variables, prevalence of risk factors and comorbidities. There was a statistically significant reduction in the average length of stay after implementation of the clinical pathway. This was achieved without any adverse effect on short term clinical outcomes such as in-hospital mortality, complication rate and morbidity. There were no significant difference in readmission rates at 6 months after discharge. The paper concludes that clinical pathways, implemented in the context of an acute care general hospital, is able to significantly improve care processes through better collaboration among healthcare professionals and improvements in work systems.

Black scorpion (Heterometrus longimanus) as a laboratory animal: maintenance of a colony of scorpion for milking of venom for research, using a restraining device

Scorpion venom is a rich source of many proteins and peptides. A method for collection of venom from scorpions using a restraining device is being described. The details and measurement of the restraining device as well as that of the current used are described.