Validation of a three-dimensionally printed simulator for training in endoscopic sinonasal surgery

BACKGROUND

The ability to incorporate different materials in the construction of 3-D printed models has resulted in the ability to mimic a variety of anatomical structures such as cartilage, mucosa and bone. The aim of this study was to evaluate the face and content validities of a model as a training tool for endoscopic sinus surgery.

METHODS

Twenty-six delegates and ten teaching faculty members were invited to complete a post-hoc questionnaire survey. The survey consisted of a 22-question 5-point Likert scale to assess the model's realism (face validity) and its effectiveness as a training tool (content validity).

RESULTS

Over 80% of the delegates agreed or strongly agreed that the appearance of anatomical structures within the model was realistic and mimicked actual sinus anatomy. In addition, a similar proportion agreed or strongly agreed that the application of instruments on the composite materials of the model realistically mimicked bone. All faculty agreed that the model was useful to develop hand-eye coordination and was a useful training tool for endoscopic sinus surgery. Overall, the sinus model received high scores regarding its use for training surgeons, especially to develop camera and instrument handling skills.

CONCLUSION

The results of this study suggest that otolaryngology doctors in their early or intermediate stage of training would benefit most from a clinical-based modular programme. The model requires further development in areas such as the realism of mucosa, incorporation of sinonasal pathology and having more complex anatomy to be useful for the training of more advanced surgeons.

Strengthening Muscle Health of Community-Dwelling Older Adults in Singapore: Evidence Towards Clinical Implementation

The prevalence of sarcopenia will inevitably increase as the population ages in Singapore, rendering it a growing public health concern with a significant impact on healthcare resources. This article firstly summarizes the current understanding of the epidemiology, diagnosis and management of sarcopenia, focusing on community-dwelling older individuals. Early identification is key to preventing and minimizing muscle loss. Appropriate interventions, including resistance exercise training, nutritional interventions and prehabilitation program, should be tailored to each patient. We suggest several key actions to ultimately improve awareness and overcome challenges in identifying and managing sarcopenia to improve patient outcomes. A paradigm shift where muscle health is seen as an integral component to maintaining good health with longer lifespan is needed. Education - of healthcare professionals and the public - serves as the foundation to improving awareness of muscle health and sarcopenia, and to promoting physical exercise across the age spectrum for sarcopenia prevention. The use of cost-effective evidence-based modalities (e.g., calf circumference measurement, 5-times chair stand test or bioelectric impedance assessment) enable early identification of muscle loss in routine practice. Providing subsidies for nutritional interventions (e.g., oral nutritional supplements) and exercise (e.g., ActiveSG gym membership) would encourage uptake of and adherence to interventions. Further high-quality research on interventions and their outcomes is important to determine the optimal strategy in different patient populations and to demonstrate clinical significance and value of addressing sarcopenia. Having local champions within healthcare institution would facilitate the much-needed change in healthcare culture where muscle health is a part of routine clinical practice.

Clinician perspectives on a culturally adapted patient decision aid concerning maintenance therapy for asthma

BACKGROUND AND OBJECTIVE

Patients with persistent asthma often show poor adherence to inhaled corticosteroids (ICS). Shared decision-making can improve adherence rates in this population. Patient decision aids (PDAs) are tools to facilitate shared decision-making. To date, only one PDA, developed in a Canadian French-speaking population, exists for patients considering ICS maintenance therapy. This PDA has been culturally adapted in this study to contextualize to the needs of multi-ethnic Asian patients in Singapore. This study explored the views of local clinicians on the content, design and implementation of this newly-adapted PDA.

METHODS

24 clinicians, who were purposively sampled from polyclinics and a tertiary institution, were interviewed on the content, design and implementation of the PDA. The interviews were audio-recorded, transcribed and analyzed via thematic analysis.

RESULTS

Clinicians generally accepted the design of the PDA. They suggested for the target users to be patients on Step 2 of GINA guidelines and the number of options to be reduced from four to two (do nothing or start inhaled corticosteroids). Moreover, they supported including a list of values for patients to select from given that Asian patients often do not articulate their values readily. The addition of more visual aids, the production of multilingual Asian editions and the involvement of nurses to administer the PDA was also suggested.

CONCLUSION

The PDA was culturally-adapted with local clinicians' perspectives to target multi-ethnic Asian patients with persistent asthma (Step 2 GINA guidelines). The main changes include a list of values and addition of visual aids.

NIST Interlaboratory Study on Glycosylation Analysis of Monoclonal Antibodies: Comparison of Results from Diverse Analytical Methods

Glycosylation is a topic of intense current interest in the development of biopharmaceuticals because it is related to drug safety and efficacy. This work describes results of an interlaboratory study on the glycosylation of the Primary Sample (PS) of NISTmAb, a monoclonal antibody reference material. Seventy-six laboratories from industry, university, research, government, and hospital sectors in Europe, North America, Asia, and Australia submitted a total of 103 reports on glycan distributions. The principal objective of this study was to report and compare results for the full range of analytical methods presently used in the glycosylation analysis of mAbs. Therefore, participation was unrestricted, with laboratories choosing their own measurement techniques. Protein glycosylation was determined in various ways, including at the level of intact mAb, protein fragments, glycopeptides, or released glycans, using a wide variety of methods for derivatization, separation, identification, and quantification. Consequently, the diversity of results was enormous, with the number of glycan compositions identified by each laboratory ranging from 4 to 48. In total, one hundred sixteen glycan compositions were reported, of which 57 compositions could be assigned consensus abundance values. These consensus medians provide community-derived values for NISTmAb PS. Agreement with the consensus medians did not depend on the specific method or laboratory type. The study provides a view of the current state-of-the-art for biologic glycosylation measurement and suggests a clear need for harmonization of glycosylation analysis methods.

Asthma care based on Chronic Care Model in an aging Asian community

To cope with the higher prevalence of asthma and other non-communicable diseases without compromising on quality of care, a Singapore public primary care institution has adopted the Chronic Care Model (CCM). This retrospective cohort study aimed to describe the proportion of patients with well-controlled asthma (based on Asthma Control Test score ≥20) between 2010 and 2016 in association with their management based on the CCM (which covers the polyclinic clinical information system, self-management measures, system re-design and decision support). Data were retrieved from the Singapore National Asthma Programme (SNAP) and institutional clinical quality databases of eight local polyclinics in eastern and southern Singapore. The data were aggregated, analysed and presented in proportions against monthly polyclinic attendances for asthma. From 2010 to 2016, the total asthma attendances increased by 31% from 27,345 to 35,731, with the highest rise among patients aged ≥60 years. The proportion of patients with good asthma control rose from 71.4% to 80.9%; those who received rescue therapy for acute exacerbations fell from 15.8% to 11.7% and those referred to emergency departments after failed rescue therapy decreased from 0.7% to 0.6%. The proportion of patients with updated asthma action plans increased from 66.7% to 73.4% (proxy for self-management). The overall health and process outcomes of asthma seemed to have improved with multiplex of system-based interventions relating to the introduction of CCM in a public primary healthcare institution in Singapore.

Achieving triple treatment goals in multi-ethnic Asian patients with type 2 diabetes mellitus in primary care

INTRODUCTION

Achieving optimal glycated hemoglobin (HbA1c), blood pressure (BP), and LDL-Cholesterol (LDL-C) in patients mitigates macro- and micro-vascular complications, which is the key treatment goal in managing type 2 diabetes mellitus (T2DM). This study aimed to determine the proportion of patients in an urban community with T2DM and the above modifiable conditions attaining triple vascular treatment goals based on current practice guidelines.

METHODS

A questionnaire was distributed to adult Asian patients with dyslipidemia at two primary care clinics (polyclinics) in northeastern Singapore. The demographic and clinical data for this sub-population with both T2DM and dyslipidemia were collated with laboratory and treatment information retrieved from their electronic health records. The combined data was then analyzed to determine the proportion of patients who attained triple treatment goals, and logistic regression analysis was used to identify factors associated with this outcome.

RESULTS

665 eligible patients [60.5% female, 30.5% Chinese, 35% Malays, and 34.4% Indians] with a mean age of 60.6 years were recruited. Of these patients, 71% achieved LDL-C ≤2.6 mmol/L, 70.4% had BP <l40/90 mmHg, and 40.9% attained HbAlc ≤7%. Overall, 22% achieved the triple treatment goals for glycemia, BP, and LDL-C control. The major determinants were the number of diabetic medications and intensity of statin therapy.

CONCLUSION

Eight in ten patients with T2DM failed to achieve concurrent glycemic, BP, and LDL-C treatment goals, subjecting them to risks of vascular complications. Primary healthcare professionals can mitigate these risks by optimizing therapeutic treatment to maximize glycemia, dyslipidemia, and BP control.

The effect of the intensity of lipid-lowering medications on the LDL cholesterol treatment goals of Asian patients with dyslipidaemia in primary care

WHAT IS KNOWN AND OBJECTIVE

Dyslipidaemia is the key risk factor for arthrosclerosis, leading to myocardial infarctions and strokes. Achieving LDL cholesterol (LDL-C) treatment goals using lipid-lowering therapy (LLT) mitigates such cardiovascular risks. This study aimed to determine the proportions and factors influencing patients with dyslipidaemia on LLT who achieved their recommended LDL-C treatment goals.

METHODS

Adult Asian patients with dyslipidaemia, aged 31-80 years, were enrolled in a questionnaire survey. Using simplified Framingham risk scores, these patients were classified into low (LR), medium (MR) and high (HR) cardiovascular risk groups. Their lipid-lowering therapy was classified into low-intensity (LI), medium-intensity (MI) and high-intensity (HI) groups according to the 2013 American College of Cardiology and American Heart Association (ACC/AHA) Blood Cholesterol Guidelines. Data on their demographic, clinical, self-reported attitude and adherence to LLT were correlated with their latest lipid profiles from their electronic health records. These data were analysed using chi-square test, or independent t-test where appropriate for categorical variables and continuous data. Logistic regression was used to identify factors relating to LDL-C goal attainment.

RESULTS AND DISCUSSION

Amongst the 917 patients treated with LLT, 60·9% were females and 56·2% aged >60 years. The commonest statins prescribed were simvastatin (77·7%), atorvastatin (15·3%), rosuvastatin (4·3%) and lovastatin (3·4%). Those who attained LDL-C treatment goals included 89·4%, 77·4% and 70% of the LR, MR and HR groups. Overall, 72·4% of the patients achieved LDL-C treatment goals. Despite 98·4% of them self-reported LLT adherence, only 85·5%, 69·5% and 50% of the LI, MI and HI subgroups attained the desired outcomes, respectively.

WHAT IS NEW AND CONCLUSION

Overall, 27·6% of patients with dyslipidaemia, including 30% of the HR group, did not achieve LDL-C treatment goals, despite on LLT. Addressing their concerns and adjusting medication doses of their LLT are needed for better outcomes.

Effectiveness of Nurse Counselling in Discouraging the Use of the infant Walkers

Infant walkers are widely used by caregivers in Singapore despite being recognized as a household hazard. The study determined the effectiveness of nurse counselling in dissuading caregivers from using the walker. Caregivers of children 4 months of age were recruited and divided into the intervention group (nurse's advice and illustrated pamphlets), a conventional group (questionnaire alone) and a control group (without any intervention in a separate polyclinic). The percentage of the caregivers, who used the walkers in each group when their child was 9 months old, was taken as a surrogate indicator of effectiveness of nurse's intervention. The study analyzed 708 caregivers. Fewer caregivers (62.7% intervention vs. 80.4% questionnaire alone vs. 83.0% control) used the walker after nurse's advice with illustrated pamphlets. 8% of the users reported walker-related injuries (n=43). Nurses' counselling could be a simple yet effective method to discourage the use of walkers. Asia Pac J Public Health 2004; 16(2): 104-108.

When the phone rings - factors influencing its impact on the experience of patients and healthcare workers during primary care consultation: a qualitative study

Background

In the primary health care setting, patients interact directly with their healthcare workers (HCW), which include their primary physicians, nurses and pharmacists. Studies have shown that such interactions, when interrupted by phone calls received by either party, can lead to adverse outcomes and negative experiences. There is insufficient data however on the factors affecting the reaction and responses of both patients and HCWs when phone calls occur amidst their interaction. Understanding these factors will allow for the introduction of targeted measures to mitigate the negative impact of such interruptions and improve patient-HCW relationships. This study therefore aims to understand the impact of unplanned phone calls during primary health care consultations on patient–HCW interactions and the factors affecting the patient and the HCW responses.

Method

This study used focus group discussions (FGD) to gather qualitative data from patients and HCWs who had visited or worked in a major public primary healthcare institution in Singapore. The FGDs were audio-recorded, transcribed, audited and analyzed using standard content analysis to identify emergent themes.

Results

15 patients and 16 HCWs participated in 5 FGDs. The key themes that emerged from these FGDs were patients’ and HCWs’ attitudes toward professionalism and respect, task and thought interruption, call characteristics, the impact on patient safety and stakeholders’ experiences. Phone calls during consultations answered by either party often resulted in the answering party feeling apologetic and would usually keep the phone conversations short as a sign of respect to the other party. Both stakeholders valued the consultation time and similarly reported negative experiences if the phone-call interruptions became prolonged. Calls from the desk phone answered by HCWs were perceived by most patients to be relevant to healthcare services, with the assumption that HCWs exercised professionalism and would not attend to personal calls during their clinical duties.HCWs expressed their concerns and distress about potential medical errors due to phone-calls interrupting their clinical tasks and thinking processes. However, they acknowledged that these same phone-calls were important to allow clarifications of instructions and improved the safety of other patients.

Conclusion

Phone interruptions affected patient and HCW interaction during consultations and factors leading to their adverse reactions need to be recognized and addressed.

Initiation of insulin for type 2 diabetes mellitus patients: what are the issues? A qualitative study

INTRODUCTION

Type 2 diabetes mellitus is a progressive condition in which the pancreatic beta-cell function deteriorates with increasing duration of the disease. When good glycaemic control is not achieved despite adherence to oral hypoglycaemic drugs, healthy diet and lifestyle, insulin should be initiated. However, this is often delayed due to various reasons. We aimed to determine the issues relating to insulin initiation for diabetic patients managed in primary care polyclinics in Singapore.

METHODS

Qualitative data was obtained during four focus group discussions, with participation from healthcare professionals (HCPs), including physicians and nurses, and type 2 diabetes mellitus patients. The data was transcribed into text, coded and grouped into themes.

RESULTS

Launching the topic and doctor-patient communication on insulin therapy were key issues in insulin initiation. Patient barriers to insulin commencement included: refusal to acknowledge the need for insulin therapy; its perception as a social stigma, an inconvenient mode of treatment or punishment for failure; and fear of needles, side-effects and complications. The HCP's attitude and experience with insulin therapy were also possible barriers.

CONCLUSION

Our findings highlight that insulin initiation is affected by the complex interaction between the patients and HCPs, and other system factors. Patients may harbour misconceptions about insulin due to the late introduction of insulin therapy by HCPs or the way the therapy is being communicated to them. The key issues to address are the disparity in perceptions of diabetic control between HCPs and patients, and education regarding the need for insulin therapy.

Mechanical endonasal dacryocystorhinostomy--a reproducible technique

BACKGROUND

A study to assess the efficacy and patient acceptability of Mechanical Endonasal Dacryocystorhinostomy (MENDCR) in patients with acquired nasolacrimal duct obstruction.

METHODS

A retrospective series of 38 patients undergoing 37 primary and 7 revision MENDCR's between March 2003 and October 2007. Patients included had symptomatic epiphora with anatomical obstruction on syringing or functional obstruction on scintillography. Short-term follow up was assessed subjectively and objectively by anatomical patency on nasoendoscopy and free flow of fluorescein from eye to nose. Medium term follow up was assessed subjectively by telephone conversation with the patient. The average follow up period was 25.2 months (range 7-50).

RESULTS

There were 44 DCR's performed on 38 patients (12 male, 26female). Average patient age was 67.0years (range 16.6-97.5). Almost all patients (95%) presented with epiphora, and a further 34% with dacryocystitis and/or mucocele. At short term follow up 40/44 (91%) were successful objectively. Of two that failed, neither had a patent ostium and one had recurrent mucocele. Both went on to revision surgery, which was successful at later review. A further two had visible ostia but no free flow of fluorescein. At long term follow up 90% were happy with the procedure and would undergo surgery again. All failures occurred by 3-month follow up.

CONCLUSION

The technique of nMENDCR is a reproducible technique with results comparable to the original authors. MENDCR is an acceptable alternative to external DCR. It is well tolerated by patients most of whom were satisfied and would undergo the same procedure again.

Factors influencing family physicians' drug prescribing behaviour in asthma management in primary care

INTRODUCTION

Little is known about the decision pathway that family physicians (FP) take in considering drug therapy for their asthma patients. This study aimed to explore the factors that influence FPs' decisions in prescribing medications for their asthma patients.

METHODS

A qualitative method using focus group discussions (FGD) was used to gather qualitative data based on a semi-structured topic guide from FPs of different training backgrounds and practices. 29 Singapore FPs working as private general practitioners (GP), polyclinic doctors and locums were recruited into five FGDs.

RESULTS

The FPs' asthma drug prescription decisions were related to the FPs' medical training and acquisition of asthma-related information and updates. Uncertainty of disease diagnosis, patients' beliefs and their perceptions of the disease and treatment, as well as the FPs' concerns about drug side effects, were significant considerations for the participants. Costs related to differential subsidies in the consultation fees and drugs between public polyclinics and GP clinics in the local primary healthcare system, was a key factor in influencing the FPs' asthma drug treatment decisions.

CONCLUSION

FPs' asthma drug prescribing behaviour is influenced by their medical training, disease definition, patient factors and drug costs in the context of the local primary healthcare system and policy.

A qualitative study of factors influencing family physicians' prescription of the Written Asthma Action Plan in primary care in Singapore

INTRODUCTION

The Written Asthma Action Plan (WAAP) educates patients on the early recognition and treatment of deteriorating asthma. It has been adopted in Singapore polyclinics and restructured hospitals in the past few years as recommended by the Singapore National Asthma Programme. Local asthma patients can choose to be treated by family physicians at public polyclinics or by private general practitioners (GPs). In a previous study, half of the physicians in primary care self-reported that they formulated an asthma action plan for their patients, but little is known about their actual practices. This qualitative study explored family physicians' views of WAAP and its implementation in primary care in Singapore.

METHODS

Qualitative data was obtained for 29 participants from polyclinics, GP clinics or locum doctors at five separate focus group discussions. The data was coded using NVivo-7 software, audited and analysed to identify emergent themes.

RESULTS

The participants generally perceived the usefulness of WAAP. While WAAP was widely used in polyclinics, GPs rarely used it. Even in polyclinics, usage varied and was associated with participants' training and practice of WAAP and task substitution to nurses. They perceived that WAAP would benefit only selected motivated patients who could understand and use it. They were hampered by language barriers in educating their multiracial patients and the perceived lack of time related to patient loads in polyclinics. The GPs lacked training and practice, role models and relied on verbal instructions as a personalised form of care delivery.

CONCLUSION

Family physicians generally perceived WAAP as useful, but implementation was hampered by lack of training and practice, language barriers and perceived benefits for patients.

Creutzfeldt-Jakob disease: which diffusion-weighted imaging abnormality is associated with periodic EEG complexes?

BACKGROUND

Clinical diagnosis of CJD remains important due to lack of access to a genetic or histopathological diagnosis. Using current WHO criteria, diagnostic certainty can be increased from "possible" to "probable" CJD if periodic complexes are recorded on EEG.

OBJECTIVE

To study the correlation between patterns of MRI-DWI hyperintensity and typical EEG findings among patients with CJD.

METHODS

Demographics, clinical findings, MRI-DWI and EEG findings of CJD patients were retrospectively reviewed.

RESULTS

A total of 14 patients ranging in age from 35 to 81 years were identified. All had dementia and cerebellar ataxia. Psychiatric manifestations were seen in 5 patients. Seven patients had both cortical and striatal DWI changes, five had isolated cortical DWI changes and two had isolated striatal DWI changes. All twelve patients with cortical DWI changes also had periodic EEG changes. In ten, periodic EEG was recorded within seven days of the DWI. The two patients with isolated striatal DWI changes did not develop periodic EEG complexes despite serial EEG recordings, 40 and 88 days from their respective DWI scans.

CONCLUSIONS

Serial EEGs are not useful for patients with isolated striatal DWI hyperintensity but will increase diagnostic certainty from "possible" to probable" CJD for patients with cortical DWI hyperintensity.

Patients with chronic hepatitis B infection: what is their quality of life?

INTRODUCTION

Hepatitis B (HBV) is endemic in Singapore. This study aimed to determine the quality of life of patients with chronic HBV infection (HBV carriers) on conservative management. They were reviewed in primary care facilities and in a district hospital in Singapore.

METHODS

This cross-sectional survey utilised a validated Hepatitis Quality of Life questionnaire, which incorporated the SF-36 health survey, to assess a convenience sample of HBV carriers' quality of life in 14 domains. The mean scores in each domain were determined, with higher scores indicating better health. Wilcoxon-Mann-Whitney test was used in the data analysis to determine statistical significance (p-value is less than 0.05).

RESULTS

The mean age of 108 participants was 44.1 (standard deviation 12.5) years. They were predominantly Chinese (90.7 percent), male (58.3 percent) and 50.7 percent of them had family members who were HBV-infected. The latter had higher scores in the hepatitis specific limitation (HLIM) domain. The majority did not have any impaired physical nor mental health. In comparison with the healthy peers in the local population, the Chinese HBV carriers scored significantly lower in the "social functioning" domain (p-value is less than 0.001), regardless of gender.

CONCLUSION

The majority of HBV carriers had good physical and mental health. Physicians should recognise the impact of the chronic infection on the social aspects of daily living of the HBV carriers, and such issues should be addressed appropriately to provide better quality care.

A robust biomarker discovery pipeline for high-performance mass spectrometry data

A high-throughput software pipeline for analyzing high-performance mass spectral data sets has been developed to facilitate rapid and accurate biomarker determination. The software exploits the mass precision and resolution of high-performance instrumentation, bypasses peak-finding steps, and instead uses discrete m/z data points to identify putative biomarkers. The technique is insensitive to peak shape, and works on overlapping and non-Gaussian peaks which can confound peak-finding algorithms. Methods are presented to assess data set quality and the suitability of groups of m/z values that map to peaks as potential biomarkers. The algorithm is demonstrated with serum mass spectra from patients with and without ovarian cancer. Biomarker candidates are identified and ranked by their ability to discriminate between cancer and noncancer conditions. Their discriminating power is tested by classifying unknowns using a simple distance calculation, and a sensitivity of 95.6% and a specificity of 97.1% are obtained. In contrast, the sensitivity of the ovarian cancer blood marker CA125 is approximately 50% for stage I/II and approximately 80% for stage III/IV cancers. While the generalizability of these markers is currently unknown, we have demonstrated the ability of our analytical package to extract biomarker candidates from high-performance mass spectral data.

Evaluation of playground injuries based on ICD, E codes, international classification of external cause of injury codes (ICECI), and abbreviated injury scale coding systems

The survey is aimed to describe the epidemiology of playground related injuries in Singapore based on the ICD-9, AIS/ ISS and PTS scoring systems, and mechanisms and causes of such injuries according to E codes and ICECI codes. A cross-sectional questionnaire survey examined children (< 16 years old), who sought treatment for or died of unintentional injuries in the ED of three hospitals, two primary care centers and the sole Forensic Medicine Department of Singapore. A data dictionary was compiled using guidelines from CDC/WHO. The ISS, AIS and PTS, ICD-9, ICECI v1 and E codes were used to describe the details of the injuries. 19,094 childhood injuries were recorded in the database, of which 1617 were playground injuries (8.5%). The injured children (mean age=6.8 years, SD 2.9 years) were predo-minantly male (M:F ratio = 1.71:1). Falls were the most frequent in-juries (70.7%) using ICECI. 25.0% of injuries involved radial and ulnar fractures (ICD-9 code). 99.4% of these injuries were minor, with PTS scores of 9-12. Children aged 6-10 years, were prone to upper limb injuries (71.1%) based on AIS. The use of international coding systems in injury surveillance facilitated standardisation of description and comparison of playground injuries.

Management of adult choledochal cyst

INTRODUCTION

Choledochal cyst is a rare benign biliary disease mostly presenting during childhood. Adult presentation is rare and associated diseases and complications are common. This paper aims to review the management of adult patients who presented to our institution with choledochal cyst, focusing on their presentation, preoperative investigations, surgical treatment given and postoperative course.

METHODS

A retrospective review of all our choledochal cyst patients from January 2000 to August 2004 was performed. Data collected included demographics and clinical information.

RESULTS

There were ten patients, eight female (80 percent) and two male (20 percent). The average age at presentation was 38.6 (range 16-81) years. The commonest presenting complaints were obstructive biliary disease (nine out of ten, 90 percent). There were seven Type I (70 percent), one type IVA (10 percent), one type IVB (10 percent) and one (10 percent) with Caroli's disease. Two patients had concomitant cholangiocarcinoma (20 percent). Three patients had associated cystolithiasis and one patient had pancreatitis. One patient had early cirrhosis due to her disease. Six patients underwent total cyst excision with a Roux-en-Y hepaticojejunostomy. One patient who previously had a biliary bypass underwent further resection of her cyst and Whipple's operation because of development of cholangiocarcinoma in the distal remnant cyst. They are currently well with no surgical complications. The average length of follow-up was 16 months (range six months to three years).

CONCLUSION

Adult patients with choledochal cyst have associated biliary problems such as the presence of cholangiocarcinoma, cystolithiasis, cholecystitis and liver cirrhosis with portal hypertension. They tend to present similar to obstructive biliary disease. The best surgical option for these patients is a total cyst excision together with a Roux-en-Y hepaticojejunostomy.

Family physicians' experiences, behaviour, and use of personal protection equipment during the SARS outbreak in Singapore: do they fit the Becker Health Belief Model?

Singapore experienced the SARS outbreak in 2003. The study aimed to describe the experience and behaviour of family physicians and the use of personal protection equipment (PPE) in their encounters with SARS patients. 8 such participants were interviewed and the content was analysed using qualitative research method. They highlighted the difficulties in procuring PPE due to severe shortage, the discomfort and inconvenience associated with its use. Despite the increasing operating cost, declining patient attendance and high price of the PPE, they persist in using PPE and change their behaviour in order to reduce the perceived threat to their lives. It fits into the Becker Health Belief Model, which explains that behaviour change depends on the balance of perceived vulnerability, severity, effectiveness, and barriers. The vulnerability and severity of SARS to healthcare workers were verified by the hospital experience. Perceived effectiveness of PPE amongst the family physicians outweighed the barriers of shortage, cost and discomfort of the PPE.

Successful management of a bleeding duodenal varix by endoscopic banding

Endoscopic treatment of bleeding duodenal varices is less invasive than the usual surgical options. However, there is limited experience with endoscopic treatment of bleeding duodenal varices, especially with that of endoscopic ligation. We report a 55-year-old man with a bleeding duodenal varix that was successfully ligated endoscopically. He has been followed up for nine months with no recurrence of bleeding. Endoscopic ligation may offer a new and effective treatment modality for bleeding duodenal varix.

What barriers do primary care physicians face in the management of patients with chronic hepatitis B infection in primary care?

INTRODUCTION

Asymptomatic chronic hepatitis B virus (HBV) carriers, followed-up in primary care, present a challenge to primary care physicians as they encounter problems in monitoring this group of patients. The study aims to explore the barriers faced by primary care physicians in the management of patients with chronic hepatitis B infection in primary care.

METHODS

Qualitative analysis of eight focus group discussions with 43 primary care physicians in Singapore was conducted.

RESULTS

Primary care physicians highlighted the HBV carriers' poor compliance to disease monitoring as a major hurdle, attributing to their lack of understanding of the disease, state of denial, fear of stigmatisation in society, failure to perceive benefits, costs and reluctance of investigations due to physical discomfort. The carriers' health-seeking behaviour, such as doctor hopping and the use of traditional medication, were other barriers. The investigators noted that the physicians placed emphasis on passive disease monitoring, focusing on the investigation results when they reviewed the carriers. They were less proactive in explaining the disease's natural history nor discussing the possibility of definitive anti-viral treatment for suitable carriers. These physicians varied in their approaches in disease monitoring of chronic HBV infection. The fees-for-service healthcare system allowed the carrier to seek consultation from different doctors, which could result in disruption of disease surveillance. This was further compounded by the differential cost of investigations in private practices and government-aided polyclinics. The absence of a national HBV registry and recall system and waiting time for referral to specialist clinics in restructured hospitals, were other barriers.

CONCLUSION

The management of HBV carriers in primary care could be enhanced by measures that eliminate the barriers involving the patient, doctor and healthcare system.

Home blood-pressure monitoring among hypertensive patients in an Asian population

Hypertension is a principal cause of mortality and morbidity in Singapore. The use of home blood-pressure monitoring (HBPM) to assess hypertensive control with digital devices in the local multi-racial population is unknown. The study determined the factors associated with hypertensive patients' use of HBPM in primary care in a multi-racial Asian population. Randomized cross-sectional questionnaire survey of hypertensive patients managed in a district polyclinic. A model predicting use of HBPM was constructed by univariate and multivariate logistic regression. A total of 224 eligible subjects were randomly selected from 1943 patients. Response rate was 78.1% (n = 175). In all, 61.7% of them were aware of HBPM but only 24% used HBPM. Using multivariate analysis by stepwise backward regression, the final fitted model showed that HBPM was associated with higher patients' socioeconomic status: (adjusted OR for middle-income status = 2.85, 95% CI: 1.2-6.78, P = 0.018; adjusted OR for high-income status = 3.46, 95% CI: 1.22-9.87, P = 0.020) and their documented diastolic BP (adjusted OR for diastolic BP > 80 mmHg = 2.26, 95% CI: 1.06-4.82, P = 0.034). Nonusers cited failure to recognize benefits (54.1%), lack of HBPM awareness (29.3%), understanding of device operation (18.8%) and perception of inaccuracy (10.5%) as deterrents. 76.2% of users were satisfied with HBPM but lacked knowledge in maintenance of devices. In conclusion, 61.7% of the study population were aware of HBPM but only 24% used it. Patients' failure to recognize benefits, lack of awareness, cost and perception of inaccuracy were barriers. Higher socioeconomic status and patient's documented diastolic BP correlated with HBPM usage.

A qualitative study of health-seeking behavior of Hepatitis B carriers

INTRODUCTION

Asymptomatic Hepatitis virus (HBV) carriers are often followed up at primary and secondary care centres in Singapore. Compliance to disease monitoring is perceived to be a barrier in their management. The study used qualitative methods to determine the health-seeking behavior of HBV carriers. Understanding such behavior will enable the attending physicians to optimise their care and promote regular disease surveillance.

METHODS

Data were collected from 39 HBV carriers from primary and secondary healthcare centres, with different demographic profiles in eight respective focus group discussions (FGD). A nurse conducted the FGDs using a semi-structured guideline. The qualitative data were analysed using standard content analysis technique.

RESULTS

There was evidence of doctor hopping among the HBV carriers in seeking the follow-up of their disease. Cost of review and investigations and preference for specialists' care appeared to be determinants of the sites of disease monitoring. Compliance to follow-up seemed to be sub-optimal, arising from apathy, denial, perceived inconvenience and cost of review. A significant proportion of the carriers had tried alternate therapy, took liver supplements but most found them to be ineffective. Most carriers had adopted healthier lifestyle after their diagnosis with regular exercise, smoking cessation and alcohol abstinence.

CONCLUSION

Many HBV carriers' inadequate understanding of the disease resulted in indifferent or inappropriate health-seeking behavior towards their disease management. There is room for health education for these carriers to enhance their awareness of the disease and improve compliance to disease monitoring.

The role of general practitioners in the management of erectile dysfunction—a qualitative study

The objective of this study was to explore the roles and perceptions of general practitioners (GPs) in the management of erectile dysfunction (ED). This qualitative study used focus group discussions and in-depth interviews. This study was conducted based on 28 GPs from an urban area in Malaysia who had managed patients with ED and prescribed anti-ED drugs. Main outcome measures included the roles of GPs in managing patients with ED (active or passive), perceptions regarding ED and the treatment, and factors influencing their decision to prescribe. Majority of the GPs assumed a passive role when managing patients with ED. This was partly due to their perception of the disease being nonserious. Some also perceived ED as mainly psychological in nature. The anti-ED drugs were often viewed as a lifestyle drug with potentially serious side effects. The fear of being perceived by patients as 'pushing' for the drug and being blamed if the patients were to develop serious side effects also hampered the management of this disease. GPs who participated in this study remained passive in identifying and treating patients with ED and this was attributed to their perception of the disease, drug treatment and patient's background.

Diagnosis and misdiagnosis of hemifacial spasm: a clinical and video study

Early recognition of hemifacial spasm (HFS) is important as it can be effectively treated. 203 family physicians participated in a video "test" on HFS. Only 9.4% (19/203) were able to diagnose HFS. 94 (46.3%) of them did not know how to manage the condition. Twenty-two (10.8%) would use steroids as a treatment and 13 (6.4%) felt no treatment was needed. Only 27 (13.3%) indicated that botulinum toxin could be employed to treat HFS. The year of graduation of the doctors significantly correlated with a correct diagnosis (P<0.05). The low positive diagnostic rate (25.7%) of HFS from referrals to the movement disorder clinic corroborated findings from the video test.

Primary care doctors' practice in the management of adult asthma patients

There is apparent disparity between the international guidelines on asthma management and the current practice in reality. This can be attributed to both patient's and doctor's factors. This study examines the practice of asthma management by a group of family physicians using a self-administered questionnaire. This comprises questions relating to the main principles of asthma management set by international guidelines. The results showed that majority of the doctors (>90%) in the study reviewed patient's asthma status based on symptoms, educate their patients on types of asthma medications and advised them on allergen avoidance including smoking. Fewer of them (50 to <90%) check trigger factors or inhaled device technique, nocturnal symptoms or ER visits. Even fewer doctors (<50%) bothered to check the patient's peak expiratory flow rate (PEFR) or used spirometry.

Advances in high-rate anaerobic treatment: staging of reactor systems

Anaerobic wastewater treatment (AnWT) is considered as the most cost-effective solution for organically polluted industrial waste streams. Particularly the development of high-rate systems, in which hydraulic retention times are uncoupled from solids retention times, has led to a world-wide acceptance of AnWT. In the last decade up to the present, the application potentials of AnWT are further explored. Research shows the feasibility of anaerobic reactors under extreme conditions, such as low and high temperatures. Also toxic and/or recalcitrant wastewaters, that were previously believed not to be suitable for anaerobic processes, are now effectively treated. The recent advances are made possible by adapting the conventional anaerobic high-rate concept to the more extreme conditions. Staged anaerobic reactor concepts show advantages under non-optimal temperature conditions as well as during the treatment of chemical wastewater. In other situations, a staged anaerobic-aerobic approach is required for biodegradation of specific pollutants, e.g. the removal of dyes from textile processing wastewaters. The current paper illustrates the benefits of reactor staging and the yet un-exploited potentials of high-rate AnWT.

Myelodysplastic syndrome with monosomy 7 and pulmonary aspergillosis

A 43-year-old man with no past history presented with symptoms of fever, cough and dyspnoea arising from invasive pulmonary aspergillosis and was found to have myelodysplastic syndrome with monosomy 7. Before initiation of chemotherapy, he deteriorated rapidly, developing multi-organ failure requiring mechanical ventilation, and he eventually succumbed despite amphotericin B treatment. The importance of monosomy 7 in determining immune function in patients with myelodysplastic syndrome is emphasised.

Relation between morbidity and current treatment in patients who present with acute asthma to polyclinics

BACKGROUND

It has been suggested that resources for asthma intervention should be focused mainly on patients in the community who experience a high burden of disease. These are who patients who have acute exacerbations which require urgent treatment.

AIM

To assess the morbidity and identify deficiencies in the treatment of patients who present for urgent treatment of acute exacerbations to primary care clinics.

PATIENTS

Adult patients who received urgent treatment for acute exacerbation of bronchial asthma

SETTING

4 primary care polyclinics.

METHODS

A cross-sectional survey of consecutive patients which related regular preventive treatment to current asthma activity. Poor asthma control was defined as step 2 or higher (American National Asthma Education and Prevention Program, report II, 1997) or > or = 2 emergency room visits in 6 months.

RESULTS

There were 116 patients of whom 53% were women. The mean (SD) age was 45(15) years and duration of current exacerbation 3 (3) days. The acute symptoms were successfully treated in 93% of patients. Quick relief medication was used regularly in 91% and inhaled corticosteroids (ICS) in 55%. Oral salbutamol was prescribed in 14% of patients. The asthma was poorly controlled in 54%. In the poorly controlled group 33% were not on regular ICS treatment and 64% were not receiving "add on" medication.

CONCLUSIONS

Patients treated for acute asthma in primary care clinics: (1) were older and had less acutely severe exacerbations than those who presented to emergency rooms, (2) over half had poorly controlled asthma and (3) a third of patients with poor asthma control were inadequately treated.

Video-assisted thoracoscopy: role in the management of intrathoracic pathology

A retrospective study was done from October 1992 to December 1996 of 48 patients who underwent video-assisted thoracoscopy. A male to female ratio of 3.7:1 was seen, with a mean age of 50 +/- 19 years. The underlying diagnoses included spontaneous pneumothorax (n = 23), malignant pleural effusion (n = 16), lung disease (n = 4), trauma (n = 2), empyema (n = 2) and oesophageal carcinoma (n = 1). The use of this modality is discussed in the treatment of various intrathoracic pathologies.

Assessment of metered dose inhaler technique in family health service patients in Singapore

OBJECTIVE

To assess the metered-dose inhaler technique in polyclinic patients with chronic lung disease.

METHOD

A cross-sectional study was conducted in three polyclinics. The inhalation technique was assessed in six steps.

RESULTS

Only 7.1% of patients could perform all six steps correctly. Percentage of patients performing each of the following steps correctly were: preparation (89.1%), exhalation (53.8%), lip closure (69.2%), inhalation (57.7%), breath-holding (32.1%) and puff interval (35.4%).

CONCLUSION

This study showed a high incidence of incorrect usage of metered dose inhaler amongst polyclinic patients.

Biodegradation of azo dyes in cocultures of anaerobic granular sludge with aerobic aromatic amine degrading enrichment cultures

A prerequisite for the mineralization (complete biodegradation) of many azo dyes is a combination of reductive and oxidative steps. In this study, the biodegradation of two azo dyes, 4-phenylazophenol (4-PAP) and Mordant Yellow 10 (4-sulfophenylazo-salicylic acid; MY10), was evaluated in batch experiments where anaerobic and aerobic conditions were integrated by exposing anaerobic granular sludge to oxygen. Under these conditions, the azo dyes were reduced, resulting in a temporal accumulation of aromatic amines. 4-Aminophenol (4-AP) and aniline were detected from the reduction of 4-PAP. 5-Aminosalicylic acid (5-ASA) and sulfanilic acid (SA) were detected from the reduction of MY10. Subsequently, aniline was degraded further in the presence of oxygen by the facultative aerobic bacteria present in the anaerobic granular sludge. 5-ASA and SA were also degraded, if inocula from aerobic enrichment cultures were added to the batch experiments. Due to rapid autoxidation of 4-AP, no enrichment culture could be established for this compound. The results of this study indicate that aerobic enrichment cultures developed on aromatic amines combined with oxygen-tolerant anaerobic granular sludge can potentially be used to completely biodegrade azo dyes under integrated anaerobic/aerobic conditions.

Massive chylothorax after anterior fusion of the thoracic spine

We report a case of massive chylothorax occurring postoperatively in a patient with Potts paraplegia who underwent transthoracic anterior debridement and fusion of the T7 and T8 vertebrae. This is an uncommon complication of anterior spinal surgery but has a significant morbidity and mortality. Diagnosis of the condition and the institution of the appropriate therapy will reduce this significantly. The treatment principles are continuous tube drainage, nutritional support and reduction of chyle production. In 50% of cases a surgical procedure will be required. There are a variety of techniques available. We describe a technique that uses a pedicled intercostal muscle flap, which to our knowledge, has not been described previously. Among the other techniques, video-assisted thoracoscopic surgery is the most promising because of its low morbidity.

A prevalence study of dysmenorrhoea in female residents aged 15-54 years in Clementi Town, Singapore

A community-based questionnaire survey to study the prevalence of dysmenorrhoea, its associated risk factors and impact on daily living was carried out on a random sample of 415 female persons aged 15 to 54 residing in Housing Development Board flats in Clementi Town. The overall prevalence of dysmenorrhoea, defined as one or more episodes of menstrual cramp or pain in the previous year, not due to a diagnosed gynaecological disease, was 51.3%. The condition was less prevalent and less severe in older women and in women with later menarche. It was also less prevalent in women who were parous, with the greatest number of parous women reporting improvement in severity after the first child. Among those with dysmenorrhoea, about 52% of students, 42% of working women, and 30% of housewives reported that their ability to perform work was affected. About 6% of all women consulted a doctor for their problem, and 10% of all employed women reported having been sick-absent because of dysmenorrhoea.

GC-MS identification of gaseous volatiles in wastewater

Gaseous volatiles from wastewater samples taken from a local sewage treatment plant were air-stripped and trapped onto Tenax GC. These volatiles were then thermally desorbed and subsequently analyzed using a gas chromatograph coupled to a mass spectrometer (GC-MS). The results show that saturated aliphatic and aromatic hydrocarbons were the most dominant compounds found in the sewage gaseous volatiles. Other compounds found were chlorinated hydrocarbons, organic acids, sulfides and phenols. A wide variety of gaseous volatiles were found in the raw wastewater, the primary clarifier effluent, the pre-aeration wastewater and the sludge samples. A comparison of the gas chromatograms for the pre- and post-aeration wastewater shows that many odorous gaseous volatiles were removed during the aeration process in the treatment plant.

Left main coronary artery obstruction: surgical experience with 93 patients

Among patients with ischemic heart disease, those with left main stem coronary artery stenosis has attracted most attention due to their ominous prognosis. During the period from August 1982 to February 1989, 93 patients underwent left main coronary artery revascularisation procedures at Singapore General Hospital. All the patients had greater than 75% obstruction of the left main coronary artery. Significant triple vessel disease occurred in 35 patients (37.6%), double vessel disease in 32 patients (34.4%), single vessel disease in 21 patients (22.6%) and left main coronary as an isolated lesion in 5 patients (5.4%). The overall hospital mortality rate is 6.5% and perioperative infarction rate is 8.6%. Since mid-1985, the hospital mortality rate has been reduced to 3.7% and the perioperative infarction rate to 4.9%. Average grafts per patient was 3.5. Intra-aortic balloon pump was used in 5 patients. Follow up period was from 5 months to 84 months with a mean of 36 months with the majority of patients in either New York Heart Association Class I or II and still alive.

Musical murmur and cardiac shudder

When echocardiographic studies show several structures vibrating at a similar frequency to an associated musical cardiac murmur, the structure vibrating most strongly may localize the origin of the murmur.

Thoracic and cardiovascular surgery in Singapore

Thoracic and Cardiovascular Surgery started in Singapore on the initiative of a number of the leading general surgeons working in general surgical units in the public institutions. Initially, only thoracic surgery was done. This was followed about 15 years later with cardiovascular surgery. A decision was made to establish a Thoracic Surgical Unit at the Tan Tock Seng Hospital in 1965. The Head of Department was appointed. Space had become available at this hospital following the very successful anti-tuberculosis chemotherapy programme. The department was set up in December 1966. It grew steadily over the years. As in other similar centres, the spectrum of patients that underwent operations in the department became predominantly cardiovascular in nature. In December 1981, this department was transferred to the Singapore General Hospital where specialised facilities based on the experience of the surgical team had been installed.

Annals of the Academy of Medicine of Singapore

Shortly after the inauguration of the Academy of Medicine in 1957, the idea of bringing out a journal to be called the "Annals" was considered. It was not until in 1972 that a regular quarterly publication entitled the Annals of the Academy of Medicine was possible. To serve the different specialist disciplines that are embodied in the Academy of Medicine, the Annals has orientated its issues to cover various specialised topics. The contribution of Guest Editors has enhanced the scope of the Annals, thereby enabling it to serve the wide-ranging interests of its members. The listing of the Annals in the Index Medicus in 1979 was an important milestone in the development of the Annals. With the appointment of a full-time Editorial Assistant in 1981, the Annals is now on a much firmer footing to establish itself as a journal of international repute.

Surgical management of rheumatic heart disease in Singapore

Over the last three decades there has been a world-wide decline in the incidence and severity of rheumatic fever and rheumatic heart disease, but the death rate in Singapore from chronic rheumatic heart disease has risen from 3.6 per 100,000 population in 1966 to 4.4 per 100,000 in 1977. Valvular lesions from rheumatic heart disease are very common, and between 1967 to 1979, 715 surgical procedures were performed for rheumatic valvular disease, and of these, 654 procedures involved the mitral valve which was most commonly affected by the disease process. Since many of the patients were female and in the child-bearing age, conservative procedures on the mitral valve were performed whenever possible. Mitral valvotomy for mitral stenosis relieved symptoms effectively; and for restenosis of the mitral valve, more than half of the patients underwent a second valvotomy with functional improvement. Mitral valve replacement was reserved for the severely distorted valve, sometimes calcified, and where there was stenosis associated with incompetence. Between 1971 to 1979, 162 mitral valves were replaced and actuarial studies showed 80% survival five years after surgery. 30 aortic and mitral valve replacements were performed in this same period with an operative mortality of 16.7%. Only 75 aortic valves were replaced for rheumatic valvular disease and 14 of these also had associated mitral and triscuspid valve disease. The prosthetic valves commonly used for replacement were the Starr-Edwards non-cloth covered valves, models 6120 and 1260. All patients that had valve replacements were treated with long-term anticoagulation with Warfarin. The incidence of thromboembolism was low, being 8% for mitral valve replacement and the majority of these episodes occurred in the first three months after surgery.

Primary carcinoma of the lung

118 patients with carcinoma of the lung seen in the Department of Cardiovascular and Thoracic Surgery, Tan Tock Seng Hospital, Singapore were followed for five years. The aim was to determine the survival of these patients in relation to the stage of the disease as well as the histologic type of carcinoma. 22 patients were in stage 1, 13 in Stage II and 83 in Stage III. Thoracotomy was performed in 62 patients and the rest had biopsy of distal lymph nodes. 43.3% of the carcinoma were squamous cell, 25% adenocarcinoma, 27% large cell, anaplastic, 2.9% oat cell and 1.8% bronchoalveolar cell carcinoma. Survival of the patients were found to be closely related to stage of the disease but not with the histologic type.

Surgery for mitral restenosis

Four hundred and twenty-five patients underwent mitral valvotomy between 1960 and 1979, the majority by the closed method. Thirty-two patients required another operation for mitral restenosis. There was high incidence of reoperation after the 6th and 7th years (23.3%) and after the 9th and 10th years (26.4%) postoperatively. Sixteen patients (47%) with restenosis underwent a second closed mitral valvotomy with a satisfactory result, 12 patients (35.4%) required valve replacement, and 6 patients (17.6%) had an open valvotomy. Another valvotomy for pure mitral restenosis can give satisfactory results, but where the valve is severely deformed or incompetent, valve replacement is preferred.