Roles and recommendations from primary care physicians towards managing low-risk breast cancer survivors in a shared-care model with specialists in Singapore-a qualitative study.

BackgroundBreast cancer is prevalent and has high cure rates. The resultant increase in numbers of breast cancer survivors (BCS) may overwhelm the current oncology workforce in years to come. We postulate that primary care physicians (PCPs) could play an expanded role in comanaging survivors, provided they are given the appropriate tools and training to do so.ObjectiveTo explore the perspectives of PCPs towards managing BCS in a community-based shared-care programme with oncologists.MethodsEleven focus groups and six in-depth interviews were conducted with seventy PCPs recruited by purposive sampling. All sessions were audio-recorded, transcribed verbatim and coded by three independent investigators. Thematic data analysis was performed and the coding process facilitated by NVivo 12.ResultsMajority of PCPs reported currently limited roles in managing acute and non-cancer issues, optimizing comorbidities and preventive care. PCPs aspired to expand their role to include cancer surveillance, risk assessment and addressing unmet psychosocial needs. PCPs preferred to harmonize cancer survivorship management of their primary care patients who are also BCS, with defined role distinct from oncologists. Training to understand the care protocol, enhancement of communication skills, confidence and trust were deemed necessary. PCPs proposed selection criteria of BCS and adequacy of their medical information; increased consultation time; contact details and timely access to oncologists (if needed) in the shared-care programme.ConclusionsPCPs were willing to share the care of BCS with oncologists but recommended role definition, training, clinical protocol, resources and access to oncologist's consultation to optimize the programme implementation

A Clinical Quality Improvement Project to Reduce the Rate of Electronic Prescription Errors in Primary Care Practice

Prescription errors are not uncommon in clinical practice. At the Bukit Merah Polyclinic, the rates of prescription errors for the month of May and June 2009 were 0.40% to 0.45% respectively. The error rates for other clinics at Singhealth Polyclinics ranged from 0.35% to 0.97% over the same period of time. The objective of the project was to reduce electronic prescription error rates at the Bukit Merah Polyclinic. Initial data showed that most of the errors occurred because of wrong patient identification, as well as errors in dosing and frequency which were perpetuated by repeating mistakes made previously when all the medications were repeated en-bloc in our Electronic Prescription Manager (Rx Manager). Using Quality Improvement tools, the team identified possible causes, and implemented interventions. Our interventions, abbreviated “IR” as an easy-to-remember mnemonic, were targeted at the main sources of errors. This involved “I”dentifying the patient correctly and “R”e-typing and amending the erroneous prescriptions on our Rx Manager, “R”e-printing and “R”e-sending them to the pharmacy, before dispensing could occur. Post-intervention results were analysed to evaluate the effectiveness of the measures taken. The results showed a significant and sustainable drop in our prescription error rates (0.45% in June 2009 before the commencement of the interventions, compared to 0.15% in December 2009, upon completion of the project). By targeting patient identification and correcting mistakes made in the Rx Manager, we managed to reduce electronic prescription error rates

Childhood Injuries in Singapore: Can Local Physicians and the Healthcare System Do More to Confront This Public Health Concern?

Childhood injury is one of the leading causes of death globally. Singapore is no exception to this tragic fact, with childhood injuries accounting up to 37% of Emergency Department visits. Hence, it is important to understand the epidemiology and risk factors of childhood injuries locally. A search for relevant articles published from 1996–2016 was performed on PubMed, Cochrane Library and Google Scholar using keywords relating to childhood injury in Singapore. The epidemiology, mechanisms of injury, risk factors and recommended prevention strategies of unintentional childhood injuries were reviewed and described. Epidemiological studies have shown that childhood injury is a common, preventable and significant public health concern in Singapore. Home injuries and falls are responsible for majority of the injuries. Injuries related to childcare products, playground and road traffic accidents are also important causes. Healthcare professionals and legislators play an important role in raising awareness and reducing the incidence of childhood injuries in Singapore. For example, despite legislative requirements for many years, the low usage of child restraint seats in Singapore is worrisome. Thus, greater efforts in public health education in understanding childhood injuries, coupled with more research studies to evaluate the effectiveness and deficiencies of current prevention strategies will be necessary

Varicella infections in patients with end stage renal disease: a systematic review

Abstract Background End stage renal disease (ESRD) is on the rise globally. Varicella infection among adult patients with ESRD has been reported to lead to multiple complications and even death. While varicella vaccination has been recommended in paediatric renal patients; recommendation on varicella vaccination among adult patients with ESRD remained sparse. This review is aimed at evaluating the impact of varicella infection among adult patients with ESRD and make a recommendation for vaccination. Methods Three databases (PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched in April 2018 with keywords ‘varicella, chronic kidney failure, chronic kidney disease, renal replacement therapy, kidney transplantation, end stage renal disease, end stage renal failure, chicken pox, vaccine, vaccination and complications’. Results 29 articles were selected for review. The studies were mainly case reports, and they included measured outcomes: prevalence of seronegativity, impact (morbidity, length of stay, and mortality) of varicella among patients with ESRD, seroconversion rates and safety of varicella vaccination. The prevalence of seronegativity among varicella-infected ESRD adults was found to be at 42 to 100%. Nineteen deaths were reported. At least 54 patients have had complications from varicella infection. Seroconversion rate post vaccination was found to be around 64–94%. Conclusion Varicella is associated with significant morbidity and mortality rates in adult patients with ESRD. Varicella vaccination should be considered for the vulnerable, seronegative patients

A case series of atypical presentation of Zika Virus infection in Singapore

Abstract Background The World Health Organization’s and Centers for Disease Control and Prevention’s definition of Zika infection are symptoms of fever, rash, joint pain, myalgia, headache and conjunctivitis. The diagnosis of Zika infection is based on the clinical history, physical examination and laboratory investigations which includes blood and urine Zika virus Polymerase Chain Reaction. Case presentation Two patients presented with atypical presentation of Zika infection to Sengkang Health, Alexandra Hospital during the recent Zika outbreak in Singapore in August 2016. Madam A presented with isolated generalized rash with no fever, joint pain, myalgia, headache or conjunctivitis. Mr. B presented with isolated fever of 39.4 °C with no rash, joint pain, myalgia, headache or conjunctivitis. Both patients’ blood Zika Polymerase Chain Reactions were positive at the time of presentation. Conclusion The described case reports illustrated the challenges that our community Family Physicians faced in diagnosing patients infected with Zika virus. Coupled with the knowledge that most patients are asymptomatic, Family Physicians need to have a high index of clinical suspicion for early identification of patients infected with Zika virus, so as to institute timely treatment and appropriate measures to mitigate the outbreak of Zika infection in the community. Appropriate epidemiological measures such as ensuring prompt and thorough contact tracing of the cases are instrumental in the control of this public health problem

Incidence and mortality rates of varicella among end stage renal disease (ESRD) patients in Singapore General Hospital, a 12-year review

Abstract Background End stage renal disease (ESRD)/ end stage renal failure (ESRF) is on the rise globally and especially in Singapore. Varicella or chickenpox is not uncommon among adults especially ESRD/ESRF patients. It has been reported to cause complications and even death among immunocompetent adults. Methods A retrospective data collection on patients with varicella infection and ESRD in Singapore General Hospital (SGH) from the year 2005 to 2016 was performed. Continuous data and categorical data were summarized as median (range) and count (%) respectively. The association of health care utilization (total length of hospital stay, readmission related to varicella, intensive care unit admission) and mortality with complication due to varicella were tested using chi-square and Mann-Whitney test for categorical and continuous outcomes respectively. Results Sixty-six patients with ESRD developed varicella during the study period (2005–2016). The case incidence rates for varicella among ESRD ranges from 97 to 267 per 100,000 populations with ESRD yearly. There were 9 deaths (13.6%). Mortality was higher among the ESRD patients with one or more varicella complications compared to patients without complications ((25% vs 7.1%, 95% CI for difference: − 1.1%, 36.9%, p = .063). Likewise, utilisation of intensive or high dependency units were higher among patients with complications compared to those without (20.8% vs 2.4%, 95% CI for difference: 1.6%, 35.3%, p = .012). Length of stay was twice as long in the group with complications compared to patients without (median (IQR) days: 14 (8, 21) vs 7 (5, 14), p = .065), although it did not reach statistical significance. Conclusions Varicella is associated with high morbidity and significant mortality rate in ESRD patients. Varicella vaccination is recommended for seronegative ESRD patients

How to care for homebound patients?

As a result of an ageing population, low birth rates and longer life expectancies in developed countries, there is an increasing worldwide prevalence of patients with functional decline, dependence and impairment of activities of daily living. The medical follow-up of these functionally dependent patients poses a challenge, especially in the traditional outpatient settings where transport of these patients to a clinic is required. Delivering care for these dependent patients in their own homes remains one of the better ways of providing optimal care for them. We describe two cases, one identified from the community and the other from a hospital setting, which necessitated the activation of home care for continued management of these patients. This article discusses how our current community and hospital home care resources can be used to care for homebound patients, and how we can overcome current limitations in delivery of home care in our healthcare system

A case report of an atypical presentation of pyogenic iliopsoas abscess

Abstract Background Iliopsoas abscess is a collection of pus in the iliopsoas muscle compartment. It can be primary or secondary in origin. Primary iliopsoas abscess occurs as a result of hematogenous or lymphatic seeding from a distant site. This is commonly associated with a chronic immunocompromised state and tends to occur in children and young adults. Secondary iliopsoas abscess occurs as a result of the direct spread of infection to the psoas muscle from an adjacent structure, and this may be associated with trauma and instrumentation in the inguinal region, lumbar spine, or hip region. The incidence of iliopsoas abscess is rare and often the diagnosis is delayed because of non-specific presenting symptoms. Case presentation We describe a patient with iliopsoas abscess who presented to the Emergency Department at X Hospital on three separate occasions with non-specific symptoms of thigh pain and fever before finally being admitted for treatment. This case illustrates how the diagnosis can be delayed due to its atypical presentation. Hence, highlighting the need for clinicians to have a high index of clinical suspicion for iliopsoas abscess in patients presenting with thigh pain and fever. Conclusion The classic triad of fever, flank pain, and hip movement limitation is presented in only 30% of patients with iliopsoas abscess. Clinicians should consider iliopsoas abscess as a differential diagnosis in patients presenting with fever and thigh pain. The rare condition with the varied clinical presentation means that cross-sectional imaging should be considered early to reduce the risk of fulminant sepsis

Roles and recommendations from primary care physicians towards managing low-risk breast cancer survivors in a shared-care model with specialists in Singapore-a qualitative study.

BackgroundBreast cancer is prevalent and has high cure rates. The resultant increase in numbers of breast cancer survivors (BCS) may overwhelm the current oncology workforce in years to come. We postulate that primary care physicians (PCPs) could play an expanded role in comanaging survivors, provided they are given the appropriate tools and training to do so.ObjectiveTo explore the perspectives of PCPs towards managing BCS in a community-based shared-care programme with oncologists.MethodsEleven focus groups and six in-depth interviews were conducted with seventy PCPs recruited by purposive sampling. All sessions were audio-recorded, transcribed verbatim and coded by three independent investigators. Thematic data analysis was performed and the coding process facilitated by NVivo 12.ResultsMajority of PCPs reported currently limited roles in managing acute and non-cancer issues, optimizing comorbidities and preventive care. PCPs aspired to expand their role to include cancer surveillance, risk assessment and addressing unmet psychosocial needs. PCPs preferred to harmonize cancer survivorship management of their primary care patients who are also BCS, with defined role distinct from oncologists. Training to understand the care protocol, enhancement of communication skills, confidence and trust were deemed necessary. PCPs proposed selection criteria of BCS and adequacy of their medical information; increased consultation time; contact details and timely access to oncologists (if needed) in the shared-care programme.ConclusionsPCPs were willing to share the care of BCS with oncologists but recommended role definition, training, clinical protocol, resources and access to oncologist's consultation to optimize the programme implementation