INTRODUCTIONRight siting has been actively advocated to mitigate rising healthcare costs as well as to free up tertiary resources for the provision of care to more complex patients, research and education. There are, however, concerns that in a block budget setting right siting will reduce patient volumes, thus impacting on subsequent funding allocations and also patient revenues. We sought to determine through modelling and simulation the financial and volume impacts of right siting of endocrinology outpatients in a large tertiary hospital in Singapore.

MATERIALS AND METHODSData were collected prospectively on patient casemix including complexity (complex defined as requiring specialist care), time required for consultations and revenues garnered. The data were used to simulate 2 scenarios: right siting of all simple cases with freed up resources directed to research and teaching (research scenario) and right siting of all simple cases with replacement by complex cases (service scenario).

RESULTSThe department sees an estimated 33,000 outpatients per year with a total annual outpatient revenue of $8.6 million. The research scenario would see a decline in patient volume to 11,880 cases per year which would result in a corresponding decrease in revenue of $5 million and freeing up of 2.8 hours/ week for each staff. The service scenario yields a drop in patient volume of 9500 per annum and a drop in revenue of $1.9 million.

CONCLUSIONRight siting reduces tertiary care patient volumes and revenues and may discourage right siting efforts. A viable business model for the tertiary institutions is needed to facilitate support for right siting.

Cost Control ; methods ; Diagnosis-Related Groups ; Endocrinology ; Health Expenditures ; Hospitals, Urban ; Humans ; Outpatient Clinics, Hospital ; economics ; utilization ; Program Evaluation ; Prospective Studies ; Public Policy ; Referral and Consultation ; economics ; standards

INTRODUCTIONIt is reported that junior doctors experience a large amount of work related stress and fatigue which has detrimental effects on their well-being and patient safety. We seek to determine the health-related quality of life (HR-QoL) of junior doctors using the Short Form 36 Health Survey (SF-36) and compare their HR-QoL with that of populations of norms and senior doctors.

MATERIALS AND METHODSThe SF-36v2 (Singapore version) was self-administered to a convenience sample of 213 doctors from a large tertiary teaching hospital. Junior doctors were defined as those less than 30 years of age (48%). Adjusted normative values were derived from the SF-36 Norms for the Singapore General Population Calculator for all 8 scales. The mean score differences between junior doctors and their adjusted normative values as well as that for senior doctors were computed and contrasted.

RESULTSOne hundred and eighty-fi ve doctors fully responded. Their mean age was 33.6 years (SD 8.1). Also, 45% were female and 88% were Chinese. Junior doctors had lower scores than senior doctors in all scales except Physical Functioning. After adjustment for gender and race, junior doctors had statistically significant lower Mental Health scores than senior doctors (P = 0.01). Compared with the normative population, junior doctors scored lower in all domains except for Physical Functioning. For Vitality, the difference is - 14.9.

CONCLUSIONJunior doctors have poorer mental health scores compared to senior doctors. Also, the lower vitality scores suggest that junior doctors are more likely to be fatigued than their normative population. More studies and efforts will be needed to identify factors that affect the quality of life in junior doctors and to evaluate the most appropriate measures to improve the efficiency of their work.

Adult ; Age Factors ; Cross-Sectional Studies ; Fatigue ; Female ; Health Status ; Health Surveys ; Hospitals, Teaching ; Humans ; Male ; Medical Staff, Hospital ; psychology ; Mental Health ; Occupational Health ; Quality of Life ; Singapore ; Stress, Psychological ; Surveys and Questionnaires

Purpose: Men are increasingly turning toward online direct-to-consumer (DTC) men’s health platforms to fulfill their health needs. Research surrounding these platforms is lacking and the motivations and predictors underlying this online health-seeking behavior is largely unknown. This review scopes the existing literature concerning DTC men’s health and identifies factors influencing engagement, as well as health outcomes of this platform. Materials and Methods: A structured search was performed following PRISMA guidelines. CINAHL via EBSCO, Embase, MEDLINE via Ovid, PsycINFO, PubMed and Web of Science were searched. Results: Peer-reviewed quantitative and qualitative studies with a focus on demographics and characteristics of those using DTC men’s health platforms, as well as studies related to patient outcomes using such platforms, were included. Ten of the 3,003 studies identified met the inclusion and exclusion criteria. Four cross-sectional descriptive studies evaluated the motivations behind men’s engagement with DTC platforms. Convenience, embarrassment and health motivation were identified as predominant factors associated with DTC platform use. The review identified a lack of qualitative studies, and major limitations were noted in the quantitative studies that impacted the accuracy of findings. Six further quantitative studies explored the quality of care provided by DTC platforms. DTC platforms were found to have a varying level of adherence to established clinical guidelines, but appeared to provide satisfactory patient outcomes with low levels of patient-reported side effects and adverse events. Conclusions There is a lack of research within the DTC men’s health space given the infancy of the field. Important predictors and motivations underlying men’s choices in accessing these platforms have been noted across several studies. However, further studies need to be conducted to investigate the psychosocial underpinnings of this behavior. Studies across a wider variety of male health conditions treated by these platforms will also help to provide insights to guide patient-centered care within the DTC landscape.

PURPOSE: In arthroscopic rotator cuff repairs there are generally weak link in tendon suture interface, arthroscopic rotator cuff repairs can have higher retear rates than open repairs. The purpose of this study was to compare the strength of UU (Ulsan University) suture than open modified MA (Mason-Allen) suture when suture anchored into bone. MATERIALS AND METHODS: The human supraspinatus tendons were harvested from the shoulder of the cadaver and split in 2 times, producing four tendons per one shoulder, for a total of 24 specimens. Two suture configurations (UU, MA) were randomized and checked on each set of tendons. Specimens were cyclically loaded under force control between 5 and 30 N at 0.25 Hz for fifty cycles. Each specimen was loaded to failure under displacement control at 1 mm/sec. Cyclic elongation, peak to peak displacement, stiffness, ultimate tensile load, mode of failure were checked. RESULTS: No significant difference was found between two suture configuration with respect to peak to peak displacement, cyclic elongation, and stiffness. With regard to ultimate failure load, there were no significant difference statistically between the UU suture and modified MA suture (109.4 N, 110.6 N). The most common mode of failure between both sutures was suture pull-out through the tendon. CONCLUSION: The UU suture and modified MA suture produced similar biomechanical properties.
Aluminum Hydroxide ; Biomechanics ; Cadaver ; Carbonates ; Displacement (Psychology) ; Humans ; Rotator Cuff ; Shoulder ; Suture Anchors ; Sutures ; Tendons

INTRODUCTION: The risk for diabetes progression varies greatly in individuals with type 2 diabetes mellitus (T2DM). We aimed to study the clinical determinants of diabetes progression in multiethnic Asians with T2DM. MATERIALS AND METHODS: A total of 2057 outpatients with T2DM from a secondary-level Singapore hospital were recruited for the study. Diabetes progression was defined as transition from non-insulin use to requiring sustained insulin treatment or glycated haemoglobin (HbA1c) ≥8.5% when treated with 2 or more oral hypoglycaemic medications. Multivariable logistic regression (LR) was used to study the clinical and biochemical variables that were independently associated with diabetes progression. Forward LR was then used to select variables for a parsimonious model. RESULTS: A total of 940 participants with no insulin use or indication for insulin treatment were analysed. In 3.2 ± 0.4 (mean ± SD) years' follow-up, 163 (17%) participants experienced diabetes progression. Multivariable LR revealed that age at T2DM diagnosis (odds ratio [95% confidence interval], 0.96 [0.94-0.98]), Malay ethnicity (1.94 [1.19-3.19]), baseline HbA1c (2.22 [1.80-2.72]), body mass index (0.96 [0.92-1.00]) and number of oral glucose-lowering medications (1.87 [1.39-2.51]) were independently associated with diabetes progression. Area under receiver operating characteristic curve of the parsimonious model selected by forward LR (age at T2DM diagnosis, Malay ethnicity, HbA1c and number of glucose-lowering medication) was 0.76 (95% CI, 0.72-0.80). CONCLUSION Young age at T2DM diagnosis, high baseline HbA1c and Malay ethnicity are independent determinants of diabetes progression in Asians with T2DM. Further mechanistic studies are needed to elucidate the pathophysiology underpinning progressive loss of glycaemic control in patients with T2DM.

Nonalcoholic fatty liver disease (NAFLD) is a leading cause of liver disease worldwide. The estimated global incidence of NAFLD is 47 cases per 1,000 population and is higher among males than females. The estimated global prevalence of NAFLD among adults is 32% and is higher among males (40%) compared to females (26%). The global prevalence of NAFLD has increased over time, from 26% in studies from 2005 or earlier to 38% in studies from 2016 or beyond. The prevalence of NAFLD varies substantially by world region, contributed by differing rates of obesity, and genetic and socioeconomic factors. The prevalence of NAFLD exceeds 40% in the Americas and South-East Asia. The prevalence of NAFLD is projected to increase significantly in multiple world regions by 2030 if current trends are left unchecked. In this review, we discuss trends in the global incidence and prevalence of NAFLD and discuss future projections.

INTRODUCTIONDeveloping effective exercise programmes for the paediatric population is a strategy for decreasing obesity and is expected to help in eventually limiting obesity-associated long-term health and societal impact. In this study, the effects of a 12-week twice weekly additional exercise training, which comprised a combination of circuit-based resistance training and aerobic exercises, in additional to typical physical education sessions, on aerobic fitness, body composition and serum C-reactive protein (CRP) and lipids were analysed in 13- to 14-year-old obese boys contrasted with a control group.

MATERIALS AND METHODSBoth the exercise group (EG, n = 12) and control group (CG, n = 12) participated in the typical 2 sessions of 40-minute physical education (PE) per week in schools, but only EG participated in additional 2 sessions per week of 45 to 60 minutes per session of exercise training, which comprised a combination of circuit-based resistance training and aerobic exercises maintained at 65% to 85% maximum heart rate (HRmax = 220 - age). Body composition was measured using dual energy X-ray absorptiometry (DEXA). Fasting serum CRP and blood lipids were analysed pre- and postexercise programme. Aerobic fitness was measured by an objective laboratory submaximal exercise test, PWC170 (Predicted Work Capacity at HR 170 bpm).

RESULTSExercise training significantly improved lean muscle mass, body mass index, fitness, resting HR, systolic blood pressure and triglycerides in EG. Serum CRP concentrations were elevated at baseline in both groups, but training did not result in a change in CRP levels. In the CG, body weight increased significantly at the end of the 12-week period.

CONCLUSIONThis study supports the value of an additional exercise training programme, beyond the typical twice weekly physical education classes, to produce physiological benefits in the management of obesity in adolescents, including prevention of weight gain.

Adolescent ; C-Reactive Protein ; analysis ; metabolism ; Exercise Therapy ; Humans ; Lipids ; analysis ; blood ; Male ; Obesity ; physiopathology ; therapy ; Physical Fitness ; physiology

Background/Aims: Nonalcoholic fatty liver disease (NAFLD) is closely associated with diabetes. The cumulative impact of both diseases synergistically increases risk of adverse events. However, present population analysis is predominantly conducted with reference to non-NAFLD individuals and has not yet examined the impact of prediabetes. Hence, we sought to conduct a retrospective analysis on the impact of diabetic status in NAFLD patients, referencing non-diabetic NAFLD individuals. Methods: Data from the National Health and Nutrition Examination Survey 1999–2018 was used. Hepatic steatosis was defined with United States Fatty Liver Index (US-FLI) and FLI at a cut-off of 30 and 60 respectively, in absence of substantial alcohol use. A multivariate generalized linear model was used for risk ratios of binary outcomes while survival analysis was conducted with Cox regression and Fine Gray model for competing risk. Results: Of 32,234 patients, 28.92% were identified to have NAFLD. 36.04%, 38.32% and 25.63% were non-diabetic, prediabetic and diabetic respectively. Diabetic NAFLD significantly increased risk of cardiovascular disease (CVD), stroke, chronic kidney disease, all-cause and CVD mortality compared to non-diabetic NAFLD. However, prediabetic NAFLD only significantly increased the risk of CVD and did not result in a higher risk of mortality. Conclusions Given the increased risk of adverse outcomes, this study highlights the importance of regular diabetes screening in NAFLD and adoption of prompt lifestyle modifications to reduce disease progression. Facing high cardiovascular burden, prediabetic and diabetic NAFLD individuals can benefit from early cardiovascular referrals to reduce risk of CVD events and mortality.

Background/Aims: Non-alcoholic fatty liver disease (NAFLD) is associated with the development of cardiovascular disease. While existing studies have examined cardiac remodeling in NAFLD, there has been less emphasis on the development of carotid atherosclerosis and stroke. We sought to conduct a meta-analysis to quantify the prevalence, risk factors, and degree of risk increment of carotid atherosclerosis and stroke in NAFLD. Methods: Embase and Medline were searched for articles relating to NAFLD, carotid atherosclerosis, and stroke. Proportional data was analysed using a generalized linear mixed model. Pairwise meta-analysis was conducted to obtain odds ratio or weighted mean difference for comparison between patients with and without NAFLD. Results: From pooled analysis of 30 studies involving 7,951 patients with NAFLD, 35.02% (95% confidence interval [CI], 27.36–43.53%) had carotid atherosclerosis with an odds ratio of 3.20 (95% CI, 2.37–4.32; P<0.0001). Pooled analysis of 25,839 patients with NAFLD found the prevalence of stroke to be 5.04% (95% CI, 2.74–9.09%) with an odds ratio of 1.88 (95% CI, 1.23–2.88; P=0.02) compared to non-NAFLD. The degree of steatosis assessed by ultrasonography in NAFLD was closely associated with risk of carotid atherosclerosis and stroke. Older age significantly increased the risk of developing carotid atherosclerosis, but not stroke in NAFLD. Conclusions This meta-analysis shows that a stepwise increment of steatosis of NAFLD can significantly increase the risk of carotid atherosclerosis and stroke development in NAFLD. Patients more than a third sufferred from carotid atherosclerosis and routine assessment of carotid atherosclerosis is quintessential in NAFLD.