We report a case of a healthy 78 -year- old indonesian man who presented with chronic weight loss, poor appetite and lethargy. CT abdomen showed bilateral adrenal masses. EUS – guided FNA was performed on the left adrenal gland. Histopathology report was Histoplasma Capsulatum. He recovered well with antifungal treatment without any complication. In this case, we found that the role of EUS – guided FNA was not only limited to diagnosis but also helped in the prognosis of the disease since the method was able to assess the general anatomy of the adrenal gland better than other imaging modalities due to its close proximity and direct visualization.

We report a case of a healthy 78-year-old indonesian man who presented with chronic weight loss, poor appetite and lethargy. CT abdomen showed bilateral adrenal masses. EUS-guided FNA was performed on the left adrenal gland. Histopathology report was Histoplasma Capsulatum. He recovered well with antifungal treatment without any complication. In this case, we found that the role of EUS -guided FNA was not only limited to diagnosis but also helped in the prognosis of the disease since the method was able to assess the general anatomy of the adrenal gland better than other imaging modalities due to its close proximity and direct visualization.

While there is an ethical obligation to improve clinical outcomes by developing better therapies, surgical innovation has largely progressed without the strict regulations required of novel pharmaceutical products. We explore the reasons why new surgical techniques are frequently introduced without the benefit of randomised controlled trials, and present an approach to the ethical evaluation of novel surgical procedures.
Biomedical Research ; ethics ; Clinical Competence ; Diffusion of Innovation ; Ethics, Medical ; General Surgery ; ethics ; methods ; standards ; Humans ; Informed Consent ; Medical Audit ; Medicine ; Singapore ; Specialty Boards

A 26 year-old Malay man presented with first attack of left eye optic neuritis that recovered fully with intravenous methylprednisolone after 3 weeks. He developed a second attack of optic neuritis in the right eye the following week. Lhermitte sign as well as Uthoff phenomenon were also positive. On day-3, he developed bilateral paraplegia and sensory loss at T8 level, which progressively worsen and became bedridden on day-5. MRI showed bilateral enhance-ment of the optic nerve with the presence of long multisegmental demyelinating plaque in the thoracic to lumbar spinal cord and the brainstem, sparing the brain hemisphere. He was promptly given high dose intravenous methylprednisolone followed by oral predni-solone. He was also assigned on intensive neuro-phy-siotherapy. He recovered after 3 months and was able to walk with walking aids. He recovered completely after 7 months and resumed working as site contactor. There was no relapse during the last 1 year follow-up. His final visual acuity improved to 6/9 in the right eye and 6/6 in the left eye. The visual field of the right eye showed per-sistent mild cecocentral scotoma. And diffuse depression.

A preliminary survey of larvae and pupae of black flies (Diptera: Simuliidae) was conducted in three recreation parks [Templer Recreation Park (TRP), Congkak River Forest Reserve (CRFR) and Ampang Forest Reserve (AFR)] located in Selangor State, which is located 18 to 35 km from Kuala Lumpur city center, Malaysia. This study was initiated to determine the distribution and abundance of filarial vectors, Simulium spp. A total of 12 species of black flies belonging to three subgenera (Gomphostilbia, Simulium and Nevermannia) were collected. Simulium (Simulium) nobile was incriminated as the most dominant species in all recreation parks. This study is a first report on the distribution and abundance of black flies obtained from recreation parks in Malaysia.

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

OBJECTIVETo compare the preemptive analgesia efficacy between two cycloxygenase-2 inhibitors, rofecoxib and etoricoxib in the ambulatory uterine evacuation patients.

METHODSIn this randomized, double-blinded, placebo-controlled trial 60 patients were randomly divided into three groups and received a single dose of placebo, rofecoxib 50 mg, or etoricoxib 120 mg, respectively, before operation. Patient's visual analogue score (VAS) was rated postoperatively at 15 min, 30 min, 60 min, time-to-discharge, 6 h and 24 h. Fentanyl (in post-anesthesia care unit) and paracetamol (at home) were supplementary analgesics and the dosage was also recorded. Patient's satisfaction score was rated at 24 h postoperatively.

RESULTSEtoricoxib 120 mg and rofecoxib 50 mg were significantly superior to placebo at 6 h postoperatively (P < 0.05) while there was no significant differences of VAS at other time points. The amounts of Fentanyl used in post-anesthesia care unit were similar in three groups, but paracetamol taken at home was much less in rofecoxib group and etoricoxib group than in placebo group (P < 0.01). Compared to rofecoxib, etoricoxib provided better pain relief after discharge (P < 0.05). The overall pain management satisfaction score was significantly higher in etoricoxib group (96 +/- 7) than in other groups (P < 0.01).

CONCLUSIONPreemptive rofecoxib 50 mg and etoricoxib 120 mg may significantly decrease VAS at 6 h postoperatively, and reduce the usage of analgesics in ambulatory uterine evacuation patients. Etoricoxib 120 mg offeres better pain relief at home compared with rofecoxib 50 mg.

Abortion, Induced ; adverse effects ; Acetaminophen ; therapeutic use ; Adolescent ; Adult ; Ambulatory Surgical Procedures ; Analgesics, Non-Narcotic ; therapeutic use ; Analgesics, Opioid ; therapeutic use ; Cyclooxygenase Inhibitors ; therapeutic use ; Double-Blind Method ; Female ; Fentanyl ; therapeutic use ; Humans ; Lactones ; therapeutic use ; Pain Measurement ; Pain, Postoperative ; prevention & control ; Preoperative Care ; Pyridines ; therapeutic use ; Sulfones ; therapeutic use

The Singapore public healthcare system has increasingly used the term "right-siting" to describe the principle that stable chronic disease patients should be managed in primary care rather than specialist settings. The majority of primary healthcare providers in Singapore are general practitioners (GPs). The aims of this paper were to measure the quality of diabetes care in specialist and GP settings, and assess right-siting efforts in a tertiary centre in Singapore. Three hundred eighty-three consecutive patients with type 2 diabetes referred to the Singapore General Hospital Diabetes Centre (SGH DBC) between January and March 2005 were analysed. At the first visit, 51 patients (13.3%) were classified as inappropriate referrals and discharged back to the referral source or to primary care. After 12 months, 136 patients (group A = 35.5%) remained on follow-up at SGH DBC. In these patients, significant improvements were seen in mean HbA1c but not blood pressure (BP) or low density lipoprotein-cholesterol (LDL-C). One hundred twenty-eight (group B = 33.4%) patients were discharged from DBC within the 12 months of the study period. Mean follow-up duration in group B was 5.5 months and HbA1c, blood pressure and LDL-cholesterol had improved significantly in these patients. Glycaemic control of group B patients at the time of discharge was significantly better than group A at 12 months (mean HbA1c = 7.15% vs 8.16%; P <0.001). More than half (55.6%) of group B patients achieved HbA1c targets compared to 32.4% from group A (P <0.001). Although mean BP and LDL-C levels fell in group B patients, the percentage of patients achieving BP and LDL-C targets did not improve significantly in both groups. From August 2005 to January 2008, GPs participating in SingHealth's Delivering on Target (DOT) programme enrolled 579 patients under their care for additional diabetic counselling by community nurse educators. Pre- and post-programme HbA1c results were submitted for 370 patients (64%). Mean HbA1c levels of these patients decreased from 8.23% to 7.32% (P <0.001). The proportion of patients who achieved HbA1c <7% increased from 26% to 51% (P <0.01). However, BP and LDL-C levels did not improve. It is difficult to base referral or discharge decisions solely on these indicators. Our studies show that both in the specialist and GP settings, significant improvements in HbA1c are seen. Results for BP and LDL-C, however, showed little improvement. Some degree of rightsiting was seen at SGH DBC with discharged patients showing greater improvements than patients who were retained. However, >30% of patients remained in SGH DBC despite achieving HbA1C targets. Our results indicate the need for better strategies to address the underlying obstacles to right-siting. Of greater concern, the lack of improvement in BP and LDL-C indicates a high degree of clinical inertia to these issues among specialists and GPs treating diabetes in Singapore.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Blood Glucose ; metabolism ; Blood Pressure ; Cholesterol, LDL ; blood ; Delivery of Health Care, Integrated ; methods ; standards ; Diabetes Mellitus ; blood ; physiopathology ; therapy ; Female ; Follow-Up Studies ; Glycated Hemoglobin A ; metabolism ; Humans ; Middle Aged ; Outcome Assessment (Health Care) ; methods ; Primary Health Care ; methods ; standards ; Retrospective Studies ; Singapore ; Young Adult