Objectives: Advances in the field of clinical nutrition have introduced a wide range of formulations to the market. Today physicians are faced with a bewildering choice of formulations. Increasingly, patients are being discharged to the community from the restructured hospitals with enteral tube feeding. It is important for the family physician to be familiar with the types of formulations and the different enteral tubes. These tubes need to be changed on a regular basis and the family physician in the community will likely be called upon to provide such services. The enteral route is always preferable to parenteral provided there are no contraindications such as ileus, gastrointestinal ischaemia, or bilious and persistent vomiting. Enteral tubes are easy to insert and cheap, and the insertion can be done at the bedside. It is important to confirm the correct placement of the tube in the stomach before initiating feeding as the tube may be coiled, twisted or malpositioned in the respiratory tract. This can be done by aspiration of the stomach contents and testing it with pH paper. In the case of an unconscious patient, this can be done with a chest X-ray.

Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75% of adults >65 years of age has sleep disturbance and 30% of them has insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significant overlap and usually treatment of the underlying disorder does not solve the problem or cure it. The elderly has multiple comorbidities and polypharmacy with a myriad of cause for insomnia. A comprehensive medical and psychiatric history together with a complete physical examination and mental state examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene education should be the initial treatment together with the treatment of the contributing physical and psychiatric conditions. Referral to an expert for cognitive behavioural therapy or multicomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are needed it can be combined with behavioural therapy. Medication used should be the lowest effective dose and prescribed for short-term use of not more than 4 weeks. Medications used need to be discontinued gradually and one needs to be mindful of rebound insomnia upon withdrawal. Wherever possible, it will be ideal to avoid benzodiazepines and other sedative hypnotics as first choice for insomnia. Over the counter sleep aids which usually contain antihistamines may not be good choices as they carry significant risk of adverse events and drug interactions. Currently the safest medications for use in the elderly includes the Z-drugs (zolpidem, zopiclone), melatonin and low dose tricyclic antidepressant Doxepin.

Community resources are limited. Most are run by Voluntary Welfare Organisations that depend on subsidies from the government and funds raised from donations and activities. The out-of-pocket payment from patients depends on per capita household means testing. Patients are matched to the type of services based on their functional statuses. The tools used for functional assessments are the RAF forms and Modified Bartel Index. Applications for most of the community services are done online through the Agency of Integrated Care. Essentially, there are three types of community resources, namely financial, psychosocial, and care resources to help patients in need. To navigate this social maze, Family Physicians will need to familiarise themselves with the type of resources available, the means testing procedure, as well as the referral system. After assessing the patient’s needs and functional status, family physicians will have to match the services that can best serve their patient’s needs.

Singapore has a rapidly ageing population with an increasingly complex chronic disease burden. The number of seniors living alone has also tripled in the last 15 years. Primary care physicians will have to change the way that we delivery primary care. Patients have multi-comorbidities and are sicker. Family Physician Practice has to enhance the coordination of medical and social care and the provision of comprehensive care across the entire cycle of care. This can be achieved by being connected to the health system and resources, making additional efforts in providing care coordination to navigate the health system, and optimising clinical social care around the patient’s needs with a multi-disciplinary team (MDT). There has been an increase in the number of services in the community but gaps still exist, especially in the coordination of healthcare and psychosocial care services. The team will need to tap on all available services to ensure patients’ medical and social needs are taken care of and they are enabled to age gracefully in place.

Wound healing is achieved through four coordinated and overlapping phases, 1) haemostasis, 2) inflammatory, 3) proliferative and 4) remodelling. This complex process can be disrupted by local or systemic risk factors, resulting in delayed healing and progression to a chronic wound. Chronic wounds interact closely with a patient’s comorbid illnesses, social circumstances and functional status. The Family Physician plays an important role to optimise patient and wound risk factors that impair wound healing. Strategies to enhance wound healing include optimising local wound care based on TIME principles, identification and optimising the underlying causes for poor wound healing and education to the patients and their caregivers in wound care, dressing changes and avoidance of risk factors to prevent recurrence. Complex chronic wound care may need a multi-disciplinary approach involving allied health members to provide additional nutritional, nursing and psychosocial support. There is a role for adjuvants such as hyperbaric oxygen therapy and platelet derived growth factor gels to enhance healing in certain wounds but stronger evidence is required to support its routine use.

Background: Individuals with AD have an increased susceptibility to colonization with Staphylococcus aureus (S. aureus), contributing to the exacerbation of the disease. Sodium hypochlorite (bleach) has both in vitro and in vivo antimicrobial activity against S.aureus. Objectives: To evaluate the efficacy and safety of diluted sodium hypochlorite (bleach) baths in patients with moderate to severe atopic dermatitis in our Malaysian population. Methods: This was a prospective randomized, investigator-blinded, placebo-controlled study. Patients were randomly assigned through computer generated simple randomized numbers to treatment (bleach baths) or placebo (distilled water baths). Patients were instructed to soak in the baths neck down for 10 minutes, twice a week for 2 months. The efficacy outcome measures were the Eczema Area and Severity Index (EASI) score, percentage body surface area involved, quantitative S. aureus counts and patient’s assessment of overall response (including itch scores). Safety outcomes were also assessed. Results: A total of 36 patients completed the study. EASI scores and body surface area showed significant improvement between treatment and placebo groups at 2 months (p=0.02, p=0.02). At baseline, 88% of patients yielded S. aureus from lesional skin. Although most cultures in the treatment group continued to yield S. aureus, there was a reduction in the density over time, although not statistically significant. Five patients reported burning/stinging and dry skin in the treatment arm which did not differ significantly compared to placebo. Conclusion: Diluted sodium hypochlorite baths as an adjunctive treatment decreased the clinical severity of patients with moderate to severe atopic dermatitis and may reduce S. aureus density. This treatment was well tolerated with minimal adverse effects.

Objective To investigate the changes of cytokines of splenocytes in mice immunized with recombinant BCG-Em Ⅱ/3 vaccine of Echinococcus multilocularis(Em)and consequently challenged with Em protoscoleces.Methods Balb/c mice were subcutaneously or intranasally vaccinated and challenged with Em were separated and cultured with EmAg,ConA or PHA,respectively.The supematants were gathered to measure the levels of IL-2,IFN-γ,TNF-α.and IL-4 by ELISA Kits.Results The levels of IL-2,IFN-γ,TNF-α and IL-4 in the subcutaneous group were(34.6±2.7),(34.5±2.8),(265.0 ±0.0)and(9.8±2.6)ng/L respeetively:those in the intranasal group were(32.5±2.2),(33.6±2.7),(130.0±0.0)and(10.4±27)ng/L respectively;those in the control were(25.0±1.9),(30.0±0.0),(10.0±0.0)and(12.5±2.7)ng/L,respectively:there were statistical differences between the immunized groups and control group(P＜0.01 or＜0.05);The level of TNF-α in the subcutaneous group was higher than that in the intranasal group.Conclusion Th1 response has been induced in mice vaccinated with rBCG-Em Ⅱ/3 vaccine and challenged with Em protoscoleces.

Objective To observe the perioperative myocardial protection of high-dose atorvastatin to acute coronary syndrome(ACS) patients during percutaneous coronary artery interventional therapy(PCI).Methods One hundred and twenty patients with ACS undergoing elective PCI were divided into group A and group B with different oral dose of atorvastatin ( 80 mg/d and 20 mg/d ) for 3 days before operation by random digits table. Troponin I (cTnI), creatine kinase isozyme MB (CK-MB), high sensitive C-reactive protein (hs-CRP), interleukin (IL)-6 levels were measured before operation, 6 hours, 12 hours after operation and total cholesterol (TC), triglyeride (TG), low desity lipeprotein cholesterol (LDL-C), high density lipeprotein cholesterol (HDL-C) levels were measured before operation and 3 days after operation.Results cTnI,CK-MB,hs-CRP and IL-6 levels in the two groups were increased significandy 6 hours and 12 hours after operation (P <0.05). Six hours after operation, cTnI and CK-MB levels in group A were significantly lower than those in group B [(0.35±0. 18 ) μg/L vs. (0.48±0. 16 ) μg/L, ( 3.78±0.45 )μg/Lvs. (4.56±0.55 )μg/L] (P < 0.05 ). Twelve hours after operation , hs-CRP and IL-6 levels in group A were significantly lower than those in group B [(4.53±0.98 ) mg/L vs. (7.03±0.88 ) mg/L, ( 30.6±11.2) ng/L vs.(43.8±12.1) ng/L] (P <0.05). TC, TG, LDL-C, HDL-C levels in the two groups did not change significantly before and after operation (P >0.05). Conclusions Myocardial protective effects of ACS patients treated with atorvastatin 80 mg/d for 3 days are better than those treated with oral atorvastatin 20 mg/d. High-dose atorvastatin can produce more beneficial effects.

Given the myriad of choices available on the market, selecting the appropriate wound dressing remains a challenge for most healthcare workers. It is important to exercise discretion and adopt a systematic approach in dressing selection following wound assessment, as this will directly impact on rates of wound healing, which in turns affects the patient’s quality of life and overall healthcare costs. This paper provides an overview of the common types of wound dressings in use currently and gives a brief synopsis of some of the latest advances in wound care technology and their applications in management of complex wounds. The consensus to date is for the use of hydrogels in the debridement stage, foams and low-adherence dressings in the granulation stage and hydrocolloids and low-adherence dressings for the epithelialization stage. Additional studies and research need to be undertaken to further evaluate the application of advanced wound technology in clinical practice.