BACKGROUND: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, people need to practice social distancing in order to protect themselves from SARS-CoV-2 infection. In such stressful situations, remote cardiac rehabilitation (CR) might be a viable alternative to the outpatient CR program. METHODS: We prospectively investigated patients hospitalized for heart failure (HF) with a left ventricular ejection fraction of < 50%. As for patients who participated in the remote CR program, telephone support was provided by cardiologists and nurses who specialized in HF every 2 weeks after discharge. The emergency readmission rate within 30 days of discharge was compared among the outpatient CR, remote CR, and non-CR groups, and the EQ-5D score was compared between the outpatient CR and remote CR groups. RESULTS: The participation rate of HF patients in our remote CR program elevated during the COVID-19 pandemic. As observed in the outpatient CR group (n = 69), the emergency readmission rate within 30 days of discharge was lower in the remote CR group (n = 30) than in the non-CR group (n = 137) (P = 0.02). The EQ-5D score was higher in the remote CR group than in the outpatient CR group (P = 0.03) 30 days after discharge. CONCLUSIONS Remote CR is as effective as outpatient CR for improving the short-term prognosis of patients hospitalized for heart failure post-discharge. This suggests that the remote CR program can be provided as a good alternative to the outpatient CR program.
Aged ; Betacoronavirus ; Cardiac Rehabilitation ; methods ; Coronavirus Infections ; epidemiology ; Heart Failure ; rehabilitation ; Humans ; Japan ; Middle Aged ; Monitoring, Ambulatory ; Pandemics ; Pneumonia, Viral ; epidemiology ; Prospective Studies ; Self Care ; Telemedicine ; methods ; Telephone

The COVID-19 pandemic has had a major impact in healthcare systems across the world, with many hospitals having to come up with protocols and measures to contain the spread of the virus. This affects various specialties' clinical practices in many ways. Since early 2020 in Singapore, the Department of Otorhinolaryngology at Tan Tock Seng Hospital had to rapidly adapt to this pandemic as we provided services to the main healthcare facility combating the virus in our country. We had to design new workflows and also remain flexible in view of the ever-changing situation. There are 6 important domains for an otolaryngology department or any clinical department in general to consider when making adjustments to their practices in an outbreak: (1) clinical work, (2) education, (3) research, (4) safety of patients and staff, (5) morale of medical staff and (6) pandemic frontline work. We hope that the sharing of our experiences and the lessons learnt will be useful for both our local and international colleagues.
Ambulatory Care ; Biomedical Research ; COVID-19/prevention & control* ; Delivery of Health Care/methods* ; Education, Medical ; Elective Surgical Procedures ; Health Workforce ; Humans ; Morale ; Otolaryngology/methods* ; Otorhinolaryngologic Surgical Procedures ; Personal Protective Equipment ; Personnel Staffing and Scheduling ; SARS-CoV-2 ; Singapore/epidemiology* ; Workflow

The ongoing pandemic in Singapore is part of a global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To control the spread of COVID-19 and prevent the healthcare system from being overwhelmed, 'circuit breaker' measures were introduced between 7 April and 1 June 2020 in Singapore. There is thus a crucial need for innovative approaches to the provision and delivery of healthcare in the context of safe-distancing by harnessing telemedicine, especially for patients with chronic diseases who have traditionally been managed in tertiary institutions. We present a summary of how the Virtual Monitoring Clinic has benefited the practice of our outpatient rheumatology service during the COVID-19 pandemic. The virtual consultations address the need for safe-distancing by limiting face-to-face appointments and unnecessary exposure of patients to the hospital where feasible. This approach ensures that the patients are monitored appropriately for drug toxicities and side-effects, maintained on good disease control, and provided with patient education.
Ambulatory Care/methods* ; Antirheumatic Agents/therapeutic use* ; COVID-19 ; Delivery of Health Care ; Humans ; Nurse Practitioners ; Pharmacists ; Rheumatic Diseases/drug therapy* ; Rheumatology/methods* ; SARS-CoV-2 ; Singapore ; Telemedicine/organization & administration* ; Tertiary Care Centers

Allergy and Immunology ; Ambulatory Care ; Autoimmune Diseases/therapy* ; COVID-19 ; Communicable Disease Control ; Connective Tissue Diseases/therapy* ; Delivery of Health Care/methods* ; Dermatology ; Humans ; Immunosuppressive Agents/therapeutic use* ; Patient Selection ; SARS-CoV-2 ; Singapore ; Skin Diseases, Vesiculobullous/therapy* ; Telemedicine/methods* ; Tertiary Care Centers ; Vasculitis/therapy*

Peritoneal dialysis (PD) is the only well-established home-based dialysis therapy in Singapore. As it is a home-based modality, PD should be considered as a preferred mode of kidney replacement therapy (KRT) for patients with kidney failure during this COVID-19 pandemic as it avoids frequent visits to hospitals and/or satellite dialysis centres. The highly infectious nature of this virus has led to the implementation of the Disease Outbreak Response System Condition orange status in Singapore since early February 2020. This paper summarises the strategies for management of several aspects of PD in Singapore during this COVID-19 pandemic, including PD catheter insertion, PD training, home visit and assisted PD, outpatient PD clinic, inpatient management of PD patients with or without COVID-19 infection, PD as KRT for COVID-19 patients with acute kidney injury, management of common complications in PD (peritonitis and fluid overload), and management of PD inventory.
Ambulatory Care/methods* ; COVID-19/prevention & control* ; Home Care Services ; Hospitalization ; Humans ; Infection Control/methods* ; Pandemics ; Peritoneal Dialysis/methods* ; Self Care/methods* ; Singapore/epidemiology*

PURPOSE: Ultra-rush schedule of subcutaneous allergen immunotherapy (UR-SCIT) administering maximum maintenance dose of allergen extract within one day can save time and effort for allergen immunotherapy in patients with allergic disease. However, UR-SCIT is associated with an increased risk of systemic reaction (SR) and typically has been conducted in a hospital admission setting. To overcome disadvantages of UR-SCIT, we evaluated the safety of UR-SCIT conducted in an outpatient clinic in patients with atopic dermatitis (AD) and allergic rhinitis (AR). METHODS: UR-SCIT was performed in 538 patients with AD and/or AR sensitized to house dust mite (HDM). A maximum maintenance dose of tyrosine-adsorbed HDM extract (1 mL of maintenance concentration) was divided into 4 increasing doses (0.1, 0.2, 0.3, and 0.4 mL) and administered to the patients by subcutaneous injection at 2-hour intervals for 8 hours in an outpatient clinic. SRs associated with UR-SCIT were classified according to the World Allergy Organization grading system. RESULTS: SR was observed in 12 of 538 patients (2.2%) with AD and/or AR during UR-SCIT. The severity grades of the observed SRs were mild-to-moderate (grade 1 in 7 patients, grade 2 in 4 patients, and grade 3 in 1 patient). The scheduled 4 increasing doses of HDM extract could be administered in 535 of 538 patients (99.4%) except 3 patients who experienced SR before administration of the last scheduled dose. SR was observed within 2 hours in 11 patients after administration of the scheduled doses of HDM extract except one patient who experienced a grade 2 SR at 5.5 hours after administration of the last scheduled dose. CONCLUSIONS: UR-SCIT with tyrosine-adsorbed HDM extract conducted in an outpatient clinic was tolerable in patients with AD and AR. UR-SCIT can be a useful method to start a SCIT in patients with AD and AR.
Ambulatory Care Facilities ; Appointments and Schedules ; Dermatitis, Atopic ; Desensitization, Immunologic ; Dust ; Humans ; Hypersensitivity ; Injections, Subcutaneous ; Methods ; Outpatients ; Pyroglyphidae ; Rhinitis, Allergic

OBJECTIVE: Mobile messengers are becoming common methods to communicate among people in various fields. This study investigated the effectiveness of mobile messengers as a tool for post-discharge case management of emergency department patients who attempted suicide and self-harm. METHODS: This study was a retrospective observational study of data collected prospectively. A total of 327 patients who attempted suicide and self-harm in the emergency department were divided into two groups: a conventional protocol group with a face-to-face or phone call interview and a new protocol group with added mobile messenger counseling. The basic characteristics, such as sex, age, methods of suicide and self-harm attempt, consent for case management, and admission to a ward, were surveyed. The rates of successful case management (transfer to a local community center or follow-up to neuropsychiatric outpatient clinic, or both) were compared as a primary outcome between the two groups. RESULTS: The conventional protocol group was 122 cases and the new protocol group was 205 cases. No significant differences in sex, age, methods of suicide and self-harm attempt, rate of consent to case management, and admission to a ward were observed between the two groups. On the other hand, the total successful management rate in mobile messenger group was higher than that of the other group (P=0.020). CONCLUSION: This study showed that mobile messengers could be an alternative communication tool for the post-discharge case management of patients who attempted suicide and self-injurious behavior. Nevertheless, a well-designed future study might be needed to determine if that method would reduce the reattempt rate.
Ambulatory Care Facilities ; Case Management ; Cell Phones ; Counseling ; Emergency Service, Hospital ; Follow-Up Studies ; Hand ; Humans ; Methods ; Observational Study ; Prospective Studies ; Retrospective Studies ; Self-Injurious Behavior ; Suicide ; Suicide, Attempted

OBJECTIVE: Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairment in social skills and communication with repetitive behaviors. Etiology is still unclear although it is thought to develop with interaction of genes and environmental factors. Oxytocin has extensive effects on intrauterine brain development. Vitamin D, affects neural development and differentiation and contributes to the regulation of around 900 genes including oxytocin receptor gene. In the present study, the contribution of D vitamin receptor and oxytocin receptor gene polymorphisms in the development of ASD in Turkish community was investigated. To our knowledge, this is the first study examining these two associated genes together in the literature. METHODS: Eighty-five patients diagnosed with ASD according to DSM-5 who were referred to outpatient clinics of Child and Adolescent Psychiatry of Başkent University and Mersin University and 52 healthy, age and gender-matched controls were included in the present study. Vitamin D receptor gene rs731236 (Taq1), rs2228570 (Fok1), rs1544410 (Bsm1), rs7975232 (Apa1) polymorphisms and oxytocin receptor gene rs1042778 and rs2268493 polymorphisms were investigated using real time polymerase chain reaction method. RESULTS: No significant difference between groups in terms of distribution of genotype and alleles in each of polymorphisms for these genes could be found. CONCLUSION: Knowledge of genes and polymorphisms associated with the development of ASD may be beneficial for early diagnosis and future treatment. Further studies with larger populations are required to demonstrate molecular pathways which may play part in the development of ASD in Turkey.
Adolescent ; Adolescent Psychiatry ; Alleles ; Ambulatory Care Facilities ; Autism Spectrum Disorder ; Brain ; Child* ; Early Diagnosis ; Genotype ; Humans ; Methods ; Neurodevelopmental Disorders ; Oxytocin* ; Polymorphism, Genetic ; Real-Time Polymerase Chain Reaction ; Receptors, Calcitriol ; Receptors, Oxytocin* ; Social Skills ; Turkey ; Vitamin D* ; Vitamins*

PURPOSE: Toe ulcers have been implicated as a causative factor in diabetic foot amputation. The aim of this study was to evaluate the outcomes of percutaneous needle flexor tenotomies of diabetic claw toes with ulcers or pending ulcers. MATERIALS AND METHODS: The authors undertook a retrospective chart review between January 2014 and June 2016 to identify those patients who underwent a percutaneous needle flexor tenotomy for diabetic claw toe deformities. We evaluated 54 toes in 42 patients. Twenty-four patients were female and the mean age at the time of operation was 57 years. The mean follow-up time was 11 months. Thirty-four patients (46 toes) had tip toe ulcers or pending ulcers and 8 patients (8 toes) had dorsal pending ulcers. All patients had palpable pulses and good capillary refill. RESULTS: Forty-three of 46 tip toe ulcers (93.5%) healed without significant complications and 8 dorsal ulcers showed no specific changes within 5 weeks. There were no recurrent ulcers at final follow-up. Four patients developed transfer lesion of the adjacent toe and needed subsequent tenotomy. CONCLUSION: Percutaneous needle tenotomy in an outpatient clinic was an effective and safe method for treating toe ulcers in neuropathic patients to offload the tip of the toe so that ulcer healing could occur.
Ambulatory Care Facilities ; Amputation ; Animals ; Capillaries ; Congenital Abnormalities* ; Diabetic Foot ; Female ; Follow-Up Studies ; Hammer Toe Syndrome* ; Hoof and Claw* ; Humans ; Methods ; Needles ; Outpatients* ; Retrospective Studies ; Tenotomy* ; Toes ; Ulcer*

BACKGROUND AND OBJECTIVES: Patients with aspirin-exacerbated respiratory disease (AERD) tend to have more severe clinical course and also tend to be recalcitrant to conventional medical and surgical treatment. This study aimed to assess the long-term outcome of endoscopic sinus surgery in AERD patients. SUBJECTS AND METHOD: Fifteen patients with AERD (n=15) were identified through a retro-spective chart review, and compared with 74 patients of CRSwNP (with asthma n=23; without asthma n=51) by analyzing preoperative and postoperative symptoms, endoscopic score, Lund-Mackay CT score, number of revision surgery or outpatient procedures, frequency of clinic visits and medications. The CRS control status was evaluated according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2012 criteria and logistic regression analyses were conducted to investigate the determining factors of preoperative and postoperative symptoms. RESULTS: The AERD group showed higher disease severity than other groups preoperatively: endoscopic score (CRSwNP s asthma 6.3±2.6 vs. CRSwNP c asthma 6.5±2.3 vs. AERD 8.8±1.4, p<0.05), CT score (12.2±4.9 vs. 17.0±4.8 vs. 18.0±2.1, p<0.05), and overall symptom score (30.8±0.4 vs. 33.8±1.5 vs. 37.9±0.7, p<0.01). The rate of revision surgery and outpatient procedures, postoperative clinic visit and prescription rate were higher in the AERD group (p<0.05, respectively). However, postoperative symptom scores and CRS control status were not significantly different among three groups (p=0.267 and p=0.996, respectively). CONCLUSION: Although AERD patients showed higher preoperative endoscopic scores and revision surgery rates, postoperative subjective symptoms were comparable to those of other groups with long-term follow up, suggesting the importance of frequent outpatient care after endoscopic sinus surgery.
Ambulatory Care ; Asthma ; Follow-Up Studies ; Humans ; Logistic Models ; Methods ; Nasal Polyps ; Outpatients ; Postoperative Care ; Prescriptions