Proteinuria and Hypertension with and without Type 2 Diabetes Mellitus: 2021 Update

@#INTRODUCTION. This 2021 paper is an update of the 2019 version. In this current update, two new items of information added. Firstly, the 2020 Consensus statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on HPDM, provided recommendations on additional medications to be considered in uncontrolled morning or night blood pressure (BP) are noted.9 Secondly, the nephroprotective properties of the SGLT-2 inhibitors are highlighted.19 Similar to the content of the 2019 version, four related areas are reviewed. They are (1) BP definition and classification; (2) Hypertension diagnosis; (3) Hypertension and proteinuria in non-diabetic patients; and (4) Proteinuria and hypertension in the patient with diabetes. METHODOLOGY. PubMed searches were done for papers to the above four topics published in the last five years (2014 to 2019). These were supplemented by papers from hand searches. RESULTS. For diagnosis of hypertension, the current cut off of 140/90 mmHg can be reduced to 130/80 to improve cardiovascular outcomes and all-cause mortality. Diagnosis of hypertension should not be based on office BP readings alone. Hypertension in older patients should be treated to prevent worse outcomes and should be individualised. In non-diabetic patients, both low grade and microalbuminuria needs to be treated; adequate BP control is needed to prevent cardiovascular outcomes and all-cause mortality. In the diabetic patient, a BP target of less than 140/90 mmHg applies to most patients, but individualisation of the BP goal is important. CONCLUSIONS. Much development in the management of proteinuria and hypertension has taken place in the last five years.

Achieving Educational Continuity under COVID-19 – Early Experiences and Lessons to Share

@#Singapore progressed to DORSCON Orange on 7 February 2020 when a local case with no history of travel out of Singapore was confirmed COVID-19 positive. With the impending lockdown, decision was made to move all postgraduate programs online. The objectives of this paper are to document early experiences and lessons learnt in the conversion of face-to-face to online teaching; and to conduct a literature search for tips on effective online teaching.

Adolescent Eating Disorder in Primary Care - A Case Study

@#Anorexia Nervosa is one of the eating disorders, as classified in the Diagnostic and Statistical Manual, the fifth edition. It is characterised by a pathological fear of weight gain associated with an overwhelming drive for thinness. Patients do present to primary care with vague, non-specific complaints. A heightened degree of suspicion is required for the diagnosis, as patients tend to hide symptoms and are often in denial. We present a case in an 11-year-old girl brought by her mother to the polyclinic with a history of restrictive eating and excessive exercise for three weeks. This case provided a learning opportunity on the assessment and management of an eating disorder, as well as the adverse effects of undernutrition.

Proteinuria and Hypertension with and and without type 2 diabetes mellitus: An Update

@#In this update four related areas are reviewed. They are: (1) Blood Pressure (BP) definition and classification; (2) Hypertension diagnosis; (3) Hypertension and proteinuria in non-diabetic patients; and (4) Proteinuria and hypertension in the patient with diabetes. METHODOLOGY. PubMed searches were done for papers to the above four topics published in the last five years (2014 to 2019). These were supplemented by papers from hand searches. RESULTS. For diagnosis of hypertension, the current cut off of 140/90 mmHg can be reduced to 130/80 mmHg to improve cardiovascular outcomes and all-cause mortality. Diagnosis of hypertension should not be based on office BP readings alone. Hypertension in older patients should be treated to prevent worse outcomes and should be individualised. In non-diabetic patients, both low grade and microalbuminuria needs to be treated; adequate BP control is needed to prevent cardiovascular outcomes and all-cause mortality. In the diabetic patient, a BP target of less than 140/90 mmHg applies to most patients but individualisation of the BP goal is important. CONCLUSIONS. Much development in the management of proteinuria and hypertension has taken place in the last five years.

Case of Advanced COPD: Lessons Learnt

@#A case study of a 76-year-old man with end-stage chronic obstructive pulmonary disease (COPD) with refractory breathlessness and the challenges in managing the dyspnoea he had been experiencing are described. A multi-modal approach is the mainstay of management, encompassing pharmacological agents, home oxygen therapy, and non-pharmacological approaches, namely, breathing techniques and smoking cessation. As this patient was at an advanced stage of disease, integration of palliative care with disease care was needed. Administering oxygen therapy for a patient who is still smoking and has household members who are current smokers need firm adherence to rules. The AIC HOME Programme is also briefly described.

Neonatal Varicella Despite Maternal Immunity – A Case Report and What Can Be Learnt

@#A 20-day-old previously well neonate presented with a 3-day vesiculopapular rash and was admitted to the paediatrics ward. He received extensive workup and treatment with IV acyclovir. The disease ran a mild, uncomplicated course, and recovery. His mother was found to be immune to varicella, having had the disease as a child. However, her immunity had not transferred to the neonate, which was unexpected. A literature review revealed that maternal varicella antibodies do not necessarily prevent infection but may help the infant avoid severe or complicated disease. A review of the management of neonatal varicella in both the immune and the non-immune mother which put the child at risk is also done. Vaccination of all susceptible young females prior to pregnancy will help to reduce the incidence of neonatal varicella in infants and is strongly encouraged. Vaccination of household contacts especially siblings, is also encouraged. Family Physicians should remain open to the diagnosis of neonatal varicella, even when the mother has a history having chickenpox as a child.

Pneumococcal Vaccination in Adults

@#Pneumonia is an important cause of mortality and morbidity worldwide including Singapore. It imposes heavy economic burdens on health care systems. S. pneumoniae is an important pathogen in community acquired pneumonia (CAP) in both developed and developing countries. Pneumococcal disease is importantly, vaccine preventable. The objectives of this review are to provide updates on: pneumococcal disease in adults; pneumococcal vaccines for adults; the need to increase uptake of pneumococcal vaccines; and recommendations on pneumococcal vaccinations in the current national adult immunization schedule. Pneumococcal disease in adults can be divided into invasive and non-invasive pneumococcal diseases. Two pneumococcal vaccines are currently available for adult vaccination in Singapore, namely, the 23-valent pneumococcal polysaccharide vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13). The current recommended pneumococcal vaccine immunization strategy is to administer the PCV13 first followed by PPSV23 a year later in pneumococcal vaccine naïve patients. In patients given PPSV23 before, PCV13 is given to complete the protection. Cost effectiveness studies in Singapore have shown that pneumococcal conjugate vaccines may confer protection against pneumococcal disease both directly and indirectly through herd effects, and reduction of nasal carriage. Uptake of pneumococcal vaccines in Singapore is currently low. Characteristics associated with increased pneumococcal vaccination uptake were higher monthly income, higher educational level, having a regular doctor, and good self-rated health. A research-guided educational intervention may be an effective model to improve the knowledge and attitudes of patients towards pneumococcal vaccinations. We need to find ways to use vaccination and other strategies to reduce the mortality and morbidity associated with pneumococcal disease in Singapore.

Legal medicine: assessing mental capacity and writing medical reports for deputy applications

Medical reports are required to support court applications to appoint a deputy to make decisions on behalf of a person who has lost mental capacity. The doctor writing such a medical report needs to be able to systematically assess the mental capacity of the person in question, in order to gather the necessary evidence for the court to make a decision. If the medical report is not adequate, the application will be rejected and the appointment of the deputy delayed. This article sets out best practices for performing the assessment and writing the medical report, common errors, and issues of concern.

HANDLING DIFFERENT PERSONALITIES IN ACP CONVERSATIONS

Documented advance care planning (ACP) discussions with patients enable doctors to have continuity and collaboration across all settings as patients move from one setting to another. These shared decision-making discussions generally consist of 3 steps: giving information; assisting patients to understand the options in the context of their situations; and helping these patients make informed decisions based on their individual preferences. Primary care physicians should take advantage of their position as healthcare providers to continue the care of the patient and the relationship they have with the patient by initiating ACP discussions. The National Medical Ethics Committees recommendation in 2010 is that such discussions should be started as part of routine care in primary care and outpatient settings before individuals become acutely unwell. Important barriers that need to be overcome are negative encounters with different personalities who can present themselves as difficult - the angry patient, the anxious patient, the patient in collusion, and the patient in denial. In this paper are some guiding principles on how to carry out ACP discussions with such patients. There is also a need for doctors to recognise that as caregivers, they may be exhibiting blocking behaviours to ACP discussions that patients are trying to initiate. These should be avoided.

Education and training in family medicine: progress and a proposed national vision for 2030

This review provides an update of education and training in family medicine in Singapore and worldwide. Family medicine has progressed much since 1969 when it was recognised as the 20th medical discipline in the United States. Three salient changes in the local healthcare landscape have been noted over time, which are of defining relevance to family medicine in Singapore, namely the rise of noncommunicable chronic diseases, the care needs of an expanding elderly population, and the care of a larger projected population in 2030. The change in the vision of family medicine into the future refers to a new paradigm of one discipline in many settings, and not limited to the community. Family medicine needs to provide a patient-centred medical home, and the discipline's education and training need to be realigned. The near-term training objectives are to address the service, training and research needs of a changing and challenging healthcare landscape.

How do primary care physicians in Singapore keep healthy?

<p><b>INTRODUCTION</b>Not much is known regarding how primary care physicians (PCPs) in Singapore keep themselves healthy and mitigate ill health. This study aims to determine the health-seeking behaviour of local PCPs and to identify the predictors of local PCPs attaining the recommended level of exercise.</p><p><b>METHODS</b>This study was a cross-sectional questionnaire survey, which included questions on the demographic characteristics, practice profiles and health-seeking behaviour of PCPs. The sampling frame was the 1,400 listed members of the College of Family Physicians Singapore. The anonymised survey was executed in two phases: a postal survey, followed by a web-based survey on the College of Family Physicians Singapore website. The two data sets were collated; the categorical variables, summarised; and the differences between subgroups (based on exercise engagement), compared using Fisher's exact test. The effect of each risk factor on exercise duration was quantified using odds ratio (OR) estimate and 95% confidence interval (CI). Multivariate logistic regression analysis was performed to identify significant predictors of exercise engagement.</p><p><b>RESULTS</b>A total of 631 PCPs participated in the survey--26% were ≤ 34 years old, 58% were male, 21% were single, 34% were singleton practitioners, and 56% were private practitioners. The percentage of PCPs who exercised ≥ 2.5 hours weekly was 29%, while 28% exercised < 0.5 hours weekly. Of the PCPs surveyed, 1% currently smoke, 0.8% drink more than 14 units of alcohol weekly, 60% undertook health screening, 65% had blood investigations done, and 64% had taken preventive measures such as getting influenza vaccination.</p><p><b>CONCLUSION</b>While local PCPs generally did not have undesirable habits such as smoking and alcohol abuse, they could further increase their exercise intensity and undertake more preventive measures such as getting vaccinated against various diseases.</p>

Health Literacy ‐ Enhancing Physician Skills

The scope of health literacy demanded of the present day health services user is broad. Enhancing physician skills consists of improving on 6 things : Recognise and assist patients with low literacy to overcome their information handling problems ; Improve usability of health information ; Improve the usability of health services ; Build knowledge to improve health decision making ; Advocate for health literacy in your organisation ; and Learn more about health literacy.

Epidemiology of Chronic Diseases and the Need for Lifestyle Advice

Chronic diseases have a serious impact on individuals and on society in general. They affect the quality of life of individuals and can be a financial burden on those who are affected. There is a disease continuum of lifestyle, high risk diseases, and end organ damage. Lifestyle change is necessary if we are to reduce the prevalence of these chronic diseases. The Health Choices, Lifestyle Advice Resource for Healthcare Professionals provides a tool for lifestyle counselling.

Family medicine education in Singapore: a long-standing collaboration between specialists and family physicians

In many countries, family medicine (FM) training has been conducted mainly by senior family physicians alone. However, FM training in Singapore in the last 30 years has involved specialists working in close collaboration with family physicians. The areas in which specialists are currently involved include the training of FM trainees in tertiary hospitals, the Master of Medicine in Family Medicine [MMed (FM)] and Graduate Diploma in Family Medicine (GDFM) programmes. This close relationship has been crucial in the continuing vocational and professional development of family physicians and in fostering closer collaboration between family physicians and specialists, thus ultimately benefiting patient care.

Translating the family medicine vision into educational programmes in Singapore

The core of the Family Medicine (FM) vision is patient-centred care, requiring specific education and vocational training. We traced how FM education started and what have been achieved. FM training began in 1971 with the formation of the College of General Practitioners Singapore. Previously, training consisted of self-directed learning, lunchtime talks and examination preparation courses run by hospital specialists. Formal FM vocational training programmes in the United Kingdom and Australia provided the model for a 3-year programme in 1988. The tripartite relationship between the local university, College of Family Physicians and Ministry of Health, together with a structured training programme, contributed to its success. To date, more than 240 Family Physicians in Singapore have been awarded the Masters in Medicine (FM) degree. The Graduate Diploma in Family Medicine programme (GDFM) was introduced in 2000 for Family Physicians who wished to practice at an enhanced level. This programme has trained 194 doctors since then. Behind the scenes, the following were important developments: counterculture with a difference, tripartite stake-holding, training the trainers and learning from others. For the FM undergraduate programme, our aim is to develop the knowledge base, core values and roles of the Family Physician. Sustaining the value of Family Medicine as a career choice is the enduring vision.