A nationwide, resident-led teaching programme for medical students in Singapore: SingHealth Student Internship Programme Bootcamp

<p><b>INTRODUCTION</b>This study aimed to describe the planning, development and evaluation of the success of the first nationwide, resident-led, large-group teaching programme for medical students - the Singapore Health Services Student Internship Programme (SIP) Bootcamp.</p><p><b>METHODS</b>This was an initial feasibility study evaluating a half-day teaching boot camp initiated, developed and conducted by the resident educators. A three-month preparation period was required to set up an education subcommittee, liaise with medical student leaders, recruit resident educators, meet all the stakeholders and conduct the boot camp. During the SIP Bootcamp, resident educators conducted clinical case presentations using a question-and-answer format. Audience participation was strongly encouraged. A 15-item questionnaire was distributed to assess the participants' learning experience and the resident educators' teaching performance using a five-point Likert scale.</p><p><b>RESULTS</b>Overall, 94.8% (n = 110) of the 116 respondents agreed that the teaching sessions were of high quality and content was relevant to their training. The resident educators appeared well-informed (96.6%, n = 112) and enthusiastic about their respective topics (98.3%, n = 114). However, a few students (9.5%, n = 11) felt that the audio-visual aids and handouts could be improved to better aid their learning process.</p><p><b>CONCLUSION</b>This teaching boot camp for medical students was the first of its kind in Singapore and feedback from medical students showed that it was well-received. Further research using different teaching methods, including small-group discussions and surgical practical sessions by resident educators from different specialties, would be of great value to students.</p>

Academic Medicine Education Institute (AM·EI): Transforming the Educational Culture of Health Professionals

<p><b>INTRODUCTION</b>The Academic Medicine Education Institute (AM∙EI), jointly established by Duke-NUS Graduate Medical School (Duke-NUS) and Singapore Healthcare Services (SingHealth), is a newly formed health professions education academy designed to cultivate best education practices and create a community of health professions educators. To achieve the aims of AM∙EI, the needs of SingHealth educators have to be understood. Therefore, this study was carried out to assess educators' perceptions towards the current education climate and their academic needs.</p><p><b>MATERIALS AND METHODS</b>A 28-item questionnaire consisting of free-response, Likert-type and ranking questions was developed. The questionnaire was electronically distributed to 200 medical and nursing educators, and made available to attendees of the 2012 Singhealth Duke-NUS Scientific Congress through hardcopies.</p><p><b>RESULTS</b>A total of 150 completed questionnaires were received (94 from electronic survey and 56 from Congress). Five themes emerged from the analysis of responses to free-response questions: 1) faculty development, 2) development of a community of educators, 3) recognition for educational efforts, 4) institutional support, and 5) better communication about SingHealth educational activities. Respondents were in highest agreement with the statements (rating of 3.7 out of 5): "The SingHealth education programmes are high quality", "New learning or teaching methods are welcomed in this institution/hospital", and "An academic appointment is important to me". The competencies that respondents felt to be the most important were facilitating discussions, presentation skills, and providing feedback (respective means = 5.1, 5, 5 of 7).</p><p><b>CONCLUSION</b>This needs assessment provided us with important insights regarding SingHealth medical educators' perceptions of their education environment and established key priorities for the AM∙EI's programming efforts.</p>

Opportunistic screening for colorectal neoplasia in Singapore using faecal immunochemical occult blood test

<p><b>INTRODUCTION</b>The use of faecal immunochemical occult blood test (FIT) has been reported to decrease mortality from colorectal cancer. The Singapore Cancer Society (SCS) gives out FIT kits to encourage opportunistic screening of colorectal cancer. Any Singapore citizen or permanent resident aged ≥ 50 years is eligible to receive two FIT kits. Participants with at least one positive FIT are referred for further evaluation. We aimed to analyse the results of SCS data from the year 2008.</p><p><b>METHODS</b>The factors evaluated included compliance, positive test rate (PR) and positive predictive value (PPV) of FIT.</p><p><b>RESULTS</b>20,989 participants received 41,978 kits in 2008. Compliance was 38.9%, with 8,156 participants returning at least one kit. 8% of participants tested positive, and 75% of these test-positive participants agreed to undergo further investigations. 33 participants had colorectal cancers, 45 had advanced polyps (≥ 1 cm) and 90 had polyps < 1 cm. Histologically, 114 polyps were adenomatous, 20 were hyperplastic and 1 was serrated. PPV of colorectal neoplasia for those who underwent further colonoscopy was 34%. Over half of the participants who had only one positive test had colorectal neoplasia.</p><p><b>CONCLUSION</b>PR and PPV of FIT in our study were comparable to that in the literature. However, compliance was low and a quarter of all participants who tested positive refused further investigations. Extensive population education programmes are required to improve compliance and tackle inhibitions among the masses. It is also important to take steps to enhance the cost effectiveness of future screening programmes.</p>

Improvements in end-of-life care with a protocol-based pathway for cancer patients dying in a Singapore hospital

<p><b>INTRODUCTION</b>More than half of all deaths in Singapore occur in hospitals. Little is known about the quality of care received by dying patients in hospitals. The Liverpool Care Pathway (LCP) provides a framework of providing good end-of-life care for dying patients and has been used with success in the United Kingdom (UK). In this study, we investigate whether adoption of a modified LCP in a Singapore hospital translated to better end-of-life care for cancer patients.</p><p><b>MATERIALS AND METHODS</b>The LCP was adapted and implemented as a pilot project on an oncology ward in Singapore General Hospital. A baseline review of 30 consecutive death records was performed, followed by a 4-month pilot and post-implementation audit of 30 consecutive patients on the adapted LCP.</p><p><b>RESULTS</b>Five types of end-of-life symptoms were analysed. There was only 1 uncontrolled symptom at death in the post-implementation group compared to 24 uncontrolled symptoms in the retrospective audit group. The prescription of breakthrough medications for symptom control increased from 21% in the retrospective audit group to 79% in the post-implementation group. Inappropriate monitoring was discontinued in 25 patients in the post-implementation group compared to none in the retrospective audit group. The documentation of resuscitation status and religion of the patient was improved, achieving full documentation in the post-implementation group.</p><p><b>CONCLUSION</b>This study shows promising results for improving end-of-life care in cancer patients with a protocol-based pathway in a Singapore hospital. Extension of this care pathway to other settings should be explored to maximise its benefits to patients dying from all causes in hospital.</p>

Phase II trial of gemcitabine in combination with cisplatin in inoperable or advanced hepatocellular carcinoma

<p><b>INTRODUCTION</b>Advanced hepatocellular carcinoma (HCC) has a dismal prognosis and is notoriously chemo-resistant. We conducted a Phase II prospective study to evaluate the activity and tolerability of gemcitabine and cisplatin in chemo-naïve advanced hepatocellular carcinoma. The trial considered a "no further interest" response rate of 10% and a target response rate of 30%. Utilising a Simon's minimax two-stage design with a type I error of 0.05 and power of 80%, 25 subjects would be required. Fifteen patients would be needed in stage 1 and if fewer than 2 responses were observed, the trial would be stopped and lack of efficacy claimed.</p><p><b>MATERIALS AND METHODS</b>Patients with advanced HCC, diagnosed based on histology or by World Health Organization (WHO) criteria, were administered gemcitabine 1000 mg/m2 and cisplatin 25 mg/m2 on day 1 and day 8 of a 21-day schedule. Assessment of response based on computer tomography was performed after every 2 cycles of chemotherapy.</p><p><b>RESULTS</b>The trial was stopped early due to a lack of efficacy. A total of 15 patients were accrued. Twelve patients were hepatitis B positive and the other 3 patients were negative for both hepatitis B and C. Only 1 patient had a history of prior heavy alcohol use. Two patients had Child C liver cirrhosis, 5 patients had Child B cirrhosis, and the remaining 8 patients had Child A cirrhosis. This regime was well tolerated and there was only 1 patient who experienced grade IV toxicities. Only 5 of 15 patients experienced grade III toxicities (nausea and emesis, 1 patient; anemia, 1 patient; thrombocytopenia, 1 patient; and neutropaenia, 2 patients). Only 1 patient experienced a partial response to the combination of gemcitabine and cisplatin. A further 3 patients experienced stable disease and 11 patients progressed on chemotherapy. The median time to progression was 6 weeks. The progression-free curve showed a sharp descent in the initial part of the study, suggesting that many patients had disease progression after enrollment. The median overall survival was 18 weeks.</p><p><b>CONCLUSION</b>The progression-free survival and overall survival in our study were extremely short. Based on the results of our phase 2 study, we are unable to recommend further studies utilising gemcitabine and cisplatin combination in patients with advanced HCC.</p>

Inhibition of Akt pathway phosphorylation as a mechanism in the pathogenesis of functional intestinal obstruction in carcinomatosis peritonei

The purpose of this study was to confirm our hypothesis that the development of functional intestinal obstruction in carcinomatosis peritonei [CP] is related to cytokine-mediated inhibition of the Akt pathway and to investigate the phenomenon of relative adrenal insufficiency in CP. Human adrenocortical cells [NCI-H295R] were treated with serum derived from eight cancer patients who had intestinal obstruction and functional adrenal insufficiency. Serum from three normal healthy subjects and three who had CP but without intestinal obstruction or adrenal insufficiency were used as controls. The differential effects of serum on the treated cells were studied using Western blot analysis. Cortisol production of these treated cells was assayed with cortisol ELISA kits. Phosphorylation of Akt at Ser473 and Ser308 in cells was significantly reduced when treated with serum from patients with intestinal obstruction but not controls. Phosphorylation of PDK1 at Ser241, mTOR downstream targets like p70S6 at Thr421/Ser424 and Thr389, and lastly 4EBP-1 at Ser70 a downstream target of p70S6 was reduced by approximately 50%, 40%, and 70%, respectively. There was enhanced phosphorylation of elF4E an initiating factor in protein translation in cells treated with patient serum compared to controls. Cortisol synthesis was stimulated upon treatment with patient serum but not with control serum. Inhibition of Akt phosphorylation is a mechanism that could play a major role in the development of intestinal obstruction in carcinomatosis peritonei. The identification of the mediating cytokines will lead to the development of cogent targeted therapeutic strategies

Image-guided radiofrequency ablation of liver malignancies: experience at Singapore General Hospital

<p><b>UNLABELLED</b>The aim of this paper was to study the efficacy, side effects and complications of radiofrequency (RF) ablation of primary and metastatic liver malignancies.</p><p><b>MATERIALS AND METHODS</b>We retrospectively reviewed 57 patients (39 men, 18 women; mean age, 63 years; age range, 44 to 83 years) who underwent RF ablation for liver malignancies from January 2002 to December 2004. A total of 87 tumours were ablated - 71 (81.6%) hepatocellular carcinomas and 16 (18.4%) metastases (from primaries in the colon, stomach and pancreas). RF ablation was performed either percutaneously (n = 71) under conscious sedation or intraoperatively (n = 16) under general anaesthesia. Follow-up ranged from 1 month to 41 months (mean, 15.2) and included computed tomography (CT) 1 day, 1 month and 3 months after ablation, and half-yearly thereafter. Patients were observed for local tumour progression and for the emergence of new tumours.</p><p><b>RESULTS</b>Four patients with a total of 5 tumours were lost to follow-up. Of the remaining 82 tumours treated, complete ablation was attained in 66 tumours after a single procedure, giving a primary effectiveness rate of 80.5%. Seven (8.5%) required 2 procedures to achieve complete ablation, giving a secondary effectiveness rate of 89% after 2 ablations. One tumour (1.2%) required 3 procedures to achieve complete ablation. One tumour required 4 procedures to date, with the latest follow-up CT still demonstrating incomplete ablation. Two tumours (2.4%) had an initial RF ablation and subsequent transarterial chemoembolisation (TACE). One tumour had an initial RF ablation followed by 32Phosphorus-biosilicon (BrachySil) injection, the latter as part of a Phase IIA trial. One tumour required 2 RF ablations and a subsequent TACE. Lastly, 3 tumours received initial RF ablation but subsequent local tumour progression was not treated as the patients were deemed unfit for repeat ablation. No procedure-related deaths or major complications were encountered. Minor complications were reported in 2 patients (3.8%) - subcapsular haematoma and thermal injury to the adjacent gastric antrum, both not necessitating surgical intervention.</p><p><b>CONCLUSIONS</b>RF ablation is an effective, safe and relatively simple procedure for the treatment of unresectable liver malignancies.</p>