MEDICAL ETHICS IN THE CONTEXT OF VACCINATIONS

Prevention of disease is one of the key functions ofprimary care. Vaccines have earned their place inpreventing communicable diseases. The rate of uptake ofvaccines does not always match with knowledge.There are barriers which the healthcare professionalsneed to address. In the new era of IT, innovation andpolicy change, many ideas can be pursued to improvevaccination uptake in the community.There is a group of our population who will need ourspecial attention to vaccinate. They are the healthcareworkers, caregivers, the foreign domestic helpers, theimmunocompromised, and the pregnant mothers.There are many areas we need to work on to improve ourvaccination rate. Primary Care Research will provide theevidence and guide the refinement of these programmes.

Managing Recurrent Urinary Tract Infections in Primary Care - Can We Do Better?

A middle-aged lady was treated and followed up for recurrent urinary tract infections (UTI) with increasingly resistant organisms without documentation of interval resolution of infection by negative urine cultures. We discuss the events following the diagnosis of her fourth urinary tract infection. Referral for further evaluation of her urinary tract in view of recurrent UTI showed she had a bladder cancer. The investigation and management of recurrent UTI is reviewed. The link between bladder cancer and recurrent urinary tract infection is also explored.

Using the SBAR4 model for Management of a Patient with Complex Comorbidites in the Nursing home - A case study

Singapore faces a rapidly ageing population. By 2030, 19 percent of the population will be aged 65 years and older. The rise of the dual-income family, the decline of extended families, as well as the increase in age-related degenerative disorders consequent to increased expectancy of life, create challenging situations. Families which are manpower and expertise challenged will find it difficult to look after their elderly infirm at home, especially if the elderly members are frail, functionally dependent, and prone to falls. Such families will increasingly look to the nursing home as solutions. To aid in allocation to nursing homes, elderly patients are classified into 4 categories by the Resident Assessment Form: Category I patients are physically and mentally independent; Category II patients are semi-ambulant; Category III patients are wheelchair-bound or bed-bound; and Category IV are highly dependent. Categories I and II are primarily admitted to sheltered homes, while the limited nursing home places are mainly reserved for Category III and IV patients. The SBAR4 Tool is useful for clerking nursing home placement applications for placement decisions; for admission clerking; and for follow-up assessments and interventions. A case study of a patient who became bed-bound after hospitalisation for pneumonia due to deconditioning is used to illustrate the use of the SBAR4 Tool in a patient admitted to a nursing home, in implementation of recommendations, and in follow-up review of this patient a year later.

Cardiovascular Diseases: A 2016 Perspective

A review was made of the current literature on cardiovascular diseases. The following key findings were found: (1) CVDs need to be reduced in Singapore and worldwide. (2) CVD risk assessment tools are population specific – use the FRS modified score for Singapore. (3) New ideas about therapeutic lifestyle change as primary prevention are to take note of the individuals who fail in lifestyle change early and to direct them to alternative strategies; educating patients to reduce sitting time, increasing physical activity, and cardio-respiratory fitness is beneficial; higher protein diets help in creating weight loss and reducing weight regain; trans fats are associated with all-cause mortality, total CHD, and CHD mortality. (4) Paradigm shifts in secondary prevention are: statin treatment intensity recommended in the 2013 ACC/AHA cholesterol treatment guidelines; setting the blood pressure targets for patients with diabetes mellitus to be less than 140/90 mmHg; and noting that the older patient (beyond 70 to 74 years) with diabetes mellitus need to be managed as one would do so with a middle-aged patient. (5) The iCVH model as the 2020 impactful strategy for cardiovascular disease reduction for Americans provides food for thought as a potential Singapore strategy -- Promote in each patient especially the young patient, the simultaneous presence of optimal levels of 4 health behaviours (body mass index, physical activity, nonsmoking status, and diet quality) and reduction of 3 disease factors (total cholesterol, blood pressure, and fasting blood glucose).

Unsteadiness And Clumsiness — Could There Be Something More Than A Minor Stroke? A CASE STUDY TO REMEMBER

Unsteadiness and falls in the elderly are a common complaint in primary care and their incidence is expected to increase as the population ages. These patients are physiologically less able to withstand traumatic forces than their younger counterparts and are thus more prone to morbidity and mortality. Aside from intrinsic and extrinsic risk factors, there may be more sinister pathologies underlying these events. We report a case of an elderly gentleman who presented with unsteadiness, clumsiness and recurrent falls. The patient’s son brought to our attention subtle suspicious findings which eventually led to further evaluation. The patient was found to have had bilateral acute on chronic subdural haemorrhages with associated mass effect, underwent emergent decompression surgery and showed marked functional recovery. We review the incidence and outcomes of recurrent falls in the elderly, as well as the incidence, risk factors and varied presentations of subdural haemorrhage in the primary care setting. The case also reminds clinicians of the tendency to overlook and undermanage such patients with seemingly “minor” falls, and the value of family members’ inputs during consultation. It highlights the need for a high index of suspicion and the necessity of lower referral thresholds for further evaluation if indicated.

Henoch-Schönlein Purpura Presenting as Abdominal Pain before Purpura: A Case Report

Henoch-Schönlein purpura (HSP) is an acute, systemic immunoglobulin-medicated small-vessel vasculitis. It is the commonest vasculitis of childhood and is typically characterised by a tetrad of abdominal pain, arthritis, palpable purpura, and renal disease. All patients develop palpable purpura, while 84-90% develop arthritis, 57-58% develop abdominal pain, and 20-54% develop renal involvement. Gastrointestinal symptoms can be the first presenting complaint with the absence of initial purpura, leading to a delay in diagnosis.

Childhood Vaccination and Childhood Exanthems

The aim of vaccination is immunisation of the child against diseases to prevent mortality and morbidity from specific infections. Adequate immunization coverage is the prerequisite for creating herd immunity. The maintenance of these levels of population immunity requires continuous vigilance and changes to immunisation schedule in response to changing circumstances. Changes have been made over the years to optimise the immunisation of poliomyelitis, measles, mumps, rubella, and varicella. The introduction of hemophilus influenza type B vaccine and pneumococcal vaccine has reduced the incidence of these infections. Vaccination against human papillomavirus infection is being expanded to protect against cervical neoplasia in females and also anal intraepithelial neoplasia in both genders. Childhood exanthems due to viral and bacterial infections, as well as immunological causes continue to be important and the ability to recognise them is necessary.

Antimicrobial Resistance: Community and Hospital

Antimicrobial resistance (AMR) increases the morbidity, mortality and costs of treating infectious diseases. (Hawkey and Jones, 2009)1. The threat from resistant organisms is now a global problem, both in the hospital and to some extent in the community. The key drivers are: medical care complexity; widespread antimicrobial use in animal husbandry; antimicrobial contaminated food distribution; international travel, and food distribution of food contaminated with multidrug resistant organism. Strategies for infection control are: good understanding of what needs to be done, consistent application of infection control measures, use of “search and destroy” techniques; and effective antimicrobial stewardship. This paper reviews the current issues and potential solutions.

Emerging Infections and Role of Family Physician

Emerging infections may be defined as infectious diseases whose incidence in humans has increased in the past 2 decades or threatens to increase in the near future. They include: new infections resulting from changes or evolution of existing organisms; known infections spreading to new geographic areas or populations; previously unrecognised infections appearing in areas undergoing ecological transformation; and old infections re-emerging as a result of antimicrobial resistance in known agents. Emerging infections occur as the result of four groups of factors: novel zoonotic emergence factors; climate change; nonzoonotic emergence factors; and human practices. As frontline doctors, family physicians have at least five roles that they must perform well: participate in global and local surveillance of emerging infections; assist in societal learning; pandemic preparedness; legislation compliance; and antibiotic stewardship.

Health Conditions that Result in Disability in Adults

Under ElderShield, policyholders who are not able to perform at least 3 of the following ADLs, will be eligible for the insurance pay-outs. The conditions that result in disability in adults can be grouped into six: Disorders from childhood – sequelae of infections, injuries, and intellectual disorders reach adulthood and contribute to the pool of adults with disability; Injuries – spinal cord injuries in younger adults, traumatic brain injury in young and old, musculoskeletal injury in particular hip fractures in the older adult; Cardiovascular system disorders - strokes, ischaemic heart disease, peripheral vascular disease, retinopathy, nephropathy, and neuropathy; Degenerative musculoskeletal disorders – osteoarthritis of the knee, hip; cervical and lumbar spondylosis. Health conditions with a high potential to result in ADL disability are strokes, pelvic/femoral fractures, and osteoporosis. Prevention of strokes through attention to the high risk diseases (obesity, hypertension, diabetes, and hyperlipidemia). In the elderly, falls is an important cause of traumatic brain injury and musculoskeletal injury. Patients on hypnotic drugs, cough preparations and anti-platelets were more likely to fall. Appropriate usage of analgesics, especially paracetamol, to relieve pain may reduce falls.

Epidemiology and Overview of Disability

Persons with disabilities (PWDs) form an integral part of our community. The Ministry of Social and Family Development (MSF) in Singapore has developed the Enabling Masterplan (EMIC) 2012 – 2016 with the vision of an inclusive society where PWDs are enabled to participate fully. A life course and integrated approach is adopted in caring for such persons with the 4 pillars of early intervention; education and healthy lifestyle; employment; and adult care. Five cross cutting issues need to be addressed: caregiver support and transition management; manpower and technology; Transport; Public education; and accessibility. Family Physicians being the medical practitioners in the frontline of medical care are touchpoints in accessibility to healthcare services and benefit schemes for this group of people.

Obesity in Singapore: Prevention & Control

Obesity is increasing in prevalence in Singapore. This is part of a worldwide phenomenon. Action is being taken in Singapore to prevent and control obesity. Obesity is most commonly caused by a combination of excessive food energy intake, lack of physical activity, and genetic susceptibility. The basic strategy of obesity prevention and control however is quite straightforward and lies in achieving the caloric balance which is to reduce calorie intake and increase physical activity. To be effective however, obesity prevention and control requires multiple prevention and control interventions across the lifespan. There is a need for Health Promotion Board (HPB) to engage and mobilise various partners and stakeholders. Policies and programs have been customised in Singapore for different segments of the population and conducted at various settings – in schools, workplaces, healthcare institutions, and communities. The current efforts to prevent and control obesity in Singapore can be grouped into 5 areas: (1) Health promotion policies;(2) Promoting supportive environments through social programmes; (3) HPB collaborating with partners to promote healthy behaviour; (4)Empowering partners and individuals; and (5) Raising awareness through health education and communication.