Cognition and reflection on the "lateral ligament of rectum" / 中华胃肠外科杂志

As total mesorectal excision (TME) for rectal cancer is widely carried out in China, lateral ligament of rectum, as an important anatomical structure of the lateral rectum with certain anatomical value and clinical significance, has been the focus of attention. In this paper, by comparing and analyzing the characteristics about ligaments of the abdomen and pelvis, reviewing the membrane anatomy and the theory of primitive gut rotation, and combining clinical observations and histological studies, the author came to a conclusion that lateral ligament of rectum does not exist, but is only a relatively dense space on the rectal side accompanied by numerous tiny nerve plexuses and small blood vessels penetrating through it.

Metformin use in patients with type 2 diabetes mellitus and chronic kidney disease: An evidence-based review

INTRODUCTION@#Practice guidelines advise caution on the use of metformin in patients with type 2 diabetes mellitus with chronic kidney disease (CKD). This review aims to examine the evidence for the benefits and risks of metformin use in patients with T2DM and CKD.@*METHODS@#The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and PubMed were searched; the references of selected papers were hand searched. Systematic reviews, randomised controlled trials, cohort studies, case series and case-control studies were included. The full text of selected articles was reviewed. The outcomes studied were all-cause mortality, cardiovascular complications, lactic acidosis and worsening of renal function. Recommendations were graded according to the Scottish Intercollegiate Guidelines Network system.@*RESULTS@#A total of 139 unique articles were identified, 14 of which met the inclusion criteria and were selected for full-text review. Four cohort studies reported an association between metformin use and improved all-cause mortality in CKD stage 4 and better. Two cohort studies reported improved cardiovascular outcomes with metformin use. Four cohort studies, 1 case series and 1 case-control study reported no significant association between metformin use and an increased risk of lactic acidosis in CKD. There is a moderate level of evidence to support reduced mortality, improved cardiovascular outcomes and a low risk of lactic acidosis with metformin use in patients with T2DM and with CKD stage 4 and above.@*CONCLUSION@#Existing recommendations to restrict metformin use in diabetes patients with CKD need to be reviewed in light of emerging evidence supporting its overall benefits in these patients.

National experts consensus on tracheotomy and intubation for burn patients (2018 version) / 中华烧伤杂志

Airway edema, stenosis, obstruction and even asphyxia are easy to occur in patients with extensive burn, deep burn of head, face, and neck area, inhalation injuries, etc., which threaten life. Timely tracheotomy and intubation is an important treatment measure, but lack of knowledge and improper handling in some hospitals resulted in airway obstruction. The technique of percutaneous tracheotomy and intubation provides convenience for emergency treatment of critical burns and mass burn. The Burn and Trauma Branch of Chinese Geriatrics Society organized some experts in China to discuss the indications, timing, methods, extubation, and precautions of tracheotomy and intubation for burn patients. The (2018 ) .

National experts consensus on tracheotomy and intubation for burn patients (2018 version) / 中华烧伤杂志

Airway edema, stenosis, obstruction and even asphyxia are easy to occur in patients with extensive burn, deep burn of head, face, and neck area, inhalation injuries, etc., which threaten life. Timely tracheotomy and intubation is an important treatment measure, but lack of knowledge and improper handling in some hospitals resulted in airway obstruction. The technique of percutaneous tracheotomy and intubation provides convenience for emergency treatment of critical burns and mass burn. The Chinese Geriatrics Society organized some experts in China to discuss the indications, timing, methods, extubation, and precautions of tracheotomy and intubation for burn patients. The (2018 ) .

Evaluation of antiviral activities of Houttuynia cordata Thunb. extract, quercetin, quercetrin and cinanserin on murine coronavirus and dengue virus infection

Objective: To evaluate the in vitro activities of the ethyl acetate (EA) fraction of Houttuynia cordata (H. cordata) Thunb. (Saururaceae) and three of its constituent flavonoids (quercetin, quercitrin and rutin) against murine coronavirus and dengue virus (DENV). Methods: The antiviral activities of various concentrations of the EA fraction of H. cordata and flavonoids were assessed using virus neutralization tests against mouse hepatitis virus (MHV) and DENV type 2 (DENV-2). Cinanserin hydrochloride was also tested against MHV. The EA fraction of H. cordata was tested for acute oral toxicity in C57BL/6 mice. Results: The EA fraction of H. cordata inhibited viral infectivity up to 6 d. Cinanserin hydrochloride was able to inhibit MHV for only 2 d. The 50% inhibitory concentrations (IC

Risk Factors for Severe Adenovirus Infection in Children during an Outbreak in Singapore

<p><b>BACKGROUND</b>Human adenoviruses (HAdVs) can cause a variety of human illnesses, with associated temporal and geographic changes in disease incidence. We report the emergence of an outbreak of HAdV infections in Singapore, presumably caused by a change of the predominating type to HAdV-7. We examined the clinical features of children admitted with HAdV infection to 1 institution and the risk factors for severe infection.</p><p><b>MATERIALS AND METHODS</b>This is a retrospective case-control study of all HAdV-infected children admitted during weeks 1 to 19 in 2013, as identified from laboratory records. A descriptive retrospective analysis of epidemiology, clinical data and the outcome of these children was also performed. Patients with severe infections were defined as cases, those with non-severe infections as controls, and the 2 groups were compared to find possible independent risk factors.</p><p><b>RESULTS</b>Eighty-five patients with HAdV infection were studied, including 11 (12.9%) cases and 74 (87.1%) controls. Binary logistic regression showed that cases were more likely to be <2 years old (adjusted OR 10.6, 95% CI, 1.8 to 63.2) and to have significant comorbidities (adjusted OR 19.9, 95% CI, 3.4 to 116.1) compared to controls. The predominant type in 2013 was HAdV-7, which differed from 2011 and 2012, when HAdV-3 was more common. There was a trend towards pneumonia being more common in patients infected with HAdV-7 than in patients infected with other types, although this did not reach statistical significance (OR 2.8, 95% CI, 0.9 to 8.7).</p><p><b>CONCLUSION</b>The emergence of HAdV-7 in a population where other HAdV types had circulated previously may have caused the outbreak in Singapore, and this was associated with more serious infections in children. Young age (<2 years) and significant comorbidities were associated with more severe HAdV infection.</p>

Wake-up Stroke and Onset-to-door Duration Delays: Potential Future Indications for Reperfusion Therapy

<p><b>INTRODUCTION</b>There is limited utilisation of acute stroke reperfusion treatments which have narrow therapeutic windows, with delayed hospital presentation being a major limiting factor in Singapore. Most patients who wake up with symptoms are ineligible for reperfusion treatments as duration from onset time is not known. We studied the profile of wake-up strokes, onset-to-door duration and their associated factors among ischaemic stroke patients in the context of potential new treatments.</p><p><b>MATERIALS AND METHODS</b>This is an observational study of consecutive ischaemic stroke patients presenting within 2 weeks of symptom onset to the Singapore General Hospital in 2012.</p><p><b>RESULTS</b>Of the 642 ischaemic stroke patients studied, 33% of the cases were wake-up strokes [median age 64 years, 88%<80 years; median NIHSS score 4, 98%<20]. The median onset-to-door duration was 14.3 hours (Interquartile range, 4.8 to 38.2 hours), 20% of them arrived <3.5 hours (considering eligibility for intravenous alteplase in the proven 4.5 hours window accounting for a one hour door-to-needle duration), 14%: ≥3.5 to <8 hours, 11%: ≥8 to <12 hours, and 56%: ≥12 hours. Most patients with known stroke risk factors including atrial fibrillation (66%), hypertension (78%) and prior stroke (81%) presented beyond 3.5 hours.</p><p><b>CONCLUSION</b>The one- third proportion of wake-up stroke in this cohort and low prevalence of relative contraindications suggest this is a promising group for emerging thrombolysis indications. With the majority of patients presenting after 8 hours, widening of the therapeutic window with new potential reperfusion treatments would not appreciably increase treatment utilisation. This study reaffirms the urgent need for public education to improve stroke awareness in Singapore.</p>

Postoperated hip fracture rehabilitation effectiveness and efficiency in a community hospital

<p><b>INTRODUCTION</b>This study aims to determine the inpatient rehabilitation effectiveness (REs) and rehabilitation efficiency (REy) of hip fracture in a Singapore community hospital (CH), its association with socio-demographic variables, medical comorbidities and admission Shah-modified Barthel Index (BI) score as well as change in independent ambulation from discharge to 4 months later.</p><p><b>MATERIALS AND METHODS</b>A retrospective cohort study using data manually extracted from medical records of all patients who had hip fracture within 90 days and admitted to a CH after the operation for rehabilitation. Multiple linear regressions are used to identify independent predictors of REs and REy.</p><p><b>RESULTS</b>The mean REs was 40.4% (95% Confidence Interval (CI), 36.7 to 44.0). The independent predictors of poorer REs on multivariate analysis were older age, Malay (vs non-Malay) patients, fewer numbers of rehabilitative therapy sessions and dementia. The mean REy was 0.41 units per day [CI, 0.36 to 0.46]. The independent predictors of poorer REy on multivariate analysis were higher admission BI and being non-hypertensive patient. The prevalence of independent ambulation improved from 78.9% at the discharge to 88.3% 4 months later.</p><p><b>CONCLUSION</b>CH inpatient rehabilitative therapy showed REs 40.4% and REy of 0.41 units per day and the optimum number of rehabilitative therapy session was from 28 to 41 in terms of rehabilitation effectiveness and the maximum rehabilitation efficiency was seen in those doing 14 to 27 sessions of rehabilitative therapy. The study also showed improvement in BI at discharge and improvement in the independent ambulation 4 months after discharge from the CH.</p>

Clinical outcome and cost comparison between laparoscopic and open appendicectomy

<p><b>INTRODUCTION</b>Local data comparing laparoscopic appendicectomy (LA) and open appendicectomy (OA) is lacking. We perform a cost and outcome comparison between LA and OA.</p><p><b>MATERIALS AND METHODS</b>A retrospective review of all appendicectomies performed for suspected appendicitis from July 2010 to December 2010 was conducted. Patient demographics, duration of surgery, complication rates, total cost of stay (COS) and length of stay (LOS) were compared between LA and OA.</p><p><b>RESULTS</b>A total of 198 patients underwent appendicectomy during the duration of study; 82 LA and 116 OA. There were 115 males (58.1%) and 83 females (41.9%). Median age was 33 years. Patients who underwent LA were significantly younger (P <0.001) with a greater proportion of females (P <0.0001) and were more likely to be negative appendicectomies (18.3% vs. 6.9%, P = 0.023). Duration of surgery was significantly longer in LA patients (86 min vs. 74 min, P = 0.003). LOS in the LA group was shorter by 1.3 days compared to OA (2.0 days vs. 3.3 days, P <0.0001). The differences in operative duration and LOS between LA and OA remained significant on multivariate analysis (P = 0.001 and P = 0.008, respectively). The COS (P = 0.359), wound infection rates (P = 0.528) and complication rates (P = 0.131) were not significantly different between the 2 groups.</p><p><b>CONCLUSION</b>LA is associated with a shorter LOS while its cost is equivalent to OA. From the perspective of utilisation of healthcare resources, LA appears to be superior.</p>

Ficolin-A enhances inhibition of the C-terminal 19 kDa region ofmerozoite surface protein-1 of plasmodium berghei using test in vivo

Malaria remains a serious public health problem with significant morbidity and mortality. This study was conducted to identify whether ficolin-A could play an active role of against malaria infection. The function of ficolin-A was analyzed in mouse model. The open reading frame of ficolin-A was cloned from the liver of new born C57BL/6 mice by RT-PCR and then inserted into the expression vector of eukaryon to construct p VAX1-ficolin-A plasmid. Meanwhile, the open reading frame of the 19-kDa fragment of merozoite surface protein-1 of Plasmodium berghei [MSP1[19]] was cloned and then the expression vector of eukaryon, p VAX1- MSP1[19] was constructed. Both recombinant vectors were used in the mouse model of infection by Plasmodium berghei. p VAX 1-ficolin-A alone could not significantly suppress parasite density and prolong survival time of infection mice; however, when injected p VAX1-ficolin-A and p VAX1- MSP1[19] together, the percent of invasion by Plasmodium was decreased [from 43.78% to 22.23% at 10 day after infection, compared to vector] and the survival time was prolonged significantly in the infection mouse model [P=0.01]. Ficolin-A can enhance the immunoprotection of MSP1[19], it implies ficolin-A may be used as immunoenhancer in the study of vaccine defending malaria

Demographics and behaviour of patients with contact lens-related infectious keratitis in singapore

<p><b>INTRODUCTION</b>This study aims to identify the demographics and hygiene behaviours associated with contact lens (CL)-related microbial keratitis in Singapore.</p><p><b>MATERIALS AND METHODS</b>The hygiene and social behaviours of lens wearers presenting with infectious keratitis in Singapore were examined using an externally validated questionnaire. Fifty-eight consecutive lens wearers who presented with infectious keratitis at Singapore National Eye Centre were surveyed using a self-administered questionnaire. Patients' demographics, CL-related behaviour, attitude to aftercare visits and microbial study results were collected and analysed.</p><p><b>RESULTS</b>More than half (55%) of the patients surveyed were female, and the average age of the participants was 25.7 ± 6.4 years. Ninety-six percent of participants used soft CL, with the majority wearing monthly disposable lenses (74.1%). Myopia was the commonest reason for use of CL. CL overwear (81%), sleeping (50.9%) and swimming (33%) with their CL were the major non-compliant behaviours discovered. When encountered with eye discomfort as a result of lens-related infective keratitis, 83% of patients sought the advice of general medical practitioners prior to presentation at the hospital. Many (59%) patients have encountered media coverage but only 24% had any behavioural change as a result. Many patients relied on the recommendations of eyecare practitioners when purchasing disinfecting solutions (26%) and other hygiene practices. Pseudomonas Aeruginosa was the most common organism grown in 22.4% of patients while 47% of patients were culture-negative.</p><p><b>CONCLUSION</b>Inadequate lens cleaning, poor aftercare, sleeping and swimming with CL were the major non-compliant behaviours among participants, and these are significant factors when assessing risks in acquiring CL-related infectious keratitis. General eyecare practitioners are the first-line of contact in patients presenting with keratitis symptoms and play an important role in emphasising the need for regular aftercare and good hygiene practices to CL wearers.</p>

Intra-arterial CT angiography visualization of arterial supply to inferior vena cava tumor thrombus prior to radioembolization of hepatocellular carcinoma

Unresectable hepatocellular carcinoma has a high frequency of vascular invasion and arterial parasitization. Trans-arterial radioembolization using yttrium-90 [Y90] microspheres is a possible treatment option. Paramount to its success is the meticulous angiographic interrogation of tumor feeding arteries and extrahepatic supply. We describe a patient with tumor invasion of the inferior vena cava with arterial supply from the right inferior phrenic artery, which was exquisitely visualized using intra-arterial computed tomographic angiography [IACTA] during the planning technetium-99m macro aggregated albumin phase. This technique was useful in planning which artery to administer Y90 microspheres into for maximal brachytherapy. Although patient outcome was poor due to significant arterio-portal shunting, we believe that IACTA is a useful adjunct to conventional digital subtraction angiography in planning radioembolization therapy

A ten-year retrospective study on livedo vasculopathy in Asian patients

<p><b>INTRODUCTION</b>This study aims to analyse the clinico-epidemiological characteristics of Asian patients diagnosed with livedo vasculopathy (LV).</p><p><b>MATERIALS AND METHODS</b>We performed a retrospective analysis of all patients diagnosed with LV from 1997 to 2007 at our centre.</p><p><b>RESULTS</b>Seventy patients were diagnosed with LV with a mean age of 39 years, female: male ratio of 3:1 and no racial predilection. Most cases remained purely cutaneous, presenting with painful leg ulcers and atrophie blanche. Peripheral neuropathy was the only extra-cutaneous complication (9%). In patients who were screened, associations included hepatitis B (7%) and hepatitis C (4%), positive anti-nuclear antibody (14%), positive anti-myeloperoxidase antibody (5%), positive anti-cardiolipin antibodies (7%) and positive lupus anticoagulant (2%). In 49 patients who achieved remission, 55% required combination therapy, most commonly with colchicine, pentoxifylline and prednisolone. In those treated successfully with monotherapy, colchicine was effective in 59% followed by prednisolone (17.5%), pentoxifylline (17.5%) and aspirin (6%). Mean follow-up period was 50 months.</p><p><b>CONCLUSION</b>LV in Asian patients is a high morbidity, chronic relapsing ulcerative skin condition. Most patients require induction combination therapy for remission. As further evidence emerges to support a procoagulant pathogenesis, a standardised protocol is needed to investigate for prothrombotic disorders during diagnosis.</p>

The health-related quality of life of junior doctors

<p><b>INTRODUCTION</b>It is reported that junior doctors experience a large amount of work related stress and fatigue which has detrimental effects on their well-being and patient safety. We seek to determine the health-related quality of life (HR-QoL) of junior doctors using the Short Form 36 Health Survey (SF-36) and compare their HR-QoL with that of populations of norms and senior doctors.</p><p><b>MATERIALS AND METHODS</b>The SF-36v2 (Singapore version) was self-administered to a convenience sample of 213 doctors from a large tertiary teaching hospital. Junior doctors were defined as those less than 30 years of age (48%). Adjusted normative values were derived from the SF-36 Norms for the Singapore General Population Calculator for all 8 scales. The mean score differences between junior doctors and their adjusted normative values as well as that for senior doctors were computed and contrasted.</p><p><b>RESULTS</b>One hundred and eighty-fi ve doctors fully responded. Their mean age was 33.6 years (SD 8.1). Also, 45% were female and 88% were Chinese. Junior doctors had lower scores than senior doctors in all scales except Physical Functioning. After adjustment for gender and race, junior doctors had statistically significant lower Mental Health scores than senior doctors (P = 0.01). Compared with the normative population, junior doctors scored lower in all domains except for Physical Functioning. For Vitality, the difference is - 14.9.</p><p><b>CONCLUSION</b>Junior doctors have poorer mental health scores compared to senior doctors. Also, the lower vitality scores suggest that junior doctors are more likely to be fatigued than their normative population. More studies and efforts will be needed to identify factors that affect the quality of life in junior doctors and to evaluate the most appropriate measures to improve the efficiency of their work.</p>

Bilateral Adrenal Histoplasmosis: Endoscopic Ultrasound – guided Fine Needle Aspiration as a Method of Diagnosis and Assessment

We report a case of a healthy 78 -year- old indonesian man who presented with chronic weight loss, poor appetite and lethargy. CT abdomen showed bilateral adrenal masses. EUS – guided FNA was performed on the left adrenal gland. Histopathology report was Histoplasma Capsulatum. He recovered well with antifungal treatment without any complication. In this case, we found that the role of EUS – guided FNA was not only limited to diagnosis but also helped in the prognosis of the disease since the method was able to assess the general anatomy of the adrenal gland better than other imaging modalities due to its close proximity and direct visualization.

Pandemic (H1N1) 2009: clinical and laboratory findings of the first fifty cases in Singapore

<p><b>INTRODUCTION</b>Since the fi rst imported case on 26 May 2009, pandemic (H1N1) 2009 has spread from travellers and has resulted in sustained community transmission. Singapore began with a strict containment policy where all suspected and confirmed cases of pandemic (H1N1) 2009 were admitted for testing. We describe here the clinical and laboratory characteristics of the fi rst 50 adult cases with confirmed pandemic (H1N1) 2009.</p><p><b>MATERIALS AND METHODS</b>A review was conducted of medical notes of adult patients with confirmed pandemic (H1N1) 2009 by polymerase chain reaction assay from combined nasal and throat swabs admitted to the Communicable Disease Centre, Tan Tock Seng Hospital.</p><p><b>RESULTS</b>From 26 May to 18 June 2009, 50 patients with a median age of 27 years old were admitted at a median of 3 days from illness onset. Half were male and all were travellers arriving in Singapore. Non-Singaporean citizens (38%) and other ethnic groups (40%) were over-represented. History of fever was reported in 90% and respiratory symptoms in 92%. Gastrointestinal symptoms were uncommon, present in 4% only. Temperatures on presentation of >or=38.0 degrees C, >or=37.8 degrees C and >or=37.5 degrees C were present in 48%, 56% and 76%, respectively. Only 46% of patients met the United States Centers for Disease Control and Prevention (US CDC) case definition of influenza-like illness (ILI). Clinical and laboratory findings were unremarkable for the majority. All cases were treated with oseltamivir and had uncomplicated recovery.</p><p><b>CONCLUSION</b>Pandemic (H1N1) 2009 had mild clinical and laboratory findings in immunocompetent patients. Use of the US CDC ILI criteria alone would have detected less than half of confirmed cases.</p>

An 11-year review of dermatomyositis in Asian patients

<p><b>INTRODUCTION</b>Dermatomyositis (DM) is a multisystem inflammatory disease with a strong association with malignancy. We aimed to describe a series of Asian patients with DM and identify any significant clinical factors associated with malignancy.</p><p><b>MATERIALS AND METHODS</b>This was a retrospective review of a multi-racial cohort of 69 Asian patients diagnosed with DM over an 11-year period from 1996 to 2006.</p><p><b>RESULTS</b>Malignancy was detected in 15 out of 68 patients (22%), the most common of which was nasopharyngeal carcinoma (7 cases). Compared to the non-malignancy group, the malignancy-associated group was older and had more male patients. There were no statistically significant clinical, serological or laboratory factors associated with a higher risk of malignancy.</p><p><b>CONCLUSION</b>This study highlights the importance of ongoing malignancy screening especially for nasopharyngeal carcinoma in Asian patients with DM.</p>

An audit study of the sensitivity and specificity of ultrasound, fine needle aspiration cytology and frozen section in the evaluation of thyroid malignancies in a tertiary institution

<p><b>INTRODUCTION</b>The aim of this study was to conduct an audit of the sensitivity and specificity of ultrasound, fi ne needle aspiration cytology (FNAC) and frozen section in the evaluation of thyroid malignancies in our practice.</p><p><b>MATERIALS AND METHODS</b>The medical records of all the patients who underwent thyroid surgery in a tertiary institution's General Surgery Department between January 2005 and December 2007 were retrospectively reviewed using a standardised data collection template. Results of the ultrasounds, FNACs and frozen sections were compared with the fi nal histological diagnosis.</p><p><b>RESULTS</b>A total of 112 patients underwent thyroid surgery in the 3-year study period. Thyroid malignancy constituted 34 (30%) of all patients who underwent thyroid surgery. The most popular diagnostic tools used were ultrasound (81%), FNAC (69%) and frozen section (59%). The sensitivity of ultrasound, FNAC and frozen section were 41.4%, 86.4% and 68.8%, respectively. FNAC was shown to be a superior diagnostic test in detecting malignancy compared to ultrasound. FNAC was able to pick up 53% of thyroid cancers missed by ultrasound. Frozen section was able to pick up 33% of thyroid cancers that were missed by both ultrasound and FNAC.</p><p><b>CONCLUSION</b>FNAC is the most reliable tool in detecting malignancies and ought to form the mainstay for investigation of thyroid nodules. The utilisation of ultrasonographic features in the evaluation of thyroid nodules might not necessary improve the detection rate of thyroid malignancy. Frozen section helps to improve the detection rate of thyroid malignancy but further studies into its cost-effectiveness ought to be performed.</p>

Paradigm shifts in corneal transplantation

Conventional corneal transplantation, in the form of penetrating keratoplasty (PK), involves full-thickness replacement of the cornea, and is a highly successful procedure. However, the cornea is anatomically a multi-layered structure. Pathology may only affect individual layers of the cornea, hence selective lamellar surgical replacement of only the diseased corneal layers whilst retaining unaffected layers represents a new paradigm shift in the field. Recent advancements in surgical techniques and instrumentation have resulted in several forms of manual, microkeratome and femto-second laser-assisted lamellar transplantation procedures. Anterior lamellar keratoplasty (ALK) aims at replacing only diseased or scarred corneal stroma, whilst retaining the unaffected corneal endothelial layer, thus obviating the risk of endothelial allograft rejection. Posterior lamellar keratoplasty/endothelial keratoplasty (PLK/EK) involves the replacement of the dysfunctional endothelial cell layer only. Whilst significant technical and surgical challenges are involved in performing lamellar micro-dissection of a tissue which is only 0.5 mm thick, the benefits of a more controlled surgical procedure and improved graft survival rates have resulted in a shift away from conventional PK. This review details the current advances in emerging lamellar corneal surgical procedures and highlights the main advantages and disadvantages of these new lamellar corneal procedures.

Consequences of right siting of endocrinology patients--a financial and caseload simulation

<p><b>INTRODUCTION</b>Right siting has been actively advocated to mitigate rising healthcare costs as well as to free up tertiary resources for the provision of care to more complex patients, research and education. There are, however, concerns that in a block budget setting right siting will reduce patient volumes, thus impacting on subsequent funding allocations and also patient revenues. We sought to determine through modelling and simulation the financial and volume impacts of right siting of endocrinology outpatients in a large tertiary hospital in Singapore.</p><p><b>MATERIALS AND METHODS</b>Data were collected prospectively on patient casemix including complexity (complex defined as requiring specialist care), time required for consultations and revenues garnered. The data were used to simulate 2 scenarios: right siting of all simple cases with freed up resources directed to research and teaching (research scenario) and right siting of all simple cases with replacement by complex cases (service scenario).</p><p><b>RESULTS</b>The department sees an estimated 33,000 outpatients per year with a total annual outpatient revenue of $8.6 million. The research scenario would see a decline in patient volume to 11,880 cases per year which would result in a corresponding decrease in revenue of $5 million and freeing up of 2.8 hours/ week for each staff. The service scenario yields a drop in patient volume of 9500 per annum and a drop in revenue of $1.9 million.</p><p><b>CONCLUSION</b>Right siting reduces tertiary care patient volumes and revenues and may discourage right siting efforts. A viable business model for the tertiary institutions is needed to facilitate support for right siting.</p>