A PUBLICATION FOR
PRIMARY CARE PHYSICIANS
MCI (P) 118/03/2015
october-december 2015
Direct Access Endoscopy in TTSH Scan the QR code using your iPhone or smart phone to view GP BUZZ on the TTSH website or visit www.ttsh.com.sg/gp/.
hypothyroidism, diabetes mellitus, asthma
News
Community
MERS: What you
The GP BUZZ editorial team: Ms Jessie Tay Ms Evelyn Tan Ms Joyce Fu
should know
ADVISORY PANEL: Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Adjunct Assistant Professor Chong Yew Lam Dr Tan Kok Leong Dr Pauline Yong Ms Susan Niam Mr Yong Keng Kwang
GP Buzz is a magazine by Tan Tock Seng Hospital, designed by
We value your feedback on how we can enhance the content of GP Buzz. Please send in your comments and queries to gp@ttsh.com.sg. © All rights reserved. No part of this publication may be reproduced, stored in a database, retrieval system or transmitted in any form by any means without prior consent from the publisher. Although the publisher and author have exercised reasonable care in compiling and checking that the information is accurate at the time of publication, we shall not be held responsible in any manner whatsoever for any errors, omissions, inaccuracies, misprint and/or for any liability that results from the use (or misuse) of the information contained in this publication. All information and materials found in this publication are for purposes of information only and are not meant to substitute any advice provided by your own physician or other medical professionals. You should not use the information and materials found in this publication for the purpose of diagnosis or treatment of a health condition or disease or for the prescription of any medication. If you have or suspect that you have a medical problem, you should promptly consult your own physician and medical advisers.
By Dr Lee Tau Hong (Associate Consultant) Department of Infectious Diseases, Institute of Infectious Diseases & Epidemiology, Tan Tock Seng Hospital
New faces of STAR team 2015.
S
ingapore Patient Conference is back for the 3rd run on 30 October 2015! We’re casting the spotlight on caregivers through the theme ‘Caring for Caregivers’. The Conference lines up an inspiring list of speakers, together with activities on caregiving resources, and respite. Visit the website www.ttsh.com.sg/SPC2015 for more information. For the first time, an award event to recognise patients, caregivers and
groups who have made significant contributions to the healthcare industry has been launched. The inaugural Singapore Patient Action Awards ceremony will take place at the Singapore Patient Conference, with nominations open to all healthcare institutions in Singapore. A STAR is born. Tan Tock Seng Hospital (TTSH) established a Specialised Transfer and Acuity Response (STAR) team to transport inpatients to their clinical appointments within and out of the hospital. The STAR team comprises enrolled nurses and health assistants who are well trained to respond single-handedly in any emergency. The team is also involved in direct patient care, such as cannulation and venipuncture in the wards. With the inception of the STAR team, the nurses and healthcare professionals in the inpatient wards can dedicate more time to the care of other patients.
october - december 2015
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Express Your Wishes: They Matter!
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dvance Care Planning (ACP) is a process of communication with individuals to help them develop individualised care plans appropriate to their stage of illness, goals, values and beliefs. It fosters understanding and reflection, helping caregivers learn their loved ones’ care preferences during crisis situations. Through ACP, patients and their substitute decision-makers are better prepared and have a greater sense of control over their care. There is less emotional and decision-making burden, and conflict within the family. From 2012 to 2014, Tan Tock Seng Hospital (TTSH) saw the number of ACP referrals almost tripling, showing that more people recognise the importance of ACP. To date, over 1,000 TTSH patients have benefited from ACP facilitation and of the cases audited, more than 95% have seen their wishes honoured. Patients of TTSH who wish to make enquiries could call TTSH ACP Office at 6359 6410 (Weekdays, 8.30am to 5.30pm). Other patients may visit www.livingmatters.sg for more information on ACP.
“Dignity at the End of Life” Mandarin Forum
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s South Korea declares an end to its outbreak of Middle East Respiratory Syndrome (MERS), we can perhaps let out a small sigh of relief. Public interest and media coverage were up several notches in June because there is more travel between Singapore and South Korea compared to the Middle East, where MERS started in 2012. At Tan Tock Seng Hospital, infection control measures were ramped up as Prime Minister Lee Hsien Loong cautioned that Singapore might well see its first MERS case. As a healthcare provider, ask your patients about travel history. If you have travelled to a MERS-affected country, do watch out for fever and respiratory symptoms such as fever and cough within 14 days of return. With good infection control and vigilance, we can prevent MERS from causing an outbreak in Singapore.
n celebration of World Hospice and Palliative Care (WHPC) Day, the forum aims to increase awareness on palliative care and how planning for end-of-life care can help patients and their caregivers maximise a patient’s self-esteem, preserve their dignity and help them move on to lead fulfilling lives. Our healthcare professionals will share their expertise through a series of talks in Mandarin on Palliative Care, as well as on related topics such as Advanced Medical Directive (AMD), Advanced Care Planning (ACP) and the Lasting Power of Attorney (LPA). There will also be a bilingual exhibition to share patients’ stories and their care journeys.
Date: 31 October 2015 (Saturday) Time: 1.00pm - 5.00pm Venue: Tan Tock Seng Hospital, Level 1,Theatrette
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Community
Community
Direct Access
Endoscopy in TTSH
By Adjunct Assistant Professor Charles Vu (Senior Consultant) Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital
Direct Access (also known as Open Access) refers to the direct referral of a patient to medical services without prior need for formal consultation. In Tan Tock Seng Hospital (TTSH), Direct Access endoscopy services for colonoscopy and gastroscopy have been available to General Practitioners (GPs) since 2007.
G
P BUZZ spoke to Adj. Asst. Prof. Charles Vu, to understand how Direct Access could potentially enhance a patient’s healthcare journey and create more opportunities for TTSH to partner GPs to provide better care for their patients.
2. How will Direct Access benefit your patients? In addition to smoother coordination and continuation of patient care, patients could get the procedure or investigation done in a shorter time by obviating the need for outpatient consultation with a specialist. An investigation report is provided to the patient on same day and a report will also be sent to the referring GP.
Direct Access is not the only way we can improve the patient referral journey. “Front-loaded” investigations can also be done before seeing the specialist e.g. imaging of a joint is performed before seeing an Orthopaedic surgeon.
3. What roles do GPs play? What are some opportunities for Specialists and GPs to work together? In general, Direct Access patients will be referred back to their GPs for follow-up, unless a more complex finding e.g cancer, is diagnosed. For more complex conditions that require specialist care, we will take the initiative to continue the patient’s care, after discussing with the referring GP. There is a need for continuing dialogue with our GPs, to gauge their needs for Direct Access to other services and to improve our existing services.
CME (October 2015 – January 2016) TITLE
DATE / TIME
VENUE
REGISTRATION DETAILS
5th NNI EMG-AFTNeuromuscular Ultrasound Workshop
26 – 29 November 2015 8.30am to 5.30pm
TTSH Theatrette, Level 1
Contact: 6357 7163 or 6357 7640 Email: nni_secretariat@nni.com.sg
5th General Practitioners Office-based Aesthetic Workshop: Fundamentals and Concepts
16 January 2016 1.30pm – 4.45pm
TTSH Theatrette, Level 1
Email: facialplasticsurgery@ttsh.com.sg
1. How was Direct Access established in TTSH? Due to the increasing and ageing population, demand for healthcare has grown significantly, resulting in long wait times in the specialist outpatient clinics and more stress on the tertiary healthcare system. Direct Access service is useful in conditions in which GPs can manage at the primary care setting but do not have the facilities or expertise to do certain specific investigations or procedures. In TTSH, a set of screening process is in place to determine if patients are medically fit or suitable for the Direct Access procedure before it is performed.
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5th General Practitioners’ Office-based Aesthetic Workshop: Fundamentals and Concepts The Department of Otorhinolaryngology, in conjunction with the 5th Singapore Facial Plastic Surgery Course, is organising the 5th GP Office-Based Aesthetic Workshop. Chaired by Dr Dennis Chua, Consultant and Director of Facial Plastic Service, the workshop will focus on the fundamentals and concepts of non-invasive aesthetic procedures. The workshop’s minimal attendance is kept deliberate, for experts to answer any questions, coupled with a live demonstration on how best to perform procedures (such as Botox, Fillers and Lasers) safely and effectively. The efficacy of Micro-Botox, Chemical Brow Lift and non-surgical facelifts will be discussed as well. For registration, please email to facialplasticsurgery@ttsh.com.sg.
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Under TTSH’s Community Right Siting Programme (CRiSP), stable chronic patients from Specialist Outpatient Clinics may now be right-sited to CRiSP-enrolled General Practitioners (GPs). As of July 2015, CRiSP covers the following chronic conditions: 1. Diabetes 2. Hypertension 3. Lipid Disorders
4. Stroke 5. Asthma 6. Osteoarthritis
7. Benign Prostatic Hyperplasia 8. Parkinson’s Disease 9. Hypothyroidism
The following feature articles provide an update on the management of hypothyroidism, diabetes mellitus and asthma. If you would like to find out more about TTSH’s Community Right Siting Programme (CRiSP), please contact the following representatives from the Primary Care Partners Office (PCPO): Evelyn Tan (Ms) Senior Account Manager Email: Evelyn_SM_Tan@ttsh.com.sg
Jayne Tong (Ms) Account Manager Email: Jayne_LM_Tong@ttsh.com.sg
Management of
Hypothyroidism By Dr Chew Chee Kian (Associate Consultant) Department of Endocrinology, Tan Tock Seng Hospital
Hypothyroidism is the clinical syndrome caused by thyroid hormone deficiency, due to under-activity of the thyroid gland. It can result from a defect arising anywhere along the hypothalamic-pituitary-thyroid axis. Primary hypothyroidism (disease of the thyroid gland) accounts for the majority of cases. Central hypothyroidism, caused by decreased secretion of thyroid-stimulating hormones (TSH) from the anterior pituitary gland, or decreased secretion of thyrotropin-releasing hormones (TRH) from the hypothalamus, happens less often. 06
Causes of Hypothyroidism The cause of hypothyroidism should be identified in every patient because it is important in the acute and longterm management of the condition. Primary hypothyroidism might be transient – requiring no therapy, or it could be caused by a medication, and resolved when the offending drug is discontinued. Causes of primary hypothyroidism include: Hashimoto’s thyroiditis The most common cause of hypothyroidism. The incidence is five to eight times more common in women than with men. Thyroidectomy Radioactive therapy External neck irradiation Iodine deficiency or excess Medication such as lithium, amiodarone, tyroxine kinase inhibitors, interferon alpha and interleukin 2 Infiltrative diseases such as hemochromatosis, sarcoidosis, tuberculosis Transient hypothyroidism such as post-partum thyroiditis, subacute thyroiditis It is important to suspect and recognise central hypothyroidism as the management differs greatly from primary hypothyroidism. Causes of central hypothyroidism include: Mass lesions Pituitary surgery Radiation Infiltrative lesions Trauma Infarction
Clinical Features and Diagnosis The clinical manifestations of hypothyroidism are highly variable, depending on the age at onset, and the duration and severity of thyroid
hormone deficiency. Common symptoms of thyroid hormone deficiency includes fatigue, cold intolerance, weight gain, constipation, dry skin, myalgia, and menstrual irregularities. Physical examination findings may include a goiter in primary thyroid disease, bradycardia and a delayed relaxation phase of the deep tendon reflexes.
Due to the highly variable and non-specific clinical manifestations of hypothyroidism, the diagnosis is heavily reliant on laboratory tests. Primary hypothyroidism is characterised by a low serum free thyroxine (FT4) level, and a high serum thyroid stimulating hormone (TSH) level, whereas central hypothyroidism is characterised by a low serum FT4 level and a serum TSH level that is not appropriately elevated. More than 90% of patients with Hashimoto’s thyroiditis have elevated antibodies to thyroid peroxidase (anti-TPO) and thyroglobulin (TgAb).
Treatment of Primary Hypothyroidism This segment will focus on the management of primary hypothyroidism. In most patients, the treatment of hypothyroidism is life-long, unless the hypothyroidism is transient or reversible (drug induced). The aim of
treatment is to restore the euthyroid state with oral levothyroxine (LT4). It is important to know that the bioequivalence of the different brands of levothyroxine preparations differs. It is thus recommended to use the same preparation for treatment in a patient. If there is a change in preparation (e.g patient is discharged from hospital to primary care clinic), the thyroid function tests should be repeated in six weeks after changing preparations, to document that the results are still within the therapeutic target. Furthermore, the absorption and bioavailability of oral T4 is highly variable. In general, about 80% of an oral dose of LT4 is absorbed. LT4 should be taken on an empty stomach, ideally an hour before breakfast, for better absorption. It should not be taken with other medication that interferes with its absorption, such as bile acid resins, proton pump inhibitors, calcium carbonate, and ferrous sulfate. The average replacement dose of LT4 in adults is approximately 1.6 mcg/kg body weight per day, but the range of required doses is wide, varying from 50 to ≥200 mcg/day depending on the cause of the hypothyroidism. The initial dose can be the full anticipated dose (1.6 mcg/kg/day) in young, healthy patients, but older patients should be started on a lower dose (25 to 50 mcg daily) due to the higher risk of underlying cardiovascular disease. After the initiation of LT4, thyroid function tests should be repeated every six weeks for LT4 titration until the thyroid function tests achieve the therapeutic target. Once the proper maintenance dose is identified, a patient with stable thyroid function can be managed at the primary care setting safely in the long-term. The patient should be reviewed and thyroid function tests performed once every six months to a year. 07
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feature with caution in the elderly and patients with postural hypotension. 4. Glucagon-like peptide 1 (GLP-1) receptor agonist
Management of Diabetes Mellitus An Update By Dr Shariffah Nadia Aljunied (Resident Physician) Department of Endocrinology, Tan Tock Seng Hospital
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he past few years have brought on a new array of oral hypoglycaemic agents. For patients whose glycaemic control is suboptimal despite being on Metformin and Sulphonylureas, the following oral hypoglycaemic drugs may be considered as part of combination therapy. 1. Alpha-glucosidase inhibitors
Acarbose works by inhibiting intestinal Îą-glucosidase which slows intestinal carbohydrate digestion and absorption. Common gastrointestinal side effects such as flatulence and diarrhoea are observed. However, its efficacy of reduction in HbA1c is modest. 2. Dipeptidyl peptidase 4 (DPP-4) inhibitors
They work by inhibiting DPP-4 activity, thus increasing post-prandial active incretin concentrations. Raised incretin levels in turn inhibits glucagon release, leading to increased insulin 08
secretion, delayed gastric emptying and lowering of blood glucose. Potential side effects include joint pain and gastrointestinal symptoms such as nausea and diarrhoea. It should be avoided in patients at risk of pancreatitis. It also has a lower risk of hypoglycaemia and may be viable alternative to Sulphonylureas in the elderly or patients prone to hypoglycaemia. 3. Sodium-glucose cotransporter 2 (SGLT2) inhibitors
These class of agents work by inhibiting SGLT2 in the proximal nephron thus decreasing glucose reabsorption and leading to an increase in urinary glucose excretion. Other potential advantages include modest weight loss and blood pressure lowering. Genital fungal infections and urinary tract infections are potential side effects. In view of its diuretic effect, it should be used
Similar to DPP-4 inhibitors, it targets the incretin system. It increases insulin release while decreasing glucagon release and delays gastric emptying. GLP-1 agonists are administered via subcutaneous injection. It also has additional benefits of weight loss and lower risk of hypoglycaemia. Gastrointestinal side effects such as nausea and diarrhoea may occur although they are usually transient. Caution should be practised in patients with a history of pancreatitis. A new agent, which is a combination of longacting basal insulin and GLP-1 agonist, has recently been approved in Europe after showing promising clinical results. Metformin remains the optimal drug for monotherapy. In instances where Metformin is not tolerated or contraindicated, Sulphonylureas or one of the above agents may be used. However, if renal impairment is the reason it is avoided, the choices becomes more limited. In such cases, short-acting Sulphonylureas, DPP-4 inhibitors (renal adjusted dose) and/or insulin therapy, may be considered. As β-cell function deteriorates with increasing duration of diabetes, patients may still fail to reach glycaemic targets despite combination therapy with two or three oral agents. In this group of patients, insulin therapy is still required (either alone or in combination with oral agents) to optimise glucose control. Also, in patients with a high HbA1c and glucotoxicity at initial presentation, insulin should be instituted. The treatment of diabetes mellitus is highly individualised with many factors to be taken into consideration such as age, risk of hypoglycaemia, comorbidities and contraindications. As more and more drugs are introduced to the market, it is also imperative that prescribers should remain aware of the cost-benefit considerations for each patient.
Asthma Management and right siting to primary care By Dr Albert Lim (Senior Consultant) Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital
Asthma is a global problem, with more than 300 million sufferers and a growing global burden to health care systems. In Singapore, it is estimated that 140 000 individuals have asthma.
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sthma is a chronic condition. The ultimate aim is to control asthma and allow patients to continue their treatment in the community once it is stable. With the advent in knowledge and treatment, there was a paradigm shift of focus of care from acute institutions, such as hospitals, to primary heath care providers (PCP) (e.g. polyclinics and general practitioners (GPs) in the last decade. PCP ensures the disease is controlled with maintenance therapy and provides regular reviews, which are recommended by the national asthma education and prevention program expert panel. The asthma team at Tan Tock Seng Hospital (TTSH) works closely with patients and collaborates with the PCP in the heartlands of Singapore. Previous studies reported a high
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default rate of primary care follow ups for asthma patients discharged from acute health care services. The postulated reason was patients who were discharged from an acute setting were not linked to the PCP to follow-up on their care. Patients were given referral letters to PCP but were told to make their own follow-up arrangements. This resulted a high default rate in follow-up at the PCP, leading to poor asthma control and increases in usage of
Fitness
acute health care systems (e.g. Emergency Department). There was an urgent need to enhance and close the gaps on follow-up care with the PCP.
Do Your Workout
The asthma team at TTSH has a dedicated right-siting officer. The role of the officer is to link patients to the PCP and provide assistance to the patients on making follow-up appointments at the PCP closest to where the patients reside. The right siting officer will call and remind the patients of their appointment with the PCP. This model of care increases the attendance rate with PCP, facilitating the link between the acute health care service and the PCP, by providing a convenient and personalised service. It reinforces patients’ behavior in self-management and cost effective healthcare. The right-siting asthma service was introduced in 2012. Asthma patients discharged from the asthma specialist outpatient clinic, ward and Emergency Department have benefited from the service, with a success rate of more than 90% recorded for patients discharged to PCP.
Right! By Mr Ray Loh (Exercise Physiologist) Sports Medicine and Surgery Clinic, Tan Tock Seng Hospital
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our warm up is an important part of your exercise routine, but are you doing it right? A good warm up routine should look into various physiological parameters. It should increase blood flow, accelerate muscle metabolism, activate key muscles required for sports, prepare the nervous system, decrease intramuscular resistance, and increase your range of motion.
Points to note A commonly seen warm up routine comprises a slow jog, followed by some static stretching. It is thought that stretching can enhance performance and prevent injury. However, there is minimal evidence to show that stretching can reduce injuries and yield better exercise outcomes. In fact, stretching without adequate conditioning increases the risk of injury and affects muscle performance for up to one hour!
Try this out! The current recommended model of pre-exercise preparations are general warm ups, sports specific muscle activation, dynamic stretching and neural activation; and done in this order. This sequence of exercise preparation is often seen in professional level soccer matches. We can see athletes going through strengthening exercises with mini bands for muscle activation, followed by dynamic stretching to improve range of motion and finally sport specific drills for neural activation before the match starts.
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The next time you go for a run, try the following preparations in sequence: 1. 3 minutes of marching on the spot 2. 10 repetitions of bent knee donkey kicks, bent knee side leg raises and inverted reaches 3. 10 repetitions of dynamic stretch for hamstring, buttocks, thighs and torso rotation 4. 2 sets of 10 repetitions of high knee march, high knee skips and straight leg skips
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PEARL CLINICS AND SERVICES (NON-SUBSIDISED) GP Appointment Hotline: (65) 6359 6500
CLINIC B1B • Orthopaedic Surgery Tel: (65) 1800-73275-00 Email: ClinicB1B@ttsh.com.sg
• Rheumatology, Allergy and Immunology Tel: (65) 6889 4027 Email: Contact@ttsh.com.sg
CLINIC 2B • Gastroenterology and Hepatology • General Surgery • Urology Tel: (65) 1800-73275-00 Email: Clinic2B@ttsh.com.sg
CLINIC 4B • Diabetes and Endocrinology • General Medicine • Haematology • Medical Oncology • Psychological Medicine • Psychological Services • Renal Medicine • Respiratory and Critical Care Medicine Tel: (65) 1800-73275-00 Email: Clinic4B@ttsh.com.sg
CLINIC 6B • Complementary Integrative Medicine
MULTI-DISCIPLINARY SPECIALIST CARE
Tel: (65) 6889 4628 Email: Clinic6B@ttsh.com.sg
• Dental Tel: (65) 6889 4627 Email: Clinic6B@ttsh.com.sg
WELLNESS SERVICES • Health Enrichment Centre
TTSH PEARL’s suite of clinics and services is guided by the four pillars of care through Evidence Care, Destination Care, Team Care and Personalised Care. We remain committed to delivering a higher level of patient care as We Value Our Patients Most. For the full range of services in Tan Tock Seng Hospital, please visit our website at www.ttsh.com.sg.
Tel: (65) 1800-73275-00 Email: HEC@ttsh.com.sg
• Travellers’ Health and Vaccination Clinic Tel: (65) 6357 2222 Email: THVC@ttsh.com.sg
PEARL LIAISON CENTRE (PLC) Tel: (65) 6357 1590 Email: PLC@ttsh.com.sg