ttsh gp buzz (jul - sep 2016)

CaTCh Them Before TheY

fall!UPdaTeS oN CommUNiTY

riGhT-SiTiNG ProGramme

A PuBLICATION FOr PrIMArY CArE PHYSICIANS

MCI (P) 194/04/2016

Scan the Qr code using your iPhone or smart phone to view

GP Buzz on the TTSHwebsite or visit

www.ttsh.com.sg/gp/.

JuLY-SEPTEMBEr 2016

DeeP VeiN tHrombosis awareNess saVes Life

The total duration for a full workout is about 20 mins. Know your own body - take short rests in between, when needed.

News

july - september 2016

The GP BUZZ ediTorial Team:Ms Evelyn TanMs Jayne Tong

adViSorY PaNel:Associate Professor Thomas Lew

Associate Professor Chia Sing JooAssociate Professor Chin Jing Jih

Adjunct Assistant Professor Chong Yew LamDr Tan Kok Leong

Dr Pauline YongMs 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 on GP Buzz. Please send in your

comments and queries to [email protected].

© 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.

About the Cover Page: Young Physicians Bringing healthcare to the Community

Over two weekends in July 2015, 125 young doctors who were commencing their residency training at National Healthcare Group (NHG) participated in a first-ever community training. The activity saw

them visiting senior citizens at community homes, senior activity centres, and flats in areas of Geylang Bahru, Ang Mo Kio and Thomson. This initiative forms part of the NHG residency curriculum, which provides doctors with a better grasp of patients in the context of their living environment and community. This July, the next batch of young doctors will visit and engage different communities as the initiative moves into its second year.

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Junior doctors and faculty members spending a half-day at the AWWA Community Home, in interaction with elderly residents. They spent their time understanding the conditions that the elderly live with, serving them food and helping to tidy their residences.

To provide you easy reference to our specialists in Tan Tock Seng Hospital, we have updated our

clinical directory:

• Named referrals are available for non-subsidised referrals only.

• For CHAS referrals, practitioners must not specify the name of the specialist at the Restructured Hospital on the CHAS referral form.

Scan this QR code to download the full copy of our specialist directory on TTSH website!

an Updated TTSh Specialist directory for 2016/17!

CommuNity

02

In conjunction with International World Alzheimer’s Day, TTSH Cognition and Memory Disorders

Service, Department of Geriatric Medicine and Alzheimer’s Disease Association (ADA) Singapore will come together and join Alzheimer’s organisations around the world to raise awareness about Alzheimer’s disease and dementia.

This year’s theme is “Remember Me”. Join us at the carnival this September to find out how to prevent dementia through healthy ageing and more importantly, to not forget about loved ones who are living with dementia, or those who may have passed away.

Scan this QR code or like IGA’s Facebook page (https://www.facebook.com/ttsh.iga/) to get updates on the event!

GP engagement workshop in September 2015.

Practical hands-on mapping exercise to equip primary care team with community and social services in the Central Regional Health System.

Reminiscence activity introduced at World Alzheimer’s Day to help persons with dementia connect with their past.

Developed and supported by TTSH Cognition and Memory Disorders Service, the Geriatric Integrated Network for Dementia (GerIND) works in

collaboration with Ang Mo Kio Polyclinic, Care for the Elderly Foundation’s (CEF) CODE 4 Home Care Programme, Project Dignity (by Palliative Medicine Department in collaboration with Dover Park Hospice and Temasek Cares), and a network of General Practitioners (GPs). The network aims to provide good, holistic dementia care across the cognition spectrum from healthy cognitive ageing to good dementia care and end-of-life care, through right-siting and community integration.

To ensure seamless integration between social and medical care, the network also partners AIC Community Intervention Teams (COMIT) to provide support for the GPs in co-managing patients living with Dementia in the community. This allows training and capability building for community-based healthcare professionals, enabling them to better care for patients with dementia in the community.

RemembeR me

betteR Dementia CaRe in the Community

CommuNity

Venous Thromboembolism — new righT-siTing Track

for Tan Tock seng hospiTal communiTy righT-siTing

programme (crisp)

Dear Partners and Friends,

This July, TTSH Community Right-Siting Programme (CRiSP) will mark two years of strategic partnership with General Practitioners (GP) to discharge and provide quality management to some 900 patients.

We are constantly looking to enhance this partnership, and have recently expanded CRiSP to include non-CHAS conditions, with Venous Thromboembolism (DVT) being the latest addition. Since 1 May 2016, TTSH has commenced right-siting of patients with DVT to our GP partners.

To support our GP partners in DVT care management, NHG Diagnostics will provide Warfarin monitoring (PT INR) at patient subsidised rates. TTSH Pharmacy will also dispense DVT drugs upon doctor’s prescription.

Learn more about useful DVT treatment techniques in our feature ‘Deep Vein Thrombosis Awareness Saves Life’ on page 4.

We thank you for your steady support and look forward to forging a closer partnership with you in this year.

Associate Professor John AbisheganadenClinical Programme Director – CRiSPHead and Senior ConsultantDepartment of Respiratory and Critical Care MedicineTan Tock Seng Hospital

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CRiSP is a partnership between TTSH and our GP partners, where stable Specialist Outpatient Clinics patients with selected chronic conditions are appropriately reviewed and managed at the GP setting.

CRiSP is seeking out GP partners in the following regions:

1. Aljunied2. Clementi

3. Eunos4. Geylang

5. Hougang6. Sembawang

7. Sengkang8. Yishun

if you would like to find out more about ttSh CRiSP, please contact:

Evelyn Tan (Ms)Senior account managerEmail: [email protected]

Jayne Tong (Ms)account managerEmail: [email protected]

In preparation for the upcoming Southern Hemisphere (SH) influenza surge, we strongly encourage enhanced vaccination rates among

our patients and staff. The SH 2016 influenza vaccine contains an A/California/7/2009 (H1N1)pdm09-like virus; an A/Hong Kong/4801/2014 (H3N2)-like virus and a B/Brisbane/60/2008-like virus.

Our recommendations are to vaccinate: 1. The elderly, children (6 months to 5 years),

pregnant women, patients of any age with co-morbidities, and travellers. Vaccine effectiveness is typically 70-90%, but may be lower among the elderly and those with co-morbidities.

2. Yourself and staff to protect yourself and your patients.

3. Those who received the 2015 SH vaccine with the 2016 SH vaccine.

Note: Patients who received the NH 2015-2016 vaccine do not need to be vaccinated with the SH 2016 vaccine, but we would encourage it for high-risk groups.

The Quadrivalent Influenza Vaccine (which also contains B/Phuket/3073/2013-like virus) has just been licensed in Singapore. Although there is a significant proportion of influenza B in the community (60% of all influenza cases in recent weeks); at this time there is no public health recommendation to use quadrivalent vaccine in preference to the trivalent vaccine.

maximiSe the tooLS avaiLabLe foR PRevention!by Dr sapna sadarangani, associate consultant, institute of infectious Diseases and epidemiology (iiDe)

Note: Patients who received the NH 2015-2016 vaccine do not need to be vaccinated with the SH 2016 vaccine, but we would encourage it for high-risk groups.

infLuenza:

by Dr Pankaj Handa, senior consultant, Department of general medicine, Tan Tock seng hospital

feature

Deep Vein Thrombosis (DVT) is a common cause of morbidity and mortality. Timely diagnosis and

prompt treatment can be lifesaving, as death may result from Pulmonary Embolism (PE).

Patients presenting at a primary care setting with unilateral swelling, pain and erythema of a lower limb should be viewed with high suspicion of DVT. However, the diagnosis of DVT can be very challenging as many skin and musculoskeletal disorders can mimic such presentation. The diagnosis of DVT rests on 3 pillars of (i) clinical suspicion, (ii) a blood test called d-dimer and (iii) compression ultrasound (CUS). While a clinical diagnosis can be difficult, an astute physician can judge the patient to be at low, moderate or high risk of DVT, based on Well’s score of pre-test probability. D-dimer is often

considered unreliable as a raised level can be seen in many other conditions and a normal value does not rule out DVT reliably. CUS has become the diagnostic modality of choice for the diagnosis of DVT.

Anticoagulation remains the cornerstone of DVT management. The anticoagulant agents available for use include (i) Heparin — unfractionated heparin (UFH) and low molecular weight heparin (LMWH), (ii) Vitamin K antagonists (VKA) — the all too familiar warfarin and (iii) Non-vitamin K antagonists (NOACs) which include direct thrombin inhibitors like dabigatran and factor Xa inhibitors like rivaroxaban and apixaban. Over the years there has been a shift in management of DVT in selected patients from inpatient to outpatient departments (OPD). The patients suitable for OPD treatment should be

DeeP VeiN tHrombosis

awareNess saVes LiVes

haemodynamically stable, have low bleeding risk and have normal renal function.

Traditional approach of treating DVT with warfarin, overlapped with a short course of LMWH till INR stabilises in target range of 2-3 is marred with difficulties in keeping INR in stable range over a longer period often due to various food and drug interactions.

NOACs have revolutionised the management of DVT and there is now the possibility for the complete management of selected patients with DVT to be undertaken by primary care. NOACs (rivaroxaban and apixaban) can be given in a fixed dose, without initial treatment with heparin. Rivaroxaban is given as 15 mg x twice a day for 3 weeks and 20 mg x once a day for the next 9 weeks. These drugs additionally enjoy minimal drug and food interactions and require no monitoring. However, NOACs are expensive, not safe in patients with compromised renal function and cannot be easily reversed in case of bleeding or at the time of urgent surgery.

Other therapies of DVT including thrombolysis (usually catheter directed) and throbectomy (surgical or percutaneous mechanical) are rarely employed in cases of massive illeofemoral thrombosis (Phlegmasia Cerulea Dolens) with risk of venous gangrene.

04

Doppler showing echogenic DVT with absent colour flow in the vein

CT scan showing saddle embolus main pulmonary artery

sent to Nurse Wai Cheng to educate on the use of his eyedrops because his intraocular pressure was poorly controlled. After seeing him, Nurse Wai Cheng came to see me and informed me that this patient had dementia and in spite of a 45-minute session, was still confused about how to use his eyedrops. This added information prompted me to consider glaucoma surgery for him so he no longer needed to instil glaucoma eyedrops; and his pressure has now improved. We often talk about treating the patient, not just the disease. I think this example aptly brings home the point. The introduction of the Glaucoma Nurse-Led Service has “closed the loop” in the glaucoma care we deliver, and brought about more holistic care for our patients in a tangible way.

since its inception in 2001, the NHG eye Institute has continued to address the increasing demand for eye care services, and areas of its research and training. It incorporates tan tock seng Hospital’s Department of Ophthalmology as its flagship clinical unit, and delivers quality tertiary and primary eye care to patients in singapore and the region. With more than 32 fellowship-trained consultants on-board, the Institute covers the entire spectrum of ophthalmic subspecialties, providing comprehensive diagnosis and advanced treatment for both common and complex eye diseases. In part two of the ‘eye Discoveries’ series by the NHG eye Institute, we will be taking a look at the introduction of a new Glaucoma Nurse-led service, and how the initiative has successfully added a holistic facet to the process of Glaucoma Care.

feature

TOWArDS MOrE HOLISTIC GlaUComa Care

by Dr owen Hee, consultant, national healthcare group eye institute, Tan Tock seng hospital

eYe diSCoVerieS:

05

I bring out the visual field test results. There are quite a few black spots amidst the white background. And I

begin to tell my patient: “The test results confirm you have glaucoma.” The experience is not entirely satisfactory; for me, nor for the patient. Why? Because I wish I had more time to explain the diagnosis. Often, time does not permit and doctors are not always very good at explaining in understandable terms. The news of a diagnosis like glaucoma represents a significant turning point in a patient’s life. Glaucoma comes with some heavy connotations. Blindness. No cure. Pain. These perceptions often occupy the public’s imagination when it comes to glaucoma; and need to be addressed adequately. Then there is treatment and monitoring. Up to 50% of patients are non-adherent to their medications. The visual field test that is the gold standard for monitoring is notoriously challenging to perform. This then gives inconclusive results because patients can struggle to perform them properly. The recognition of these issues started a “movement” to improve patient

education so that they understand their disease better, understand how to properly instil their eyedrops and learn how to perform visual field tests reliably. From 2012 to 2015, Assistant Nurse Clinician Soo-Hoo Wai Cheng was earmarked, and underwent vigorous training for the role of Glaucoma Nurse. With the introduction of dedicated consultation slots with Nurse Wai Cheng, our glaucoma patients can now find out more about their diagnosis, treatment and tests. But more than that, these sessions have given us valuable insights into each patient. I had a patient whom I

NHG eye Institute Direct Access Hotline:

NHG Eye Institute is able to accommodate same-day/next day appointments. Depending

on the level of care needed and the requested timing, most

patients can be seen by an Eye specialist on the same

day especially for requests received in the morning.

For appointments, GPs should call 6359 6500.

Nurse Wai Cheng explaining the condition to a glaucoma patient.

RESouRCES FoR FALLS MANAGEMENT:TTSH Falls and Balance Clinic provides multidisciplinary fall evaluation for elderly patients with high risk of falls. Referral criteria are as follows:

Ambulant elderly aged 65 years and above More than one fall during the past 6

months Unsteadiness in gait and balance

Enquiry Hotline: 6359 6100 Fax: 6359 6101

Day Rehabilitation Centre provides rehabilitation and exercise Apply through Agency of Integrated Care website: http://www.aic.sg/ HDB EASE Programme provides installation of grab bars, non-slip flooring and ramps to make flats more elder-friendly.Apply directly to HDB: http://www.hdb.gov.sg/cs/infoweb/residential/living-in-an-hdb-flat/for-our-seniors/ease

Health Promotion Board provides more resources on Falls Prevention

(www.hpb.gov.sg)

feature

06

Fall prevention among the elderly is a very pertinent topic, as the consequence of falls can have the potential to affect elderly persons physically, psychologically and socially.

wHo is at HigH risk of faLLiNg?

How to maNage a HigH faLL risk PatieNt?

Review their: Vision on an annual basis; Medication: to look for any link between medication to falls and

postural hypotension; Postural blood pressure; Gait, Balance; and Injury risk such as Osteoporosis.

by Dr Noor Hafizah bte ismail, senior consultant, Department of continuing and community care, Tan Tock seng hospital and Nurse Clinician Loo yen Leng, fall care nurse clinician, Tan Tock seng hospital

CatCH tHem before tHeyfaLL!

Someone who has had a recent fall (last 6 months)

Someone with unsteadiness and difficulty walking

Those with poor vision and dizziness

Someone who is taking more than 5 prescription medications (especially psychotropic medications)

Advise patient: Proper footwear Regular exercise including strength and

balance Proper use of walking aids Environment modification especially for

patients with home falls, poor function and visual impairment (i.e. install grab bars, non-slip flooring and lighting)

Postural hypotension precautions (i.e. getting up slowly and sitting at the edge of the bed for a while, exercising the ankle for 10mins before standing and stabilising oneself before walking).

sPotLigHt

TITLE CME POINTS DATE TIME VENUE REGISTRATION DETAILS

GP Symposium: General Medicine

Update 20162 core points 13 August 2016 1.00pm to 4.00pm

Theatrette, Level 1,

Tan Tock Seng Hospital

Please email: [email protected]

or call 6357 7893

Family Practitioner Symposium

Haematology Sharing 2016

2 core points 20 August 2016 12.30pm to 4.30pmTheatrette,

Level 1,Tan Tock Seng Hospital


or e-Register via Google form: http://tinyurl.com/

2016haematologysharing

(Applicable for Internet Explorer 11, Firefox, Google Chrome, iPhone Safari)

Mental Health in the Community

2 core points 27 August 2016 1.00pm to 4.00pmConference Rooms 1 and 2,

Level 1, Tan Tock Seng Hospital


or call 6357 3176 / 8206

CME Talk: Approach To Common

Eye Conditions

Workshop: Demonstration of

Examination Techniques

2 core points 24 September 2016 1.00pm to 4.30 pm

TTSH Eye Centre Conference Room,



GP Symposium:Pancreas Cancer -

a neglected stepchild in Oncology?

To be confirmed

26 November 2016 12.30pm to 3.30pmSeminar Rooms 1 & 2,



or call 6357 2637

Cme (JuLY – SEPTEMBEr 2016)

07

A confirmation email will be sent after your registration. Kindly email the contact person if you do not receive any confirmation after your registration. Thank you.

faLL! mental health GP Cme Training: managing anxiety in Primary Care

On 2 April 2016, Primary Care Partners Office, in conjunction with the Agency for Integrated Care (AIC) Mental Health Division organised the second Mental

Health General Practitioners (GP) CME Training on ‘Managing Anxiety in Primary Care’. The training guides GP partners

to handle patients with anxiety disorders at their clinics, and introduces the TTSH-AIC Mental Health GP Partnership Programme.

Since April 2015, TTSH has right-sited patients with stable Anxiety, Depressive Disorder and Schizophrenia to mental health trained GP partners. This training platform updates our GP partners with effective patient management methods and the community support services available to them.

A/Prof Jaspal Singh sharing management of patients with stable mental health condition with our GP partners. Our team of TTSH GP partners supporting our vision of ‘Adding years of healthy life’.

by kelvin Loh, senior physiotherapist, Department of physiotherapist, Tan Tock seng hospital

fitNess

exerCiSeS for raiNY aNd haZY daYS

Fitness and health ensures a productive and fulfilling life, and can both be achieved through regular exercise. The saying goes,

‘exercise is medicine’ as it has been proven to be effective in managing lifestyle-related chronic diseases such as diabetes, hypertension and heart disease (Pedersen et al. 2006). World Health Organisation (WHO) recommends healthy adults aged 18-64 years old to perform at least 150 minutes of moderate-intensity aerobic exercise per week. This is commonly done through outdoor exercises.

Despite its benefits, outdoor activities have their limitations due to unpredictability of the weather. Exercising under poor weather conditions could potentially bring harm to one’s health, especially during hazy periods. Other factors like lightning risk, or chronic lung diseases such as Chronic Obstruction Pulmonary Disease (COPD) (M Gao et al. 2015) make indoor exercises an effective alternative (Joyce S et al. 2015).

Exercising indoors is safe, fun and effective. Exercises can be tailored according to an individual’s needs. For example, Burpees work the entire body and take up very little space. Other exercises include push-ups, squats and dynamic lunges. Each workout should include the four types of exercises, with varied speed and repetition.

health and fitness are essential. The most common exercises are cycling, running and swimming. however, outdoor activities are dependent on weather conditions and can limit consistency. indoor exercises have been found to be an effective alternative.

1. burPeesa. Stand straight, then go into squat position with both hands placed on the ground before you.b. Kick feet back so that you are in a push up position, then

immediately drop your chest to the ground.c. Push your chest up and return to squat position as fast as you can.d. follow with a leap in the air, with a clap.

3. PusH-uPa. in a high plank position, with hands below the shoulders and toes supporting the

other end.b. ensure your spine is straight by engaging your core (abdominal muscle) and keep

your chin tucked in.c. Lower your body as much as you can, while keeping elbows tucked close to the

trunk. butt, spine and head should remain in-line.d. exhale when pushing up.

2. forwarD LuNgea. Stand upright, feet hip-width apart.b. take a reasonably big step forward with one leg.c. bend your front knee 90 degrees, your back knee

should touch the ground. Keep your back in an upright position.

d. Return to standing position.e. Repeat the movement with the other foot.

4. JoggiNg agaiNst tHe waLLa. incline standing with hands against a wall.b. ensure trunk and head are in-line at all times.c. flex one hip up 90 degrees and return to original position.d. Land on your mid-foot, followed by heel.e. Repeat with the other leg with varied speed.

Reference:1. B. K. Pedersen and B. Saltin. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian Journal of Medicine & Science in Sports. Volume

16, issue S1, pages 3-63, February 20062. M Gao, R Jia, T Qiu, M Han, Y Song, X Wang- Atmospheric Environment 2015-Elsevier. Seasonal Size Distribution of Airborne Culturable bacteria and Fungi and

Preliminary Estimation of Their Deposition in Human Lungs During Non-Haze and Haze Days3. Joyce S. Ramos, Lance C. Dalleck, Arnt Erik Tjonna, Kassia S. Beetham, Jeff S. Coombes. 2015. The Impact of High-Intensity Interval Training Versus Moderate-

Intensity Continuous Training on Vascular Function: a Systematic Review and Meta-Analysis

(Perform 3 sets of 10 repetitions)




The total duration for a full workout is about 20 mins. Know your own body - take short rests in between, when needed.

MULTI-DISCIPLINARY SPECIALIST CARE

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.

PEARL CLINICS AND SERVICES(NON-SUBSIDISED)

GP Appointment Hotline: (65) 6359 6500

CLINIC B1B•OrthopaedicSurgery Tel: (65) 1800-73275-00 Email:[email protected]

•Rheumatology,AllergyandImmunology Tel: (65) 6889 4027 Email: [email protected]

CLINIC 2B•GastroenterologyandHepatology•GeneralSurgery•Urology Tel: (65) 1800-73275-00 Email:[email protected]

CLINIC 4B•DiabetesandEndocrinology•GeneralMedicine•Haematology•MedicalOncology•PsychologicalMedicine•PsychologicalServices•RenalMedicine•RespiratoryandCriticalCareMedicine Tel: (65) 1800-73275-00 Email:[email protected]

CLINIC 6B•ComplementaryIntegrativeMedicine Tel: (65) 6889 4628 Email:[email protected]

•Dental Tel: (65) 6889 4627 Email:[email protected]

WELLNESS SERVICES•HealthEnrichmentCentre Tel: (65) 1800-73275-00 Email:[email protected]

•Travellers’HealthandVaccinationClinic Tel: (65) 6357 2222 Email:[email protected]

PEARL LIAISON CENTRE (PLC) Tel: (65) 6357 1590 Email:[email protected]