A Systematic Implementation of Telemedicine in Singapore's COVID-19 Community Recovery Facilities.

Introduction: This article describes the experience of the Singapore Armed Forces (SAF) implementing telemedicine consultations for COVID-19-positive patients recovering within community recovery facilities (CRFs) in a semi-inpatient setting. Materials and Methods: The SAF adopted a systematic approach to telemedicine implementation and scaling up, with Phase 1 being the deployment of medical teams operating on-site clinics daily at six CRFs and telemedicine only provided for after-hours medical consultations on an ad hoc basis. Subsequently in Phase 2, most clinical consultations in the CRFs were conducted virtually. Results: Phases 1 and 2 recorded 1,902 and 449 clinical consultations, respectively. The mean number of clinical encounters was 33 per 1,000 occupants per day in Phase 1, and 12 per 1,000 occupants per day in Phase 2 (p < 0.001). Acute respiratory illness (52.3% in Phase 1 and 46.7% in Phase 2) was the most common reason for consultations. With full telemedicine in Phase 2, there was reduction in the mean number of clinical encounters per 1,000 occupants per day (p = 0.001), lower man-hours in personal protective equipment (PPE) (p < 0.001), and rise in escalation of care (p < 0.001) but without adverse events reported. Conclusions: Telemedicine for patients was safe, improved medical manpower efficiency, and reduced man-hours in PPE. The increased escalation of care in Phase 2 due to the lack of physical examination capabilities was to be expected to ensure patients' safety. Overall, it is recommended that for stable and mild medical conditions, telemedicine is a viable, safe, and efficient health care delivery tool in crisis situations similar to COVID-19.

Liberalized Versus Strict Cow's Milk Elimination for the Treatment of Children with Eosinophilic Esophagitis.

OBJECTIVES: Cow's milk is a commonly implicated trigger in eosinophilic esophagitis (EoE). Exclusive cow's milk avoidance has been reported previously, but the degree of elimination required for remission is unclear. Strict food avoidance may confer a risk of developing immunoglobulin E (IgE)-mediated allergy. The goal of this study was to evaluate the effectiveness of cow's milk elimination (CME) in children with EoE and compare responses of strict and liberalized CME diets. METHODS: Children (≤16 years) diagnosed with EoE who were treated with exclusive CME diets were evaluated clinically and histologically. Strict diets eliminated all milk products, including 'may-contain' and baked milk goods. Liberalized diets eliminated obvious sources including milk, cheese, yogurt, cream-based products but permitted foods with traces of milk and baked goods. RESULTS: Cow's milk elimination induced histological remission of <15 eosinophils per high-powered field in 18 of 31 children (58%) and complete remission in 23%. Overall, 77% had decreased eosinophils with this single intervention. Symptoms were improved in 90% of patients, regardless of histologic response. A liberalized (n=7) CME diet was associated with a nonsignificantly lower response compared with strict (n=24) elimination (29% versus 67%, P=0.099). Eight responders to strict elimination were transitioned to a liberalized diet; 63% maintained remission. CONCLUSION: Cow's milk elimination induced clinicopathological remission in a majority of patients with EoE, supporting its use as a first-line intervention. Liberalized CME allows dietary freedom and may prevent subsequent development of anaphylactic milk allergy but may be inferior to strict CME for improving EoE.

Diagnosis and management of eosinophilic esophagitis in children.

QUESTION: After a few years of difficulty swallowing solids and feeling like food was getting stuck, a 13-year-old boy in my practice with peanut allergy and asthma was recently diagnosed with eosinophilic esophagitis (EoE). What is EoE and how is it diagnosed and managed? ANSWER: Eosinophilic esophagitis is an immune-mediated disease resulting in inflammation of the esophagus. It is increasing in prevalence and incidence in countries like Canada, and frequently occurs in children with other allergic conditions. Unexplained feeding difficulties, vomiting, and solid-food dysphagia, especially in boys with atopy, supports the possibility of having EoE. A formal diagnosis is obtained by reviewing esophageal biopsies obtained through upper endoscopy performed while the patient is taking a proton pump inhibitor. Once EoE has been established, management should involve working collaboratively with gastroenterology and allergy specialists. Medical or dietary treatments are acceptable therapeutic approaches.

A tandem organocatalytic α-chlorination-aldol reaction that proceeds with dynamic kinetic resolution: a powerful tool for carbohydrate synthesis.

A tandem, proline-catalyzed α-chlorination/aldol reaction is described that involves a dynamic kinetic resolution of α-chloroaldehyde intermediates. The resulting syn-chlorohydrins are produced with good to excellent diastereoselectivity in high enantiopurity and provide new opportunities for the synthesis of carbohydrates.

Vertebral fracture in a pilot during centrifuge training: finding of osteopenia.

We report on a case of an F-16 pilot who suffered a compression fracture of the L5 vertebral body during centrifuge training. The pilot sustained the injury during a rapid onset to 6 G run. He was subsequently diagnosed to have osteopenia with a bone mineral density T-score of -1.95. This report discusses the medical and operational management of the pilot with this rare condition. The pilot has since returned to flying duties, albeit in a transportplatform.

Catatonia and psychosis associated with sibutramine: a case report and pathophysiologic correlation.

Sibutramine is a serotonin and norepinephrine reuptake intake inhibitor approved for the management of obesity. It has various CNS adverse effects and a few case reports of psychiatric manifestations. Here, we report a case of severe catatonic and psychotic symptoms associated with sibutramine overuse in the patient who had no prior psychiatric history. The symptoms subsequently resolved completely with cessation. Given the widespread use of sibutramine, this case would be of interest to practitioners of internal medicine and psychiatry. Moreover, as sibutramine may be used for weight management in patients on antipsychotic medications, the implications on psychotic symptoms need to be explored further. We also discuss possible pathophysiologic underpinnings.