Exploring measurement tools to optimise hospital physician distribution.

INTRODUCTION: Equitable healthcare delivery is essential and requires resources to be distributed, which include assets and healthcare workers. To date, there is no gold standard for measuring the correct number of physicians to meet healthcare needs. This rapid review aims to explore measurement tools employed to optimise the distribution of hospital physicians, with a focus on ensuring fair resource allocation for equitable healthcare delivery. MATERIALS AND METHODS: A literature search was performed across PubMed, EMBASE, Emerald Insight and grey literature sources. The key terms used in the search include 'distribution', 'method', and 'physician', focusing on research articles published in English from 2002 to 2022 that described methods or tools to measure hospital-based physicians' distribution. Relevant articles were selected through a two-level screening process and critically appraised. The primary outcome is the measurement tools used to assess the distribution of hospital-based physicians. Study characteristics, tool advantages and limitations were also extracted. The extracted data were synthesised narratively. RESULTS: Out of 7,199 identified articles, 13 met the inclusion criteria. Among the selected articles, 12 were from Asia and one from Africa. The review identified eight measurement tools: Gini coefficients and Lorenz curve, Robin Hood index, Theil index, concentration index, Workload Indicator of Staffing Need method, spatial autocorrelation analysis, mixed integer linear programming model and cohortcomponent model. These tools rely on fundamental data concerning population and physician numbers to generate outputs. Additionally, five studies employed a combination of these tools to gain a comprehensive understanding of physician distribution dynamics. CONCLUSION: Measurement tools can be used to assess physician distribution according to population needs. Nevertheless, each tool has its own merits and limitations, underscoring the importance of employing a combination of tools. The choice of measuring tool should be tailored to the specific context and research objectives.

Intravenous thrombolysis for multi-ethnic Asians with acute ischaemia stroke in Malaysian public primary stroke centres versus acute stroke ready hospitals: Comparison of real-world clinical outcomes.

INTRODUCTION: Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator is beneficial in acute ischaemic stroke (AIS). We aim to compare the realworld clinical outcomes and service efficiency of IVT in Malaysian primary stroke centres (PSCs) versus acute stroke ready hospitals (ASRHs). MATERIALS AND METHODS: We conducted a multi-centre cohort study involving 5 PSCs and 7 ASRHs in Malaysia. Through review of medical records of AIS patients who received IVT from 01 January 2014 to 30 June 2021, real-world data was extracted for analysis. Univariate and multivariate regression models were employed to evaluate the role of PSCs versus ASRHs in post-IVT outcomes and complications. Statistical significance was set at p<0.05. RESULTS: A total of 313 multi-ethnic Asians, namely 231 from PSCs and 82 from ASRHs, were included. Both groups were comparable in baseline demographic, clinical, and stroke characteristics. The efficiency of IVT delivery (door-toneedle time), functional outcomes (mRS at 3 months post- IVT), and rates of adverse events (intracranial haemorrhages and mortality) following IVT were comparable between the 2 groups. Notably, 46.8% and 48.8% of patients in PSCs and ASRHs group respectively (p=0.752) achieved favourable functional outcome (mRS≤1 at 3 months post-IVT). Regression analyses demonstrated that post-IVT functional outcomes and adverse events were independent of the role of PSCs or ASRHs. CONCLUSION: Our study provides real-world evidence which suggests that IVT can be equally safe, effective, and efficiently delivered in ASRHs. This may encourage the establishment of more ASRHs to extend the benefits of IVT to a greater proportion of stroke populations and enhance the regional stroke care.

Pontine stroke: a rare mimicker of Bell's palsy.

Pontine infarct is a rare but clinically significant cause of an isolated facial nerve palsy. Prompt diagnosis with the use of magnetic resonance imaging (MRI) allows early initiation of treatment for such patients. We report a 62-year-old gentleman with diabetes, hypertension, and gout, presenting with lower motor neuron facial nerve palsy. This report highlights that isolated facial nerve palsy is not always associated with Bell's palsy, which remains the commonest cause of facial nerve paralysis. A thorough neurological examination and good clinical correlation with the patient's history and physical findings, coupled with the use of facial nerve anatomical knowledge and early employment of MRI, are imperative in clinching the diagnosis.

Clinical outcomes of acute stroke thrombolysis in neurologist and non-neurologist centres - A comparative study in Malaysia.

BACKGROUND: Thrombolytic therapy with intravenous alteplase is a well-established treatment for acute ischaemic stroke (AIS). However, in Malaysia, treatment prescription is often limited by the availability of neurologists. The objective was to compare the outcomes of acute stroke thrombolysis therapy prescribed by neurologists in the Seberang Jaya Hospital (SJH) and non-neurologists in the Taiping Hospital (TH). METHODS: In this cross-sectional study, all AIS patients who received thrombolytic therapy in SJH and TH between January 2012 and September 2019 were included. Clinical data was extracted from admission records. The outcomes assessed were the percentage of patients who achieved excellent functional outcome at 3 months (modified Rankin scale of 0 to 1), rates of symptomatic intracranial haemorrhage (SICH), and mortality. RESULTS: A total of 63 AIS patients who received thrombolytic therapy were included, of which 37 patients (58.7%) were treated in SJH. The median NIHSS on admission was 12 in SJH and 11.5 in TH. In all 21.6% of patients from SJH and 30.7% of patients from TH achieved favourable functional outcome at 3 months (p=0.412). There were no significant differences between the two centres in terms of the rates of SICH (10.8% in SJH and 3.8% in TH, p=0.314) and 3-month mortality (24.3% versus 12.5%, p=0.203). CONCLUSION: The 3-month functional outcomes and complication rates of stroke thrombolysis in hospitals with or without neurologists are not significantly different. Thus non-neurologist hospitals may be able to provide thrombolysis service to AIS patients safely and effectively.

Influence of bariatric surgery on weight reduction and control of chronic disease among obese patients in Malaysia.

INTRODUCTION: This study was designed to determine the influence of bariatric surgery on changes in the body mass index (BMI), and the control of diabetes, hypertension and dyslipidaemia among obese patients in Malaysia. MATERIALS AND METHODS: This was a retrospective cohort study undertaken at a public tertiary care centre in the state of Perak, Malaysia. Information of obese patients who underwent bariatric surgery was obtained from their medical records. The changes in the BMI, HbA1C, systolic and diastolic blood pressure (SBP and DBP), and lipid levels between three months before and after the surgery were assessed. RESULTS: The patients (n=106) were mostly Malay (66.0%), had at least one comorbidity (61.3%), and had a mean age of 40.38±11.75 years. Following surgery, the BMI of the patients was found to reduce by 9.78±5.82kg/m2. For the patients who had diabetes (n=24) and hypertension (n=47), their mean HbA1C, SBP and DBP were also shown to reduce significantly by 2.02±2.13%, 17.19±16.97mmHg, and 11.45±12.63mmHg, respectively. Meanwhile, the mean total cholesterol, triglyceride and low-density lipoprotein levels of those who had dyslipidaemia (n=21) were, respectively, lowered by 0.91±1.18mmol/L, 0.69±1.11mmol/L and 0.47±0.52mmol/L. CONCLUSION: The findings suggest that in addition to weight reduction, bariatric surgery is helpful in improving the diabetes, hypertension and dyslipidaemia control among obese patients. However, a large-scale trial with a control group is required to verify our findings.

A Review of Metabolic Syndrome Research in Malaysia.

Seventy-three articles related to metabolic syndrome were found in a search through databases dedicated to indexing all literature with original data involving the Malaysian population between years 2000 and 2015. Metabolic syndrome affects 25 to 40% of adult population of Malaysia with the risk increasing with age. Obese children are also at risk. Indian ethnicity has the highest rates, followed by Malay and chinese. It was found that socioeconomics determinants such as living in urban areas, unemployment, lower income, lower education level and shift workers had higher prevalence of metabolic syndrome. Metabolic syndrome is associated with other medical conditions like cardiovascular diseases, psychiatric disorders, erectile dysfunction, polycystic ovarian syndrome and colorectal cancer. Several biomarkers have been determined to be relevant to our local population but their usage in clinical setting needs further research. Literature into effectiveness of management of metabolic syndrome in Malaysia is lacking and the results were only modest. there are several diagnostic criteria available for metabolic syndrome internationally and their individual significant to our local population is not clear. It also makes it difficult to compare results between studies using different criteria. Finally, we could not identify any local study to look at the health economic burden of metabolic syndrome locally.

A Review of Stroke Research in Malaysia from 2000 - 2014.

Over 100 articles related to stroke were found in a search through a database dedicated to indexing all literature with original data involving the Malaysian population between years 2000 and 2014. Stroke is emerging as a major public health problem. The development of the National Stroke Registry in the year 2009 aims to coordinate and improve stroke care, as well as to generate more data on various aspects of stroke in the country. Studies on predictors of survival after strokes have shown potential to improve the overall management of stroke, both during acute event and long term care. Stroke units were shown to be effective locally in stroke outcomes and prevention of stroke-related complications. The limited data looking at direct cost of stroke management suggests that the health economic burden in stroke management may be even higher. Innovative rehabilitation programmes including braincomputer interface technology were studied with encouraging results. Studies in traditional complementary medicine for strokes such as acupuncture, Urut Melayu and herbal medicine were still limited.

A review of dengue research in malaysia.

Dengue infection is a major cause of morbidity and mortality in Malaysia. To date, much research on dengue infection conducted in Malaysia have been published. One hundred and sixty six articles related to dengue in Malaysia were found from a search through a database dedicated to indexing all original data relevant to medicine published between the years 2000-2013. Ninety articles with clinical relevance and future research implications were selected and reviewed. These papers showed evidence of an exponential increase in the disease epidemic and a varying pattern of prevalent dengue serotypes at different times. The early febrile phase of dengue infection consist of an undifferentiated fever. Clinical suspicion and ability to identify patients at risk of severe dengue infection is important. Treatment of dengue infection involves judicious use of volume expander and supportive care. Potential future research areas are discussed to narrow our current knowledge gaps on dengue infection.

How should front-line general practitioners use personal protective equipment (PPE)?

The COVID-19 outbreak continues to evolve with the number of cases increasing in Malaysia, placing a significant burden on general practitioners (GPs) to assess and manage suspected cases. GPs must be well equipped with knowledge to set up their clinics, use Personal Protective Equipment (PPE) appropriately, adopt standard protocols on triaging and referrals, as well as educate patients about PPE. The correct use of PPE will help GPs balance between personal safety and appropriate levels of public concern.

COVID-19: Four Paediatric Cases in Malaysia.

OBJECTIVE: This is a brief report of 4 paediatric cases of COVID-19 infection in Malaysia BACKGROUND: COVID-19, a coronavirus, first detected in Wuhan, China has now spread rapidly to over 60 countries and territories around the world, infecting more than 85000 individuals. As the case count amongst children is low, there is need to report COVID-19 in children to better understand the virus and the disease. CASES: In Malaysia, until end of February 2020, there were four COVID-19 paediatric cases with ages ranging from 20 months to 11 years. All four cases were likely to have contracted the virus in China. The children had no symptoms or mild flu-like illness. The cases were managed symptomatically. None required antiviral therapy. DISCUSSION: There were 2 major issues regarding the care of infected children. Firstly, the quarantine of an infected child with a parent who tested negative was an ethical dilemma. Secondly, oropharyngeal and nasal swabs in children were at risk of false negative results. These issues have implications for infection control. Consequently, there is a need for clearer guidelines for child quarantine and testing methods in the management of COVID-19 in children.

Comparing T2 and T2-T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial.

BACKGROUND: Thoracoscopic sympathectomy is a useful therapeutic option for palmar hyperhidrosis. Surgeons differ in the level of the sympathetic chain ablated. This study aimed to compare the blockade of the T2 with levels T2 and T3 to verify the effectiveness of different ablation levels in relieving hyperhidrosis symptoms. METHODS: For patients undergoing bilateral thoracoscopic sympathectomy for palmar hyperhidrosis, T2-T3 ablation is performed bilaterally. In our series, 25 consecutive patients were blindly randomized to undergo unilateral T2 and T3 ablation followed by contralateral ablation of level T2 only. The patients were followed up and analyzed for comparison of symptoms bilaterally, compensatory hyperhidrosis, and levels of satisfaction postoperatively. RESULTS: The study group consisted of 25 patients with a male:female ratio of 3:2 and a mean age of 32 years (range, 19-50 years). The mean operative time was 35 min. The patients were followed up for a mean period of 23 months (range, 2-65 months). All 25 patients confirmed that their palmar sweating resolved postoperatively, with both palms equally dry. Of the 25 patients, 20 (80%) complained of compensatory hyperhidrosis, which also was bilaterally symmetric. The areas involved were trunk (80%), lower limbs (32%), and armpits (12%). Overall, 80% of the patients were very satisfied with the procedure. The remaining 20% experienced mild to moderate compensatory hyperhidrosis, which did not seem to affect their lifestyle. CONCLUSION: The findings show that T2 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis is as effective as T2-T3 ablation in terms of symptomatic relief, recurrence, compensatory hyperhidrosis, and patient satisfaction.

Laparoscopic versus open ventral hernia mesh repair: a prospective study.

BACKGROUND: An incisional hernia develops in 3% to 13% of laparotomy incisions, with primary suture repair of ventral hernias yielding unsatisfactory results. The introduction of a prosthetic mesh to ensure abdominal wall strength without tension has decreased the recurrence rate, but open repair requires significant soft tissue dissection in tissues that are already of poor quality as well as flap creation, increasing complication rates and affecting the recurrence rate. A minimally invasive approach was applied to the repair pf ventral hernias, with the expectation of earlier recovery, fewer postoperative complications, and decreased recurrence rates. This prospective study was performed to objectively analyze and compare the outcomes after open and laparoscopic ventral hernia repair. METHODS: The outcomes for 50 unselected patients who underwent laparoscopic ventral hernia repair were compared with those for 50 consecutive unselected patients who underwent open repair. The open surgical operations were performed by the Rives and Stoppa technique using prosthetic mesh, whereas the laparoscopic repairs were performed using the intraperitoneal onlay mesh (IPOM) repair technique in all cases. RESULTS: The study group consisted of 100 patients (82 women and 18 men) with a mean age of 55.25 years (range, 30-83 years). The patients in the two groups were comparable at baseline in terms of sex, presenting complaints, and comorbid conditions. The patients in laparoscopic group had larger defects (93.96 vs 55.88 cm2; p = 0.0023). The mean follow-up time was 20.8 months (95% confidence interval [CI], 18.5640-23.0227 months). The mean surgery durations were 90.6 min for the laparoscopic repair and 93.3 min for the open repair (p = 0.769, nonsignificant difference). The mean postoperative stay was shorter for the laparoscopic group than for the open hernia group (2.7 vs 4.7 days; p = 0.044). The pain scores were similar in the two groups at 24 and 48 h, but significantly less at 72 h in the laparoscopic group (mean visual analog scale score, 2.9412 vs 4.1702; p = 0.001). There were fewer complications (24%) and recurrences (2%) among the patients who underwent laparoscopic repair than among those who had open repair (30% and 10%, respectively). CONCLUSIONS: The findings demonstrate that laparoscopic ventral hernia repair in our experience was safe and resulted in shorter operative time, fewer complications, shorter hospital stays, and less recurrence. Hence, it should be considered as the procedure of choice for ventral hernia repair.

Recurrent episodes of arthritis in a hyperthyroid patient.

Antineutrophil cytoplasmic antibody (ANCA)- associated vasculitis is a potentially life-threatening adverse effect of antithyroid medications. We present a 22-year-old woman with Graves' disease who developed recurrent episodes of arthritis while on treatment with propylthiouracil. A diagnosis of propylthiouracil-induced ANCA-associated vasculitis was established only after exhaustive rheumatological investigations failed to establish a cause for her arthritis. Anti-myeloperoxidase antibody (anti-MPO) titres were grossly elevated at 172.7 RU/mL (0-20). Her arthritis resolved promptly following the withdrawal of propylthiouracil and the anti-MPO titres declined over 16 months to 66.8 RU/mL. While she did not develop the life-threatening renal or respiratory tract complications, there was a delay in establishing the correct diagnosis with its attendant morbidity. This case highlights the need for greater awareness of this relatively rare adverse effect of antithyroid medications so as to allow its early detection, leading to the prompt cessation of the offending medication.

The history of surgical teaching and the department of surgery.

Undergraduate surgical teaching in Singapore began 100 years ago, when the Medical School was founded. A significant step had been taken to enable local students to be trained in and to attain the diploma of Licentiate in Medicine and Surgery (LMS). Plans for postgraduate education were temporarily derailed when the Japanese occupied Singapore in 1942. Postgraduate surgical teaching received an official boost when the primary Australasian examinations were conducted in Singapore in 1957, providing a platform for surgical independence when the higher degree, the Master of Medicine (M Med) in Surgery, was established in 1970. Currently, the Joint Committee on Specialist Training, comprising the Division of Graduate Medical Studies, the Academy of Medicine, Singapore and the Ministry of Health, oversees the training of surgical specialists in Singapore.

Parathyroid carcinoma: a case series.

INTRODUCTION: We present 3 patients with parathyroid carcinoma and describe their presentations, clinical profiles, and management. MATERIALS AND METHODS: A case series review of medical records. RESULTS: Two women and 1 man (age range, 32 to 57 years) had parathyroid cancer and primary hyperparathyroidism (PHPT). One patient presented with osteitis fibrosa, 1 with renal stone and a neck mass, and 1 with recurrence of PHPT after excision of supposedly benign parathyroid adenoma 4 years ago. All had severe hypercalcaemia and elevated parathyroid hormone levels that ranged from 4 to 43 times above the normal range. Exploration of the neck clearly identified 1 parathyroid tumour with local invasion; 2 other specimens showed capsular and vascular invasion on frozen section and final histology. All 3 patients underwent parathyroidectomy and ipsilateral hemithyroidectomy. Parathyroid size ranged from 1.3 to 4 cm and no lymph node metastasis was identified. No patient had tumour recurrence after a follow-up period of 1 year. CONCLUSION: Parathyroid carcinoma is a rare endocrine malignancy. Suspicious features include marked hypercalcaemia, neck mass, and local recurrence. Parathyroidectomy with ipsilateral hemithyroidectomy and nodal clearance gives the best chance of reducing local tumour recurrence.

Can localization studies be used to direct focused parathyroid operations?

BACKGROUND: There is considerable controversy today concerning the most appropriate surgical approach for patients with primary hyperparathyroidism. The conventional surgical operation involves a bilateral neck exploration through a collar incision with identification of all parathyroid tissue and removal of abnormal parathyroid glands while the patient is under general anesthesia. The success rate of this operation is about 95% or greater in the hands of an experienced endocrine surgeon. Preoperative localization techniques are generally considered to be unnecessary before initial parathyroid operations. The purpose of this investigation was (1) to evaluate the individual and combined accuracy of ultrasonography and technetium 99m sestamibi scans in localizing abnormal parathyroid glands and (2) to determine whether such scans could be used to direct a focused operation. METHODS: We retrospectively studied 338 patients with sporadic primary hyperparathyroidism who had preoperative neck localization studies, ultrasonography and/or technetium 99m sestamibi scans, and parathyroid exploration (238 patients or, reexploration, 60 patients) from January 1996 to April 2000 at the University of California San Francisco/Mount Zion Medical Center. The preoperative localization studies were recorded as true-positive, false-positive, and false-negative and compared with the surgical and pathologic findings and with the outcome of the operation. RESULTS: All of the abnormal parathyroid glands were correctly identified by ultrasonography in 184 of 303 patients (60.7%) and by technetium 99m sestamibi scanning in 183 of 237 patients (77.2%). The sensitivities of ultrasonography and sestamibi were 65% and 80%, respectively. Among the 202 patients who received both ultrasonography and sestamibi scans, a parathyroid tumor was identified at the same site in 105 (52%) of them. When both techniques identified a parathyroid tumor at the same site, the tests were correct in 101 of 105 patients and the sensitivity increased to 96%. CONCLUSIONS: When both the ultrasonography and sestamibi scans identified the same, solitary parathyroid tumor in patients with sporadic primary hyperparathyroidism, this was the only abnormal parathyroid gland in 96% of the patients. A focused parathyroidectomy could therefore be performed in such patients with an acceptable ( approximately 95%) success rate.

Robotically assisted laparoscopic cholecystectomy: a pilot study.

HYPOTHESIS: Since the advent of laparoscopic surgery in 1987 and the introduction of robotics into medicine in 1991, medical technology has advanced to robotic applications in performing surgery. In our study, we investigated the feasibility of performing simple laparoscopic maneuvers and laparoscopic cholecystectomy using a robotic surgical system. DESIGN: The study used a ZEUS robotic system (Computer Motion Inc, Goleta, Calif), consisting of 3 interactive robotic arms fixed at the operating table and remotely controlled by the surgeon. After initial training, using a bench model and 3 isolated porcine livers to perform cholecystectomy, 7 female pigs underwent robotically assisted laparoscopic cholecystectomy. The surgeon, seated at the console, manipulated the 3-mm laparoscopic instruments and performed the surgery. RESULTS: Robotically assisted laparoscopic cholecystectomy was accomplished in all 7 pigs, with a mean operative time of 46 minutes (range, 30-62 minutes). There were no complications. The mean time to setup of the robotic system decreased from 30 minutes to 14 minutes. All the robotic maneuvers were performed without any particular difficulties, and the movements were stable, accurate, and reliable, with good control. CONCLUSIONS: Our preliminary experimental study showed that robotically reproduced laparoscopic maneuvers, such as tying, suturing, dissection, clipping, and cautery, seemed to be as accurate and as fast as maneuvers made without robotics. We conclude that our initial experimental and animal study confirmed the feasibility of robotically assisted laparoscopic cholecystectomy. Further reports are needed to show that robotics can be used for clinical applications in surgery.

Needlescopic thoracic sympathectomy: treatment for palmar hyperhidrosis.

BACKGROUND: Open thoracic sympathectomy has been the established option for patients with essential hyperhidrosis. Recently, video-assisted endoscopic sympathectomy has provided a simple, safe, reliable, and cost-effective alternative to the earlier technique. With advances in instrumentation, performing the procedure through 2-mm and 3-mm needlescopic ports is now possible. The authors evaluate the effectiveness of so-called needlescopic thoracic sympathectomy for the treatment of primary hyperhidrosis. METHODS: Thirty five consecutive patients with a mean age of 24 years, including 23 men and 12 women, underwent bilateral needlescopic thoracic sympathectomies at the National University Hospital of Singapore. RESULTS: The mean operative duration was 56 minutes, and the mean hospital stay was 1.2 days. In no patient did Horner's syndrome or significant pneumothorax develop. The rate of success, defined as completely dry hands, was 97%. Two patients had unilateral recurrences that responded well to repeat needlescopic sympathectomies. We performed a total of 72 sympathectomies. CONCLUSIONS: Our study demonstrates that the use of miniature port access sites produces excellent medical and cosmetic results and is associated with a short hospital stay and low risk of complications.

Anaplastic thyroid carcinoma with destructive thyrotoxicosis in a patient with preexisting multinodular goiter.

Presentation of anaplastic thyroid carcinoma with thyrotoxicosis is extremely rare and its occurrence in a patient with Wegener's granulomatosis has not been reported previously. We describe an elderly lady with Wegener's granulomatosis who developed a rapidly growing anaplastic thyroid carcinoma in a preexisting multinodular goiter and discuss the mechanism of thyrotoxicosis in this patient.