Category Archives: Singapore

A New Class of Diabetes Medication Arrives in Singapore

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Despite current treatment including insulin, only 40% of patients in Indonesia35% of patients in Singapore and 22% of patients in Malaysia have good diabetes control.

A new class of medication called the SGLT2 inhibitor has been approved in Singapore, the first one being Invokana (canagliflozin). It has a unique mode of action for the treatment of type 2 diabetes mellitus.

In the kidneys when blood is pushed through a glomerulus (the smallest operating unit in the kidney), glomerular filtrate (earliest urine) is formed. It contains glucose (sugar), different ions, water and waste products. The good stuff is retained through reabsorption. Glucose is reabsorbed through the SGLT2 channels.

SGLT2 inhibitors block the action of the SGLT2 channels, so glucose is lost in urine. Thus the blood glucose drops and diabetes control improves. Patients also lose weight as they are losing energy in the urine. The glucose in the urine also drags water with it and thus patients’ blood pressure drops.

The most important benefit is that it is not dependent on insulin secretion, so the risk of a dangerously low blood sugar (hypoglycemia) is prevented. With this extra class of oral medication, patients may be able to delay their use of insulin.

There are side effects though. First, the sugar in the urine increases the risk of a urine tract infection and fungal infection around the urethra. Second, patients can get dehydrated unless they replenish their fluids with an extra glass of water.

I am very glad that we now have another weapon in the treatment of diabetes.

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Universal Screening of Gestational Diabetes Proposed

Pregnancy

Photo credit:  Stuart Miles/freedigitalphotos.net

The U.S. Preventive Services Task Force (USPSTF) has just recommended that all pregnant women be screened for gestational diabetes. For health care professionals, the document is here.

In pregnancy, the baby and the placenta induces a higher of sugar level in the mother, to ensure that the baby will have enough sugar for use and growth. Normally, the mother’s pancreas will work harder to overcome this by making more insulin. However, sometimes that fails and blood sugar starts to rise, causing gestational diabetes. The main problem of gestational diabetes is that the baby has too much sugar and so grows to too big a size, sometimes more than 4kg. This may make giving birth difficult.

Gestational Diabetes was last reported in Singapore to affect 13.8% of all pregnant mothers in 1988.

Fortunately, the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial cleared showed that proper treatment to normalize the blood sugar helps to prevent complications . For healthcare professionals, the paper is here.

Because effective treatment protects the mother and baby, all women in the US are now encouraged to have an oral glucose tolerance test (OGTT). In Singapore, women who are high risk are encouraged to have the OGTT. These risk factors are: obesity, family history of diabetes, previous gestational diabetes, and previous birth to a baby heavier than 4kg.

In pregnancy, diet and exercise is key to control the blood sugar. A lot of pregnant women can control their blood sugar with simple changes to their diet by decreasing refined carbohydrates such as white sugar, white rice, rice-based noodles (bee-hoon) and white bread.

However, in severe cases insulin will be needed. Oral medication are generally not advised for pregnant mothers.

To know more, here is a video shot by Leonny Atmadja from Our Channel.

Asian Students are tops in Academic Assessment Again!

Asian girl reading

Photo Credit: By Sira Anamwong from freedigitalphotos.net

The OECD has just published the Programme for International Student Assessment (PISA) report. Who are the top 7?

1. China-Shanghai

2. Singapore

3. China-Hong Kong

4. Taipei

5. Korea

6. China-Macao

7. Japan

What do they have in common? A Confucian culture. Even in America, Asian American students do well academically.

Foreigners may not realize how important studying is in the Asian family. Ever since Confucius taught about the importance of studying and opened a sort of a school, Confucian countries have put lots of importance on studying. The pressure is immense. In Singapore it is not uncommon for a parent to take a year off work to help their child to take the primary school leaving exam.The highest scoring candidates in exams become mandarins. Some popular Chinese saying shows how important it is:

1. All trades are lowly except for studying

2. Study hard and you will find great wealth and a beautiful wife in the books

Ahem. Certainly very chauvinistic. But this is ancient China after all.

There is of course a huge downside: children who have poor grades think they are failures. A lot of children, even those who are successful in the system, are burnt out by the time they enter university and end up hating lifelong learning.

Doing well in life requires more than just grades, and it may shock those top scorers when they start working and learn that grit, determination, EQ, connections and pure luck are far more important. I do try to teach my children those things as well.

2 Hour wait at Singapore Specialist Clinic

ImagePhoto credit: Ambro

A poor patient has been made to wait at the specialist’s clinic for 2 hours for every visit in a government hospital in Singapore. She did not even dare to go to the toilet for a break because she was afraid that she would miss her turn. The writer quite kindly pointed out that the doctors and nurses at the clinic were doing their best, just that there were way too many patients.

As a doctor I understand the doctor’s point of view, but I had also brought my wife to see her doctor before and we had to wait for 1-2 hours at that same hospital. That was despite the fact that the gynecologist and I were friends (we were made to wait just like everyone else and I thought that was the absolute right thing to do).

How long is too long? One should of course see what other countries are doing. Well researched data are however only readily available for America, where the average wait was 21 minutes. Patients described their wait as about 2 hours in Germany.

Patients feel disrepected when they are made to wait too long and that is the primary reason they would not recommend their doctor. It has gotten so bad that in America, a frustrated patient sued a doctor after waiting for 4 hours and won $250 in a small court.

There are many reasons of long waiting times. The primary reason is of course high demand (many patients) and low supply (lack of doctors/funding/doctors sick). This kind of problems can only be resolved by having more doctors and funding which many governments are reluctant to do because it means higher healthcare spending.

Sometimes patients are late for their appointment. When they arrive later, the doctor is already seeing other patients and they have to be “squeezed in” and this causes longer waits for everyone. On the other hand, it is difficult to expect patients to be on time when doctors make them wait…

Sometimes new medical problems occur. This happens when an appointment is booked for a routine visit lasting 15 minutes, but the patient has a new problem that needs to be addressed. Of course the doctor would need to tend to that problem as well, making other patients wait.

However, another reason is the practice of overbooking. Some patients do not turn up and do not have the courtesy to inform the clinic. To avoid letting the clinic and doctors left idle, it is a common practice for clinics to overbook their patients. However, that creates a long wait when everyone actually turns up. While we can ask patients to tell us early if they decide not to come, technology may be the solution. Most patients usually stick to their appointments, but some don’t. By analyzing past patient behavior, they can predict the total patient volume accurately 95% of the time. Hopefully this will let us manage our resources better and cut down on waiting time for patients.

H1N1 in the news in Singapore

Child receiving Vaccine

Image courtesy of  David Castillo Dominici / FreeDigitalPhotos.net

It has just been reported that 6 children in 2 kindergartens have come down with the H1N1 virus (used to be called swine flu). The H1N1 first came to news in 2009 when it killed many people in Mexico. Fortunately the virus had turned out to be much milder than it first appeared, and all the current influenza vaccines protect against the H1N1 virus.

The Singapore’s Health Promotion Board provides useful information on the seasonal influenza virus.

How to avoid the flu? Frequent washing of hands is important. People who are sick should rest at home, and when they go out, they should wear a mask and cover their mouth with tissue paper when sneezing. However, the best protection is to get vaccinated.

I am going to vaccinate my children tonight. Hope they are not going to be too cranky after that.

The Magic of Singapore Healthcare

Myth Or Magic - The Singapore Healthcare System

The Singapore Healthcare is generally admired to be of high quality at ridiculously low cost. Singapore spends 4% of her GDP as compared to 17% in America, with better outcomes. In the Undercover Economist, Tim Harford had openly admired the healthcare system of Singapore back in 2008: http://econlog.econlib.org/archives/2008/01/singapores_heal.html

Recently, some opinion leaders had explored learning from the Singapore system: http://www.huffingtonpost.com/2013/08/29/most-efficient-healthcare_n_3825477.html

I am a doctor in Singapore and am proud of our system.

However, people who advocate learning from the Singapore system would do well to read Dr Jeremy Lim’s Myth or Magic: the Singapore Healthcare System. He detailed what the government had to do to make our healthcare system so efficient. A lot of government intervention is required. The government controls the whole system, including the supply, the demand and the prices. Then the free market is allowed to function for the efficiency.

Whether this system can be replicated elsewhere is not something I can answer. Readers of this book can decide whether this is possible.