Tag Archives: United States

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.

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Avoid Glibenclamide for patients who are elderly or have renal failure

Finger prick meter

Photo credit:  Gualberto107/freedigitalphotos.net

Glibenclamdie (glyburide in America) is a common and useful drug for type 2 diabetes. It is effective and the blood sugar lowering effect long-lasting. However, the strength is also a weakness: it can sometimes be so powerful that the patient can suffer prolonged hypoglycemia (low blood sugar level).

The Health Sciences Authority of Singapore had looked at the data and found that in Singapore, patients who are above 60 or those with kidney failure have a much increased risk of severe and protracted hypoglycemia. They have now advised all doctors to avoid using glibenclamide in those patients.

There are many other alternative drugs in the same class such as gliclazide and they are also generics, available at a low price at our clinics.

If you are taking glibenclamide and had recently turned 60 or have renal failure, please do not stop your medicine immediately, but talk to your doctor about it.

Urine Spills in Factories Making Generic Drugs

capsulesPhoto credit: antpkr

I love the US Food and Drug Administration (FDA). They set the standards for generic drug safety, allowing small countries like Singapore to save a lot of time and money to check on the quality of generic drug manufacturing. Unfortunately, what they found in the Wockhardt factory was not pretty: urine on the floor, dirty uniform, moldy storage areas.

Yikes! I would not give my patients these drugs, no matter how cheap they are!

On the other hand, this piece of news creates a problem for doctors and patients. Generic drugs are much cheaper than the originals and allow governments to treat a lot more patients. While the rich patients would of course demand genuine medication, it is not feasible to treat everyone with expensive branded medication. We need the generics and we need to make sure that their standard of quality is good.

The best way to ensure quality compliance is spot checks. Keep up the good work, FDA!

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.

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.