Clinical practice poster session 13
Track 13
| Thursday, October 26, 2023 |
| 1:30 PM - 2:05 PM |
| Exhibition Hall |
Speaker
Dr Wongani Kumwenda
Family Medicine Registrar
Kamuzu University of Health Sciences
How to take an informed consent in a setting of language barrier?
Summary
Background
Before taking a patient for surgery, a surgeon needs to take an informed consent. This allows the patient to know what exactly will happen: it includes the step by step process of the procedure, possible anticipated complications and the patient is told any other alternatives to the procedure. This becomes complicated when there are language differences between the patient and the surgeon. Ways to try bridge these gaps have been solicited but there is still a challenge in low resource settings where it relies mostly on human interpreters who can omit or not know how to interpret some medical terms as such this becomes a challenge to the surgeon and poses a threat to the patient.
Case report
A 30-year-old female, presented with infected wounds. She presented 2 weeks after sustaining burns from an open flame as she had an epileptic seizure as she was cooking. She had gone to seek help from a traditional healer but saw no improvement so decided to come to the facility. On admission, wounds were debrided and was being dressed daily with chlorine. To prevent contractures to the right eye lid, she was done a full thickness skin graft and the donor site was the abdomen. After the procedure, she complained of why the graft was taken on the abdomen and not the thigh. She was worried that her appearance will affect her marriage.
Discussion
Reasons to why this had occurred were looked into and it was found that the informed consent was in English only and it was generalized for all procedures: making it easy for the surgeon or interpreter to forget. Plans to come up with a translated informed consent and specific procedure informed consents in addition to what was already being done were discussed.
Before taking a patient for surgery, a surgeon needs to take an informed consent. This allows the patient to know what exactly will happen: it includes the step by step process of the procedure, possible anticipated complications and the patient is told any other alternatives to the procedure. This becomes complicated when there are language differences between the patient and the surgeon. Ways to try bridge these gaps have been solicited but there is still a challenge in low resource settings where it relies mostly on human interpreters who can omit or not know how to interpret some medical terms as such this becomes a challenge to the surgeon and poses a threat to the patient.
Case report
A 30-year-old female, presented with infected wounds. She presented 2 weeks after sustaining burns from an open flame as she had an epileptic seizure as she was cooking. She had gone to seek help from a traditional healer but saw no improvement so decided to come to the facility. On admission, wounds were debrided and was being dressed daily with chlorine. To prevent contractures to the right eye lid, she was done a full thickness skin graft and the donor site was the abdomen. After the procedure, she complained of why the graft was taken on the abdomen and not the thigh. She was worried that her appearance will affect her marriage.
Discussion
Reasons to why this had occurred were looked into and it was found that the informed consent was in English only and it was generalized for all procedures: making it easy for the surgeon or interpreter to forget. Plans to come up with a translated informed consent and specific procedure informed consents in addition to what was already being done were discussed.
Takeaways
1. Identify ways to improve on how acquire an informed consent in their respective settings
Biography
Wongani is a first year student pursuing Master of family Medicine at Kamuzu University of health sciences in Malawi. She has special interest in research: quality improvement. She is inquisitive and wants to learn either at her colleagues and even patients she sees everyday.
Dr Woo-young Shin
Chung-ang University College Of Medicine
Patterns of patients with polypharmacy in adult population from Korea
Summary
Polypharmacy and its rising global prevalence is a growing public health burden. Using a large representative nationwide Korean cohort (N= 761,145), we conducted a retrospective cross-sectional study aiming to identify subpopulations of patients with polypharmacy and characterize their unique patterns through cluster analysis. Patients aged ≥30 years who were prescribed at least one medication between 2014 and 2018 were included in our study. Six clusters were identifed: cluster 1 mostly included patients who were hospitalized for a long time (4.3± 5.3 days); cluster 2 consisted of patients with disabilities (100.0%) and had the highest mean number of prescription drugs (7.7± 2.8 medications); cluster 3 was a group of low-income patients (99.9%); cluster 4 was a group of highincome patients (80.2%) who frequently (46.4 ± 25.9 days) visited hospitals/clinics (7.3± 2.7 places); cluster 5 was mostly elderly (74.9 ± 9.8 years) females (80.3%); and cluster 6 comprised mostly middleaged (56.4 ± 1.5 years) males (88.6%) (all P< 0.001). Patients in clusters 1–5 had more prescribed medications and outpatient visit days than those in cluster 6 (all P< 0.001). Given limited health care resources, individuals with any of the identifed phenotypes may be preferential candidates for participation in intervention programs for optimal medication use.
Takeaways
1. This is the frst study to determine subpopulations of patients with polypharmacy and characterize their patterns in a large nationwide cohort.
2. We identifed six distinct phenotypes of patients with polypharmacy in the Korean adult population.
3. These fndings could contribute to reducing the burden of inappropriate polypharmacy and facilitate appropriate medication use by developing tailored strategies for patients with diferent tendencies and characteristics.
2. We identifed six distinct phenotypes of patients with polypharmacy in the Korean adult population.
3. These fndings could contribute to reducing the burden of inappropriate polypharmacy and facilitate appropriate medication use by developing tailored strategies for patients with diferent tendencies and characteristics.
Biography
Woo-young Shin is currently working in the department of Family Medicine, at Chung-ang University Gwangmyeong Hospital in Gwangmyeong, South Korea, specialising in geriatrics. Woo-young has been treating a variety of geriatric diseases in older patients, as well as providing primary care including the management of chronic diseases for patients in the community.
Dr Cheridine Oro-Josef
National Board Of Trustee
Philippine Academy of Family Physicians
Management of Covid 19 among older women in a retirement facility
Summary
Covid 19 (SARS COV 2) has affected the elderly more than any vulnerable age group. In a retirement home of medical missionary nuns, several older women 80 and above contracted COVID19 all at the same time. They were all symptomatic with positive rapid antigen test results. Immediate isolation of cases was done and a daily monitor for vital signs and oxygen saturation were documented. Despite some presenting with worsening symptoms, no hospitalization was done. Conservative supportive management was advocated using oxygen for respiratory support, symptomatic treatment, antimicrobials for those deemed necessary, community support and counseling were primarily initiated. Teleconsultation with Family Physician/ Geriatrician was helpful to isolated patients. The goal of this presentation is to share clinical experience in handling older persons with Covid 19 infection living in retirement facilities without resorting to hospitalization.
Takeaways
1. Managing older persons with Covid 19 in a retirement facility is complex yet possible
2. Counseling and Traditional Supportive Therapy is helpful in managing emerging infectious diseases
3. Older persons , though vulnerable, may survive Covid 19 while being managed at home
2. Counseling and Traditional Supportive Therapy is helpful in managing emerging infectious diseases
3. Older persons , though vulnerable, may survive Covid 19 while being managed at home
Biography
Dr. Cheridine Oro- Josef is a practicing Geriatric Medicine and Family Medicine Specialist in Marikina and surrounding areas.
She finished Medicine and Surgery at the Royal and Pontifical University of Santo Tomas, did her Residency Training in Family and Community Medicine in the same institution and went into Fellowship in Geriatrics with the Philippine College of Gerontology and Geriatrics, Inc. She then went on to earn a Masters Degree in Management, Major in Hospital Administration.
After her Residency Training, she joined several multispecialty and HMO clinics as a Family Medicine Specialist. However, she decided to go into private practice and has established her own name in Marikina. She started in a small clinic in Nangka and Sto. Nino where her patients rapidly grew in number in a short period of time. During this time, she volunteered her services to the City Health Office, Senior Citizens Clinic and in 2010, organized the Above 60 Academy which now has more than 200 members attending her monthly educational programs and lectures. Dr. Josef would go to several communities and even organized a Seniors for Seniors program where the older persons find time to visit those who are bedridden or abandoned older persons. She empowers senior citizens and helps them understand their aging process. Thanks to her, older persons are more aware of their health concerns and the physiologic changes of aging. In 2016, the need to educate the younger population regarding care for the elderly gave rise to the Teen Academy which is a partnership program with DepEd Marikina. Student Council leaders of public and private schools in Marikina were educated on the plight of the older persons. Training programs and mentoring was established. Public school teachers also benefitted from the expertise of Dra Josef. Teleconsultations were set up especially during the pandemic. Retired and retiring teachers were given lectures on what to anticipate in the coming of years.
Dr. Josef now holds several clinics in Marikina: St Ignatius Multispecialty and Health Care Services, St. Vincent General Hospital and Marikina Doctors Hospital and Medical Center. She attends to her patients daily. She practices both Family and Geriatric Medicine. Seventy percent of her patients are elderly but as a primary care provider, she attends to all cases and does proper referral to other specialists when necessary. Dr. Josef also manages patients in the hospital as well as their homes. She schedules home visits to patients who are bedridden and unable to visit her clinic. She also has teleconsultation schedule for those who are in need of such. She has also regularly made multiple on screen appearances across many notable tv and radio networks such as GMA, DZMM, CNN and DZRV-AM (better known on air as Radio Veritas).
Aside from clinic practice, Dr Josef is a part time Faculty and Special Lecturer for Ateneo School of Medicine and Public Health as well as the Miriam College, College of Arts and Sciences and College of Psychology. She handles modules on Geriatric Care and Healthy Aging Certificate Courses.
Dr. Josef is an active member of the Marikina Valley Medical Society. She does community projects with the society especially the partnership with DepEd Marikina where she encouraged MVMS members to help in managing teachers and staff of the department. She would also join activities as volunteer physician, as member or as speaker.
In the community, she has joined and initiated projects as an Inner Wheel Club officer and as a wife of a Rotarian. She is also an active parent coordinator for her children’s school, Ateneo Senior High School and PAREF Rosehill School.
Dr CHUNG WAI NG
Singapore Health Services
Leveraging on information technology and vaccine logic to support to vaccine providers and safeguard against vaccination errors in primary care
Summary
Vaccination is an important preventive strategy in primary care against vaccine-preventable diseases. For a large public primary care institution in Singapore that provides large volume of vaccination to the masses, vaccination errors remain a great challenge. Errors include administration of vaccine doses before the minimum age, administration beyond recommended age, inadequate interval between doses, dose duplication, and administering too soon after recent receipt of antibody-containing products. Errors may result in suboptimal immune response with reduced vaccine efficacy, the need to repeat the invalid dose, increased risk of adverse reactions, increased cost, logistic burden of rescheduling, the need for service recovery, and distress to patient and healthcare staff.
To reduce vaccination errors, a team of family physicians and primary care nurses collaborate with medical informatics team to create a smart system, by leveraging on our existing electronic medical records and information technology (IT). The system, which is based upon a vaccine logic, can (1) detect and flag up inappropriate instances for vaccination, and (2) provide decision support to clinical staff during routine patient care. Decision support is provided via visual alerts that guide clinical staff on whether to reschedule a vaccine dose, or escalate the situation to a senior colleague for advice. The system is tested using mock scenarios in a test environment before being used in actual clinical care.
The challenges and lessons learnt in the process are discussed. Also outlined, are the principles behind the use of IT to facilitate safe administration of vaccines to the masses.
To reduce vaccination errors, a team of family physicians and primary care nurses collaborate with medical informatics team to create a smart system, by leveraging on our existing electronic medical records and information technology (IT). The system, which is based upon a vaccine logic, can (1) detect and flag up inappropriate instances for vaccination, and (2) provide decision support to clinical staff during routine patient care. Decision support is provided via visual alerts that guide clinical staff on whether to reschedule a vaccine dose, or escalate the situation to a senior colleague for advice. The system is tested using mock scenarios in a test environment before being used in actual clinical care.
The challenges and lessons learnt in the process are discussed. Also outlined, are the principles behind the use of IT to facilitate safe administration of vaccines to the masses.
Takeaways
1. How a smart system detects inappropriate vaccination instances: the concept of vaccine logic.
2. Point-of-contact decision support that is useful for the clinician on the ground.
3. Challenges and lessons encountered in the use of a smart system: what are the assumptions and limitations, how does the system fail, and when does clinical assessment override automation.
2. Point-of-contact decision support that is useful for the clinician on the ground.
3. Challenges and lessons encountered in the use of a smart system: what are the assumptions and limitations, how does the system fail, and when does clinical assessment override automation.
Biography
Dr Ng Chung Wai Mark is a family physician in Singapore. He graduated from the National University of Singapore in 1996 and has been a practicing clinician in the primary care setting since 2000. Currently he chairs the Infection Prevention and Control Committee and oversees infection prevention processes in the institution. His is also the associate program director and core faculty of the SingHealth Family Medicine Residency Program. His areas of interest include infectious diseases, travel medicine, vaccines, medical education and primary care dermatology.
Dr Clara Apollos
Family Medicine Resident
Ministry of Health Holdings, Singapore
When HbA1c misleads: A case report
Summary
Introduction:
Haemoglobin A1c (HbA1c) can provide a reliable measure of average blood glucose levels over the previous two to three months. It is widely used to monitor glycaemic control in patients with diabetes mellitus. However, its accuracy is not guaranteed.
Case Report:
A 71-year-old male with type 2 diabetes mellitus, hypertension and hyperlipidemia presented to his General Practitioner for routine care. His HbA1c was 6.0% (42 mmol/mol). It ranged 4.8%-6.4% (29-46 mmol/mol) over the past three years. Fasting plasma glucose on the same visit was 13.9 mmol/L and liver panel showed stable transaminitis. Self-monitoring of blood glucose (SMBG) indicated fasting pre-breakfast levels ranging between 9-11 mmol/L and post-prandial levels of 11-15 mmol/L. Other medical history includes non-alcoholic steatohepatitis with hepatocellular carcinoma (currently in remission after resection and transarterial chemoembolisation in 2021). Given the discrepancy between HbA1c and glucose readings, his medications were titrated based on SMBG readings. Dose of metformin was increased from 250mg BD to 500mg BD, improving glycaemic control.
Discussion:
The incongruence between the HbA1c and the other glycaemic readings is likely due to chronic liver disease which increases erythrocyte turnover, causing spuriously low HbA1c readings. Other conditions that alter erythrocyte production and/or survival with inaccurate HbA1c readings include renal failure, haemoglobinopathies, haemolytic anaemias and bone marrow suppression.
Fructosamine and glycated albumin are alternative blood tests that reflect average glucose over the preceding two to three weeks. SMBG enables patients to record their glycaemic control, but require multiple sampling of capillary blood glucose. Continuous Glucose Monitoring systems have gained traction recently.
Conclusion:
HbA1c is not always a reliable reflection of glycaemic control in diabetics. Primary care practitioners must be wary of confounding factors and use other methods of monitoring glycaemic control where required.
Haemoglobin A1c (HbA1c) can provide a reliable measure of average blood glucose levels over the previous two to three months. It is widely used to monitor glycaemic control in patients with diabetes mellitus. However, its accuracy is not guaranteed.
Case Report:
A 71-year-old male with type 2 diabetes mellitus, hypertension and hyperlipidemia presented to his General Practitioner for routine care. His HbA1c was 6.0% (42 mmol/mol). It ranged 4.8%-6.4% (29-46 mmol/mol) over the past three years. Fasting plasma glucose on the same visit was 13.9 mmol/L and liver panel showed stable transaminitis. Self-monitoring of blood glucose (SMBG) indicated fasting pre-breakfast levels ranging between 9-11 mmol/L and post-prandial levels of 11-15 mmol/L. Other medical history includes non-alcoholic steatohepatitis with hepatocellular carcinoma (currently in remission after resection and transarterial chemoembolisation in 2021). Given the discrepancy between HbA1c and glucose readings, his medications were titrated based on SMBG readings. Dose of metformin was increased from 250mg BD to 500mg BD, improving glycaemic control.
Discussion:
The incongruence between the HbA1c and the other glycaemic readings is likely due to chronic liver disease which increases erythrocyte turnover, causing spuriously low HbA1c readings. Other conditions that alter erythrocyte production and/or survival with inaccurate HbA1c readings include renal failure, haemoglobinopathies, haemolytic anaemias and bone marrow suppression.
Fructosamine and glycated albumin are alternative blood tests that reflect average glucose over the preceding two to three weeks. SMBG enables patients to record their glycaemic control, but require multiple sampling of capillary blood glucose. Continuous Glucose Monitoring systems have gained traction recently.
Conclusion:
HbA1c is not always a reliable reflection of glycaemic control in diabetics. Primary care practitioners must be wary of confounding factors and use other methods of monitoring glycaemic control where required.
Takeaways
1. Confounding factors that may affect HbA1c
2. When to suspect a spurious HbA1c result
3. Alternative methods of monitoring glycaemic control in patients with diabetes mellitus
2. When to suspect a spurious HbA1c result
3. Alternative methods of monitoring glycaemic control in patients with diabetes mellitus
Biography
Clara Apollos graduated medical school in the midst of the COVID-19 pandemic and is currently a Family Medicine resident with SingHealth in Singapore.
