Background: This study aims to evaluate the inter-rater reliability and perceived usability of a newly developed drug-related problem (DRP) classification system for use by pharmacists in the intermediate and long-term care (ILTC) setting in Singapore. Methods: This was a cross-sectional survey study involving the use of a self-administered questionnaire. All 55 pharmacists affiliated to the Pharmaceutical Society of Singapore (PSS) ILTC Pharmacists Workgroup who were above 21 years old and not authors of the classification system were invited to participate. The inter-rater reliability of participants’ classification of 46 mock DRP cases using the new DRP classification system was determined using Fleiss’s kappa (κ). Participants’ perceived usability of the classification system was evaluated using six items with five-point Likert scales (1—“strongly disagree”, 5—“strongly agree”). Results: Thirty-three pharmacists responded to the survey. Overall inter-rater reliability was found to be substantial (κ = 0.614; 95% CI: 0.611–0.617). All usability items received positive ratings (“strongly agree” or “agree”) from at least 69% of participants. Conclusion: The new DRP classification system has substantial external validity and appears to be suitable for use by pharmacists to document and report DRPs in the ILTC setting in Singapore and facilitate evaluation of the impact of pharmaceutical care in the ILTC setting.

Objective: Optimizing glycemic control is challenging with insulin non-adherence. This study aimed to characterize the prevalence of non-adherence among Singaporean pediatric patients with type 1 diabetes mellitus (T1DM) and investigate its associated outcomes. Methods: Singaporean patients with T1DM aged ≤18 years old with ≥1 year of insulin prescription between 2012 and 2016 were included in this retrospective, single-center longitudinal study. Patients on insulin pumps were excluded from the study. Non-adherence was defined as medication possession ratio (MPR) <100%. Glycemic control was defined using mean hemoglobin A1c (HbA1c) within the study period. Health-care utilization was defined as the number of outpatients, inpatient, and emergency visits. The t-test, Chi-square test, logistic regression, and Poisson regression were used to analyze means, proportions, factors associated with non-adherence, and association of non-adherence and health-care utilization, respectively. Sensitivity analyses were performed for MPR thresholds of 80% and 95%. Results: A total of 206 patients were included in this study. Non-adherent patients were older, had a longer duration of diabetes since diagnosis and shorter duration of follow-up. Gender, race, financial class, and number of concurrent medications were comparable between groups. The prevalence of non-adherence was 34.0% (95% confidence interval [CI]: 27.9–40.7%). Non-adherent patients had a higher average HbA1c (non-adherent: 9.6% [2.1] vs. adherent: 8.6% [1.3], p<0.001). Non-adherence was not associated with health-care utilization. Patients with >5 years of diabetes were more likely to be non-adherent. Conclusion: Non-adherence defined as MPR <100% is associated with poorer glycemic control. Further interventions may focus on patients with >5 years of diabetes to improve their adherence to insulin therapy.

Esophageal perforation is associated with high morbidity and mortality. Early detection and treatment are vital as delays substantially increases mortality risk. Management options include surgical repair, drainage, diversion, endoscopic stenting/clipping and conservative management. Treatment of choice depends on etiology, location and duration between perforation and detection. Surgical repair remains as the mainstay of treatment if perforation is diagnosed &lt;24 hours. However, for perforation detected &gt; 24 hours, management is controversial with many advocating non-operative therapy. We present the case of a 68-year-old gentleman who underwent laparoscopic repair of an iatrogenic esophageal perforation. He first presented with dysphagia secondary to esophageal peptic stricture, initial biopsy showing no signs of malignancy. Patient underwent serial endoscopic dilatations, which was complicated with an iatrogenic esophageal perforation during his second dilatation. He underwent an urgent laparoscopic distal esophagectomy and proximal gastrectomy to resect the diseased part of the esophagus- intraoperatively noted a 1cm perforation over distal esophagus. A double tract reconstruction was then performed to restore continuity of the gastrointestinal tract and reduce gastric reflux to the esophagus. Patient was started on clear feeds on post-operative day 1 with gradual escalation of feeding to soft diet on post-operative day 4. His post-operative recovery was largely uneventful and he was discharged on post-operative day 7. Histological examination however returned as a pT3N1a moderately differentiated oesophageal squamous cell carcinoma. A PET-CT scan and repeat gastroscopy done showed no residual or distant disease. His condition was discussed in multidisciplinary meeting and patient then underwent definitive chemotherapy and radiotherapy. Although early recognition, detection and treatment of esophageal perforation are important for good outcomes, delays in diagnosis and treatment are usually due to rarity of this condition and lack of familiarity with management. Our video aims to showcase the surgical repair of a distal esophageal perforation and reconstruction in a minimally invasive fashion. Aim of surgery should include repair of perforation, cleaning up contamination, restoring gastrointestinal continuity and resolution of any underlying etiology.

During the six-month period February to July 2022, the service engaged with 83 participants. End-of-life and ACP conversations were facilitated with 77 (93%) of these clients and 64 (78%) participants progressed their ACP documentation. Fourteen (12%) participants identified as culturally diverse, 5 (4%) self-identified as living with a disability and 2 (2%) reported belonging to the LGBTIQA+ community. Based on these initial positive results, Carers WA has extended the pilot for a further 12 months and additional funding has been provided to employ another ACP Support Officer. Conclusion Findings from the ACP Support Pilot strongly suggest that one-to-one support results in increased ACP discussions and completion of associated documentation. Further research is needed to consolidate initial findings and identify any implications.

Oesophageal diverticulum is a rare cause of dysphagia. They are classified based on location- Zenker’s diverticulum distal to the cricopharyngeus; epiphrenic diverticulum above the lower oesophageal sphincter (LES)- or pathophysiology – traction vs pulsion. The prevalence of epiphrenic pulsion diverticulum ranges from 0.2% to 0.8%. We present a case of epiphrenic diverticulum and its management. A 68 year old lady presents with dysphagia to solids and liquids, belching, food regurgitation, and acid brash for 10 years. She had no loss of weight, but experienced daily regurgitation and occasional retrosternal pain. Physical examination was unremarkable. We worked her up with further investigations and scans. A CT abdomen reported a hiatus hernia and mural thickening of distal oesophagus with upstream oesophageal distension. A oesophagogastroduodenoscopy showed residual food in oesophagus. The lower oesophagus was dilated and the LES appeared tight with no masses. There was no hiatus hernia on endoscopy. Barium swallow revealed the lower oesophageal dilatation to be an epiphrenic diverticulum. Manometry studies showed oesophago-gastric junction outflow obstruction. She underwent laparoscopic excision of esophageal diverticulum, cardiomyotomy and anterior partial fundoplication. The video serves to highlight the surgical key steps. She was discharged on post-operative day 3 without complications and barium swallow pre/post op as shown. Oesophageal diverticulum, although rare, remains a differential for dysphagia. For epiphrenic diverticulum, it is important to understand that this is a pulsion diverticulum, with an accompanying gastro-oesophageal outflow obstruction. In addition to surgical management with a laparoscopic diverticulectomy, a cardiomyotomy and partial fundoplication to treat underlying motility disorder is important. This case study and video serves to highlight the condition and present minimally invasive surgical management.