Thiam Chye Tan
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gmsttc@nus.edu.sg
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Publication Development of a Supportive Parenting App to Improve Parent and Infant Outcomes in the Perinatal Period: Development Study(JMIR PUBLICATIONS, INC, 2021-12-24) Shorey, Shefaly; Tan, Thiam Chye; Thilagamangai; Mathews, Jancy; Yu, Chun Yan; Lim, Siew Hoon; Shi, Luming; Ng, Esperanza Debby; Chan, Yiong Huak; Law, Evelyn; Chee, Cornelia; Chong, Yap Seng; Dr Evelyn Chung Ning Law; DEAN'S OFFICE (MEDICINE); ALICE LEE CENTRE FOR NURSING STUDIES; DEAN'S OFFICE (DUKE-NUS MEDICAL SCHOOL); PSYCHOLOGICAL MEDICINE; ANAESTHESIA; DUKE-NUS MEDICAL SCHOOL; PAEDIATRICSBackground: The transition to parenthood can be challenging, and parents are vulnerable to psychological disorders during the perinatal period. This may have adverse long-term consequences on a child's development. Given the rise in technology and parents' preferences for mobile health apps, a supportive mobile health intervention is optimal. However, there is a lack of a theoretical framework and technology-based perinatal educational intervention for couples with healthy infants. Objective: The aim of this study is to describe the Supportive Parenting App (SPA) development procedure and highlight the challenges and lessons learned. Methods: The SPA development procedure was guided by the information systems research framework, which emphasizes a nonlinear, iterative, and user-centered process involving 3 research cycles-the relevance cycle, design cycle, and rigor cycle. Treatment fidelity was ensured, and team cohesiveness was maintained using strategies from the Tuckman model of team development. Results: In the relevance cycle, end-user requirements were identified through focus groups and interviews. In the rigor cycle, the user engagement pyramid and well-established theories (social cognitive theory proposed by Bandura and attachment theory proposed by Bowlby) were used to inform and justify the features of the artifact. In the design cycle, the admin portal was developed using Microsoft Visual Studio 2017, whereas the SPA, which ran on both iOS and Android, was developed using hybrid development tools. The SPA featured knowledge-based content, informational videos and audio clips, a discussion forum, chat groups, and a frequently asked questions and expert advice section. The intervention underwent iterative testing by a small group of new parents and research team members. Qualitative feedback was obtained for further app enhancements before official implementation. Testing revealed user and technological issues, such as web browser and app incompatibility, a lack of notifications for both administrators and users, and limited search engine capability. Conclusions: The information systems research framework documented the technical details of the SPA but did not take into consideration the interpersonal and real-life challenges. Ineffective communication between the health care research team and the app developers, limited resources, and the COVID-19 pandemic were the main challenges faced during content development. Quick adaptability, team cohesion, and hindsight budgeting are crucial for intervention development. Although the effectiveness of the SPA in improving parental and infant outcomes is currently unknown, this detailed intervention development study highlights the key aspects that need to be considered for future app development.Publication Serum progesterone distribution in normal pregnancies compared to pregnancies complicated by threatened miscarriage from 5 to 13 weeks gestation: A prospective cohort study(2018) Ku, C.W; Allen, J.C; Lek, S.M; Chia, M.L; Tan, N.S; Tan, T.C; DUKE-NUS MEDICAL SCHOOLBackground: Progesterone is a critical hormone in early pregnancy. A low level of serum progesterone is associated with threatened miscarriage. We aim to establish the distribution of maternal serum progesterone in normal pregnancies compared to pregnancies complicated by threatened miscarriage from 5 to 13 weeks gestation. Methods: This is a single centre, prospective cohort study of 929 patients. Women from the Normal Pregnancy [NP] cohort were recruited from antenatal clinics, and those in the Threatened Miscarriage [TM] cohort were recruited from emergency walk-in clinics. Women with multiple gestations, missed, incomplete or inevitable miscarriage were excluded from the study. Quantile regression was used to characterize serum progesterone levels in the NP and TM cohorts by estimating the 10th, 50th and 90th percentiles from 5 to 13 weeks gestation. Pregnancy outcome was determined at 16 weeks of gestation. Subgroup analysis within the TM group compared progesterone levels of women who subsequently miscarried with those who had ongoing pregnancies at 16 weeks of gestation. Results: Median serum progesterone concentration demonstrated a linearly increasing trend from 57.5 nmol/L to 80.8 nmol/L from 5 to 13 weeks gestation in the NP cohort. In the TM cohort, median serum progesterone concentration increased from 41.7 nmol/L to 78.1 nmol/L. However, median progesterone levels were uniformly lower in the TM cohort by approximately 10 nmol/L at every gestation week. In the subgroup analysis, median serum progesterone concentration in women with ongoing pregnancy at 16 weeks gestation demonstrated a linearly increasing trend from 5 to 13 weeks gestation. There was a marginal and non-significant increase in serum progesterone from 19.0 to 30.3 nmol/L from 5 to 13 weeks gestation in women who eventually had a spontaneous miscarriage. Conclusions: Serum progesterone concentration increased linearly with gestational age from 5 to 13 weeks in women with normal pregnancies. Women with spontaneous miscarriage showed a marginal and non-significant increase in serum progesterone. This study highlights the pivotal role of progesterone in supporting an early pregnancy, with lower serum progesterone associated with threatened miscarriage and a subsequent complete miscarriage at 16 weeks gestation. © 2018 The Author(s).Publication Treatment of recurrent vulvo-vaginal candidiasis with sustained-release butoconazole pessary(2012-12) Heng, L.Z.; Chen, Y.; Tan, T.C.; DUKE-NUS GRADUATE MEDICAL SCHOOL S'POREVulvo-vaginal candidiasis (VVC) is a common infection among women. 5% of women with acute infection experience recurrent vulvo-vaginal candidiasis (RVVC). There is currently no optimal or recommended regime for RVVC. Although antifungal agents, such as imidazoles, have been successfully used as a first-line treatment for acute VVC, its effectiveness is limited in RVVC. This could be due to patient factors, drug application (such as leakage) or dosing factors. A sustained-release (SR) bioadhesive vaginal cream (2% butoconazole nitrate) has incorporated VagiSite technology, a topical drug delivery system that allows SR of the drug. We describe its efficacy and the successful use of a butoconazole-SR formulation in the treatment of two cases of RVVC.Publication Health Promotion Board-Ministry of Health Clinical Practice Guidelines: Obesity(SINGAPORE MEDICAL ASSOC, 2016-06-01) Lee, Yung Seng; Biddle, Stuart; Chan, Mei Fen; Cheng, Anton; Cheong, Magdalin; Chong, Yap Seng; Foo, Ling Li; Lee, Chung Horn; Lim, Su Chi; Ong, Wee Sian; Pang, Jonathan; Pasupathy, Shanker; Sloan, Robert; Seow, Mollie; Soon, Grace; Tan, Benedict; Tan, Thiam Chye; Teo, Soo Lay; Tham, Kwang Wei; van Dam, Rob M; Wang, John; Dr Shu Qin Ooi; DEAN'S OFFICE (MEDICINE); SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; DUKE-NUS MEDICAL SCHOOL; PAEDIATRICSThe Health Promotion Board (HPB) has developed the Clinical Practice Guidelines (CPG) on Obesity to provide health professionals in Singapore with recommendations for evidence-based interventions for obesity. This article summarises the introduction, epidemiology and executive summary of the key recommendations from the HPB-MOH CPG on Obesity for the information of SMJ readers. The chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Health Promotion Board website: http://www.hpb. gov.sg/cpg-obesity. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines. © Singapore Medical AssociationPublication Risk score to stratify miscarriage risk levels in preconception women(Nature Research, 2021-06-08) Xin Hui Choo; Chee Wai Ku; Yin Bun Cheung; Keith M Godfrey; Yap-Seng Chong; Lynette Pei-Chi Shek; Kok Hian Tan; Thiam Chye Tan; Sadhana Nadarajah; Fabian Kok Peng Yap; Marjorelee T Colega; Mary Foong-Fong Chong; Shiao-Yng Chan; See Ling Loy; Jerry Kok Yen Chan; SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; DUKE-NUS MEDICAL SCHOOL; PAEDIATRICS; OBSTETRICS & GYNAECOLOGYSpontaneous miscarriage is one of the most common complications of pregnancy. Even though some risk factors are well documented, there is a paucity of risk scoring tools during preconception. In the S-PRESTO cohort study, Asian women attempting to conceive, aged 18-45 years, were recruited. Multivariable logistic regression model coefficients were used to determine risk estimates for age, ethnicity, history of pregnancy loss, body mass index, smoking status, alcohol intake and dietary supplement intake; from these we derived a risk score ranging from 0 to 17. Miscarriage before 16 weeks of gestation, determined clinically or via ultrasound. Among 465 included women, 59 had miscarriages and 406 had pregnancy ≥ 16 weeks of gestation. Higher rates of miscarriage were observed at higher risk scores (5.3% at score ≤ 3, 17.0% at score 4–6, 40.0% at score 7–8 and 46.2% at score ≥ 9). Women with scores ≤ 3 were defined as low-risk level (< 10% miscarriage); scores 4–6 as intermediate-risk level (10% to < 40% miscarriage); scores ≥ 7 as high-risk level (≥ 40% miscarriage). The risk score yielded an area under the receiver-operating-characteristic curve of 0.74 (95% confidence interval 0.67, 0.81; p < 0.001). This novel scoring tool allows women to self-evaluate their miscarriage risk level, which facilitates lifestyle changes to optimize modifiable risk factors in the preconception period and reduces risk of spontaneous miscarriage.Publication Macronutrient composition and food groups associated with gestational weight gain: the GUSTO study(Dr. Dietrich Steinkopff Verlag GmbH and Co. KG, 2019) Lai J.S.; Soh S.E.; Loy S.L.; Colega M.; Kramer M.S.; Chan J.K.Y.; Tan T.C.; Shek L.P.C.; Yap F.K.P.; Tan K.H.; Godfrey K.M.; Chong Y.S.; Chong M.F.F.; SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; DUKE-NUS MEDICAL SCHOOL; PAEDIATRICS; OBSTETRICS & GYNAECOLOGYPurpose: To examine the associations of energy, macronutrient and food intakes with GWG on 960 pregnant women from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) mother-offspring cohort. Methods: Dietary intake was assessed at 26–28 weeks’ gestation with a 24-hour recall and 3-day food diary. GWG z-scores were calculated from first (4–13 weeks’ gestation) and last (30–40 weeks gestation) measured weights; inadequate and excessive GWG were defined using the Institute of Medicine recommendations based on weights between 15 and 35 weeks’ gestation. Associations were examined using substitution models for macronutrient composition, with linear or multinomial logistic regressions. Results: Mean ± SD daily energy intake was 1868 ± 598 kcal, and percentage energy intakes were 51.8 ± 8.9% from carbohydrate, 15.7 ± 3.9% from protein and 32.6 ± 7.7% from fat. Higher energy intake (per 500 kcal increment) was associated with 0.18 SD higher GWG. In isocaloric diets, higher-carbohydrate and lower-fat intakes (at 5% energy substitution) were associated with 0.07 SD higher GWG, and 14% higher likelihood of excessive GWG. Concordantly, the highest tertile of carbohydrate-rich foods intake was associated with 0.20 SD higher GWG, but the highest tertile of fruit and vegetable intake was independently associated with 60% lower likelihood of inadequate GWG. Additionally, the highest tertile of dairy intake was associated with 0.18 SD lower GWG; and the highest tertile of plant-based protein foods intake was associated with 60% and 34% lower likelihood of inadequate and excessive GWG. Conclusions: Balancing the proportions of carbohydrates and fat, and a higher intake of plant-based protein foods may be beneficial for achieving optimal GWG. © 2018, Springer-Verlag GmbH Germany, part of Springer Nature.Publication An end to "see one, do one and teach one" residency training programme - Impact of the training, education, surgical accreditation and assessment (TESA) programme on medical care and patients' safety(2007-09) Tan, T.-C.; Tan, K.-T.; Tee, J.C.S.; DUKE-NUS GRADUATE MEDICAL SCHOOL S'POREIntroduction: The delivery of optimal and safe medical care is critical in healthcare. The traditional practice of "See one, do one and teach one" residency training programme is no longer acceptable. Materials and Methods: In the past, there was no structured residency training programme in our hospital. There were several cases of organ injuries from surgeries performed by the residents. In 2005, we conducted a pilot study to organise a structured teaching, education, surgical accreditation and assessment (TESA) residency programme for 15 residents in the Division of Obstetrics and Gynaecology, KK Women's and Children's Hospital. We performed a written questionnaire survey of the residents on the new programme and patients' expectation (n = 2926) as subjective outcomes in the 1-year follow-up. We also studied the complication rates of all minor and major surgeries performed by the residents in 2004 and 2005 as an objective outcome. Results: All the residents (n = 15) surveyed supported the TESA programme. Patients' expectation improved significantly from 71% in 2004 (n = 1559) to 83% in 2005 (n = 1367) (P = 0.03). There were 10,755 surgeries in 2004 and 10,558 surgeries in 2005 performed by our residents, with 6 cases (5.6%) of organ injuries in 2004 compared to 3 cases (2.8%) in 2005. This reduction was not statistically significant. Conclusion: The TESA residency programme in our hospital has an impact on the delivery of optimal and safe medical care while ensuring the training of residents to be competent specialists.Publication Hepatitis C virus mediated chronic inflammation and tumorigenesis in the humanised immune system and liver mouse model(Public Library of Science, 2017) Zheng Z.; Sze C.W.; Keng C.T.; Al-Haddawi M.; Liu M.; Tan S.Y.; Kwek H.L.; Her Z.; Chan X.Y.; Barnwal B.; Loh E.; Chang K.T.E.; Tan T.C.; Tan Y.-J.; Chen Q.; MICROBIOLOGY AND IMMUNOLOGY; DUKE-NUS MEDICAL SCHOOLHepatitis C is a liver disease caused by infection of the Hepatitis C virus (HCV). Many individuals infected by the virus are unable to resolve the viral infection and develop chronic hepatitis, which can lead to formation of liver cirrhosis and cancer. To understand better how initial HCV infections progress to chronic liver diseases, we characterised the long term pathogenic effects of HCV infections with the use of a humanised mouse model (HIL mice) we have previously established. Although HCV RNA could be detected in infected mice up to 9 weeks post infection, HCV infected mice developed increased incidences of liver fibrosis, granulomatous inflammation and tumour formation in the form of hepatocellular adenomas or hepatocellular carcinomas by 28 weeks post infection compared to uninfected mice. We also demonstrated that chronic liver inflammation in HCV infected mice was mediated by the human immune system, particularly by monocytes/macrophages and T cells which exhibited exhaustion phenotypes. In conclusion, HIL mice can recapitulate some of the clinical symptoms such as chronic inflammation, immune cell exhaustion and tumorigenesis seen in HCV patients. Our findings also suggest that persistence of HCV-associated liver disease appear to require initial infections of HCV and immune responses but not long term HCV viraemia. © 2017 Zheng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Publication A Novel Human Systemic Lupus Erythematosus Model in Humanised Mice /631/250/38 /631/250/256/2515 /13/21 article(Nature Publishing Group, 2017) Gunawan, M; Her, Z; Liu, M; Tan, S.Y; Chan, X.Y; Tan, W.W.S; Dharmaraaja, S; Fan, Y; Ong, C.B; Loh, E; Chang, K.T.E; Tan, T.C; Chan, J.K.Y; Chen, Q; MICROBIOLOGY AND IMMUNOLOGY; DUKE-NUS MEDICAL SCHOOL; OBSTETRICS & GYNAECOLOGYMouse models have contributed to the bulk of knowledge on Systemic Lupus Erythematosus (SLE). Nevertheless, substantial differences exist between human and mouse immune system. We aimed to establish and characterise a SLE model mediated by human immune system. Injection of pristane into immunodeficient mice reconstituted with human immune system (humanised mice) recapitulated key SLE features, including: production of human anti-nuclear autoantibodies, lupus nephritis, and pulmonary serositis. There was a reduction in the number of human lymphocytes in peripheral blood, resembling lymphopenia in SLE patients. Concurrently, B cells and T cells were systemically hyperactivated, with a relative expansion of CD27+ and CD27-IgD- memory B cells, increased number of plasmablasts/plasma cells, and accumulation of effector memory T cells. There was also an increased production of human pro-inflammatory cytokines, including: IFN-?, IL-8, IL-18, MCP-1, and IL-6, suggesting their role in SLE pathogenesis. Increased expression of type I IFN signature genes was also found in human hepatocytes. Altogether, we showed an SLE model that was mediated by human immune system, and which recapitulated key clinical and immunological SLE features. The advancements of humanised mice SLE model would provide an in vivo platform to facilitate translational studies and pre-clinical evaluations of human-specific mechanisms and immunotherapies. © 2017 The Author(s).Publication Gestational age-specific normative values and determinants of serum progesterone through the first trimester of pregnancy(Nature Research, 2021-02-18) Ku, Chee Wai; Zhang, Xiaoxuan; Zhang, Valencia Ru-Yan; Allen, John Carson; Tan, Nguan Soon; Østbye, Truls; Tan, Thiam Chye; DUKE-NUS MEDICAL SCHOOLProgesterone is a steroid hormone that is critical for implantation and maintenance of pregnancy, and low levels are associated with higher miscarriage risk. However, little is known about its trajectory during early pregnancy. We sought to determine the gestational age-specific normative values of serum progesterone on a week-by-week basis, and its associated maternal and fetal factors, during the first trimester of a viable low-risk pregnancy. A cross-sectional study was conducted at KK Women’s and Children’s Hospital from 2013 to 2018. 590 women with a single viable intrauterine low-risk pregnancy, between gestational weeks 5 and 12, were recruited. Serum progesterone showed an increasing trend during the first trimester, with a transient decline between gestational weeks 6–8, corresponding to the luteal–placental shift. Lowest levels were seen at week 7. Maternal age, BMI, parity, gestational age and outcome of pregnancy at 16 weeks’ gestation were found to be associated with progesterone levels. Normative values of serum progesterone for low-risk pregnancies would form the basis for future work on pathological levels of serum progesterone that may increase risk of miscarriage. Larger studies are required to validate these normative values, and personalize them to account for maternal age, BMI, parity and gestational age. © 2021, The Author(s).