This is an intensive 5 hour instructional course intended to familiarize participants with the basics of echocardiography in children. All participants will receive direct practical instruction from experienced cardiac ultrasonographers and paediatric cardiologists.

There will be abundant opportunities for hands-on scanning of children and adolescents specially recruited for the course with more than two thirds of course time dedicated to supervised echocardiography by participants.

By the end of the course, all participants should be familiar with basic echocardiographic applications and the acquisition of fundamental echocardiographic views. There will be lectures on applications of echocardiography in systemic and non cardiac illness.

To register, please contact Ms 6772 4408, or email paefs@nus.edu.sg.
Click here for more details.

Assessment Of Health-Related QoL

1. HRQoL Assessment In SLE Patients In Singapore
2. HRQoL Assessment In Cancer Patients In Singapore
3. Figuring Out The Factors: Clinimetric And Psychometric Measures Of HRQoL Of Rhinitis Patients In Singapore
4. Measuring Health Utilities In Singapore

The assessment of HRQoL in Asia has been largely based on translated, (possibly) culturally adapted, and validated instruments originally developed in Europe and North America. A recent review showed that some major HRQoL instruments do not yet have a Chinese version available; many more do not have a Malay or Tamil version (Cheung and Thumboo, PharmacoEcon 2006). There are also other problems like non-response to sensitive questions, which are much more pronounced in Asian than Caucasian populations (Cheung et al., Qual Life Res 2006).

This track aims to (a) review the state of HRQoL assessments in Singapore, (b) discuss some latest research in Singapore, and (c) discuss the needs for and direction of further research.

Dermatology
Focus On Dermatological Diseases In The Asian Skin

1. Managing Childhood Atopic Dermatitis - Our Experience In Singapore
2. Tropical Cutaneous Infections
3. Photodermatoses In Asians
4. Pigmentary Disorders In Asian Skin

This Dermatology track focuses on common and important dermatological conditions seen in the clinics, with an emphasis on the ‘uniquely Asian’ aspects of these conditions. The Asian skin is more prone to developing pigmentary problems and these will be highlighted in the talk on Pigmentary disorders in Asian skin. We will also be covering Tropical cutaneous infections, as a number of important cutaneous infections such as leprosy are far more prevalent in Asians. There will also be a talk on the Photodermatoses in Asians, highlighting the photodermatoses more commonly encountered in Asian patients. Atopic dermatitis is a very common and chronic skin disease and we will look at the Singapore experience in managing this challenging disease.

Endocrinology Symposium

1. A Brave New World - Transplant Endocrinology (Made Easy)
2. Osteoporosis - What Is New?
3. Evaluation Of Thyroid Nodules - What Clinicians Need To Know

Enabled by advances in medical science, endocrinologists (and internists) are confronted with many new challenges. One of these evolving fields is transplant endocrinology. Proliferation of solid organ, hematologenous and cell-based transplant in many disciplines together with the use of growing gamut of immuno-suppressives with profound endocrine and metabolic actions, transplant endocrinology proves to be a brave new world for the practicing physicians.

Osteoporosis, a worldwide public health concern, especially in an aging population like Singapore, has made tremendous advances in prediction, imaging and pharmacotherapy. The discussant will provide in-depth review of the field beyond bone mineral density and bisphosphonates.

Evaluation of thyroid nodule (both solitary and multiple) is a common clinical dilemma. Assessment of thyroid hormono-genesis function, anatomical compression and mitogenicity which directly affects the downstream management plan requires careful considerations. The lecturer with extensive personal experience in this field will share his insights and clinical pearls.

Haematology – Oncology
NK-T Cell Lymphoma - An Asian Phenotype

1. Diagnostic Issues in NK-T Cell lymphoma
2. Unraveling Molecular Genetics of NK-T Cell lymphoma
3. Therapeutic Frontiers in NK-T Cell lymphoma

NK-T cell lymphoma is a subtype of Non-Hodgkin's lymphoma that is much more prevalent in the East compared to the West. This disease has a very poor prognosis with limited therapeutic avenues. The lack of progress stem from a lack of understanding of disease biology. Advances in genetics and molecular biology in recent years, have provide new opportunities to understand this disease. These progress may lead to better diagnosis and treatment of the disease.

Neurology
The Burden Of Neurological Diseases

1. The Global Burden Of Neurological Disease With Special Reference To Nervous System Infections
2. The Burden of Parkinson's Disease in Singapore
3. Stroke: Insights On Emerging Treatments And Preventions

To present the direction of the burden of common neurological disease and how this is changing and can be best prevented and influenced.

The commonest neurological problem in general practice is that of Headache and other common ailments are Stroke and Neurodegenerative diseases such as Parkinsons disease. In the four sessions an emphasis is placed on prevention and cost effective as well as novel treatments of each of the four diseases.

Nursing
Transforming Nursing Practice To Impact Global Healthcare 

1. Transforming Nursing: The Global Road
2. Transforming Nursing: The TTSH Journey
3. Transforming Nursing Through Research And Evidence-Based Practice
4. Transforming The Way We Learn / Teach
5. Evidence Based Practice: Transforming The Way We Deliver Care

The Keynote Speaker will be touching on Nursing in the region versus Nursing in Singapore (benchmarking) and our professional strides towards excellence. Issues discussed include how we shine (e.g. empowered nurses) and where we lag; how we position ourselves as the Asian nursing model of excellence and whether nursing in Singapore can serve as the benchmark for others.

This track will also cover how we have impacted healthcare via improved nurse-patient ratios, decreased cost through lower LOS and better patient outcomes; improved patient survival rates, improved patient knowledge, higher educated and better empowered nurses.

Finally, we will also look at nursing in Singapore:
1. Have we transformed nursing through data-driven decision making?
2. How can we challenge nurses to take nursing to new heights for better outcomes &
3. How higher education can assist in the transformation? (APNs, degree nurses)

Psychiatry & Addictions  

1. Gambling Disorder – Current Diagnostic and Treatment Perspectives
2. Gambling Disorder – Case Study
3. Alcohol and Substance Use Disorders: Current Treatment Perspectives (1)
4. Alcohol and Substance Use Disorders: Current Treatment Perspectives (2)
5. Addiction and Family: From A Community and Treatment Perspective - "When Your Loved One Can’t Do Without It”

Synopsis:

Gambling Disorders: Current Diagnostic and Treatment Perspectives
Gambling addiction is a relatively new area in the field of addiction. An overview of current screening, diagnostic and treatment approaches for this disorder will be presented. It will also provide an introduction to the roles of the counsellor and the gambling treatment services offered at the National Addictions Management Service.

Alcohol and Substance Use Disorders: Current Treatment Perspectives
There is widespread misconception that alcohol/ substance abuse treatment is not effective. There are now extensive data showing that addiction is eminently treatable if the treatment is well delivered and tailored to the needs of the individual. This presentation will provide an overview of current behavioral and pharmacological treatments that can help manage alcohol/ substance use disorders, prevent relapse and restore people to productive functioning in society. It will also give a brief introduction to the addiction treatment provided by the National Addictions Management Service (NAMS).

Addiction and Family: From A Community and Treatment Perspective-
"When Your Loved One Can’t Do Without It”
Participants will learn about the impact of addiction on the family, the roles that families play in supporting recovery and treatment, as well as the challenges involved. This workshop also integrates perspectives from early detection by community based agencies to completion of clinical treatment.

Psychiatry (TCR & Neuroscience)
Translational And Clinical Research In Neuroscience: Vulnerability,
Disease Progression, And Treatment In Schizophrenia And Related Psychoses   

1. Clinical Trial With A Neurosteroid Targeting Cognitive And Negative Symptoms In Schizophrenia
2. Longitudinal Youth-At-Risk Study
3. Understanding The Genetic Architecture Of Neurocognitive Endophenotypes In Schizophrenia
4. Genetic Study Of Schizophrenia In Chinese Population

The overall objective of the TCR in Neuroscience Flagship Programme is to identify key genetic, biological, cognitive, clinical and social risk factors for psychotic disorders, and establish the efficacy & safety of a neurocognitive enhancer for schizophrenic patients. Not only will this programme significantly contribute to the basic understanding of the disease process, it will provide a better means of identifying individuals who are at risk of developing psychosis.

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Research Career Development Symposium

1. Biomedical strategy on developing Clinician Investigators
2. Senior Clinician Investigator - Motivating the Next Generation
3. Mid-careered Clinician Investigator - Window of Opportunities in Research
4. Young Clinician Investigator - The First Spark

Synopsis:
The NHG Research & Development Office (RDO) administers two major funding programmes to support clinicians who want to pursue a research career.

(1) NHG-NUS Clinician Leadership in Research (CLR)
The CLR programme is a joint collaboration between the National Healthcare Group and the National University of Singapore. The aim of this programme is to nurture clinician scientists and researchers. This programme combines a one-to-one mentorship, assessment and a follow-through training programme. Young investigators will have the choice to pursue one of the three available tracks while on this programme i.e. clinical research, translational research or health services research.

(2) Investigator-Clinician (IC) Track
The IC career track in NHG is for doctors who wish to pursue research as their primary career. Emplacement on the IC track is on an invitation basis only. NHG-RDO will identify / shortlist candidates from the cluster’s research talent pool (doctors who have won NHG or national-level research grants or research scholarships) for consideration.

During the symposium, we will be awarding the new 2009 CLR candidates and graduating our 2007-2008 CLR awardees. NHG will also be awarding the first cohort of Clinical Research Coordinators who successfully passed the CCRP (Certification in Clinical Research Professional) examination, an internationally recognised certification administered by the Society of Clinical Research Associates (SoCRA). A newly appointed IC track awardee is currently undergoing an overseas research stint at the The Christie NHS Foundation Trust, Manchester, United Kingdom.

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Sexually Transmitted Infections
Sexual Health – The Uniquely Singaporean Experience    

1. An Update and Overview of STIs
2. Adolescents And Sex: Multilevel Ecological Factors Associated With Premarital Sexual Intercourse In Singapore
3. Women And STI's - Strategies For Awareness And Empowerment Of Sexual Health
4. STIs/HIV In Men-Who-Have-Sex-With-Men (MSM): An Update On The Current Situation & Intervention Programmes
5. HIV Risk-Related Behaviours Among Indirect Sex Workers Based In Non-Brothel Entertainment Establishments In Singapore

According to the WHO, STIs rank in the top 5 disease categories for which adults seek health care in developing countries. In Singapore, the DSC clinic attendance of public patients rose from 27676 in 2004 to 29650 in 2007.

This symposium aims to highlight the current trends & epidemiology, provide an update on commonly diagnosed STIs & the challenges facing physicians in the management of STIs/HIV in Singapore.

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* Please note that scientific programme is accurate at the time of update. Details are subject to changes.

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Cardiology
Cardiology Today, For Tomorrow

1. Cardiac CT: Bread And Butter Applications
2. Cardiovascular Studies And Radiation Dose
3. Making Sense Of Pacemakers And Implantable Cardioverter Defibrillator Implant
4. Anti Arrhythmic Drug Therapy Or Radiofrequency Catheter Ablation - For Non-Cardiologist
5. Cardiac Stem Cells For Clinical Use In Human; Hype Or Hope
6. Aortic VaIve: Current Status Of Percutaneous Replacements In 2009

This annual conference hosted by NHG Cardiology will provide an update on key aspects of management of cardiovascular disease, with an emphasis on what is new in the field relevant to the care of patients with cardiovascular disease. This conference will be of interest to general internists, specialists in fields other than internal medicine and family physician and allied health staff with an interest in cardiovascular disease.

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Career Development Workshop (Clinical Research) 

1. Developing A Clinical Research Career Plan
2. How To Identify High Impact, Fundable Projects
3. How Do You Work With Quantitative Experts?
4. Infrastructure, Teams And Help!

This workshop will focus on the key ingredients needed to develop career as a Clinician Investigator/Scientist based on the experience of the presenters.

How does one develop a long term career development strategy when one needs shorter-term, fundable projects that make major contributions? What is the role of "opportunistic" vs "strategic" research career planning? How does one develop questions and subsequent proposals that have the highest theoretical or practical impact? What is needed in terms of didactic training, mentored research experiences, biostatistical or other quantitative collaborations, management skills, or clinical and administrative infrastructure support to succeed? What kind of multi disciplinary team is needed? Where can one find help? Can one have such a career when patient demands are so high? When time is so short? How does one work with biostatistical, epidemiological or other quantitative experts? This interactive seminar (limited to 30 people) will discuss these issues.

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Dermatologic & Laser Surgery

1. PanFacial Augmentation
2. Botulinum Toxin : New Indications And Advances In Injection Techniques
3. Updates On Dermatological Lasers And Light Devices
4. Non Melanoma Skin Cancers : What Are The Treatment Options

This symposium will bring to light the advances in facial rejuvenation, the techniques and technologies that are available or may soon become reality for practising dermatologist. The first 3 speakers will draw upon their experience and present what is in, whether it works and the practicalities of performing these procedures. Skin cancers continues to increase in our current context, and the 4th speaker will touched on the options that we have in treating this common condition.

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Ear Nose & Throat (ENT)
New Technologies In Otolaryngology:
A Review Of Outcome And Their Roles In Clinical Practice

1. Image Guided Surgery
2. Advances in Cochlear and Middle Ear Implants
3. Sinuplasty
4. Scarless-in-the-neck Endoscopic Thyroidectomy

With the rapid advancement in medicine, new technologies have been introduced over the years. It is important to periodically review these technologies objectively to determine their role in clinical practice. In this session, the four technologies selected include Image-guided surgery, Cochlear Implant, Sinuplasty & Endoscopic Thyroidectomy. For each topic, the current data on efficacy, outcome, comparison with the historical technique or data will be made & their roles in current practice determined.

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Gastric Cancer

1. Screening For Gc In Singapore: An Update From SGCC
2. Gastric Cancer Stem Cell: Its Prospective Discovery And Implications
3. Advances In Endoscopic Imaging
4. New Imaging Modalities For Staging
5. Minimally Invasive Treatment For Early Gastric Cancer
6. Towards Personalized Therapy For GC

Although its incidence declines slowly, gastric cancer remains the 2nd most common cause of cancer deaths worldwide. In Singapore, it is the fifth most common cancer in men and 7th in women. In the past, surgery was the only treatment and the results were often disappointing due to advanced stage of disease at diagnosis. In the last decade, there has been much improvement in diagnosis, staging and treatment of gastric cancer globally and in Singapore. The current state-of-art treatment is ‘stage-orientated’, from endoscopic surgery to multimodality treatment, depending on the stage of cancer. In this symposium, we shall share with the audience current topics of gastric cancer spanning from identification of gastric cancer initiating cells, to imaging and to the latest treatment including personalized therapy based on genomic signatures.

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Geriatric Medicine

1. Technologies and New Concept of Care in Geriatrics
2. Integrating Care: Ideas, Tears And Headways

Many countries in Asia is facing a problem of greying population. The increase in comorbidities and challenges in physical functioning and mental capacities pose a strain on both the healthcare system, as well as the consumers, who need to navigate through the complexities of the current care models. There are efforts in recent years in the right sitting of care for patients. This will be more important as our population ages. The traditional care model will have to evolve to accommodate these new challenges.

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Health Services Research

1. Planning For Cardiovascular Disease Management: Global Trends In Cardiology And Cardiothoracic Surgery
2. Establishing Guidelines For Fasting In Patients Undergoing Procedural Sedation With Or Without Analgesia
3. Evaluation Of Medical Devices: Use Of Bedrails For Falls Prevention
4. Bevacizumab Vs Ranibizumab For Age Related Macular Degeneration - A Tale Of Two Drugs
5. Promoting Facts Based Decision Making In Hospital Operations
6. Backing Judgment With Model: Pharmacy Automation To Increase Patient Safety
7. The Journey Of An OR Project: From Framing To Modeling And Insights
8. Analytical Insights Of A Study Of Patient Wait Time In SOC
9. Integrating Multi-Disciplinary Research In HSR
10. Transforming Healthcare With Evidence: Bridging The Gap Between Researcher & Clinicians
11. Predicting Positive Blood Cultures In Patients Presenting With Pneumonia At An Emergency Department
12. Analysing Clinical Outcomes Of Hospitalisation Using Large Administrative Databases
13. Detection Of Clustered Sites Of Elderly Polyclinic Patients Using GIS For Future Planning Of Health Services
14. Cost-Effectiveness Analysis For The Various Measures On H1N1, SARS, And Spanish Flu

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Obstetrics & Gynaecology

1. Holistic Approach To Management Of Peri/ Postmenopausal Women
2. Adolescent Gynaecology
3. Contraception

Synopsis:
The Obstetrics & Gynecology Track covers health issues in three periods of women’s life.

Adolescence Gynaecology
Adolescence is a period characterized by intense endocrine and metabolic changes making it the most fascinating period of human life. Body composition and the amount of fat tissue are of paramount importance in adolescence, extreme variations of which can result in serious pubertal problems. At the one extreme is low body weight due to eating disorders resulting in severe menstrual and metabolic disturbances, while obesity with its sequelae of PCOCS, acne hirsutism and subsequent infertility is the other. Pubertal (primary) amenorrhea is of particular interest with disorders that may be chromosomal, gonadal, anatomic, adrenal, hypothalamo-pituitary level, also delayed puberty, premature ovarian failure, childhood cancer survivors etc. They may need life treatment and follow-up or surgical corrections, later solving infertility problems.

Menopause
Menopause is caused by natural cessation of ovarian function, but nowadays can be considered as endocrinopathy due to dramatic increase in human life span as modern women spend 20-30 years in postmenopause. Short term menopausal problems are uncomfortable and may disrupt normal life style; long term consequences are often debilitating and life threatening (cardiovascular problems, brain function deterioration, osteoporosis) Sequential and holistic approach to management of peri/postmenopause (HRT/ERT/Tibolone/bone protective medications, life style changes) gives a chance for healthy active old age. Global standards and recommendations for HRT and cancer risks also discussed.

Contraception
Contraception is a concerted action using various devices, sexual practices or medications in order to deliberately prevent/reduce the likelihood of pregnancy. History of birth control began as early as the ancient Egypt. Modern medicine offers great variety of contraceptives, but oral contraceptives are broadly accepted and also act as mode of treatment for various hormonal imbalances, bone protection etc. Similarly intrauterine devices (IUCD) are also highly effective and popular and newer version, like Mirena have levonorgestrel-releasing intrauterine system that delivers small amounts of hormones directly into uterus and may be treatment of heavy periods. Mechanism of action and safety of contraceptions is discussed.

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Omega-3 Fatty Acids in Nutrition, Physical and Mental health

1. Introduction To Omega-3 Fatty Acids In Health And Nutrition
2. Cardiovascular
3. Infant And Maternal Nutrition
4. Fish Oil and Aggression
5. Conduct, Learning Disorders And The SASSI Trial

The specific aims and associated hypotheses are as follows: 1. To assess the effectiveness of omega-3 fatty acid dietary supplementation in reducing both conduct disorder and also comorbid ADHD / conduct disorder. 2. To identify factors that moderates the relationship between omega-3 supplementation and outcome for antisocial behavior. 3. To assess the effectiveness of social skills training in reducing conduct disorder. 4. To assess whether omega-3 supplementation interacts with social skills training in reducing antisocial behavior. 5. To uncover mechanisms of action underlying any treatment effect.

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Pathology & Laboratory Medicine 
Soft Tissue Pathology

1. Update on PEComa
2. Spindle Cell Tumours Of The Gastrointestinal Tract
3. TTSH Pathology Archives : Interesting Soft Tissue Tumours

Soft tissue pathology is one of the most diagnostically challenging fields in the practice of histopathology. A distinguished panel of speakers who will share with us some important and exciting issues in soft tissue pathology. Dr KL Chuah will discuss the clinico-pathologic aspects, management implications and latest developments on an increasingly recognized mesenchymal tumour - perivascular epithelioid cell tumour, affectionately known as “PEComa”. Dr Cora Chau will touch on the diagnostic approach to spindle cell tumours encountered in the gastrointestinal tract. Updates on common lesions such as gastrointestinal stromal tumour (GISTs) will also be provided. Finally, using a case-based approach, Drs HY Lee and Clarence Teo will present a variety of interesting topics in soft tissue pathology from the archives of TTSH Pathology.

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1. Introduction And Overview Of Responsible Conduct And Professionalism In Research
2. Responsible Mentorship In Clinical Research
3. Research Ethics: Issues In Community And Media Engagement
4. Responsible Data Management And Stewardship In Biomedical Research
5. Responsible Data Reporting, Publication And Authorship
6. Responsible Grant Stewardship In Clinical Research

Responsible conduct in research, a key component of research ethics, is of critical importance to promoting scientific enquiry as a trustworthy profession. The series of talks in this symposium deals with a variety of aspects of responsible conduct in research, such as management of research data with honesty and integrity, appropriate practice in publication and authorship, responsible mentorship in clinical research and conscientious stewardship of grant in clinical research.

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1. Josie King Video Followed By Discussion
2. Open & Fair Culture
3. Incident Decision Tree
4. Definitions Of AE, ADE, And Near-Misses
5. Occurrence Reporting
6. Human Factors
7. PS Walkabouts
8. RCA
9. Medication Error Analysis Tool
10. Staff Support Schemes (Emotional Issues)
11. Teamwork Skills / Communication Tools
12. Error Proofing

Thousands of Singaporeans receive high-quality healthcare that helps to re-establish their quality of life. However, far too many are not. Quality and patient safety obstacles are mirrored in various health care service elements such as medication errors, reporting, analysis, clinician engagement, and patient engagement. Improving quality and patient safety knowledge continually advances efforts such as implementing lessons learned, adopting creative technologies, training clinicians and empowering patients, and enhancing error reporting systems.
This 3-hour workshop will be structured as a Rapid Fire Presentation sequence where eight to twelve topics regarding various improvement quality and patient safety strategies will be discussed. These topics will be broad based and taught as more of an overview educational training.

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Rehabilitative Medicine
Enhancing Function, Improving Wellness  

1. "Before You Run That Marathon, ……” - a guide to exercise prescription and training for able bodied and disease population
2.  “Training The Next Oscar Pistorius” - management of the lower extremity amputee
3.  Sex And Sexuality In The Disabled
4.  Future Shock - The Rise Of Technology In Rehabilitation

Synopsis:
This symposium highlights the role of Rehabilitation Medicine in enhancing function and promoting wellness in able and disabled people. In particular, chosen topics are both meaningful and educational for doctors, nurses, therapists and other allied health professionals.

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Stem Cell

1. Use of Stem Cells in Orthopaedic Surgery
2. Injectable Stem Cells Therapy For Cartilage Defects In The Knee
3. Role Of Stem Cells In The Repair Of Meniscus

The first session is a brief introduction on the use of stem cells in orthopaedic surgery.
The second session is the use of injectable stem cells in the treatment of osteoarthritis of the knee.
The third session is the role of stem cells in the repair of meniscus.

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1. Lessons From Landmark Clinical Trials In Diabetes Mellitus
2. Management Issues Of Obesity In Children And Adolescences
3. Diabetes In Elderly - Clinical Challenges

Rapid accumulation of lessons from landmark clinical trials in diabetes and metabolism is shaping our management strategies. However, numerous controversies are also generated by these clinical trials e.g. the importance of glycemic management in the prevention of diabetic vascular complications. The discussant will help the clinicians with an insightful synthesis of these landmark trials taking into considerations the quality of existing evidence. The epidemic of Diab-estiy (twin disorders of diabetes and obesity) is affecting not just the adults but also children and adolescences, who are particularly vulnerable to diabetic vascular complications. Is management strategy the same as in adults? Is pharmacotherapy safe in growing children? The lecturer, a senior pediatric diabetologist will present the state-of-the-art knowledge in this field. One reason for the rapidly growing prevalence of diabetes mellitus in Singapore is our “graying” population demography. Therapeutic medical nutritional intervention and emphasis on aerobic exercise in young adults may not be directly extrapolated to elderly with diabetes. In addition, the multiple co-morbidities and polypharmacy in these fragile individuals also pose a unique clinical challenge. The speaker will share his extensive clinical experience in managing the elderly with diabetes.

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1. Developmental Pathways To Metabolic Disease
2. Studying Developmental Factors In A Birth Cohort
3. Studying Development Factors In Adults With Metabolic Disease

Synopsis:
Developmental processes and genomic factors are important contributors to individual variation in the propensity to develop metabolic disease in an obesogenic environment.1 There are particularly cogent arguments that this is important in populations undergoing rapid socioeconomic and nutritional transition such as in Singapore and the rest of Asia. Epigenetic pathways play an important role in this nexus between genes, environment, and development. Our TCR is designed around unique opportunities in Singapore to examine the various developmental pathways that influence the risk of developing type 2 diabetes and obesity and responds to the concerns arising from the very high incidence of diabetes in Singapore. This area of science has considerable public health, diagnostic and pharmaceutical potential and these studies will provide translational opportunities for targeted intervention and prevention.

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* Please note that scientific programme is accurate at the time of update. Details are subject to changes.