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The teaching of obstetrics and gynaecology in Singapore from 1905 to the present.

Medical education commenced a century ago in 1905. In 1922, the Department of Midwifery and Gynaecology was established. This was renamed the Department of Obstetrics in 1951. Medical undergraduate curriculum in Obstetrics and Gynaecology has evolved and undergone radical changes. From a compulsory 11-week residential posting in Kandang Kerbau Hospital, medical students are now only expected to be resident when they are scheduled for night duties. Having been an examination subject by itself in the Final MBBS Examination, Obstetrics and Gynaecology has in the latest revised undergraduate medical curriculum been incorporated into the Surgical tract and has ceased to be evaluated as a subject on its own. In this review, the establishment of postgraduate training in Obstetrics and Gynaecology is traced over the last 50 years and the important changes over the years are described. The first local Master of Medicine (Obstetrics and Gynaecology) was awarded in 1971. Currently, the specialist training for Obstetrics and Gynaecology in Singapore spans a period of 6 years, comprising 3 years of basic structural training and 3 years of advanced structural training. Over the years, the Department of Obstetrics and Gynaecology, National University of Singapore, has played a pivotal role in the teaching of clinical and laboratory research. This has added substantially to Singapore's efforts to become a world-class knowledge hub, especially in the areas of relevance to Obstetrics and Gynaecology.

Education, Medical↗

Paediatrics in Singapore: the early days.

Paediatric services in Singapore started at the end of the 19th century. Because of inadequate housing, poor sanitation and inadequate health services, malnutrition and infections were the main problems. Infant mortality was in excess of 300/1000. There were many prominent doctors who worked in extremely demanding environments in order to better the health of children at that time. Over the years, there has been a steady improvement of healthcare in Singapore and this has been mainly due to the foresight and hard work of the pioneers. With excellent primary healthcare and specialised paediatric centres, paediatric services in Singapore are among the best in the world.

History, 19th Century↗

Should Singapore have a second medical school?

The case for establishing a second medical school in Singapore is strong. Given the recent explosive advances in medicine and biology, Singapore has identified the life sciences as an area of great economic potential, and aspires to become a regional "medical hub" capable of achieving excellence in healthcare, medical education and biomedical research. The existing medical faculty at the National University of Singapore is currently taking in 230 students per year, creating a very heavy teaching load which, coupled with even heavier clinical duties, makes it extraordinarily difficult for staff members to derive professional satisfaction and to pursue research interests. Creating a second medical school will alleviate some of these problems, which have contributed in no small way to the exodus of experienced clinicians and teachers to the private sector. Perhaps more importantly, having a second medical school will permit direct comparisons of the relative merits of different approaches to medical education, healthcare, and administrative practices. This in turn should lead to improvements in all these areas, thereby creating working environments more likely to satisfy staff aspirations, improve medical education and enhance research. Concerns about possible "unhealthy competition" and "costly duplication" with the establishment of a second medical school are largely unfounded if resources are managed appropriately.

Education, Medical↗

Sun protection in Singapore's schools.

INTRODUCTION: The World Health Organisation has identified schools as key players in the global effort to reduce the rising incidence of skin cancer. Singapore lies 70 miles from the Equator, with one of the world's highest ultraviolet (UV) index scores. It is a multi-ethnic society, with many expatriates. Children in Singapore are likely to be exposed to high levels of UV radiation, and represent a variety of skin types. This study aimed to assess sun protection measures in schools, the frequency of reported sunburn in schoolchildren of different ethnic groups, the level of parental and school concern about sun exposure, the sun-protective measures currently in place, and the parental and school support for public education and "sunsmart" school programmes. METHODS: Questionnaires were sent to principals and parents of primary schoolchildren in 20 local and eight international schools in January 2003. RESULTS: The majority of children in all ethnic groups in Singapore were reported to suffer to some degree from sunburn during their first ten years. Over 50 percent of parents and head teachers predicted an increased risk of skin cancer in their children. Some protective measures were in place. But teachers and parents were concerned, and most favoured the promotion of more active measures. CONCLUSION: The reported incidence of sunburn among Singaporean school children is higher than expected across all ethnic groups. Given the current level of sun protective measures in place, more could be done to educate parents and schools regarding "sunsmart practice", and reducing their future risk of skin cancer and eye damage.

Adolescent↗

Birth defects in Singapore: 1994-2000.

INTRODUCTION: To study characteristics of birth defect cases among live births, stillbirths and abortions in Singapore between 1994 and 2000. METHODS: Index cases for the National Birth Defects Registry (NBDR) were obtained from all neonatal nurseries in Singapore, all hospital discharge summaries, cytogenetic and pathology reports from all pathology laboratories in Singapore, and from the compulsory reporting of all termination of pregnancy cases and stillbirths delivered. Further information was obtained from case notes retrieved from the medical record offices, antenatal clinics, cytogenetic laboratories, pathology departments and the Registry of Births and Deaths. The notified cases (live births, stillbirths and abortions) between 1994 and 2000 were extracted from the NBDR and analysed with regard to ethnicity, maternal age, trend over the seven years and types of birth defects using the British Paediatric Association Classification. RESULTS: Between 1994 and 2000, a total of 7,870 cases (6,278 births and 1,592 abortuses) were notified, giving a rate of 23.99 birth defect cases per 1000 live births. There was a decreasing trend in birth defect incidence (19.76 to 16.85 per 1,000 live births) among live births and stillbirths and an increasing trend of abortion (3.25 to 7.57 per 1,000 live births) for birth defects. Malays had a higher rate of congenital defects at birth (24.4/1,000 live births) compared to Chinese (18.4/1,000 births). The 25-29 years age group had the lowest overall rate (22.6/1,000 live births) compared to the 19 years and below group at 31.6/1,000 live births and the 45-49 years group at 126.6/1,000 live births. The five most common groups of anomalies (per 1,000 live births) were those of heart (9.07), musculoskeletal (4.98), chromosomal (4.35), urinary (3.12) and nervous systems (2.90). The five most common aborted anomalies (per 1,000 live births) were those of chromosomal (2.40), nervous (1.23), heart (0.95), musculoskeletal (0.85) and urinary systems (0.36). CONCLUSION: There was an increasing trend of abortion for birth defects, accompanied by a falling trend in the congenital anomalies of live births. Both extremes of maternal age were at higher risk of non-chromosomal birth defects while advanced maternal age was at higher risk of chromosomal defects.

Adolescent↗

Treatment outcome of Singapore residents with pulmonary tuberculosis in the first year after introduction of a computerised treatment surveillance module.

INTRODUCTION: A key intervention of the Singapore Tuberculosis Elimination Programme (STEP) was the introduction in 2001 of a computerised treatment surveillance module (TSM) for the real-time monitoring of the treatment progress of the country's notified tuberculosis (TB) cases until a final outcome. We report the treatment outcome as at December 31, 2002 for the cohort of Singapore residents with new and relapsed pulmonary TB in whom treatment was commenced in 2001. METHODS: Each TB notification will activate the TSM, which requires a return on the patient's treatment progress, treatment delivery mode and the treating physician's management decision at each clinic visit to the STEP Registry until an outcome is reached. RESULTS: There were 1,354 Singapore residents with new or relapsed pulmonary TB who started treatment in 2001. Of these, 620 (45.8 percent) underwent directly-observed therapy (DOT) at their nearest polyclinic. As at December 31, 2002 , 79 percent of patients completed treatment, nine percent died (two percent from TB), nine percent interrupted treatment (they were either lost to follow-up or refused treatment), 1.8 percent were still on treatment, 0.6 percent left the country, and 0.5 percent had permanent cessation of treatment due to drug reactions. Factors associated with treatment completion were Chinese ethnicity (odds-ratio [OR] 1.5, 95 percent confidence interval [Cl] 1.1-2, p-value is 0.02), age younger than 65 years (OR 1.8, 95 percent Cl 1.3-3.0, p-value is 0.003) and the use of DOT (OR 3.1, 95 percent Cl 2.3-4.1, p-value is less than 0.05). CONCLUSION: The findings from the TSM's first year provide a baseline for future programme evaluation.

Antitubercular Agents↗

Changes in the levels of major cardiovascular risk factors in the multi-ethnic population in Singapore after 12 years of a national non-communicable disease intervention programme.

INTRODUCTION: The National Healthy Lifestyle Programme, a population-wide non-communicable disease intervention programme, was started in 1992. A National Health Survey is carried out every six years to evaluate the impact of this programme on the cardiovascular risk factor profile of the resident population of Singapore. METHODS: The 2004 National Health Survey (NHS 04) was a population-based survey carried out over a period of four months from September to December 2004. A combination of disproportionate stratified sampling and systematic sampling was used to select a representative sample (n=7,078) for the survey. The reference population comprised 2.4 million multi-racial Singaporeans aged 18-69 years. Anthropometric and blood pressure measurements were carried out on all subjects and blood samples were taken for biochemical analysis. The results were compared with those of a similar survey conducted in 1998. RESULTS: A total of 4,084 Singapore residents took part in the survey, giving a response rate of 57.7 percent. The age-standardised prevalence of hypertension (greater than or equal to 140/90 mmHg) in Singapore residents aged 30-69 years decreased from 28.0 percent in 1998 to 24.0 percent (p-value is less than 0.001) in 2004. The prevalence of high total cholesterol (greater than or equal to 6.2 mmol/L) among those aged 18-69 years fell from 26.0 percent in 1998 to 18.1 percent (p-value is less than 0.001) in 2004. The prevalence of diabetes mellitus in residents aged 18-69 years in 2004 was 7.8 percent, compared to the 1998 level of 9.5 percent (p-value is less than 0.01). The level of obesity (body mass index is greater than or equal to 30 kg/sqm) increased slightly from 6.2 percent in 1998 to 6.8 percent (p-value equals 0.1627). The prevalence of daily smoking decreased from 15.0 percent in 1998 to 12.5 percent in 2004 (p-value is less than 0.001), while that of regular exercise increased from 17.0 percent to 25.0 percent (p-value is less than 0.001). Ethnic differences in the prevalence of diabetes mellitus, hypertension, hypercholesterolaemia, and exercise were observed. CONCLUSION: The NHS 04 results suggest that the National Healthy Lifestyle Programme significantly decreased daily smoking, high blood cholesterol and hypertension, and increased regular exercise over 1998 levels. The results also suggest that the programme stabilised the prevalence of obesity and diabetes mellitus.

Adolescent↗

Seroepidemiology of pertussis in the adult population of Singapore.

INTRODUCTION: Pertussis is a highly communicable, vaccine-preventable respiratory disease and a frequent but often underestimated cause of prolonged cough illness in adults. Protection after childhood vaccination is minimal after 10 years without boosting. The need for adult booster depends on the national epidemiology. MATERIALS AND METHODS: We did a seroepidemiological survey amongst the adult population (aged 18 to 45 years) of Singapore. None had received pertussis booster vaccine in the preceding 10 years. We measured IgG antibodies to pertussis whole cell antigen. RESULTS: Two hundred and seventy subjects with the median age of 30 years were enrolled. We found positive IgG antibody levels in 97% of the population. Seropositivity was not associated with age, gender or race. CONCLUSION: The seroprevalence in adults was much higher than the previously documented seroprevalence of around 50% in the adolescent age group in Singapore. The increase is most likely due to natural infection with B. pertussis. Pertussis booster vaccine for adolescents/young adults in Singapore would be indicated.

Adolescent↗

Direct and indirect costs of osteoarthritis in Singapore: a comparative study among multiethnic Asian patients with osteoarthritis.

OBJECTIVE: To estimate and compare the direct and indirect costs of osteoarthritis (OA) in multiethnic Asian patients with OA in Singapore. METHODS: The study was a retrospective and cross-sectional design. Patients were stratified according to ethnicity and presence or absence of joint surgery. Direct costs were estimated from both a societal and a patient perspective using the Singapore General Hospital database; indirect costs were estimated using the human capital approach. All costs were expressed as mean costs per patient per annum in 2003 Singapore dollars. RESULTS: A total of 1179 patients (83.6% Chinese, 7.2% Malay, 3.5% Indian, 5.7% others) were included in estimating direct costs, of which 513 (43.5%) had total knee replacement (TKR) and 92 (7.8%) total hip replacement (THR), while 105 patients (71.4% Chinese, 14.3% Malay, 14.3% Indian) were included in estimating indirect costs. Direct costs to patients ranged from 1460 dollars to 7477 dollars for Chinese, 1362 dollars-7211 dollars for Malays, 1688 dollars-6226 dollars for Indians, and 1437 dollars-12,140 dollars for other ethnic patients; direct costs to society ranged from 3351 dollars to 15,799 dollars for Chinese, 2939 dollars-15,436 dollars for Malays, 3150 dollars-10,990 dollars for Indians, and 2597 dollars-17,879 dollars for other ethnic patients. In contrast, the indirect costs ranged from 1215 dollars to 3834 dollars for Chinese, 1138 dollars-6116 dollars for Malays, and 1371 dollars-5292 dollars for Indians. However, most ethnic variations were not statistically significant. CONCLUSION: The economic burden of OA to society and patients increased by 3-fold or more in the patients with TKR/THR compared to those without. The ethnic differences in health resources consumed were more apparent when the disease progressed.

Aged↗

Organisation, operational aspects and clinical experience of National University of Singapore Bone Bank.

The National University of Singapore (NUS) Bone Bank was started in October 1988 and is the first such bank in Singapore. Two Revco Freezers were installed to store bones at -80 degrees C. The NUS Bone Bank Protocol follows the multi-centre protocol in USA with Massachusetts General Hospital as the Central Registry. It strictly follows the guidelines for banking of musculo-skeletal tissues set up by the American Association of Tissue Banks. Strict donor selection is practised including screening for Aids, hepatitis, syphilis and infection. It does not provide for storage of articular cartilage. Currently, procurement is obtained from living donors. Mainly femoral heads have been obtained (63 donors to date). One whole tibia, one whole fibula, one lower end of femur have also been procured. Bone allograft transplantation has been safely performed in 14 recipients--mainly spinal fusions (seven cases), Sub-talar joint fusion in children (three cases) and packing Giant Cell tumors (two cases). Other cases include revision hip surgery (one case) and augmenting of hypoplastic mandible (one case). The biggest problem faced by the NUS Bone Bank is lack of donors. There is definitely a need for bone allografts in Singapore where such transplantation is legal. Presently, there is also a demand for whole bones to bridge large bone defects resulting from tumour resection and for reconstructing post-traumatic defects. This can only be met if we can procure more whole bones especially from cadaveric donors.

Bone Transplantation↗

Epidemiology of injuries in Singapore.

Injuries are a major public health problem in developed industrialised countries and are the leading cause of premature mortality. This study has shown the same picture for Singapore. Injuries are the fifth leading cause of crude death but the most important cause of premature mortality being responsible for 23,800 potential years of life lost before the age of 65 years. The most vulnerable ages are from the preschool to the economically active age groups. Singapore males have twice the death rate of females (52 vs 20 per 100,000 population) because of the relatively higher proportion of males (78.5% among males vs 48% among females) who work and are therefore at higher risk. Indian males have the highest ethnic-and-sex-specific mortality rates (107 vs 48 among Chinese males and 39 among Malay males per 1000 population). Road traffic accidents were the leading cause of mortality from injuries but this has been over taken by suicides. Information on the specific causes and specific high risk behaviour and factors for injuries in Singapore is weak. This needs to be strengthened to enable more effective cause-specific control programmes to be drawn up.

Accidental Falls↗

Gastrointestinal infections in Singapore children.

Acute gastroenteritis is the commonest gastrointestinal disorder in children. It accounted for about 10% of the admissions to a general paediatric unit in Singapore. About 5% of total paediatric admissions to all the government hospitals in Singapore were due to acute gastroenteritis. Some 50% of the cases had no identifiable organism in the stools. Most of the remaining cases were due to bacterial or viral infections. The commonest bacteria responsible for acute gastroenteritis nowadays is Salmonella species. Other bacteria such as E. coli, Shigella and Campylobacter were responsible for a smaller proportion of bacterial diarrhoea in children. Rotavirus was the commonest viral agent responsible for acute diarrhoea among Singapore children. Most patients had mild diarrhoea and severe dehydration following acute gastroenteritis was not common. About 60% of the patients admitted to hospital were younger than two years of age. Bacterial infections were more common in infancy. Viral diarrhoea were more likely to be watery and bacterial diarrhoea were more likely to be bloody and mucoid. With regard to chronicity, it was the groups with mixed infection or bacteria infection which had a prolonged course. Treatment was directed at maintaining hydration and prevention of complications. Except for secondary lactase deficiency, other long term complications were rare.

Adolescent↗

Public awareness of AIDS in Singapore.

Singapore had 52 cases of AIDS as at June 1990. This places Singapore in the low-infection-load group of countries. Constant vigilance is necessary however. The Health education programme against AIDS in Singapore was launched in 1985. This first ever National Survey on public awareness of AIDS was carried out by the Research and Evaluation Department, Ministry of Health HQ, in late 1987, to assess the impact of the programme. It showed the level of knowledge of among Singaporeans to be high and comparable in many areas to that in the USA. The survey however also showed lack of credibility in the knowledge of AIDS among the public in certain important areas. This poses challenges to the public education programme.

Acquired Immunodeficiency Syndrome↗

Common environmental contact allergens in Singapore.

Contact allergens produce three types of reactions. The commonest reaction is allergic contact dermatitis (ACD). The commonest contactants in Singapore causing ACD are, in decreasing order of importance, nickel, fragrances, neomycin, lanolin, colophony, flavine, rubber chemicals, paraphenylenediamine, clioquinol and chromates. Another type of allergic contact reaction is immunologic contact urticaria (ICU). ICU is an IgE mediated mechanisms. Contact allergens causing ICU in Singapore are proteinaceous foodstuffs and rubber latex products. Photoallergic contact dermatitis is occasionally seen in Singapore. The commonest agent is Musk Ambrette, a perfume fixature found in male colognes.

Dermatitis, Contact↗

Clinical biochemistry in Singapore.

During the period from 1982 to mid-1989, there has been very significant changes and improvement in the practice and application of clinical biochemistry in Singapore. This paper highlights recent developments in the repertoire of biochemical analyses, utilisation of laboratory tests, biochemical screening in preventive health care, handling and delivery of patient specimens, advances in analytical techniques, automation, computerisation, quality assurance, training of laboratory personnel, and professional activities. It also draws attention to the restructuring of the Singapore General Hospital and the government Department of Pathology which frees these government institutions from the constraints of the civil service so that they would be sufficiently flexible to respond readily to the changing needs and expectations of the patients and users of laboratory services. This is the most prominent event and policy change in the history of health care services in Singapore that is expected to result in more cost-effective utilisation of resources and greater improvement in the quality of health care.

Automation↗

Pattern of glomerulonephritis in Singapore children--a renal biopsy perspective.

This study was aimed at determining the pattern of glomerulonephritis (GN) in Singapore children from a histopathological perspective. Fifty-seven consecutive children, aged between 10 weeks to 16 years, who underwent a renal biopsy at the Departments of Paediatrics, National University of Singapore and Singapore General Hospital over an 8 year period were studied. The main indications for biopsy were nephrotic syndrome (67%), recurrent gross haematuria (16%), nephritic syndrome (7%), and renal failure (10%). Primary GN occurred in 81%, while secondary GN was seen in 19%, the most common being lupus nephritis. Of the primary GN, minor abnormalities was the most common (22%), followed by focal global sclerosis (20%), focal segmental glomerulosclerosis (17%), diffuse mesangial proliferative GN (11%), focal mesangial proliferative GN (9%), membranous GN (7%), diffuse endocapillary GN (4%), diffuse sclerosing GN (4%), diffuse mesangial sclerosis (4%), and diffuse crescentic GN (2%). Immunofluorescent examination was performed in 50 children. IgA nephropathy was diagnosed in 17% of the patients with primary GN. Of the children with primary nephrotic syndrome due to minimal change disease or focal global sclerosis, about half had IgM mesangial deposits. Of 47 patients who were followed up, 9 developed chronic renal failure, of which 7 reached end-stage disease (4 have died, while 3 are on chronic dialysis). Three other patients died of other complications. The histopathological findings influenced the therapeutic decision in 49% of our patients. In summary, the pattern of GN in our cohort of patients tended to reflect more severe glomerular lesions, mainly due to our criteria of selection for renal biopsy.

Adolescent↗

Ischaemic heart disease and its risk factors in Singapore in comparison with other countries.

Mortality from ischaemic heart disease in Singapore is now reaching comparability with the West. For the early 1980s, rates for Indians and Malays were higher than in U.S.A. and England and Wales and while those for Chinese were lower they were considerably higher than in Japan. In keeping with this the levels of the major risk factors in Singapore are now comparable to the West. Cigarette smoking in males is virtually the same as in Britain, while the proportion of hypertensives on medication is higher than in the West. The main cause for concern is the current high levels of serum cholesterol in Singapore and strenuous health education efforts are needed to bring about dietary changes.

Adolescent↗

Fat and fibre in the Singapore diet.

Data on fat and fibre content in the Singapore diet are presented. Food availability data show an upward trend in per capita fat and fibre supplies over the last 25 years. However, food availability is usually an overestimate of actual consumption. Data on food consumption levels show that fat intake in Singapore is in reality relatively lower than the corresponding intake in Western countries. Fibre intake is also lower than in the West. At the same time, the incidence of colorectal cancer is increasing. This provides an interesting opportunity for analytical studies to further elucidate the likely role of diet in the aetiology of colorectal cancer in Singapore.

Colonic Neoplasms↗