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PubMed1999

The natural history of dengue illness based on a study of hospitalised patients in Singapore.

AIM OF STUDY: To study the clinical features of dengue illness in hospitalised patients in Singapore. METHODS: One-hundred and thirty hospitalised patients with serologically confirmed dengue illness, from 1 April 1992 to 31 October 1992, were analysed retrospectively. RESULTS: Teenagers and young adults between 15 to 30 years of age were most commonly affected. The male to female ratio was 1.3:1. The mean duration of fever and rash prior to admission were 5.2 +/- 1.5 (mean +/- SD) days and 1.7 +/- 1.7 days respectively. Petechiae were present in 52.3% of the patients. Three-quarters of the patients with petechiae had platelet counts (PCs) of 100 x 10(3) ul-1 or less. Thrombocytopenia (PCs of 100 x 10(3) ul-1 or less) was first documented 5.8 +/- 1.4 days after the onset of illness. The nadir of thrombocytopenia occurred on the 6.4 +/- 1.6 day of illness. The mean duration of thrombocytopenia was 3.6 +/- 1.6 days. Nineteen patients (14.6%) had non life-threatening clinical bleeding or coagulopathy, namely bleeding gums (9 patients), epistaxis (5), vaginal spotting/menorrhagia (4) and prolonged PTT (3). Six patients (4.6%) required platelet transfusion because of severe thrombocytopenia (PCs less than 30 x 10(3) ul-1) and clinical bleeding. There was no secondary fall in the PCs over 2 or more consecutive days when the PCs were in the recovery phase. It took 1 more day to reach PCs of 100 x 10(3) ul-1, the "safe" level commonly used in Singapore to decide discharge of patients, as compared to 80 x 10(3) ul-1. At PCs of 80 x 10(3) ul-1 or more, 2 patients had bleeding gums, 1 each had epistaxis and vaginal spotting. No transfusion was required for these 4 patients. The mean hospital stay was 4.2 +/- 1.5 days. There was no mortality in this study. CONCLUSION: Dengue illness is a relatively benign self-limiting illness. When the PCs are on the rising trend and in the absence of clinical bleeding, it is reasonably safe to discharge patients when the PCs reach 80 x 10(3) ul-1, instead of 100 x 10(3) ul-1. This will shorten each patient's stay by 1 day, resulting in cost saving and more efficient use of hospital beds.

Adolescent↗
PubMed1999

A clinical study of seven cases of trichotillomania in Singapore.

The aims of this paper were: to study the profile of trichotillomania cases referred to a child guidance clinic in Singapore, to identify potential risk factors and to study the management and outcome of these cases. This is a descriptive, retrospective study of all cases of trichotillomania presenting to the clinic between January 1996 and January 1998. There were 7 cases seen in a 2-year period which is less than 1% of new cases seen at the clinic. The female to male ratio was 1.33:1 with a mean age of 9.3 years. All cases met the DSM-IV criteria for trichotillomania. All 6 pulled their hair in tufts with 1 who was almost hairless. Associated problems included tics, nail-biting, anxiety and shortness of temper. Treatments included behavioural treatment, stress management, parental education and counselling as well as medications. Two improved and were discharged, with 3 still undergoing treatment and 2 defaulted follow-up. The 7 cases seen in Singapore are similar in clinical features to cases found overseas. A behavioural approach with reduction of environmental stress is most effective. Drugs were less effective. More systematic studies need to be done.

Behavior Therapy↗
PubMed1999

Trends in mortality, incidence, hospitalisation, cardiac procedures and outcomes of care for coronary heart disease in Singapore, 1991-1996.

In this study, we used Singapore population-based data from 1991 to 1996 to examine recent trends in mortality, incidence and hospitalisation for acute myocardial infarction (AMI), and explored the roles of primary prevention and medical care interventions in explaining these trends. We examined trends in medical interventions, namely coronary angiography (catheterisation), coronary artery bypass graft (CABG), and percutaneous transluminal coronary angioplasty (PTCA), length of stay, and payment methods, and explored the roles of technological, healthcare financing and delivery, and regulatory factors in influencing the diffusion and outcomes of these medical interventions. During the period 1991 to 1996, there were parallel declines in resident population rates of mortality, incidence and hospitalisation for AMI. The rates of angiograms, CABG and PTCA among residents also increased greatly, with the greatest increase among elderly aged 60 years and above. The rates of invasive cardiac procedures for AMI were all lower in females than in males. The population case-fatality rate of AMI declined slightly only for persons below 40 years of age. The case-fatality rate was higher in females than in males. The number of hospitalisations and cardiac procedures all rose sharply, and was phenomenal for PTCA (247%). The increase in volume of resource use was starkly greater in private hospitals than in restructured hospitals. The ratios of PTCA to CABG from 1991 to 1996 for private and restructured hospitals showed a greater rate of technology substitution in restructured hospitals than in private hospitals. The average length of stay (LOS, 6.7 days) was fairly constant in restructured hospitals. For private hospitals, LOS declined from 7.6 days in 1991 to 5.6 in 1996. LOS varied little among individual restructured hospitals, but widely among private hospitals. The most common method of payment for AMI hospitalisation was Medisave alone (50%), but for CABG surgery, the proportion of payment made through this method was only 12%. Out-of-pocket payments, Medisave, Medishield and private insurance have increased steadily. These data indirectly suggest that primary prevention and medical care interventions might have begun to succeed in reducing the rates of coronary heart disease in Singapore. The sharp increases in cardiac procedures may be explained by changing supply and demand factors for care of AMI and chronic ischaemic heart disease, including consumer preference for cardiac procedures, overuse of medical intervention, and technological change. More studies are needed to test these hypotheses.

Adult↗
PubMed1999

The development of postgraduate training programmes in Singapore.

Singapore is a small country compared to Pakistan. Being an urban modern developed nation with a high population density, adequate doctors (& specialists), and good infrastructure, it has one medical school enrolling 200 students annually, one Graduate School of Medical Studies (GSMS) responsible for entry postgraduate examinations (the M Med) and one Academy of Medicine (AM) responsible (jointly with the Graduate School) for exit certification/examinations (FAMS) into 35 specialties. There is also one College of Family Physicians with a significant role in the training of Family Physicians jointly with the Graduate School. The Aga Khan University runs 14 residency (3 to 4 years) and 2 fellowship programmes. It has the College of Physicians and Surgeons of Pakistan, which awards fellowships to trained postgraduate doctors. Formal postgraduate education in Singapore began in the 1960s with the help of the Australasian Royal Colleges. The Graduate School of Medical Studies was born in 1969 to conduct Master of Medicine courses and examinations, either alone or jointly with overseas colleges. Over the years up till 1996, the M Med covered 11 disciplines. Programmes are set up based on local needs for a specialty, subspecialty, skill or expertise. Both the GSMS and AM have heavy responsibilities under the Specialists Accreditation Board (SAB) of the Ministry of Health, to administrate the 35 Specialist Training Committees. Syllabus, log books, registers, supervisors, mentors, interviews and exit certification/examinations are essential components of the specialist training programmes which last 6 to 7 years. As new specialties and subspecialties develop internationally, they will be introduced locally at the appropriate time. Through the local training programmes, doctors become specialists in their early thirties. The challenge is to develop systems to ensure that for the next 30 years of their practice, they remain up-to-date, competent and effective doctors.

Certification↗
PubMed1996

The use of removable partial dentures amongst private dental practitioners in Singapore.

A questionnaire survey was carried out in 1995 amongst university trained general dental practitioners in the city state of Singapore to assess the use of removable partial dentures (RPD). 37% of the original sample of 469 completed and returned the questionnaire. The results of this survey indicate that RPDs are a common treatment modality in Singapore. Acrylic partial dentures appear to be the preferred choice for RPD treatment. The work profile of those who had a postgraduate qualification in removable prosthodontics did not differ from that of the general dental practitioner.

Acrylic Resins↗
PubMed1999

Aetiology and distribution of mandibular fractures in the National University Hospital, Singapore.

Sixty-seven consecutive mandibular fractures treated mainly in 1998 were surveyed retrospectively. Treatment was performed at the National University Hospital, Singapore. Males outnumbered females by 5:1, with Chinese the commonest racial group involved (56.7%). Most patients were between 20 and 29 years of age. Road traffic accidents formed the largest proportion (61.2%) followed by industrial accidents and assaults. The symphyseal and parasymphyseal regions were most commonly fractured (46.5%). Almost a third of the patients sustained other facial fractures. Treatment was commonly administered within one to two days of discovery of the fracture and open reduction was the treatment plan of choice in 79.1% of the time. Discussion on how aetiology affects the fracture pattern in Singapore is carried out.

Accidents, Traffic↗
PubMed1999

One-year review of pityriasis rosea at the National Skin Centre, Singapore.

Pityriasis rosea is a common, acute, self-limited papulosquamous eruption of possible viral aetiology. The aim of this study was to describe the profile of pityriasis rosea seen at a referral skin centre in Singapore. A retrospective chart review was conducted of all the patients with a diagnosis of pityriasis rosea seen during 1996. There were 368 patients; their ages ranged from 9 months to 82 years with a peak in the 20 to 29 years age group. There were slightly more males (1.2:1). The clinic incidence was 6.5 per 1000 cases. No ethnic predilection was noted and cases were seen evenly throughout the year. About a quarter of the patients gave a history of a viral infection shortly before or during the occurrence of the rash. Most cases had a typical truncal distribution. The herald patch was observed in 63 patients (17%). Inverse distribution involving mainly the extremities were seen in 22 cases (6%) and eczematised lesions were noted in 20 cases (5.4%). The two main differential diagnoses considered were tinea infection and secondary syphilis. A fungal scrape and a rapid plasma reagin test were done in 58 and 59 patients, respectively, and the results were negative. Treatment was symptomatic and consisted of topical steroids and antihistamines. Thirty patients (8%) were given oral prednisolone for extensive eruptions. The pattern of pityriasis rosea in Singapore is similar to that reported in other countries except for a male predominance and absence of monthly variation. A lower incidence and an older group of patients were also seen in our series as compared to African patients.

Adolescent↗
PubMed1999

The epidemiology of atopic dermatitis at a tertiary referral skin center in Singapore.

Atopic dermatitis is a common chronic, relapsing, pruritic ecematous skin condition with a predilection for the flexural areas and occurs in patients with a personal or family history of atopy. The aim of this study is to describe the profile of atopic dermatitis seen at the National Skin Centre in Singapore. A retrospective chart review was conducted of all the patients with atopic dermatitis seen during the first six months of 1994. There were 492 patients whose ages ranged from one month to 74 years with an equal sex ratio. The prevalence was 2%. The onset of the disease occurred before the age of 10 years in 61.2% of patients. In 13.6% of the patients, the onset was after the age of 21 years. Two hundred and fifty-four patients (52%) had "pure" atopic dermatitis without concomitant respiratory allergies. Two hundred and thirty-eight patients (48%) suffered from a "mixed" type, with 23% having allergic rhinitis, 12% having asthma and 13% having both asthma and allergic rhinitis. Two hundred and thirty-one patients (47%) had at least one first-degree family member with atropy: atopic dermatitis (17%), asthma (15%) and allergic rhinitis (15%). Most of the patients, 416 (84.5%), had subacute eczema at presentation. Ichthyosis vulgaris was present in 38 patients (8%) and pityriasis alba in 13 patients (3%). The most common infective complication was bacterial infection (impetiginized eczema, folliculitis, cellullitis) present in 95 patients (19%) followed by viral infections (eczema herpeticum, viral warts and molluscum contagiosum) in 17 patients (3%). Allergies were noted in 43 patients (9%) based on the history given. The most common was drug allergies (penicillin and co-trimoxazole) in 28 patients followed by food allergies in 11 patients. Common aggravating factors reported include heat, sweating, stress, thick clothing and grass intolerance. Most patients could be controlled with a fairly simple regimen of moisturizers, topical steroids and antibiotics for acute flares. Short courses of systemic steroids were used in 78 patients (16%). Three patients were treated with phototherapy, Two on UVAB and one on PUVA. The pattern of atopic dermatitis in Singapore is similar to that reported in the Western literature except for a lower prevalence and a significant proportion of adult onset atopic dermatitis.

Adolescent↗
PubMed1999

Sensitization to Blomia tropicalis and dermatophagoides pteronyssinus-a comparative study between Singapore and Taiwan.

Blomia tropicalis (Bt) and Dermatophagoides pteronyssinus (Dp) are the predominant domestic mites species in Singapore and Taiwan. This study aims to characterize and compare the mite sensitization profiles in both countries. Skin prick tests were performed on 203 Singaporeans with Dp and Bt crude extracts. In vitro IgE and IgG4 reactivity to extracts and specific allergens (Der p 1, Der p 2 Der p 5 and Blo t 5) were determined by immunoassays. Approximately 91% of the tested Singaporeans were skin test positive for both Bt and Dp. Both populations share similar frequencies of in vitro IgE reactivity to all the allergens tested, but they differ in the pattern and magnitude of allergen sensitization. Although Der p 1, Der p 2 and Blo t5 are major sensitizing allergens in both countries, Blo t 5 is a more potent one in Singapore, probably reflecting the high level of exposure to Bt. The unique major Bt and Dp allergens should be included for precise diagnosis and effective immuno-therapeutic treatment of mite allergy in both countries.

Adolescent↗
PubMed1999

Contact allergy in Singapore.

Contact allergy, viz. allergic contact dermatitis, photo-allergic contact dermatitis and contact urticaria, is a well-studied sub-specialty of dermatology in Singapore. Over the years, numerous studies and anecdotal reports on the subject have been published in both international and local refereed journals. This article reviews the epidemiological data on patch testing and photo-patch testing in Singapore. It also summarizes published clinical reports on important contact allergens that are found in both non-occupational and occupational setting.

Adult↗
PubMed1999

The presentation of elderly people at an emergency department in Singapore.

OBJECTIVE: This study aims to provide demographic and clinical data of elderly people attending one of the hospital emergency departments in Singapore. DESIGN: Patients aged 60 years and above who attended the Emergency Department (ED) at Alexandra Hospital, Singapore, during 4 randomly selected one-week periods in 1996 were retrospectively studied. MAIN OUTCOME MEASURES: Patient profile; presenting symptoms; diagnoses; types of investigations done, and outcome following attendance. RESULTS: A total of 455 ED attendance cards were analysed. The age of patients ranged from 60 to 102 years with a mean age of 72.8 years. Two hundred and sixty-one (57.4%) were males and 194 (42.6%) were females. Four hundred and twenty-seven (93.9%) were emergencies, 25 (5.5%) were non-emergencies and in 3 (0.6%) the priority rating was unknown. Two hundred and ninety (63.7%) were admitted, of whom 166 (57.2%) were males. One (0.2%) was admitted for social reason. The 3 most common symptoms were abnormalities of breathing (10.6%), falls (9.4%) and musculoskeletal pain (8.2%). Majority had 1 (40.4%) or 2 (41.6%) symptoms. The symptoms were mainly acute (1 day, 45.2%) or less than a week (25.7%). The 3 most common diagnoses were chest infection or pneumonia (8.2%), non-fracture head injury (7.2%) and heart failure (6.6%). Most patients (90.5%) had only 1 diagnosis. The 3 most common tests done were chest X-ray (172 patients, 37.8%), electrocardiography (119 patients, 26.2%) and blood glucose (86 patients, 19.0%). One hundred and twenty (26.4%) patients did not require any investigation. CONCLUSION: The elderly constituted 12.4% of attendance at the ED but formed 34.5% of admissions. They were more likely to have emergency problems. Understanding the common presenting symptoms and diagnoses of the elderly will help doctors at the ED provide better care. Elderly patients with complex problems who are not hospitalised would probably benefit from further geriatric assessment.

Acute Disease↗
PubMed2000

The status of the cagA gene does not predict Helicobacter pylori-associated peptic ulcer disease in Singapore.

Discrepancies among reports from different geographical regions worldwide on the association between the presence of cagA and peptic ulcer disease prompted this study on the predictive value of the cagA gene in Helicobacter pylori-associated gastroduodenal diseases in the Singapore population. H. pylori strains were obtained from 169 patients with a peptic ulcer, 83 with non-ulcer dyspepsia, and nine with gastric cancer. The presence of the cagA gene was evaluated by polymerase chain reaction (PCR). The expected 400 bp PCR product coding for the cagA gene was present in 232/261 (89%) H. pylori isolates. Of these, 151/169 (89%) strains from patients with peptic ulcer, 73/83 (88%) strains from patients with non-ulcer dyspepsia and 8/9 (89%) strains from cancer patients were positive for the cagA gene. There was no statistically significant difference between the prevalence of cagA-positive strains from patients with distinct clinical outcomes (p > 0.05). The prevalence of cagA-positive strains in the Singapore population is high regardless of clinical disease status. The results suggest that the cagA gene is not a universal virulence marker of H. pylori.

Adolescent↗
PubMed2000

Mental health literacy in Singapore: a comparative survey of psychiatrists and primary health professionals.

OBJECTIVES: To assess the beliefs amongst health professionals in Singapore about management of 3 major mental disorders, comparing psychiatrists and a sample of primary care physicians, and so identify target areas for the education of primary health professionals. MATERIALS AND METHOD: A questionnaire earlier distributed to psychiatrists at Woodbridge Hospital was posted to both Singapore general practitioners and polyclinic doctors. The questionnaire assessed the capacity of respondents to identify vignettes of depression, schizophrenia or mania, and then assessed respondents' views about the likely helpfulness of a number of interventions. RESULTS: The psychiatrists and primary health professionals differed little in terms of diagnostic accuracy for depression and schizophrenia; however, only half the general practitioners and three-quarters of the polyclinic doctors correctly diagnosed mania, which was consistently diagnosed by the psychiatrists. A number of distinct differences were identified between the groups concerning the likely helpfulness and disorder specificity of various psychotropic drugs. The primary health physicians were more likely to favour non-specific management approaches, whilst the psychiatrists generally supported a focused biological approach to treatment, especially for the psychotic disorders. Some of the differences in beliefs about mental health management may well be contributed by the different patients treated by each group of clinicians. CONCLUSIONS: The findings have important clinical implications in terms of diagnosing common psychiatric conditions accurately and giving us professionals' views about a range of interventions for such conditions, while also assisting review of educational programmes for identifying and managing major mental disorders.

Adult↗
PubMed2000

A community study of male androgenetic alopecia in Bishan, Singapore.

BACKGROUND: Androgenetic alopecia is the most common form of hair loss. It affects a large number of the local male population, with 1,812 men seeking treatment for hair loss at the sole dermatological tertiary referral centre in Singapore in 1994. The aim of this study was to assess the prevalence of male androgenetic alopecia in the community. METHODS: A questionnaire-based cross-sectional survey with a one-stage sampling method was conducted. Each male was diagnosed clinically and the severity graded according to the Norwood Criteria. The survey area was in Bishan East, a housing estate with 8,004 households. A total of 335 households were selected for the survey. RESULTS: The household response rate was 84%. Within these households, 254 out of 378 men participated in the study (67% response rate). The prevalence of androgenetic alopecia was found to be 63%. The prevalence of the condition increased with age, from 32% among young adults aged 17 to 26 years to 100% among those in their 80s. Proportionately more Indians (87%) were affected compared to Chinese (61%). 81% of the respondents with androgenetic alopecia did not seek help as they did not view it as a problem. Of those seeking treatment, 74% used non-medical methods of unproven effectiveness. CONCLUSION: There is a high prevalence of androgenetic alopecia in the community in Singapore. Age specific prevalence and racial differences correlate well with both Western and local studies respectively.

Adolescent↗
PubMed2000

Deaths due to disease of seafarers on board Singapore ships.

Based on records kept in the Singapore Mercantile Marine Office, the paper presents the results of a study on deaths due to disease of seafarers on board Singapore ships. Out of a total of 373 deaths, altogether 69 fatalities were attributed to diseases. More than 65% (n=45) of theses deaths were due to circulatory diseases commonly associated with life-style factors, but only 24 cases had a specific and 9 cases had an unspecific diagnosis confirmed by a medical, practitioner. A total of 32 seafarers (46.4%) died of a sudden death and were found dead by their shipmates whereas 17 seafarers (24.6%) died on board after a short illness. In only two cases was it reported that Radio Medical advice had been sought indicating either a lack of interest of the ship's management or a lack of knowledge or information on the availability of such services. Eight of the fatalities who died on board had seen a doctor and been declared fit to stay on board, pointing to deficiencies in the port medical services or pressures on port doctors to avoid a costly repatriation. The mean annual mortality rate for deaths due to all causes was 26.5 per 10,000 seafarers and due to disease was 4.9 per 10,000 seafarers.

Cause of Death↗
PubMed2000

Correlation of baseline quantitative plasma human immunodeficiency (HIV) type 1 RNA viral load with clinical status and CD4+ T-cell counts in treatment-naïve HIV-positive patients in Singapore.

INTRODUCTION: Quantitative measurement of plasma HIV-1 RNA viral load has been available in Singapore since 30 November 1996. This study investigates the relationship, in antiretroviral-naïve, HIV-positive Singapore residents, between the baseline HIV-1 RNA viral load and clinical status at the time of quantification. The association of HIV-1 RNA viral load with CD4+ T-cell counts was also studied. MATERIALS AND METHODS: HIV-1 RNA viral load was determined using Amplicor HIV-1 Monitor Test. One hundred and eighty subjects had baseline plasma HIV-1 RNA levels quantified during the period 30 November 1996 to 27 July 1998. They were classified into three clinical groups: A for asymptomatic infection (n = 110), B for symptomatic infection (n = 29) and C for AIDS (n = 41). RESULTS: The differences between mean HIV-1 RNA levels were statistically significant (P < 0.001) for groups A and B (mean difference = -0.61 log10), and for groups A and C (mean difference = -0.75 log10). However, there was no statistically significant difference (P = 0.68) between groups B and C (mean difference = -0.13 log10). Of those subjects with CD4+ T-cell counts measured within 30 days of viral load quantification, there were statistically significant negative correlations between HIV-1 viral load and CD4+ T-cell counts for groups A (n = 91, r = -0.536, P < 0.01) and C (n = 34, r = -0.446, P < 0.01) but not group B (n = 26, r = -0.297, P > 0.05). CONCLUSION: This suggest that the more advanced the phase of HIV infection, the higher the baseline plasma viral load and the lower the CD4+ T-lymphocyte counts.

Adult↗
PubMed2001

Gastrointestinal colonisation of vancomycin-resistant enterococcus in a Singapore teaching hospital.

Vancomycin-resistant enterococcus (VRE) has become an important nosocomial pathogen in many countries but is still rare in Singapore. A study was conducted from January to March 1997 at a 900-bed teaching hospital to determine the prevalence of intestinal colonisation of VRE in the patient population. A total of 299 consecutive stool specimens received by the microbiology laboratory for routine testing were plated onto two different selective media for comparison. VRE isolated were phenotypically characterised using minimum inhibitory concentrations (MICs) to vancomycin and teicoplanin and then typed using pulsed-field gel electrophoresis (PFGE) with Smal digestion of DNA. VRE were detected in the stool of 35 patients (12.3%). This group consisted of four isolates with VanB (one Enterococcus faecalis and three E. faecium) and 31 isolates with VanC (30 E. casseliflavus and one E. gallinarum). Two patients (0.7%) carried isolates (both VanB) with high level resistance to vancomycin (MIC > or = 256 microg/ml) while the rest had isolates of low level resistance (MIC = 8 microg/ml). Except for isolates from the same patients, PFGE patterns were diverse, suggesting that the VRE isolates were genotypically different and possibly introduced from many sources. This study demonstrates that VRE colonisation is not uncommon in the Singapore patient population.

Adult↗
PubMed2001

Suicide in Singapore: a changing sex ratio over the last decade.

AIM OF STUDY: To examine for any change in the sex ratio of suicides in Singapore over the last decade. METHODS: Data on suicides in Singapore for the decade 1989-98 were examined, both as an overall set and as four age-based sub-groups. RESULTS: The male to female ratio increased significantly over the decade, contributed to most distinctly by changed rates in young adults (ie a group defined as 29-40 years). The changed sex ratio appeared limited to Chinese subjects, where the suicide rate/100,000 population was consistently higher than for the non-Chinese. The changed ratio appeared more to reflect an absolute decrease in female suicides rather than any distinct absolute increase in male suicides. CONCLUSIONS: The previous distinct male preponderance in suicide,which had progressively diminished by the early eighties, has become distinct again, but is now seemingly more driven by a disproportionate decline in the absolute rate of suicides in younger females. We speculate on possible social determinants of this intriguing epidemiological trend.

Adult↗