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PubMed2002

The growth and development of orthopaedic sports medicine in Singapore.

Orthopaedic sports medicine is currently a well established subspecialty of orthopaedic surgery in Singapore. It had its beginnings in the late 1960s and has since grown to be one of the major orthopaedic subspecialties. Knee, shoulder and ankle injuries constitute the majority of cases seen by the orthopaedic sports medicine specialists. Significant scientific contributions to the international literature have been made by our specialists over the years. Today, Singapore is a regional hub for the provision of orthopaedic sports medicine care and training.

Ankle Injuries↗
PubMed2002

A twelve-year review of radical cystectomies in Singapore General Hospital.

INTRODUCTION: Bladder carcinoma is the tenth most common cancer affecting men in Singapore. This study reviews the complication rates and long-term outcome after radical cystectomy for bladder carcinoma. PATIENTS AND METHODS: A retrospective case-record review of 90 consecutive radical cystectomies in the Department of Urology at the Singapore General Hospital from 1 January 1989 to 31 December 2000 was performed. Patients were included if they were operated for muscle-invasive tumour, high-grade tumour with carcinoma in-situ (CIS), recurring multifocal high-grade tumour, CIS unresponsive to intravesical therapy, or endoscopically uncontrollable tumour. Patients were excluded if they had metastatic disease or non-bladder primary carcinomas. RESULTS: The patients were predominantly male (M:F, 80:10) and Chinese (Chinese:Malay:Indian:Others, 70:10:3:7) with a mean age of 64.1 +/- 9.9 years (range, 39 to 83 years). Fifty-one patients underwent ileal conduit creation, 36 had ileal neobladder creation, 2 had ureterosigmoidostomies and 1 had Mainz II pouch creation following radical cystectomy. Perioperative mortality was 2.2% (n = 2). Early complications constituted 39% (n = 35), whilst late complications constituted 14% (n = 13) of cases. The mean follow-up was 27.1 +/- 29.7 months (range, 1 to 137 months). The mean time to recurrence was 26.0 +/- 29.5 months (range, 3 to 137 months). The overall survival was 70%, 43% and 37% at 1, 3 and 5 years, respectively. The disease-free survival was 64%, 35% and 32% at 1, 3 and 5 years, respectively. CONCLUSION: The results of our radical cystectomies for bladder carcinoma are comparable to other established urology units although the morbidity remained significant.

Adult↗
PubMed2002

The social cost of smoking in Singapore.

This study provides estimates for the cost of smoking in Singapore in 1997.A first attempt for Singapore, the paper reports on two different methods used, namely, the human capital approach and the demographic approach. These two measures are similar in that they compare the economic cost of smoking in the actual situation with the hypothetical alternative where there had been no smoking. The direct cost of smoking includes the amount spent on hospital care for five main diseases related to smoking whilst the indirect cost includes the value of lost income. The mortality cost of smoking is derived from the aetiological fractions of these diseases. The results from the human capital approach show that the social cost of smoking in 1997 ranged from S$673 million to S$839 million. Assuming there has been no smoking since 1990, calculations from the demographic approach indicate that national output would have increased by S$614 million in 1998. Nonetheless, the results from both approaches show that most of the cost of smoking is incurred by males.

Cost of Illness↗
PubMed2002

Validation of 13C-urea breathtest for the diagnosis of Helicobacter pylori infection in the Singapore population.

INTRODUCTION: Several tests are available for determining the presence of Helicobacter pylori (H. pylori) infection. These may be invasive or non-invasive. The carbon urea breath test (C-UBT) is generally considered to be a simple, non-invasive and accurate test for the detection of H. pylori infection both before and after treatment. Commercially available 13C-UBT kits are generally validated in their country of manufacture and the stated accuracy of their tests may not be applicable to our local population. AIM: The aim of our study was to determine the accuracy of a commercial 13C-urea breath test kit, Hp-Plus (Utandningstester i Sverige AB, Sweden), in the Singapore population. PATIENTS AND METHODS: One hundred patients for oesophago-gastro-duodenoscopy (OGD) were recruited into this prospective study. Gastric biopsies were obtained for the biopsy urease test and histological examination. Blood samples were obtained for H. pylori serology. Breath samples were then obtained at baseline and after consumption of 100 mg of labelled 13C-urea. The presence of H. pylori infection was defined by a positive result on any two of the three tests (biopsy urease test, histology, serology) performed for the detection of H. pylori. Using this "gold standard", the sensitivity, specificity, and positive and negative predictive values of the 13C-UBT were calculated. RESULTS: In the Singapore population, the 13C-UBT (Hp plus) has a sensitivity and specificity of 94.2% and 100% respectively for the detection of H. pylori infection. The positive predictive value and negative predictive value of the 13C-UBT is 100% and 88.6% respectively. CONCLUSION: The 13C-UBT is a simple, safe, and accurate non-invasive test for the detection of H. pylori infection, making it a valuable tool in local clinical practice.

Adult↗
PubMed2002

Deep vein thrombosis is not rare in Asia--the Singapore General Hospital experience.

INTRODUCTION: Venous thromboembolism (VTE) is perceived to be rare in Asia, but our recent clinical experience at Singapore General Hospital (SGH) suggests otherwise. Between 1996 and 1997, there were 388 cases of confirmed deep vein thrombosis (DVT). MATERIALS AND METHODS: All patients with symptomatic DVT confirmed by duplex ultrasound studies from January 1996 to December 1997 were retrospectively studied. Their case notes were searched for a record of predisposing risk factors. RESULTS: Ultrasound imaging indicated acute thrombosis in 320 patients (82.5%), and previous, but not acute thrombosis in 68 patients (17.5%). The overall frequency rate of acute DVTs was 15.8 per 10,000 hospital admissions. The average age of patients with acute thrombosis was 58.2 years. 9.2% of patients developed pulmonary embolism (PE). Their most frequently recorded clinical predispositions were immobilisation (67%), malignancy (33%) and recent surgery (30%). One hundred and thirty patients were tested for antithrombin, protein C or protein S deficiency, and the presence of antiphospholipid antibody and 45 (35%) were found to have at least 1 positive result. CONCLUSION: DVT is not uncommon in Singapore. Our frequency rate of acute DVT of 15.8 per 10,000 admissions is much higher than previously reported rates of 2.8 and 7.9 per 10,000 admissions in 1990 and 1992, respectively. These findings confirm the need for increased awareness of VTE in Asian populations, and support the relevance of systematic studies of thrombosis risk and prophylaxis in Asia.

Adolescent↗
PubMed2003

Angiotensin I-converting enzyme (ACE) gene polymorphism and breast cancer risk among Chinese women in Singapore.

Angiotensin II has been shown to have possible mitogenic and angiogenic effects in human cell lines and animal models of breast cancer. It is converted from its precursor to its active form by the angiotensin I-converting enzyme (ACE). A recent epidemiological study observed lower breast cancer incidence in female users of ACE inhibitors relative to nonusers with comparable cardiovascular conditions. To study the hypothesis that reduced ACE activity is associated with reduced risk of breast cancer, we conducted a nested case-control study within the Singapore Chinese Health Study Cohort to investigate the associations between the ACE A-240T and I/D gene polymorphisms, and breast cancer risk. For this analysis, 189 incident breast cancer cases and 671 female cohort control subjects were compared. The low-activity A and I alleles were the putative "low-risk" alleles. The I/D and A-240T genotypes exhibited significant linkage disequilibrium among Singapore Chinese (contingency coefficient = 0.74; P < 0.001). With adjustment for breast cancer risk factors, women with one or two copies of the low activity A allele showed a statistically significant reduction in risk compared with those with the TT genotype [odds ratio (OR), 0.55; 95% confidence interval (CI), 0.34-0.90]. The risk reduction was enhanced after excluding subjects with medical conditions for which ACE inhibitors are commonly prescribed (OR, 0.49; 95% CI, 0.27-0.89). Comparable results were obtained with respect to the I/D genotype and risk of breast cancer. When the I/D and A-240T genotypes were considered simultaneously, compared with women with the high-activity genotypes (either TT or DD or both), those with the low-activity genotypes (presence of both A and I alleles) exhibited lower breast cancer risk (OR, 0.46; 95% CI, 0.27-0.81). Our findings support experimental data implicating ACE and angiotensin II in breast cancer, and suggest that the renin-angiotensin system may serve as a therapeutic target for breast cancer treatment and prevention.

Aged↗
PubMed2003

Learning developmental biology has priority in the life sciences curriculum in Singapore.

Singapore has embraced the life sciences as an important discipline to be emphasized in schools and universities. This is part of the nation's strategic move towards a knowledge-based economy, with the life sciences poised as a new engine for economic growth. In the life sciences, the area of developmental biology is of prime interest, since it is not just intriguing for students to know how a single cell can give rise to a complex, coordinated, functional life that is multicellular and multifaceted, but more importantly, there is much in developmental biology that can have biomedical implications. At different levels in the Singapore educational system, students are exposed to various aspects of developmental biology. The author has given many guest lectures to secondary (ages 12-16) and high school (ages 17-18) students to enthuse them about topics such as embryo cloning and stem cell biology. At the university level, some selected topics in developmental biology are part of a broader course which caters for students not majoring in the life sciences, so that they will learn to comprehend how development takes place and the significance of the knowledge and impacts of the technologies derived in the field. For students majoring in the life sciences, the subject is taught progressively in years two and three, so that students will gain specialist knowledge in developmental biology. As they learn, students are exposed to concepts, principles and mechanisms that underlie development. Different model organisms are studied to demonstrate the rapid advances in this field and to show the interconnectivity of developmental themes among living things. The course inevitably touches on life and death matters, and the social and ethical implications of recent technologies which enable scientists to manipulate life are discussed accordingly, either in class, in a discussion forum, or through essay writing.

Curriculum↗
PubMed2003

A review of 2,517 childhood injuries seen in a Singapore emergency department in 1999--mechanisms and injury prevention suggestions.

BACKGROUND: Childhood injuries cause significant mortality and morbidity in Singapore. With injury surveillance, patterns of repeated injury can be identified and injury prevention strategies devised. METHODS: We conducted a retrospective study of all children aged 12 and below seen for trauma in an Emergency Department over one year. Data captured in the real-time computer system was studied with regards to patient profile, mechanism of injury and patient disposition. Clinical summaries were extracted with follow-up telephone interviews done. RESULTS: Two thousand five hundred and seventeen children aged 12 and below were seen for accidental trauma in 1999, accounting for 37.1% of the total attendance for that age. Mean age was 7.7 years with males making up 62.7%. Home injuries (56.4%) were the most common, followed by road-related (14.4%), sports (8.2%) and playground injuries (7.4%). 48.5% sustained head and face injuries. Pre-school children (age <5) were more likely to sustain home injuries (p<0.0001), a higher proportion of head injuries (p<0.0001), foreign bodies, burns and poisoning compared to school-going children (age 6-12), who were more likely to sustain injuries in road accidents, sports, at playgrounds or schools, with more limb, trunk and multi-trauma. We highlight drownings, falls from height, rollover falls from beds, slamming door injuries, the low use of child car restraints, bicycle injuries and playground falls as areas of concern. CONCLUSION: Several injury prevention strategies have been suggested and it is hoped these may contribute to addressing preventable childhood injuries in Singapore. We also advocate the establishment of a national childhood injury surveillance database.

Chi-Square Distribution↗
PubMed2003

Erectile dysfunction in Singapore: prevalence and its associated factors--a population-based study.

PURPOSE: To study the prevalence of erectile dysfunction (ED) in Singapore males aged 30 and above and its association with demographic, medical and other risk factors. METHODOLOGY: A population based cross sectional study of 729 men aged 30 and above in Singapore was conducted using the abridged, five-item version of the International Index of Erectile Function (IIEF-5). Presence of erectile dysfunction was defined as IIEF-5 score of less than 21. Erectile dysfunction was further categorised into mild (IIEF-5: 16-20), moderate (IIEF-5: 11-15) and severe (IIEF-5: <11). A logistic regression model was used to identify significant independent risk factors for ED. RESULTS: Overall, 51.3% of respondents (n=374) reported some degree of erectile dysfunction. Of these, 23.2% have mild ED, 8.8% have moderate ED and 19.3% had severe ED. The prevalence of ED increased from 42.8% for men in their forties to 77.4% in their sixties. The prevalence of severe ED increased from 9.1% in men in their forties to 43.5% in their sixties and 77.0% in those aged 70 and above. Age above 50 years is the single most significant risk factor on multivariate analysis when adjusted for all confounding factors. Other important risk factors include Indian ethnic group, lower household income, physical inactivity, diabetes mellitus and cardiac diseases. CONCLUSION: Erectile dysfunction is common amongst Singaporean men. Age is the single most important physiologic factor affecting erectile function. The prevalence and severity increased significantly with age after 50 years old. With an ageing population, erectile dysfunction may become a significant health problem. Health care providers should plan their resources accordingly.

Adult↗
PubMed2003

The Singapore Tuberculosis Elimination Programme: the first five years.

The Singapore Tuberculosis Elimination Programme (STEP) was launched in 1997 because the incidence of the disease had remained between 49 and 56 per 100,000 resident population for the preceding 10 years. STEP involves the following key interventions: directly observed therapy (DOT) in public primary health care clinics; monitoring of treatment progress and outcome for all cases by means of a National Treatment Surveillance Registry; and preventive therapy for recently infected close contacts of infectious tuberculosis cases. Among other activities are the revamping of the National Tuberculosis Notification Registry, the discontinuation of BCG revaccination for schoolchildren, the tightening up of defaulter tracing, and the education of the medical community and the public. Future plans include an outreach programme for specific groups of patients who are unable to attend their nearest public primary care clinics for DOT, the detention of infectious recalcitrant defaulters for treatment under the Infectious Diseases Act, the molecular fingerprinting of tuberculosis isolates, and targeted screening of high-risk groups. The incidence of tuberculosis fell from 57 per 100,000 population in 1998 to 48 per 100,000 in 1999 and continued to decline to 44 per 100,000 in 2001. With political will and commitment and the support of the medical community and the public it is hoped that STEP will achieve further progress towards the elimination of tuberculosis in Singapore.

BCG Vaccine↗
PubMed2003

Severe acute respiratory syndrome--Singapore, 2003.

The Singapore Ministry of Health (MOH), with assistance from the World Health Organization (WHO), has been investigating an outbreak of severe acute respiratory syndrome (SARS). This is a novel condition caused by the SARS-associated coronavirus (SARS-CoV) and is characterized by both an atypical pneumonia and efficient nosocomial transmission. This report summarizes epidemiologic features of this outbreak in Singapore, including the influence of super spreaders and the national prevention and control strategy.

Adolescent↗
PubMed2003

Mass newborn screening in Singapore--position and projections.

INTRODUCTION: This paper describes the development, current position and projected development of mass newborn screening in Singapore. METHODS: A search was conducted through the Medline and through the abstract books of conferences for papers on mass newborn screening in Singapore. This was complemented with the author's own records of the outcome of screening newborns at the National University Hospital. RESULTS: Cord blood screening for glucose-6-phosphate dehydrogenase (G6PD) deficiency began in 1965; through patient isolation, prompt treatment of jaundice and parent education, kernicterus has been eliminated. Pilot screening for congenital hypothyroidism began in 1981 and has become nationwide since 1990. Screening rates are almost 100% and with early treatment, mental retardation has been eliminated in those affected. However, academic difficulties are present in about a third of patients. Screening for hearing impairment now covers 80% of newborns. The incidence of significant impairment is 1 in 1000 births and interventions have been in place before a year of age. Two strategies--measuring automated auditory brainstem responses (AABR) and otoacoustic emissions supplemented with AABR--are being evaluated. CONCLUSIONS: The programme requires refining of screening strategies, creation of a central registry of cases, provision of educational support and expansion to include screening with tandem mass spectrometry for multiple inborn errors of metabolism.

Forecasting↗
PubMed2003

Clinical characteristics of an outbreak of hand, foot and mouth disease in Singapore.

BACKGROUND: We experienced a hand, foot and mouth disease (HFMD) outbreak in late year 2000 in Singapore. Between 14 September 2000 and 14 November 2000, a total of 3526 cases of HFMD were notified. There were 652 patients clinically suspected to have HFMD, who were seen at the Children's Emergency department of KK Women's and Children's Hospital of Singapore. OBJECTIVE OF THE STUDY: To study the clinical profile and virologic isolates of children admitted with HFMD during the outbreak. STUDY DESIGN: A prospective observational study. METHODS: Analysis of clinical features and virologic studies of 129 selected cases of HFMD and herpangina. RESULTS: The median age was 25 months with a range of between 4 months and 11 years. The majority were less than 5 years old (87%). The male-to-female ratio was 1.3:1. The median numbers of day of illness to presentation to the hospital was 3 days. Poor feeding and loss of appetite accounted for 76.7% of the admissions. Symptoms of vomiting were present in 37.2% of the cases. Oral ulcers were found in 96.1%, rashes over hands in 87.6%, over feet in 86.8% and over buttocks in 54.3%. Only 4.7% exhibited no rashes other than oral ulcers and were labelled as herpangina. The median duration of fever was 3 days, ranging from 2 to 7 days. An intravenous drip was required in 68.2% due to poor feeding. Viral cultures were sent in 89.1% of patients of whom 61.7% of patients were positive for viruses. Of the positive cultures, types of viruses isolated were EV71 (enterovirus 71) in 59/71 (83%), Coxsackievirus (A16, A24, A2 B3, B4) in 6/71 (8.4%), EV Untypable in 4/71 (5.6%) and mixed [EV71, echo25, cytomegalovirus (CMV)] in 2/71 (2.8%). EV71 was isolated mostly from stool samples followed by vesicle fluid culture and throat swabs. Two siblings aged 14 months and 2.5 years died during this period at day 5 of illness, their post-mortem examinations showed interstitial pneumonitis of the lungs. EV71 was isolated from the brain, heart, tonsils, intestines, throat and rectal swabs. A raised total white cell count of 14,000/L versus 12,000/L was significantly associated with complicated HFMD (P = 0.04). There was no difference in clinical characteristics of EV71 versus non-EV71 infections. Other viral illnesses, e.g. measles and CMV, may be mistaken for HFMD in the outbreak setting. CONCLUSIONS: HFMD tends to occur in younger children less than 5 years old due to low herd immunity. Poor feeding due to mouth ulcers accounts for admission to hospital requiring intravenous drip. EV71 accounted for the majority (75%) of the positive isolations, followed by coxsackievirus and untypable EV, mixed infection of echovirus or CMV. The yield of virus isolation was highest from stool, followed by vesicles and throat swabs. There is no difference in clinical characteristics of EV71 and non-EV71 virus infections. Enterovirus can cause mild symptoms to fatal death. Two infants died of interstitial pneumonitis and encephalitis.

Child↗
PubMed1992

Cervical cancer: trends in incidence and mortality in Singapore 1968 to 1987.

Analysis of data collected by the population-based Singapore Cancer Registry reveals that the age-standardised incidence of cervical cancer has decreased from 18.2 per 100,000 females in 1968-72 to 16.2 per 100,000 in 1983-87, and its ranking among the most common female cancers has fallen from second to fourth place behind cancers of the breast, colon/rectum and lung. Mortality from the disease has also shown a corresponding fall from 7.3 per 100,000 to 5.5 per 100,000 women over the same period. Cervical cancer incidence rates are in general highest among Indian women, intermediate in Chinese and lowest in Malays. Age-specific incidence curves over time show a marked fall in rates in women over 50 years of age, whereas younger women (35-44 years old) show a small increase. A similar increase in rates has been observed in various other countries. Internationally, Singapore's incidence rate falls between the highs of South America and parts of Asia, and the lower rates of North America and Europe. The decrease in rates is comparable with the overall global trend, but falls short of that achieved by countries with systematic cytological screening programmes.

Adult↗
PubMed2003

Our experience with eclampsia in Singapore.

AIM: To assess the incidence, epidemiological factors, preceding symptoms and signs, management regimens and obstetric outcomes of eclampsia in a tertiary care hospital in Singapore. METHOD: A retrospective study of all obstetric patients who suffered one or more eclamptic seizures in our hospital between January 1994 and December 1999. RESULT: There were 62 cases of eclampsia among 92,305 deliveries (6.7 per 10,000 deliveries). The incidence was highest among Indians. Those aged between 25 and 34 had the lowest incidence, while women younger than 25 or older than 34 had a significantly higher incidence. Forty (64.5%) patients had symptom or sign of impending eclampsia of which headache was the most common. Most of the patients (81.6%) who received antenatal care with us suffered their first eclamptic seizure in hospital, compared to 50% of the unbooked patients. There was one maternal death (mortality rate 1.6%), and 15 (24.2%) women had significant morbidity. There were 61 singleton pregnancies and one twin pregnancy. There were six intrauterine deaths and 57 livebirths. The perinatal mortality rate was 95.2 per 1,000 births. CONCLUSION: Eclampsia is still a major cause of maternal and foetal mortality and morbidity in Singapore. Race and age appear to be risk factors for eclampsia with Indian women and those at the extremes of reproductive age at greater risk. Antenatal care is important in reducing perinatal mortality and possibly maternal complications.

Adolescent↗
PubMed2003

Dietary cryptoxanthin and reduced risk of lung cancer: the Singapore Chinese Health Study.

High prediagnostic serum beta-cryptoxanthin levels have been found to be associated with reduced risk of lung cancer in a recent cohort study of Chinese men in Shanghai, China. Data on dietary beta-cryptoxanthin, and other specific carotenoids and antioxidants in relation to lung cancer, particularly in non-Western populations, are scarce. The aim of the present study was to assess the roles of dietary antioxidants in the development of lung cancer. Between April 1993 and December 1998, 63,257 Chinese men and women ages 45-74 years in Singapore participated in a prospective study of diet and cancer. At baseline, an in-person interview was conducted using a structured questionnaire for information on usual dietary habits, tobacco smoking, and other lifestyle factors. A Singapore food composition database was used to estimate intake of alpha-carotene, beta-carotene, beta-cryptoxanthin, lycopene, lutein/zeaxanthin, vitamins A, C, and E, and folate in study subjects. During the first 8 years of follow-up, 482 lung cancer cases occurred among cohort members. High levels of dietary beta-cryptoxanthin were associated with reduced risk of lung cancer; relative to the lowest quintile, the self-reported smoking adjusted relative risks (95% confidence intervals) for the highest quintile were 0.73 (0.54-0.98) among all of the subjects and 0.63 (0.41-0.99) among current smokers. Before adjustment for cigarette smoking, dietary vitamin C was associated with a statistically significant reduction in risk of lung cancer. However the inverse vitamin C-lung cancer association was largely explained by smoking and dietary beta-cryptoxanthin. Other carotenoids (alpha-carotene, beta-carotene, lycopene, and lutein/zeaxanthin), vitamins A and E, and folate were not associated significantly with lung cancer risk after adjustment for cigarette smoking. We recognized that potential measurement errors in cigarette smoking may exert an effect on the dietary beta-cryptoxanthin-lung cancer association. After additional adjustments were made for the residual confounding by smoking using statistical models, about 15-40% reduction in risk of lung cancer was seen for subjects in the highest versus lowest 10th percentile of dietary beta-cryptoxanthin. The present study lends additional credence to prior experimental and epidemiological data in support of the hypothesis that dietary beta-cryptoxanthin is a chemopreventive agent for lung cancer in humans.

Aged↗
PubMed1992

Nontuberculous mycobacterial disease of the lungs in Singapore.

Information on lung disease due to nontuberculous mycobacteria (NTM) is lacking in Singapore. A review of the records at the Central Tuberculosis Laboratory up to the end of 1988 showed that 23 patients seen between 1976 to 1988 inclusive had cultures which were repeatedly positive for NTM. Of the 23 cases analyzed, 15 were found to have lung disease which could be attributed to NTM. There were 9 males and 6 females with a male to female ratio of 1.5:1. The patients were either middle aged or elderly. The 2 main infective agents were M avium-intracellulare and M kansasii. Ten (67%) patients had moderately advanced and 5 (33%) had far advanced disease. Concurrent disease of the lung was present in 10 patients (67%). Seven (47%) patients had bronchiectasis, 1 (7%) had both bronchiectasis and chronic obstructive pulmonary disease (COPD) and 2 (13%) had COPD. A past history of pulmonary tuberculosis was present in 10 patients (67%). Lung disease due to NTM is uncommon in Singapore. Treatment failure was attributed to poor compliance, a possibility which could not be excluded in those patients who had adverse reactions.

Adult↗
PubMed1992

Some observations on the epidemiology of peptic ulcer disease in Singapore.

Several lines of evidence suggest that, of the three main races of Singapore, peptic ulcers are more common among the Chinese and Indians when compared to the Malays. These include studies on hospital series of patients with or without appropriate control groups, studies on the incidence of surgery for perforated ulcer as well as mortality statistics. A reduction in the Chinese:Malay difference in the incidence of perforated ulcer over three decades suggests that environmental factors are involved in producing these racial differences. However, we have to date been unable to determine the factor(s) responsible. The incidence of perforated ulcer in Singapore is increasing while ulcer mortality is declining. This is similar to the situation in Hong Kong but different from that in the western countries.

China↗