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PubMed2000

Public health medicine training in Singapore.

Public health as a discipline is difficult to characterize because it has to respond to changes in human societies. As such, public health training has two dimensions--(1) Orientation and (2) Competencies. Our orientation should be broad and multidisciplinary to keep "alive the idea of improving the public health as a primary value". On the other hand, competencies define our professional status and role, which are focused mainly on our work on status of health, surveillance and disease control, health services and their evaluation. The core competencies can be organized according to the following categories: (1) Epidemiologic, (2) Programme-based, (3) Laboratory-based and (4) Practice-based. The Singapore Programme is a 6-year post-intern medical training, with core components and electives clustered around 2 themes: (1) Health Policy and Management, (2) International Health.

Curriculum↗
PubMed2001

Primary anorectal malignant melanoma: clinical features and results of surgical therapy in Singapore--a case series.

INTRODUCTION: Primary malignant melanoma arising from the anorectum is uncommon. The natural history of anorectal malignant melanoma is that of a very poor prognosis with early dissemination of disease. Successful surgical treatment has been rare. The present series reviews the clinical features and results of surgical management of patients with anorectal malignant melanoma treated in the Department of Colorectal Surgery, Singapore General Hospital. MATERIALS AND METHODS: Data for all patients treated for anorectal malignant melanoma during an 11-year period from 1989 to 1999 were reviewed. The age, sex, presenting symptoms, duration of symptoms prior to diagnosis, size of tumour, extent of disease, type of surgery and length of survival were analysed. RESULTS: Four men and 2 women, ranging in age from 31 to 81 years with histologically proven primary anorectal malignant melanoma, were included in the study. The most common (67%) presenting symptom was rectal bleeding. The mean tumour size was 2.5 cm (range 1 to 5 cm). All underwent abdomino-perineal resection. Three died of disseminated disease within 17 months while the other 3 were still alive at the time of this study; the longest up to 6.5 years from the time of diagnosis. CONCLUSION: The prognosis of primary anorectal malignant melanoma is poor. However, it is worthwhile treating aggressively as long-term survivor may be encountered in some.

Adult↗
PubMed1999

From snoring to sleep apnea in a Singapore population.

We have no information on snoring and obstructive sleep apnea (OSA) in our population, which is predominantly Chinese. Our perception is that sleep apnea syndrome is more common than the 2-4% prevalence (Young et al., 1993) often quoted, judging from the experience in our sleep disorder unit. We studied the snorers in an adult population in Singapore and then went on to see how many snorers suffer pathological apnea and sleep apnea syndrome. Room partners, 220 of them aged 30-60 years, were interviewed for their observation of snoring among each other. 106 consecutive habitual loud snorers of a similar age group in the same population were studied with polysomnography in our sleep laboratory. An apnea index greater than 5 was considered pathological. 24.09% were loud habitual snorers. 87.5% of loud habitual snorers had significant obstructive apneas on the polysomnogram and 72% of these apneics complained of excessive daytime sleepiness (EDS). Given the clinical observation that all apneics snored, by extrapolating these figures, we guess that sleep apnea syndrome affects about 15% of the population. Multiple Sleep Latency Tests validated EDS in our cases with clinical hypersomnia. Hypersomnolence was significantly related to the poor delta wave sleep. Contrary to what was believed, OSA occurred predominantly in stage 1 and 2 non-rapid eye movement (NREM) sleep rather than in REM sleep. The frequent arousals prevented sleep going beyond stage 1 and 2.

Adult↗
PubMed1975

Knowledge, attitudes, and practice of family planning in Singapore.

The First National Survey on Family Planning in Singapore was designed to gather data that would aid in evaluating the program of the National Family Planning and Population Board and the influence of government population policies on attitudes toward family planning. Interviews with 2,078 currently married women aged 15--44 revealed high levels of contraceptive knowledge and use, satisfaction of clinic users with the Board's services, and attitudes that favor greater acceptance of abortion and sterilization. Continued promotion of the concept of the two-child family appears necessary in light of divided opinions of respondents on this government recommendation.

Abortion, Legal↗
PubMed2001

Extrahepatic bile duct length in the Singapore population.

BACKGROUND: Although the length of the common bile duct is well documented, the length of extrahepatic biliary tree is less well studied, particularly in among the Asian population. The extrahepatic bile duct (BD) length is defined as the measurement from the hepatic hilum to the papilla. OBJECTIVE: This study was performed to assess the normal range of extrahepatic BD length, as defined above, in the Singapore population. This information would be useful in assisting the local endoscopy unit in procuring the different lengths of biliary stents. METHOD: Between 1.8.96 to 1.12.97, 486 cholangiograms were obtained post-ERCP, of which only 100 cholangiograms that were representative of a non-distorted BD were used for analysis. The BD length, taken from the mid-point of the confluence of the left and right hepatic ducts at the hilum to the papilla, was measured with a string placed on the cholangiogram. The true length was obtained after correction for radiological magnification. RESULTS: The range of bile duct lengths followed a normal distribution curve with a mean length of 9.6 cm. The range was from 6.9 cm to 12.6 cm. With respect to the length of stents commonly deployed, the cumulative percentage of BD length less than and equal to 7-, 9-, 10- and 12-cm were 1%, 38%, 57% and 98% respectively. CONCLUSION: From a practical point of view, this study suggests that endobiliary stent of 5 cm in length should be readily available for drainage of distal CBD strictures as 1% of our population has BD length less than 7 cm. However, as 2% of the population has BD length greater than 12 cm, 15 cm stents should be available in the endoscopy unit for drainage of hilar obstructions/strictures.

Adult↗
PubMed2001

Problem-based learning in medical education: the Singapore hybrid.

INTRODUCTION: Problem-based learning (PBL) is an innovative educational strategy to enhance student-centred, interactive and integrated learning through intensive small group tutorials. PBL is problem-first learning in which a commonly encountered medical problem serves as the primary focus of and stimulus for learning. Several adaptations have evolved since its implementation at McMaster University in 1969. In 1999, the Singapore medical school implemented PBL as a key feature within its new hybrid curriculum. METHODS: The review will focus on the educational implications and impact of the present curriculum reform with emphasis on the implementation of PBL within the new hybrid medical curriculum. RESULTS: Our early experience in implementing PBL resembles those of several other "traditional" medical schools, namely, a generally favourable and positive response from staff and students mixed with varying degree of anxiety to change. CONCLUSION: Appropriate training and changing the mindsets of staff and students, strong leadership from the Dean and a deep commitment by all concerned are essential to ensure the successful implementation of PBL within a "traditional" medical school. PBL will enhance the quality of medical education and the educational preparation of our students to meet the challenges of future medical practice.

Education, Medical↗
PubMed2001

Introduction of problem-based learning in a traditional medical curriculum in Singapore--students' and tutors' perspectives.

OBJECTIVES: The Faculty of Medicine at the National University of Singapore was founded in 1905 and has trained many generations of medical practitioners. Teaching has been based on a traditional British-style curriculum with 2 years of training in the basic clinical sciences and 3 years in the clinical disciplines. Starting in the academic year 1999-2000, a more integrated curriculum was introduced. In conjunction with this, approximately one-fifth of the curriculum time was dedicated to problem-based learning (PBL). This will be the first time that PBL is being implemented in the medical school and both staff and students will be new at it. Thus, the objective of this study was to gather information on the reactions of both staff and students after the actual implementation. MATERIALS AND METHODS: A questionnaire was designed to assess the following: (1) What are tutors' and students' opinions on the relative benefits on students' learning process and participation of PBL versus traditional lectures? (2) What is the level of satisfaction with various aspects of their PBL experience? (3) What were the difficulties that were encountered? RESULTS: Several positive and negative aspects of the tutors' and students' experiences were revealed. Most reported fairly high levels of satisfaction with their PBL experience. CONCLUSIONS: Overall, the experiences have been positive and both groups are willing to "struggle" with this new way of learning.

Education, Medical↗
PubMed2001

Malignant melanoma seen in a tertiary dermatological centre, Singapore.

INTRODUCTION: Primary malignant melanoma is an uncommon skin tumour in Singapore compared with the Western countries. The clinical characteristics of melanoma have been rarely reported in Asians. OBJECTIVES: Our purpose was to study the incidence, clinical characteristics and risk factors of biopsy proven malignant melanoma seen in a tertiary referral skin hospital. METHODS: Case records of patients with histology proven malignant melanoma from January 1989 to December 1998 were retrieved. Patients were interviewed and a complete skin and systemic examination was performed. Data on demographics, histological types, clinical characteristics and risk factors were collated. RESULTS: Between 1989 and 1998, 27 patients were diagnosed with histology proven malignant melanoma. There was a predominance of Chinese with a female to male ratio of 1.3:1. There was a mean lag period of 1.6 years to diagnosing melanoma and there is a general lack of knowledge among the local patients. Most of the lesions (89%) occurred on the extremities. Acral lentiginous melanoma (41%) and nodular melanoma (41%) were the two commonest histologic types. Of the nodular melanomas, 64% were observed in patients below 50 years (64%) while majority of the acral lentiginous melanomas occurred in those above 50 years (91%). In terms of risk factors, we reported a high prevalence of diabetes mellitus with acral lentiginous melanoma. CONCLUSIONS: This study highlighted interesting aspects in terms of clinical characteristics and risk factors in our local patients. It also served as a remainder of the need to raise awareness among the public and medical community of skin cancers or melanomas as they are potentially treatable if detected early.

Adolescent↗
PubMed2001

Efficacy of a nitroimidazole containing tripletherapy regime in Singapore.

BACKGROUND: There has been a gradual increase in the proportion of Singapore patients with metronidazole resistant strains of Helicobacter pylori. We studied the efficacy of a nitroimidazole containing regime in eradicating H. pylori. METHODS: Consecutive treatment naive patients with peptic ulcer disease and culture proven H. pylori were recruited. From each patient, two antral biopsies were taken for rapid urease test and two for histology. Two biopsies each from the gastric antrum and corpus were taken for H. pylori culture. Antibiotic sensitivity to amoxycillin, metronidazole, clarithromycin and tetracycline were tested using the disc diffusion method. Patients were treated with lansoprazole 30 mg bd, tinidazole 500 mg bd and clarithromycin 500 mg bd for seven days. Successful eradication was defined as either negative urea breath tests 4 and 12 weeks after treatment, or negative histology and culture at least four weeks after the end of treatment. RESULTS: A total of 64 patients were culture positive (51 males, 13 females). Forty-two patients had duodenal ulcers (DU), 17 gastric ulcers (GU), and 5 DU and GU. Metronidazole resistance was detected in 16 patients (25%). Three of the 16 patients (19%) had a mixed population of resistant and sensitive strains of H. pylori. None of the H. pylori isolates were resistant to amoxycillin, tetracycline or clarithromycin. Overall, eradication was achieved in 51/64 patients (80%). Eradication rate was 88% (42/48) among those with metronidazole sensitive strains, and 56% (9/16) among those with metronidazole resistant strains (p < 0.02). CONCLUSION: A high proportion of our patients with metronidazole resistant strains of H. pylori failed eradication therapy when a nitroimidazole containing regime was used. It may not be appropriate to use a nitroimidazole containing without prior knowledge of the antibiotic sensitivity pattern of the H. pylori isolate.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2000

A pilot survey of orthodontic awareness among a group of young people in Singapore.

A questionnaire survey was conducted in 1995 on a group of students and their teachers (n = 80) from 3 Independent Schools in Singapore, to assess their orthodontic need, demand, attitude and awareness. Motivational factors and barriers to treatment were also analysed. 36% had orthodontic experience, another 49% perceived need but did not elect to have treatment. Parents and dentists remain the main motivational force behind orthodontic demand. The survey demonstrated high orthodontic utilisation in this group of subjects.

Adolescent↗
PubMed2001

Dental technician training in Singapore--a survey.

This postal survey was carried out in 1999 amongst dental technicians in Singapore to assess their status of training, interest towards a local dental technology course and national certification. A hundred and seven questionnaires were sent to technicians of 37 private and two institutional laboratories. Sixty technicians responded giving a response rate of 56.1%. Half of the respondents were above 40 years and more than 40% were not formally trained. Ninety-five percent (95%) agreed that there was a need for national certification. The preferred duration of a structured dental technology course was three years part-time followed by two years full-time. This study has shown that there is a need to train new and existing technicians through introduction of a local structured dental technology course and continuing education. National certification could be introduced when more technicians are formally trained.

Adult↗
PubMed2000

Mandible fractures: a 3-year retrospective study of cases seen in an oral surgical unit in Singapore.

A retrospective study of patients referred to the Department of Oral and Maxillofacial Surgery at Singapore General Hospital/National Dental Centre with mandibular fractures over a 3-year period from June 1995 to May 1998 was carried out. The cause, age, sex, race and anatomical distribution of the fractures were analysed for each of the 123 patients. The main cause of trauma was road traffic accidents (RTAs) (35.8%), of which 79.5% were motorcyclists. The highest incidence of trauma was in the 20-29 year age group (46.3%). Males outnumbered females in a ratio of 7.8:1. The parasymphysis was the most common site of injury (30.9%), and combined condylar and parasymphyseal fractures (26.0%) was the most common combination seen.

Accidents, Traffic↗
PubMed2001

Occupational asthma in Singapore.

AIM: Since the first notified case of occupational asthma in 1983, a total of 90 cases were confirmed as on 31st December 1999. In this study, demographic data, causative agents and impact on the workers were described. METHODS: The data was derived from notifications to the Ministry of Manpower and referrals to the Occupational Lung Disease Clinic jointly run with Department of Respiratory Medicine, Tan Tock Seng Hospital. RESULTS: Of the 90 cases, 19 (21%) were females and 71 (79%) were males. There were 48 (53%) Chinese, 22 (24%) Malays, 14 (16%) Indians and 6 (7%) of other ethnic origins. The mean age at diagnosis was 35.8 +/- 9.3 yrs. The mean duration of exposure prior to onset of symptoms was 34.9 +/- 57.3 months. The most common causative agent was isocyanates (28 cases, 31%) followed by solder flux (12 cases, 13%) and welding fumes (8 cases, 9%) respectively. Thirteen (14.4%) workers were assessed to have permanent disability under the Workmen's Compensation Act. CONCLUSIONS: Since 1990, occupational asthma has overtaken silicosis and asbestosis as the most common occupational lung disease in Singapore. The most common causative agent is isocyanates. Occupational asthma is a condition associated with disability in the workplace and may still be largely under-reported.

Adult↗
PubMed1975

Epidemic pleurodynia (Bornholm disease) outbreak in Singapore. A clinical and virological study.

In 1974, an outbreak of Bornholm disease occurred in Singapore. The period 1st May to 31st July was delineated for study. From the clinical presentation 53 patients were placed into two categories "typical Bornholm disease" and "atypical Bornholm disease". The clinical features of only those in the "typical Bornholm disease" group including those with positive Coxsackie B3 virus isolation were described. The virological studies, both faecal isolation for virus and serology were correlated with clinical diagnosis. Fever and characteristic abdominal or chest pain appear to be constant features of Bornholm disease. Positive faecal virus isolation are significantly high in the "typical Bornholm disease" group. Bornholm disease could be diagnosed clinically with fair accuracy. The importance of diagnosing Bornholm disease is emphasized.

Age Factors↗
PubMed2001

Implementing chronic disease management in the public healthcare sector in Singapore: the role of hospitals.

The public health care delivery system in Singapore faces the challenges of a rapidly ageing population, an increasing chronic disease burden, increasing healthcare cost, rising expectations and demand for better health services, and shortage of resources. It is also fragmented, resulting in duplication and lack of coordination between institutions. A disease management approach has been adopted by the National Healthcare Group (NHG) as a critical strategy to provide holistic, cost-effective, seamless and well-coordinated care across the continuum. The framework in the development of the disease management plan included identifying the diseases and defining the target population, organizing a multi-disciplinary team lead by a clinician champion, defining the core components, treatment protocols and evaluation methods, defining the goals, and measuring and managing the outcomes. As disease management and case management for chronic diseases are new approaches adopted in the healthcare delivery system, there is a lack of understanding by healthcare professionals. The leadership and participation of hospital physicians was sought in the planning, design and outcomes monitoring to ensure their 'buy-in' and the successful implementation and effectiveness of the program. The episodic diagnosis related group (DRG)-based framework of funding and subvention for healthcare, and the shortage of step-care care facilities, have been recognized by the Ministry of Health as an impediments to the implementation, and these are currently being addressed.

Case Management↗
PubMed2002

Osteoporotic hip fractures in Singapore--costs and patient's outcome.

INTRODUCTION: Little data are available on costs and outcome associated with osteoporotic hip fractures in Singapore. MATERIALS AND METHODS: A retrospective study was carried out on 280 consecutive hip fractures in patients older than 60 years admitted over a 3-year period. RESULTS: The mean age of patients was 80 years. Sixty-eight per cent were female and 58% were intertrochanteric fractures. Two hundred and sixty-four patients (95%) were operated upon. The mean total hospitalisation period was 17 days. Seventy-six per cent were staying in their own homes prior to the hip fracture while 22% were admitted from nursing homes. After surgery, 63% of patients returned to their homes while 26% needed nursing home care. The index admission mortality rate was 5.7%. Mortality was 26% at 1 year. Of those alive at 1 year, ambulatory status was: 28% were walking without aids, 39% were walking with aids, 24% were wheelchair bound and 9% were bedridden. Poor ambulatory function at discharge was related to increased mortality at 1 year. The average cost incurred was S$7367. The average government subsidy amounted to 82%. Ninety-one per cent of patients were warded in subsidized beds. Breakdown of cost was as follows: hospital stay, 42.6%; surgery, 36.5%; ward treatment, fee 9%; laboratory and X-ray investigations, 4.4%; implant costs, 3.5%; drugs, 1.6% and rehabilitation, 1.1%. Multivariate analysis showed that the cost is significantly related to days spent awaiting surgery, preoperative sepsis, operative complications and cerebrovascular accidents. Young age, good American Society of Anesthetists (ASA) status and endoprosthesis replacement were factors that allowed for early ambulation and lower costs. CONCLUSION: The mortality rates and functional outcome are not very different from published studies in the West. More of our patients returned to their own homes after hospitalisation. Early surgery, close involvement of the medical social worker and intensive physiotherapy or provision of outpatient therapy facilities may help cut cost of treatment.

Activities of Daily Living↗
PubMed2002

Epidemiology of beta-haemolytic group G streptococcal bacteraemia in Singapore (1996 to 1998).

INTRODUCTION: Group G streptococcus (GGS) accounted for 8% to 44% of all bacteraemias due to beta-haemolytic streptococci according to various reports. The aims of this study were 1) to describe the epidemiology of GGS bacteraemia in Singapore for which local data are lacking and 2) to compare its frequency of isolation to the other Lancefield groups. PATIENTS AND METHODS: The study period was from 1 January 1996 to 30 June 1998. The laboratory records of 2 large acute care hospitals were examined. There was a total of 85 patients. The medical records of 52 patients were available for analysis. In addition, laboratory microbiological data from 1993 to 1999 were reviewed and the number of blood cultures that were positive for beta-haemolytic streptococci groups A, B, C and G was collated. RESULTS: The majority involved the elderly. The mean age was 67 years. The skin was the major portal of entry. Local conditions predisposing the skin to infection occurred in 40.4%. Co-morbidity included malignancies in 28.8% of patients, diabetes mellitus in 11.5% and liver disease in 9.6%. Mortality was 15.4% including fatal septic shock. Recurrent bacteraemia occurred in 5.8% of the patients. The majority (90.4%) were community-acquired infections. GGS, along with group B streptococcus (GBS), was the most common streptococcus among the beta-haemolytic streptococci causing bacteraemia in these 2 hospitals.

Adult↗
PubMed2002

Bacteriologically-negative pulmonary tuberculosis--the Singapore tuberculosis control unit experience.

INTRODUCTION: Patients with radiological features suggestive of active pulmonary tuberculosis (PTB) from areas with a high prevalence of the disease have a high clinical likelihood of PTB regardless of the bacteriological findings. It is the established practice in many countries to initiate therapy in such patients. Our study aimed to determine if treatment for bacteriologically-negative PTB in our local population was appropriate and to identify features at presentation that would be predictive of active PTB, as defined by good and appropriate response to anti-tuberculous treatment. MATERIALS AND METHODS: A retrospective review of a randomised sample consisting of 100 bacteriologically-negative PTB patients given a course of anti-tuberculous treatment at the Singapore Tuberculosis Control Unit (TBCU). Based on their treatment response and outcome, patients were classified as probable active or unlikely active PTB. Patients' characteristics, clinical presentation and radiological findings were analysed for their association with likelihood of probable active PTB. RESULTS: Fifty-six per cent of patients in this study had probable active PTB. The decision to treat this group of patient was appropriate. There was no serious adverse reaction in the patients treated. The presence of symptoms, especially cough at presentation, a history of contact with tuberculosis and cavitation on chest radiograph, were associated with an increase risk of probable active disease. CONCLUSION: The TBCU's practice to treat patients suspected of having radiological PTB in the setting of negative sputum smear and culture seems to be appropriate in the majority of cases.

Adult↗