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Shiftwork in Singapore.

In 1985, over 94,000 persons were engaged in shiftwork. With the continued emphasis on capital-intensive industries and growing demand for "round-the-clock" services, shiftwork is increasingly becoming an economic necessity in many industries in Singapore. A survey in 1991 confirmed this trend. The study covered 4,996 private sector establishments employing 25 or more paid employees. 34.4% of the establishments had shiftworkers. In terms of employees, 32% or 206,965 employees were working shifts. While the 8-hour shift schedule was still the predominant pattern, there was a ten-fold increase in the number of 12-hour shiftworkers. A trend towards permanent shift schedules was also noted. It was interesting that the proportion of shiftworkers doing nightwork decreased to 36.9% from 45.1% in 1985. The health implications of shiftwork have been widely reported. So far, our own studies indicate no serious long-term health effects among shiftworkers. However, further studies are needed to determine if preventive measures can be taken to minimise the common complaints of sleep problems and tiredness, particularly among rotating shiftworkers.

Female↗

Acute physiology and chronic health evaluation (APACHE II) scoring in the Medical Intensive Care Unit, National University Hospital, Singapore.

The intensive care unit provides multisystem support and therapy to critically ill patients, and represents an expensive part of hospital medicine. This survey validates the use of APACHE II as a severity scoring system that allows reliable prediction of outcome of intensive care patients in Singapore. The mortality rate of 37.4% in our medical intensive care unit compares favourably with the other established intensive care units in the United States of America. Our results also indicate that the aged fared as well as their younger counterparts. Patients with sepsis fared poorer than expected from their APACHE II scores, and stroke patients needing intensive care admission had an extremely poor prognosis (mortality rate of 85.7%). High APACHE II scores are associated with invasive haemodynamic monitoring.

Adolescent↗

The Mental Diseases Hospital, Singapore (1st 100 years)--Part IV.

This article (in four parts) traces the history of the first four Mental Hospitals built in Singapore, which were occupied in 1840, 1861, 1887 and 1928. The management of the patients is described; also their lives and deaths. Mention is also made of the doctors and others who looked after them.

History, 20th Century↗

Fatal varicella infections in Singapore.

Varicella (chickenpox) is common in Singapore. The annual incidence of reported cases for the period 1977-1990 ranged from 790 to 18,934, with a mean of 4,747. Mortality from chickenpox is rare. However, failure to recognise the severity and the potential complications of the disease, especially in immunocompetent patients, exists because of the common knowledge that chickenpox is a mild and self-limiting illness. We report six cases of fatal varicella in immunocompetent patients during the period 1988 to 1990.

Adolescent↗

Prospective study of the aetiology of adult community acquired bacterial pneumonia needing hospitalisation in Singapore.

A prospective survey of 96 consecutive adult patients with community acquired pneumonia requiring hospitalisation was carried out at National University Hospital, Singapore. Causative pathogens were identified in 58% of patients. Mycobacterium tuberculosis was the most common pathogen (21%), followed by Streptococcus pneumoniae (12%), Haemophilus influenzae (5.2%), Mycoplasma pneumoniae (5.2%) and Staphylococcus aureus (4.2%). Gram-negative organisms (apart from Haemophilus influenzae) were found in 10% of pneumonia patients. More than half of the patients had pre-existing illness, the most common was diabetes mellitus (21%).

Adolescent↗

Neurobehavioural effects on workers in a video tape manufacturing factory in Singapore.

This study was carried out in a video tape manufacturing factory in Singapore where workers were exposed to mixed solvents consisting of methyl ethyl ketone (MEK), cyclohexanone (CHE), tetrahydrofuran (THF), and toluene (TOL). The objectives were to quantify workers' exposure to the various solvents and to evaluate if there were any neurobehavioural changes among the workers compared to controls. Nineteen exposed workers out of the workforce of forty-five were studied. Twenty-six workers (with no exposure) matched for ethnic group, age, and years of education served as controls. Eight-hour personal environmental samples were analyzed for the 19 workers along with symptom questionnaires, clinical examinations, and neurobehavioural tests including the Santa Ana Dexterity, Finger Tapping, Digit Span, and Visual Reproduction tests. The mean TWA concentrations for MEK, THF, CHE, and TOL were all below the current American Conference of Governmental Industrial Hygienists Threshold Limit Values (TLV). However, the total solvents concentration index exceed unity in one of the work areas. Significant differences were observed for prevalence of headache, and eyes and nose irritation among the exposed workers. There were also significant differences for the Santa Ana test for both-hands, Digit Span test and Visual Reproduction test. However, no dose-effect relation between behavioral scores and airborne solvent exposure was noted. The study suggests that solvent-exposed workers in video tape manufacturing plants may have poorer visual motor control and recent memory impairment (visual and verbal) than unexposed workers. Dermal absorption of solvents may have played a role in these results by increasing workers exposure.

Adult↗

Perspectives of end stage renal failure therapy in Singapore.

Haemodialysis in Singapore started in 1961 when a patient with kidney failure was dialysed using the twin coil artificial kidney. Over the years, we have seen various new techniques like rapid high efficiency dialysis, haemodiafiltration (HDF) and rapid high flux HDF introduced. Dialysers with newer membranes have improved solute transport, biocompatibility and water removal. Mini heparinisation and heparin-free dialysis have circumvented problems of bleeding in high risk patients. Technological advances in haemodialysis will continue with more new modalities introduced. Newer forms of vascular access through the subclavian and internal jugular veins have phased out the use of chronic arterio-venous (AV) shunts. Continuous ambulatory peritoneal dialysis (CAPD) was introduced in 1980. This has been a boon for cardiac and diabetic patients. The initial problems with peritonitis are now manageable with our current rate of 24.1 patient months compared to 13.2 patient months in 1983. This has been achieved through the use of ultraviolet (UV) germicidal exchange device and transfer tube changes by trained nursing personnel as well as better patient training and education. New techniques have included the "O" disconnect set, the use of 2.5 litre dialysate, low calcium dialysate and the introduction of continuous cycling peritoneal dialysis (CCPD). Future focus will be on the problems of nutrition and protein loss. Renal transplantation remains the ideal renal replacement therapy. Cadaveric renal transplantation was initiated in 1970 and living related donor transplant in 1976. From 1970-1985, immunotherapy was azathioprine-based and from 1985, cyclosporin A (CyA) was introduced. CyA has abrogated many immunological risk factors. Preformed cytotoxic antibodies are still important.(ABSTRACT TRUNCATED AT 400 WORDS)

Humans↗

Do-not-resuscitate orders: towards a policy in Singapore.

Despite the fact that the pioneers of cardio-pulmonary resuscitation (CPR) designed the techniques for victims who were meant to be "salvable", currently CPR is largely applied to anyone who collapses, regardless of their underlying illness. However, the central fact is that CPR (and all its related complex and expensive technology) has a very low success rate (in terms of eventual hospital discharge) and the most important determinant of survival has always been the nature and stage of the underlying illnesses. All these bespeak of a need to have do-not-resuscitate (DNR) orders which will incorporate the pertinent medical, ethical, socio-cultural and legal components. In this discussion paper some guidelines for DNR orders relevant to Singapore are proposed, the main rationale of the guidelines are explained and some challenges and needed changes associated with its implementation are addressed.

Attitude to Health↗

Sexual behaviour of male inmates of a detention facility in Singapore: risks of intraprison human immunodeficiency virus transmission.

Sexual urges and needs do not cease merely upon the incarceration of an individual. They continue to exist in varying degrees in different individuals. This study looks into the sexual behaviour of all the male inmates of a detention facility in Singapore, both before and during their incarceration. In the advent of acquired immune deficiency syndrome (AIDS), high risk behaviours are investigated with the view to applying the results towards the formulation of policies on prevention of intraprison transmission of human immunodeficiency virus (HIV). Taking masturbation as an expression of the degree of sexual needs, the three high risk groups for HIV infection--the promiscuous heterosexuals, the homosexuals/bisexuals and the intravenous drug users--had higher in-detention masturbation rates than the others. In addition, those incarcerated for 180 to 360 days up to the day of the study had higher masturbation rates than those incarcerated for less than 180 days and longer than 360 days. In-detention homosexual behaviour was also demonstrated in this study. Recommendations include health education programmes on AIDS and risk reduction and removal of the prohibition on masturbation. Mandatory HIV testing and segregation of high risk or HIV-positive inmates are not recommended.

Adult↗

Usefulness of dinucleotide polymorphism markers in genetic analysis of Duchenne's muscular dystrophy cases in Singapore.

Dinucleotide polymorphisms are short tandem repeat sequences that can be used as probes for haplotype analysis in Duchenne's muscular dystrophy (DMD). There are approximately a total of 50,000 to 100,000 such loci in the human genome, and they are highly informative due to the variability of allele lengths at these loci. Primers can be designed to amplify across such repeats located in the dystrophin gene to provide diagnostic information when RFLP analysis is uninformative. We report the usefulness of three such loci for analysis of DMD families in Singapore. The STR50 marker consists of (CA)n repeats located in intron 50 of the dystrophin gene while DYS1 marker is located upstream to the transcriptional start site for the brain dystrophin promoter and BSTRH marker is identified in the 3' untranslated region of the gene. End-labeled PCR products were resolved on 6% denaturing polyacrylamide sequencing gel. Alleles were identified by comparison with sequencing markers. PCR product typically ranged between 174 bp to 255 bp with five to six alleles observed. The heterozygosity rates estimated from 50 X chromosomes of unrelated individuals were 76.0% (BSTRH), 86.6% (DYS1) and 93.3% (STR50). In 38 DMD families studied, the results obtained show that these markers were highly informative and reveal Mendelian mode of inheritance. They were useful for linkage analysis, identification of deletion mutations, confirmation of paternity and mapping of gene recombination.

Alleles↗

Medical genetics in Singapore.

This paper is a brief review of the scope of research and clinical work in human genetics in Singapore. Clinical genetics and karyotyping were established in the early sixties. G6PD deficiency was discovered then as the commonest cause of kernicterus in the newborn. Screening of all newborns was instituted. The measures taken have been very successful and kernicterus is virtually unknown since the early 1970s. Numerous G6PD variants have been discovered and characterized. During the 1980s the emphasis shifted to molecular genetics. Work on the molecular genetics of alpha- and beta-thalassemias, Duchenne muscular dystrophy, hemophilia and retinoblastoma have been established, and good progress on diseases such as neurofibromatosis, leukemias, and lymphoid malignancies. The diagnosis of tuberculosis by DNA amplification (PCR) has been successfully implemented. Numerous papers have been published on the molecular genetics of coronary artery disease, as well as in population genetics.

Adult↗

A study on the epidemiology of hepatitis C infection among blood donors in Singapore.

BACKGROUND: Hepatitis C viral (HCV) infection has been identified as the main cause of post-transfusion hepatitis (PTH) since 1989. Despite this, little is known regarding the prevalence and mode of transmission of the disease. The purpose of this study was therefore to study the demographic factors associated with HCV infection among Singaporean blood donors. METHODS: In this study, the screening questionnaire records of HCV-positive donors were analysed. A total of 241 donors, tested positive for HCV between 7 December 1992 and 31 August 1994, were included. Demographic details studied included the age, sex, race, citizenship, occupation and number of previous donations. In additions, the associations of HCV infection with other screened diseases were analysed. RESULTS: The prevalence of HCV infection was found to be 0.370 per cent (241/65208) among the donors. Of these, 200 (0.389 per cent prevalence) were male and 41 (0.298 per cent prevalence) were female. The mean age was 34.2, SD = 9.4. The prevalence of the disease was found to increase with age. Significant differences were seen among the races (chinese versus Malay, 0.329 percent versus 0.513 percent, p < 0.05). There was also a significant association of HCV with Human Immunodeficiency Virus (HIV) infection among the donors (0.4 percent co-infection versus 0.004 percent in the general donor population, p < 0.01). CONCLUSION: The incidence of HCV infections is relatively low among blood donors in Singapore. The differences in prevalence seen among the different groups studied suggest that the disease is community acquired and may be due to the lifestyle of the donors.

Adult↗

Molecular changes of colorectal cancer in Singapore.

Improved success in the management of colorectal cancer requires a better understanding of its development and biological behaviour. The key for this is molecular genetics. Gene changes parallel the multi-step changes in the adenoma-carcinoma sequence. Cancer results from a variable combination of defects in oncogenes, tumour suppressor, mutator and apoptotic genes. These changes are similar whether they occur in inherited disorders like adenomatous polyposis coli (APC) and hereditary non-polyposis colorectal cancer (HNPCC) or acquired cancer in the elderly. In Singapore, the c-myc and c-Ki-ras proto-oncogenes are found to be activated in 70% and 29% of tumours respectively. Allelic loss of chromosome 5q and 17p occurs in 25% and 70% of tumours respectively, while point mutation of the p53 tumour suppressor gene occurs in 50% of colorectal cancers. Both the frequency and the nature of the lesion occurring are compatible to the changes detected in Caucasian patients, suggesting common aetiological factors. The biological behaviour of colorectal adenocarcinomas is determined by the nature of defects or mutations in key genes such as the p53 tumour suppressor gene. Lymphatic spread is associated with the presence of point mutations and haematogenous spread is associated with loss of heterozygosity of p53. Survival is worse when conserved regions of the gene are mutated compared with those outside, and worst when codon 175 is mutated. Sensitivity to radiotherapy and chemotherapy is also determined by p53 mutation which controls apoptosis. Prognosis could now be individualised and with the prospect of gene therapy, molecular genetics will have a major impact on the management of colorectal cancer.

Adenocarcinoma↗

Psychiatric day centres--the Singapore experience.

Psychiatric Day Centres are an important aspect of psychiatric community services and care. In Singapore we have developed our Day Centres with the needs of our own patients in mind. At present there are four Psychiatric Day Centres and they focus on vocational and psychosocial rehabilitation. A wide range of structured activities are provided at each of the Day Centres and the programmes are individualised as far as possible to meet the needs of each patient. A multidisciplinary team looks after each patient. This paper outlines the historical aspects of Psychiatric Day Centres and highlights the objectives of the Day Centres administered by Woodbridge Hospital. Patients are grouped into three categories according to their occupational and social skills; programmes and care are provided according to their needs. Of the one hundred and eighty attenders, the sex distribution is almost equal and they are mainly in the twenty to forty-nine age group. Schizophrenia is the most common illness among the attenders and the majority are in the Sheltered Work Group. More than half of them had attended a Day Centre for between one to two years and less than a third had recent admissions to hospital.

Adult↗

Murine typhus: a forgotten cause of febrile illness in Singapore.

We report 6 cases of marine typhus presented to us within a period of 3 months. The diagnoses were made based on the Weil-Felix reaction in the context of supportive clinical and epidemiological features, and response to appropriate antimicrobial therapy. This review serves to remind us that murine typhus is still an important cause of acute febrile illness in Singapore, especially among the migrant Indian workers.

Acute Disease↗

Primary biliary cirrhosis--an uncommon disease in Singapore.

Primary biliary cirrhosis (PBC) is uncommon in Singapore. Twelve consecutive patients with PBC were seen between 1987 and 1994 at the National University Hospital. Eleven were women and the mean age at presentation was 53 years. Three patients presented with pruritus and jaundice whilst three had decompensated cirrhosis. The remaining six patients had no symptoms attributed to their liver disease when first detected, three of them presented with associated conditions including sicca syndrome and interstitial lung fibrosis, lichen planus, and carcinoma of breast. All patients had elevated serum alkaline phosphatase and positive anti-mitochondrial antibodies. Liver histology (10/12) showed Stage II disease (2), Stage III (5) and Stage IV (3). Three patients also had co-existing gall bladder stones but their endoscopic retrograde cholangiograms were normal. The mean follow-up period was 32.6 months and four patients died during follow-up. The only male patient had liver transplantation, two patients had symptomatic treatment while the rest were treated with ursodeoxycholic acid. In conclusion, local patients tended to presented relatively early in the course of the disease with 50% being asymptomatic and in the precirrhotic Stages.

Adult↗

Cervical screening in elderly women in Singapore.

The study was conducted to determine the pick-up rate of abnormal cervical smears and the prevalence rate of cervical cancer in women aged 60 years and above and the demographic characteristics of the women screened. The pick-up rate of abnormal cervical smears was 1.65%. The prevalence rate for cervical intraepithelial neoplasia and frank carcinoma was 6.4 and 5.0 per thousand women screened respectively. The study group comprised 89.7% Chinese, 4.7% Malays, 3.6% Indians and 2.0% Others. The pick-up rate of abnormal smears was 1.9% in the Chinese and 1.3% in the Indians. There were no abnormal smears in the Malays and Others. The results demonstrate the importance of a routine cervical cancer screening programme among elderly women aged 60 years and above in Singapore.

Age Factors↗

A study of treponema pallidum haemagglutination positive blood donors in Singapore.

The Treponema Pallidum Haemagglutination (TPHA) test has been used for screening of syphilis among blood donors in Singapore since September 1992. Among the 79 500 donations that were screened between September 1992 and December 1993, 191 were tested positive (incidence rate of 0.24%). Seventy-two donors (37.7%) were evaluated at the Department of Sexually Transmitted Disease Control clinic. Seventy-nine percent of these donors had high risk sexual exposure and 33.3% had a history of sexually transmitted diseases. Eighty-three percent of the donors were diagnosed to have late latent syphilis, 9.7% were diagnosed to have a serological scar and the remaining had secondary syphilis, early latent syphilis and a false positive reaction. At least 65.3% of these donors would have been missed if the reagin test was used alone as the screening test. Thus, the TPHA test is a good marker for screening those who have high risk sexual behaviour and it is a more sensitive test than the reagin test for screening blood donors.

Adult↗