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PubMed1997

Ophthalmic manifestations in human immunodeficiency virus infection in Singapore.

The paper retrospectively reviews the spectrum of ophthalmic manifestations in human immunodeficiency virus (HIV) infection in Singapore between May 1995 and October 1996. One hundred and eighteen patients were examined for ocular abnormalities. Criteria for examination were 1) visual complaints, 2) absolute CD4 count of less than 50 cells/ul, 3) patients with acquired immunodeficiency syndrome-defining illness or 4) any relevant systemic illnesses which may have ocular involvement. Only 25 patients (21.2%) had visual symptoms. Eighteen patients (15.3%) had abnormalities associated with microvasculature. Forty-four patients (37.3%) had opportunistic infection involving the eye of which 37 were that of cytomegalovirus retinitis (CMVR). Seven patients (5.9%) had neuro-ophthalmic disorders. One patient presented with proptosis due to orbital lymphoma. Four patients (3.4%) had episcleritis and 3 patients (2.5%) had symptomatic dry eyes. It is still not known if episcleritis and dry eyes are associated with HIV infection or are coincidental. Fifty-one patients (43.2%) had no ocular pathology and remained so throughout the period of study. Nine patients (7.6%) had more than one pathology. The major cause of visual loss was due to ocular infections, with CMVR being most prevalent. Recognising the ophthalmic signs in HIV patients will facilitate early diagnosis. Prompt treatment of eye involvement can prevent or delay blindness, which is psychologically and functionally important to these patients.

AIDS-Related Opportunistic Infections↗
PubMed1997

Emerging pathogens for pneumonia in Singapore.

The death rate from pneumonia in Singapore has increased steadily over the past decade. The emerging respiratory pathogens may have contributed to this increased mortality. New challenges have arisen from changes in the characteristics of the host and the susceptibilities of the various pathogens to antibiotics. There has been a 60-fold increase in the incidence of penicillin resistance in Streptococcus pneumoniae, the major pathogen for community-acquired pneumonia (CAP). Gram-negative bacilli are the major pathogens in severe CAP with Klebsiella pneumonia being the most frequently isolated organism. There has been a small increase in the number of cases of Legionnaire's disease and a marked increase in the incidence of melioidosis. While the overall incidence of tuberculosis has been unchanged, the number of non-residents with tuberculosis has doubled in the past 5 years. The rising prevalence of human immunodeficiency Virus infection is reflected in an increasing number of apparently healthy young men who present with CAP caused by Pneumocystis carinii. There is increasing resistance to antibiotics among gram-negative bacilli and Staphylococcus aureus, the dominant pathogens in hospital-acquired pneumonia. New strategies are urgently needed to prevent the emergence of pathogens in the hospital environment which may be resistant to all known antibiotics.

AIDS-Related Opportunistic Infections↗
PubMed1997

Dengue--a re-emerging infectious disease in Singapore.

Despite its well-established integrated nationwide Aedes mosquito control programme which incorporates source reduction, public health education and law enforcement, Singapore has not been spared from the regional resurgence of dengue. The disease incidence has been increasing from 9.3 per 100,000 in 1988 to 102.7 per 100,000 in 1996 at the time when the Aedes house index (HI) has dropped to around 1% from > 25% in the 1960s. Majority of the cases reported from 1990 to 1996 were dengue fever (DF); dengue haemorrhagic fever (DHF) constituted only 6.7%. The case-fatality rate was 0.1% with 13 (81.3%) of 16 serologically confirmed deaths above 19 years of age. The median age has shifted from 14 years in 1973 to 27 years in 1996. The proportion of primary infections also increased from about one-third in 1990 to nearly half in 1996. All four dengue serotypes have been detected from infected persons with dengue 2 predominating in 1990, 1991 and 1993, dengue 3 in 1992 and 1994 and dengue 1 in 1995 and 1996. The disease incidence was significantly correlated with Aedes aegypti HI and residents of compound houses had a significantly higher rate of infection as well as a higher morbidity rate compared with dwellers of high-rise public housing estates. Seroprevalence surveys confirmed the low level of dengue transmission. The immunity level of the general population has been declining with only 6.4% of children and young adults below 25 years of age possessing haemagglutination-inhibition antibody to dengue 2. It would appear that the successful vector control programme over the last two decades has brought about a paradoxical situation in that outbreaks tend to occur more frequently and with even greater intensity because of the low herd immunity of the population. Until the dengue vaccine is commercially available for mass immunisation of the population, community-based integrated control of Aedes aegypti remains the key to the prevention and control of DF/DHF.

Adolescent↗
PubMed1997

Prevention and control of hepatitis B virus infection in Singapore.

Hepatitis B virus (HBV) accounted for 24% to 54% of the reported acute viral hepatitis cases in Singapore from 1982 to 1996. The prevalence of HBV infection, as indicated by the presence of markers of HBV, increased from 9.3% in children below 5 years of age to 54.6% in adults above 55 years. The overall hepatitis B surface antigen (HBsAg) prevalence was 5.7% for males and 3.4% for females, with the highest rate among the Chinese. About 39% of the HBsAg carriers were hepatitis B 'e' antigen positive. The main mode of transmission during the first year of life was perinatal, with 43% of the babies born to HBsAg-positive mothers developing the carrier state. Horizontal transmission within the infected household was significantly associated with sharing of personal and household articles. Based on the findings of seroprevalence surveys in various population groups and clinical trials on the safety, immunogenicity and efficacy of various doses and schedules with the plasma-based and yeast-derived hepatitis B vaccines in newborn babies, a national childhood hepatitis B vaccination programme was formulated and implemented in phases, starting with babies born to carrier mothers on 1 October 1985 and finally extending to all newborns on 1 September 1987. The hepatitis B prevention and control programme has been successful. During the period 1994 to 1996, more than 90% of children completed the full schedule of immunisation by below one year of age, and 85% had evidence of vaccination at school entry at age six. Follow-up of 2 cohorts of vaccinated children showed that perinatal transmission has been reduced by 80% to 100%. Horizontal transmission has also declined through other public health measures. The efficacy of the hepatitis B vaccine and the adequacy of reduced doses in the long-term protection of chronic carrier state have been shown in children and adults. The incidence of acute hepatitis B has declined from 10.4 per 100,000 in 1985 to 4.8 per 100,000 in 1996. There is a noticeable reduction in HBsAg prevalence in selected population (school children, national servicemen and antenatal women). The age-standardised incidence rate of primary liver cancer among males had also dropped from 27.8 per 100,000 per year during 1978 to 1982 to 19.0 per 100,000 per year during 1988 to 1992.

Age Factors↗
PubMed1997

A case report of visceral leishmaniasis in Singapore.

Visceral leishmaniasis (Indian kala-azar) caused by infection due to the protozoan Leishmania donovani is endemic in the Indian subcontinent and adjoining regions. Prolonged fever, hepatosplenomegaly, anaemia and pancytopenia, in the appropriate setting, are important clinical markers towards the diagnosis. Diagnosis is established by blood film or bone marrow examination for Leishman Donovan (LD) bodies and/or culture. Treatment with sodium stibogluconate, pentamidine isethionate or even amphotericin B is usually successful. We report the first case of culture-proven visceral leishmaniasis in Singapore, in a 30-year-old Bangladeshi worker who presented with pyrexia of unknown origin (PUO). He had the classical constellation of symptoms and signs as mentioned above. Diagnosis was confirmed by culture on the Novy, NcNeal and Nicolle (NNN) medium. He was successfully treated with 20 days of pentamidine isethionate daily infusions at a dose of 2 mg/kg/day.

Adult↗
PubMed1997

The demography, clinical manifestations and natural history of human immunodeficiency virus (HIV) infection in an older population in Singapore.

In this retrospective study, we report 43 cases (41 males and 2 females) of human immunodeficiency virus (HIV) infection in the Singapore population aged 50 years and above at first presentation. We found an increasing proportion of these older individuals among our HIV-seropositive patients; from 4.8% in 1991 to 16.7% by mid-1996. The mean age at presentation was 59.2 years (range 50 to 75 years). They were mainly heterosexuals (93%) and the majority (79.1%) were previously or currently married. Thirty-six (83.7%) patients had multiple sexual exposures to commercial sex workers. Nearly all had acquired the infection through the sexual route. The majority (76.7%) were symptomatic at presentation. Common clinical presentations were weight loss (72%), respiratory symptoms (60%) and oral candidiasis (56%). More than half (58.1%) of the patients had acquired immunodeficiency virus (AIDS) at the time of first presentation with a low median CD4 count of 17 cells/mm3. Pneumocystis carinii pneumonia and tuberculosis were the common AIDS-defining diseases. Survival in patients presenting with AIDS (median survival 3 months) is poorer compared to younger HIV-seropositive patients (< 50 years; median survival 1 year). No increase in age-related infection or malignancy was seen. Common causes of death were pneumonia and septicaemia. Physicians should consider HIV infection in older patients particularly when he/she presents with unexplained weight loss, respiratory symptoms and oral candidiasis. A history of high-risk sexual behaviour must be sought in all patients, including the elderly.

AIDS-Related Opportunistic Infections↗
PubMed1997

Sexually-transmitted diseases in Singapore--trends in the last two decades.

We review the epidemiology and trends of sexually transmitted diseases (STDs) in Singapore from 1977 to 1996. There has been a progressive decline in the incidence of bacterial STDs over the period of observation. However, viral STDs have not shown the same trends, remaining at a relatively constant level. Early detection and treatment of STDs, and health education and prevention measures targeting sex workers have been a major factor in controlling STDs. Vigilant monitoring of antibiotic resistance patterns in Neisseria gonorrhoeae has allowed timely changes to recommended treatment regimens. The advent of the human immunodeficiency virus (HIV) infection pandemic in the 1980s and public education campaigns have contributed to the success of the STDs control programme. In view of the incurable nature of many viral STDs, prevention and counselling have become a cornerstone of STD control. Surveillance and monitoring of STD trends will continue to provide important information regarding the effectiveness of existing health programmes and help us formulate new plans for the future.

Female↗
PubMed1997

Epidemiology of falls among the elderly community dwellers in Singapore.

AIM: Falling is a serious medical problem for elderly persons. This study was done to look at prevalence and risk factors for falls in community dwelling elderly in Singapore. METHOD: A random sample of 3,000 persons aged 60 years and above was chosen from a database based on the 1990 population census. Letters were sent out to 2,582 subjects who had local and complete addresses. In the letter, they were informed about the purpose of the survey, and invited to participate in a questionnaire and clinical health screening at an appointed date at a polyclinic. Participants were reminded the day before their appointment by telephone, and a new appointment could be given at the subject's convenience. RESULTS: We found a prevalence rate of falls of 17.2%. Two-thirds of these had single falls, while one-third had recurrent falls, defined as having more than one fall within the previous one year. The following factors were found to be significantly associated with increase falling in the elderly: age > or = 75 years (O.R. = 1.82, 95% C.I. 0.95-3.50), female sex (O.R. = 2.5, 95% C.I. 1.40-4.48), Malay race (O.R. = 2.66, 95% C.I. 1.21-5.86), poor vision (O.R. = 1.7, 95% C.I. 0.99-2.90), Barthel's score of less than 20 (O.R. = 1.76, 95% C.I. 0.94-3.28), those taking 2 or more drugs daily (O.R. = 2.1, 95% C.I. 1.22-3.72) and the presence of hypertension (O.R. = 1.78, 95% C.I. 1.06-3.01). Fall rate is also twice as high in women as in men. At the same time, we found that women in the group we studied also tend to exercise less than the men. Fallers also had significantly more mobility and activities of daily living (ADL) disabilities (reflected by a lower Barthel's score) and this is consistent with other results. The only factor that reduced the risk of falling was regular exercise (O.R. = 1.64, 95% C.I. 0.93-2.93). CONCLUSION: In our study, we found differences between the group with single and recurrent falls. In the group with single falls, the fall tend to occur outdoors (O.R. = 2.97, 95% C.I. 1.03-8.60) and during the day (O.R. = 3.47, 95% C.I. 1.20-10.0), tend to be accidental (O.R. = 3.16, 95% C.I. 1.05-9.50) and tend to seek medical attention (O.R. = 3.68, 95% C.I. 1.23-11.0). Overall, 32 persons (46.4%) seek medical treatment after their falls, and of these, 65.6% were women. Risk factors for falls should be screened for all elderly.

Accidental Falls↗
PubMed1998

Results of intermediate measures from a population-based, randomized trial of mammographic screening prevalence and detection of breast carcinoma among Asian women: the Singapore Breast Screening Project.

BACKGROUND: Although increasing rates of breast carcinoma incidence have been observed in Asian countries, appropriate strategies for detecting early stage breast carcinoma in such communities have been difficult to formulate, particularly because no large population screening trial specifically involving Asian women has been reported. The objective of this study was to evaluate the effectiveness and quality of mammography as a screening technique for Singaporean women, who are predominantly Chinese. METHODS: In this prospective study, 166,600 women in Singapore ages 50-64 years were randomized to either 2-view mammography without physical examination (67,656) or observation (97,294, controls) over 2 years. RESULTS: Of these women, 28,231 (41.7%) responded and were screened; they were more likely to be married, have more formal education, be working, be Chinese, and be in a higher socioeconomic group (P < 0.001 for all variables). To assess for response bias that could affect outcome, results were also evaluated for nonrespondents (n = 39,425). The incidence rate of cancers among nonrespondents (1 per 1000 woman-years) was less than the 1.3 in women not invited to have screening (P = 0.03, relative risk [RR], 1.3; 95% confidence interval [CI], 1.0-1.7). However, cancers arising from nonrespondents did not differ significantly in stage distribution when compared with cancers within the control group. For every 1000 women screened, 4.8 cancers were detected. The prevalence ratio (the number of cancers detected per 1000 women at first screening divided by the corresponding incidence rate in controls per year) was 3.6 for screened women and 2.4 for women invited to have screening. The majority of cancers detected through screening were early stage, with 64% as either ductal carcinoma in situ (26%) or Stage I disease (38%) and was significantly more than the corresponding 26% in women not invited to have screening (P < 0.001). When only invasive cancers were considered, screened women still had more early cancers, with 65% having no lymph node involvement, compared with 47% in the group not invited to have screening (P = 0.001; RR, 1.4; 95% CI, 1.2-1.7). Women who were screened had half the risk of having Stage II or later cancers (P < 0.0001; RR, 0.5; 95% CI, 0.4-0.7) when compared with women not invited to have screening. This higher detection rate of early cancers through screening was accomplished with acceptable recall rates of 8% for further mammographic films or physical examination and a biopsy rate of 1.0% (10 per 1000 women screened). The interval cancer rate was 2.1 per 10,000 women screened in the first year of follow-up. CONCLUSIONS: These positive results of intermediate measures suggest that, in Asian communities, screening mammography could be an important modality for detecting early stage breast carcinoma. However, the low compliance rates suggest that health education efforts must focus on issues related to acceptability if such programs are to succeed.

Aged↗
PubMed1998

Case report of Usher's syndrome in two sisters--first reported case in Singapore.

A 28-year-old Chinese woman presented with poor night vision since childhood. Ocular examination showed pigmentary retinopathy and systemic examination revealed sensorineural hearing loss. Family history showed a similar condition in her youngest sister. Ocular and systemic examination of her sister showed similar findings. This is presented as the first case report of Usher's syndrome in Singapore. A general discussion of Usher's syndrome is also presented.

Adult↗
PubMed1993

Simply marking dentures in the SAF. Singapore Armed Forces.

Forensic dentistry is important to the armed forces and denture markers are useful adjuncts in forensic dental identification. The dental services in the Singapore Armed Forces (SAF) recognise this need and have been marking dentures since 1987. The "inclusion method" chosen for marking dentures in the SAF is described.

Denture Identification Marking↗
PubMed1993

Singapore dentists' knowledge, advocacy and utilisation of mouthguards.

A questionnaire was distributed to Singapore Registered Dental Practitioners, seeking demographic details, knowledge of mouthguards in preventing dental injury during contact sport, current attitudes to advice and provision to at-risk patients. 636 questionnaires were posted and 226 valid replies were received. Most dentists believed that mouthguards reduced the prevalence of dental injury in contact sports. Undergraduate education was the primary source of dentists' knowledge. Seventy-four per cent of respondents actively recommended mouthguards, but only 26 per cent made one or more in 1992. Only 3 dentists made more than 10. Twenty-eight per cent were comfortable with their knowledge in this area, and 76 per cent would be willing to assist a public awareness campaign.

Athletic Injuries↗
PubMed1998

Ankylosing spondylitis in Singapore: a study of 150 patients and a local update.

This paper presents the results of a clinical study of 150 patients in Singapore with ankylosing spondylitis (AS) and reviews recent developments locally with regards to the disease. The patients were predominantly males (ratio 7:1) and Chinese (n = 147). The onset of disease is usually in the early twenties and there was a mean delay of 6.3 years before diagnosis was made. Peripheral joint involvement is common but apart from uveitis (17%), extra-articular manifestations are rare. AS patients have abnormal lipid profiles and lower bone mineral density compared to healthy controls. HLA*B2704 is the predominant subtype in our Chinese patients whilst HLA*B2706 was found only in healthy controls. Intensive group physiotherapy is beneficial for patients with spondyloarthropathy.

Adolescent↗
PubMed1998

Clinical presentation and disease associations of gout: a hospital-based study of 100 patients in Singapore.

The aim of this retrospective study was to characterise the clinical presentation and disease associations of Oriental patients with gout seen in our hospital over a six-month period. One hundred patients comprising of 77 males and 23 females [89% Chinese, 7% Malays, 2% Indians and 2% others; mean age was 50.9 years (range 18 to 82 years), mean age at onset of disease was 43.7 years (range 16 to 78 years)] were studied. The disease was familial in 18% and 44% of patients had a history of alcohol ingestion. Co-morbid conditions included hypertension (36%), hyperlipidaemia (25%), renal failure (17%), ischaemic heart disease (13%), diabetes mellitus (4%), systemic lupus erythematosus (3%), psoriasis (2%) and ankylosing spondylitis (1%). The majority of patients (68%) had at least one associated disease. At the onset of disease, the joints commonly involved were the ankles (39%) and knees (27%) whilst the first metatarsophalangeal (MTP) joint was affected in only 26% of cases. Polyarticular onset was uncommon (n = 6). The precipitating factors reported by the patients included food (n = 23), alcohol (n = 12), drugs (n = 4), trauma (n = 3) and surgery (n = 2). Eleven patients had a history of renal calculi and 15% had tophaceous gout. Majority of patients (71%) had been treated with urate-lowering drugs (allopurinol). We concluded that gout in Singapore predominantly affects middle-aged men who often have an accompanying illness.

Adolescent↗
PubMed1998

Corticosteroid contact hypersensitivity screening in Singapore.

BACKGROUND: Topical corticosteroids have been in use since 1957. Two percent to 5% of patients attending patch test (PT) clinics have problems with corticosteroid contact hypersensitivity. Controversies abound with regard to the choice of steroids in the standard battery, the method of patch testing and reading, and the ideal concentration and vehicle. OBJECTIVE: To assess betamethasone 17-valerate (1% pet.), fluocinolone acetonide (0.25% petrolatum [pet.]), and tixocortol pivalate (1% pet.) used in the authors' standard battery. METHODS: Data were analyzed for patients seen between January 1994 and December 1996 who had positive PT reactions to one or more of these steroids. RESULTS: 3,603 patients had standard PTs, of which 20 had positive reactions to one or more of these steroids. There were three positive reactions to betamethasone 17-valerate, 17 to tixocortol, and none to fluocinolone. On further patch testing to the authors' steroid battery, only one tixocortol-positive patient had a positive reaction to hydrocortisone (1% ethanol/ dimethyl sulfoxide [DMSO]). CONCLUSIONS: Corticosteroid allergy is found to be relatively uncommon in Singapore on the basis of this screening series. The frequency of negative reactions to fluocinolone acetonide is sufficiently low for this corticosteroid to be excluded from the authors standard series. The significance of positive tixocortol reactions remains unknown. From the review of other relevant literature, the authors recommend that budesonide be added to their present series. Testing betamethasone 17-valerate in 1% ethanol may yield more positive allergic reactions. Individuals with a positive allergic PT reaction to one corticosteroid should subsequently be tested to a full corticosteroid series.

Administration, Topical↗
PubMed1998

A needs assessment and proposal for HIV education among human resource managers in Singapore.

AIM OF STUDY: To assess the educational needs of human resource managers in Singapore with regard to the management of HIV at the workplace. No such study has been described before in an Asian country. METHOD: A self-administered questionnaire was mailed to all companies (with more than 100 employees) of a local employers federation (n = 368). RESULTS: A response rate of 64.1% was achieved. Respondents' knowledge about HIV transmission was found to be good. However, their attitudes and practices towards infected workers were unfavourable on such issues as pre-employment screening, medical coverage and termination of employment. Possible reasons for this disparity include inadequate information specific to workplace needs, multiple determinants of attitudes (other than knowledge) and various environmental factors. CONCLUSION: Strategies for an educational intervention are proposed to facilitate the development of a rational HIV management policy by local managers.

Adult↗
PubMed1998

Down syndrome screening in Singapore--the effectiveness of a second trimester serum screening policy modelled on 29,360 pregnancies in KK Women's and Children's Hospital.

AIM OF STUDY: To assess the effectiveness of a proposed second trimester Down syndrome serum screening policy in Singapore. METHOD: Auditing the effectiveness of an age-only policy and comparing it against a serum screening policy modelled on the same maternal population of KK Women's and Children's Hospital in 1994 and 1995. RESULTS: KK Women's and Children's Hospital's (KKH) maternal age distribution is similar to the national age distribution of mothers. Sixteen percent (16.7%) of mothers in KKH, in 1994 and 1995, were 35 years or older at delivery. Based on our hospital birth defect registry, 66% (35/53) of Down Syndrome pregnancies occurred in mothers who were 35 years or older at delivery and 43% (23/53) in the oldest 6.5% of mothers (38 years or older at delivery). Using various models on KKH's population structure to estimate the expected number of Down Syndrome livebirths expected, 52%-55% and 34%-36% of Down Syndrome livebirths were expected to occur in the oldest 16.7% and 6.5% of mothers respectively. These simulated figures are much lower than the figures from the data and needs further study, assuming that the Western Down Syndrome risk model to be applicable to our population. The overall uptake of amniocentesis irrespective of gestational age at booking was 28%. In mothers who were 35 years or older at delivery and booked before 22 weeks gestation, the uptake rate of amniocentesis was 49%. There was a substantial difference in the uptake rate when the counselling was done by trained counsellers compared to those who were not. CONCLUSION: We would expect that for a fixed amniocentesis rate of 6.5% and 16.7%, serum screening would be able to detect 71% and 85% respectively of the Down syndrome pregnancies. This is more efficient than figures published from Western populations as our patients are older.

Amniocentesis↗
PubMed1998

A case series of Paget's disease of bone: diagnosing a rather uncommon condition in Singapore.

Paget's disease of bone is an uncommon condition in the Asian population, with only 2 cases reported in medical literature so far. We discuss 5 cases of Paget's disease who presented over an 8-year period with a wide and interesting variety of clinical features. Though 4 out of the 5 patients were asymptomatic, all of them had characteristic radiological features and elevated serum alkaline phosphatase levels of varying degrees. Diagnosis was based on the clinical features, the elevated serum alkaline phosphatase levels, and most importantly, the distinctive radiographic features, which are almost pathognomonic of the condition. The incidence of Paget's disease is probably under-reported in Asia and Singapore, as it is rarely encountered and can be easily overlooked due to its usually asymptomatic and benign nature. A high index of suspicion and an active search for its typical features are thus essential for its detection.

Aged↗