The prevalence of albuminuria among diabetic patients in a primary care setting in Singapore

INTRODUCTION

Microalbuminuria is an early sign of kidney damage. The prevalence of microalbuminuria in Singapore has been reported to be 36.0%–48.5%. However, the prevalence of microalbuminuria reported in these studies was determined with one urine sample using a qualitative urine test. The aim of this study was to determine the prevalence of micro- and macroalbuminuria using a more stringent criterion of two positive quantitative urine albumin-creatinine ratio (ACR) tests.

METHODS

We conducted a cross-sectional study of patients with type 2 diabetes mellitus (T2DM) who were followed up at a primary care clinic in Singapore. Patients were diagnosed to have albuminuria if they had two positive ACR tests within a seven-month period.

RESULTS

A total of 786 patients with T2DM met the study’s inclusion criteria. 55.7% were already on an angiotensin-converting enzyme inhibitor (ACEI) and/or angiotensin receptor blocker (ARB). The prevalence rates of micro- and macroalbuminuria were 14.2% and 5.7%, respectively. Patients with albuminuria were more likely to have hypertension (odds ratio [OR] 3.47, 95% confidence interval [CI] 1.55–7.80). Diabetics with poorer diabetic control (OR 1.88, 95% CI 1.26–2.79), and higher systolic (OR 1.69, 95% CI 1.14–2.49) and diastolic (OR 1.96, 95% CI, 1.20 to 3.22) blood pressures were more likely to have albuminuria.

CONCLUSION

In the present study, the prevalence of microalbuminuria is significantly lower than that previously reported in Singapore. The presence of hypertension, poor diabetic control and suboptimal blood pressure control are possible risk factors for albuminuria in patients with T2DM.     

Incidence of discontinuation of angiotensin-converting enzyme inhibitors due to cough,in a primary healthcare centre in Singapore

INTRODUCTION

The incidence of cough induced by angiotensin-converting enzyme (ACE) inhibitors has been reported to be 5%–20%, with less than half of affected patients requiring discontinuation due to persistent cough. However, the incidence in the local Asian population has not been studied. This study aimed to objectively evaluate the incidence of discontinuation of ACE inhibitors due to cough, in a primary healthcare centre in Singapore.

METHODS

We retrospectively reviewed the medical records, both electronic and written, of patients who attended Tampines Polyclinic to identify those who were newly prescribed ACE inhibitors. The written medical records were analysed to identify patients who discontinued the use of ACE inhibitors and to find out the reasons for discontinuation.

RESULTS

A total of 424 patients were identified during the study period. Out of the 424 patients, 129 (30.4%) discontinued the use of ACE inhibitors due to cough. Overall, 90 (21.2%) patients who were initially started on ACE inhibitors were eventually switched to angiotensin receptor blockers (ARBs).

CONCLUSION

In our cohort, the incidence of discontinuation of ACE inhibitors due to cough is higher than most other studies. The relationship between ethnicity and tolerance of medications should not be underestimated. As there is a high incidence of discontinuation of ACE inhibitors due to cough in the local population, ARBs may be a reasonable substitute as a first-line medication, if clinically indicated.     

Evaluation of the Patient Safety Leadership Walkabout programme of a hospital in Singapore

INTRODUCTION

The Patient Safety Leadership Walkabout (PSLWA) programme is a commonly employed tool in the West, in which senior leaders visit sites within the hospital that are involved in patient care to talk to healthcare staff about patient safety issues. As there is a lack of perspective regarding PSLWA in Asia, we carried out an evaluation of its effectiveness in improving the patient safety culture in Tan Tock Seng Hospital, Singapore.

METHODS

A mixed methods analysis approach was used to review and evaluate all documents, protocols, meeting minutes, post-walkabout surveys, action plans and verbal feedback pertaining to the walkabouts conducted from January 2005 to October 2012.

RESULTS

A total of 321 patient safety issues were identified during the study period. Of these, 308 (96.0%) issues were resolved as of November 2012. Among the various categories of issues raised, issues related to work environment were the most common (45.2%). Of all the issues raised during the walkabouts, 72.9% were not identified through other conventional methods of error detection. With respect to the hospital''s patient safety culture, 94.8% of the participants reported an increased awareness in patient safety and 90.2% expressed comfort in openly and honestly discussing patient safety issues.

CONCLUSION

PSLWA serves as a good tool to uncover latent errors before actual harm reaches the patient. If properly implemented, it is an effective method for engaging leadership, identifying patient safety issues, and supporting a culture of patient safety in the hospital setting.     

Tuberculosis trends over a five-year period at a tertiary care university-affiliated hospital in Singapore

INTRODUCTION

Tuberculosis (TB), a potentially fatal infectious disease, poses significant health problems. The objective of this study was to analyse trends among newly diagnosed TB patients seen at the Singapore General Hospital (SGH).

METHODS

This study was a retrospective case record review of notified TB patients at SGH between 2006 and 2010 (inclusive).

RESULTS

A total of 1,979 cases of TB were notified over the five years. The number increased from 368 in 2006 to 407 in 2010 (p = 0.51), in tandem with the increasing number of patients seen at the hospital and the rising population in Singapore. Singaporean residents accounted for 82.8% of the cases, while non-Singaporean residents and non-residents made up the remainder. The year-to-year percentage of non-Singaporean residents and non-residents notified remained stable throughout the five years (p = 0.783). The number of male Singaporean residents (70.7%) notified was more than twice that of female Singaporean residents (29.3%). The majority of patients infected with TB (31.9%) were elderly patients aged > 65 years. Although testing for the human immunodeficiency virus increased from 43.8% (2006) to 64.2% (2010), the number detected with coinfection remained stable (14 and 12 patients in 2006 and 2010, respectively). Mortality rates also remained stable at 12.0%.

CONCLUSION

We cannot afford complacency, as there was no downward trend in the number of notified TB cases at SGH from 2006 to 2010. As the elderly contribute significantly to the TB burden, increased efforts are required to manage this vulnerable population.     

Food allergy in Singapore: opening a new chapter

With the exception of shellfish, the overall food allergy rates in Singapore have not reached the epidemic proportions of the West. The rates of egg, milk and fish allergies remain low. However, the patterns of some food allergies in Singapore have changed over the last decade. For example, peanut allergy, once rare in Singapore, is now the most common cause of anaphylaxis in children. Studies analysing lifestyle practices, particularly with respect to prevention of food allergy, are necessary in order for practitioners to understand global differences and maintain this low prevalence.     

Cost of post-stroke outpatient care in Malaysia

INTRODUCTION

This study aimed to investigate the direct cost of outpatient care for patients with stroke, as well as the relationship between the aforementioned cost and the sociodemographic and stroke characteristics of the patients.

METHODS

This was a cross-sectional study involving patients with first-ever stroke who were attending outpatient stroke rehabilitation, and their family members. Participants were interviewed using a structured questionnaire designed to obtain information regarding the cost of outpatient care. Stroke severity was measured using the National Institute of Health Stroke Scale.

RESULTS

This study comprised 49 patients (28 men, 21 women) with a mean age of 60.2 (range 35–80) years. The mean total cost incurred was USD 547.10 (range USD 53.50–4,591.60), of which 36.6% was spent on attendant care, 25.5% on medical aids, 15.1% on travel expenses, 14.1% on medical fees and 8.5% on out-of-pocket expenses. Stroke severity, age > 70 years and haemorrhagic stroke were associated with increased cost. The mean cost of attending outpatient therapy per patient was USD 17.50 per session (range USD 6.60–30.60), with travelling expenses (41.8%) forming the bulk of the cost, followed by medical fees (38.1%) and out-of-pocket expenses (10.9%). Multiple regression analysis showed that stroke severity was the main determinant of post-stroke outpatient care cost (p < 0.001).

CONCLUSION

Post-stroke outpatient care costs are significantly influenced by stroke severity. The cost of attendant care was the main cost incurred during the first three months after hospital discharge, while travelling expenses was the main cost incurred when attending outpatient stroke rehabilitation therapy.     

The potential for a controlled human infection platform in Singapore

For over 100 years, controlled human infection (CHI) studies have been performed to advance the understanding of the pathogenesis, treatment and prevention of infectious diseases. This methodology has seen a resurgence, as it offers an efficient model for selecting the most promising agents for further development from available candidates. CHI studies are utilised to bridge safety and immunogenicity testing and phase II/III efficacy studies. However, as this platform is not currently utilised in Asia, opportunities to study therapeutics and vaccines for infections that are important in Asia are missed. This review examines the regulatory differences for CHI studies between countries and summarises other regulatory differences in clinical trials as a whole. We found that the regulations that would apply to CHI studies in Singapore closely mirror those in the United Kingdom, and conclude that the regulatory and ethical guidelines in Singapore are compatible with the conduct of CHI studies.     

Granulomatous cervicofacial lymphadenitis in children: a nine-year study in Singapore

INTRODUCTION

Granulomatous cervicofacial lymphadenitis (GCL) is not uncommon in children. Nontuberculous mycobacteria (NTM) seem to be the predominant cause. We sought to study the clinical and microbiological profile of patients with GCL, and identify features that may impact outcome.

METHODS

Children aged < 16 years who presented to KK Women’s and Children’s Hospital, Singapore, between January 1998 and December 2006, and who had GCL were identified from laboratory records. Clinical and laboratory data was collected and analysed for risk factors for patients with positive lymph node cultures, and for patients with and without recurrence after treatment.

RESULTS

In all, 60 children were identified, with a median age of 56 (interquartile range [IQR] 34–101) months. Median duration of symptoms before presentation was 5 (IQR 4­–8) weeks. The majority presented with single (73.3%) or unilateral (96.7%) lymphadenopathy, located in the submandibular, preauricular/parotid or infra-/post-auricular region (76.7%). Out of 51 patients, 26 (51.0%) had a tuberculin skin test reading of ≥ 10 mm. Out of 52 patients, 10 (19.2%) had positive mycobacterial cultures, which included seven isolates of NTM. Out of 34 cases, tuberculous polymerase chain reaction was positive in 11 (32.4%). With regard to recurrence after initial treatment, age < 5 years at presentation was found to be a predictor for recurrence (p = 0.008), while initial complete excision of affected nodes predicted no recurrence (p = 0.003).

CONCLUSION

In our study, younger age was noted to be associated with a higher chance of recurrence, while complete excision of the involved node at initial presentation predicted non-recurrence.     

Psychiatry in primary care and training: a Singapore perspective

Proactive steps have been taken by the public healthcare sector in Singapore to bring about awareness of mental health in terms of mental health promotion, early recognition and seeking help, with an increasing focus on making mental healthcare accessible and delivering it within the community setting where possible. Examples are the Mental Health General Practitioner Partnership Programme, National Mental Health Blueprint and Community Mental Health Masterplan. The current challenge is to train and involve more primary care doctors in the care of persons with mental health conditions. This paper describes the goals of psychiatric training in primary care and the avenues for training that are available to family medicine residents and family physicians.     

Prevalence of faecal incontinence in the community: a cross-sectional study in Singapore

INTRODUCTION

Faecal incontinence (FI) is a stigmatised condition that remains a silent affliction for many populations. To date, no local study has been performed to determine its prevalence in our population. The existing literature from the West has shown highly variable rates, ranging from 0.8% to 18.0%. The aim of this study was to determine the cross-sectional prevalence of FI in Singapore and to identify at-risk groups.

METHODS

A door-to-door questionnaire survey was performed between February and March 2013. We randomly selected 1,000 individuals from the electoral roll to be surveyed using the validated Comprehensive Fecal Incontinence Questionnaire.

RESULTS

A total of 381 participants agreed to be enrolled in the study. The mean age of the participants was 52 (range 21–86) years, and slightly more than half of the participants were female (52.8%). Among the female participants, 73.1% had children (78.8% underwent normal vaginal delivery). The overall prevalence of FI in our study population was 4.7%. The prevalence of FI was observed to be significantly associated with increasing age (p = 0.004) and female gender (p = 0.029); women were three times more likely to suffer from FI than men.

CONCLUSION

With the ageing population of Singapore, the results of the present study provide further impetus to continue public outreach efforts as well as develop clinical programmes that address the growing need for specialist treatments for people with FI.     

When babies turn yellow

Neonatal jaundice is a common condition seen in the primary care setting. Most afflicted babies have physiological jaundice and their prognosis is good. However, others have pathological jaundice, which must be detected early. High levels of serum bilirubin can also result in bilirubin encephalopathy. This article describes consultation tasks in the primary care setting with the aim of providing a guide for the safe management of neonatal jaundice. They include clinical assessment of the baby’s well-being; looking out for features that suggest pathological jaundice; assessment for the presence of high-risk features; utilising appropriate laboratory tests for monitoring; assessing the degree of jaundice to decide if the child can be safely followed up in primary care; and providing advice on primary prevention measures and allaying parental concerns. The importance of stool colour examination and its role in early detection of cholestatic jaundice is emphasised.     

COVID-19 in Singapore – a case series from primary care

As the COVID-19 pandemic worsens, early case detection is vital to limiting community spread. We describe our experiences with four COVID-19 cases at the polyclinics in January and February 2020. This retrospective case series highlights the challenges primary care clinicians face in the early identification of suspect cases based on clinical criteria only. To improve case detection, clinicians can sharpen their clinical acumen by keeping abreast with the latest COVID-19 developments and by maintaining a high state of vigilance.     

Hoarding in Singapore

Hoarding refers to an excessive acquisition of objects and inability to part with apparently valueless possessions. While it can lead to excessive clutter, distress and disability, it is important to note that not all cases of hoarding are pathological. This article aims to suggest how one can make recommendations to patients and families when they encounter someone exhibiting hoarding behaviour. It also introduces the Hoarding Task Force and relevant legislation in Singapore to address the issue of hoarding in the community.     

The 11-item Medication Adherence Reasons Scale: reliability and factorial validity among patients with hypertension in Malaysian primary healthcare settings

INTRODUCTION

The aim of this study was to assess the reliability and validity of a modified Malaysian version of the Medication Adherence Reasons Scale (MAR-Scale).

METHODS

In this cross-sectional study, the 15-item MAR-Scale was administered to 665 patients with hypertension who attended one of the four government primary healthcare clinics in the Hulu Langat and Klang districts of Selangor, Malaysia, between early December 2012 and end-March 2013. The construct validity was examined in two phases. Phase I consisted of translation of the MAR-Scale from English to Malay, a content validity check by an expert panel, a face validity check via a small preliminary test among patients with hypertension, and exploratory factor analysis (EFA). Phase II involved internal consistency reliability calculations and confirmatory factor analysis (CFA).

RESULTS

EFA verified five existing factors that were previously identified (i.e. issues with medication management, multiple medications, belief in medication, medication availability, and the patient’s forgetfulness and convenience), while CFA extracted four factors (medication availability issues were not extracted). The final modified MAR-Scale model, which had 11 items and a four-factor structure, provided good evidence of convergent and discriminant validities. Cronbach’s alpha coefficient was > 0.7, indicating good internal consistency of the items in the construct. The results suggest that the modified MAR-Scale has good internal consistencies and construct validity.

CONCLUSION

The validated modified MAR-Scale (Malaysian version) was found to be suitable for use among patients with hypertension receiving treatment in primary healthcare settings. However, the comprehensive measurement of other factors that can also lead to non-adherence requires further exploration.     

Cosmetic procedures among youths: a survey of junior college and medical students in Singapore

INTRODUCTION

Although cosmetic procedures have become increasingly popular among the younger population in recent years, limited research on this subject has been done in the Asian context. We aimed to explore the views and knowledge regarding cosmetic procedures among junior college (JC) and medical students in Singapore.

METHODS

In the first phase of the study, a cross-sectional, self-administered survey of 1,500 JC students aged 16–21 years from six JCs was conducted in 2010. The same survey was then conducted on a random sample of Year 2–5 medical students from an undergraduate medical school in 2011.

RESULTS

In total, 1,164 JC and 241 medical students responded to the surveys. There was an overall female to male ratio of 1.3:1. Of all the respondents, 2.5% of the JC students and 3.0% of the medical students admitted to having undergone cosmetic procedures. Among those who claimed to have never had cosmetic procedures done, 9.0% and 44.0% of the JC and medical students, respectively, responded that they would consider such procedures in the future. Those who disapproved of their peers undergoing cosmetic surgery comprised 35.0% of JC students and 56.8% of medical students. Among the JC and medical students, 52.0% and 36.1%, respectively, were unaware of any risks associated with cosmetic procedures.

CONCLUSION

The younger population is increasingly accepting of cosmetic procedures. However, there is a general lack of understanding of the risks associated with such procedures. Education of both the general public and medical students may help prevent potential medicolegal issues.     

Deliberate self-harm in adolescents

Deliberate self-harm refers to an intentional act of causing physical injury to oneself without wanting to die. It is frequently encountered in adolescents who have mental health problems. Primary care physicians play an important role in the early detection and timely intervention of deliberate self-harm in adolescents. This article aims to outline the associated risk factors and possible aetiologies of deliberate self-harm in adolescents, as well as provide suggestions for clinical assessment and appropriate management within the primary care setting.     

Vaccination in the primary care setting: when is it safe to proceed?

Primary care practitioners play an important role in administering and advocating vaccinations against vaccine-preventable infectious diseases and ensuring herd immunity in our population. This is a follow-up article to an earlier one which dealt with the principles of vaccine scheduling and administration. This article describes several false contraindications to vaccination that a primary care practitioner may encounter, including pregnancy, current breastfeeding, history of febrile seizures, and having immunosuppressed or pregnant household contacts. We aimed to provide a guide for safe and timely vaccine administration in the primary care setting.     

Intra-articular glucocorticoid injections in patients with juvenile idiopathic arthritis in a Singapore hospital

INTRODUCTION

This study aimed to evaluate the efficacy and safety of intra-articular glucocorticoid (IAG) injections in our institution in children with juvenile idiopathic arthritis (JIA).

METHODS

This is a retrospective assessment of IAG injections performed by the Department of Paediatrics, National University Hospital, Singapore, from October 2009 to October 2011. A total of 26 procedures were evaluated for efficacy, considering parameters such as clinical response, changes in systemic medication, length of time between repeat injections, safety, consent-taking, pre- and post-procedural advice, compliance with aseptic technique, and post-procedural complications.

RESULTS

A total of 26 IAG injections of triamcinolone hexacetonide were administered over 17 occasions (i.e. patient encounters) to ten patients with JIA during the study period. After the injections, clinical scoring by a paediatric rheumatologist showed overall improvement by an average of 2.62 points out of 15. Besides six patient encounters that had an increase in systemic medication on the day of the injection, five required an increase within six months post injection, two required no adjustments, and one resulted in a decrease in medications. In all, 21 injections did not require subsequent injections. The mean interval between repeat injections was 7.8 months. Cutaneous side effects were noted in three anatomically difficult joints. Medical documentation with regard to patient progress was found to be lacking.

CONCLUSION

As per the recommendations of the American College of Rheumatology, we safely used IAG injections as the first-line therapy in our group of patients with oligoarticular JIA, and/or as an adjunct to systemic therapy in our patients with JIA.