Services In Singapore Research Articles

The management of BRCA1 and BRCA2 carriers in Singapore.

Singapore is a densely populated small island nation, with a multiethnic and multireligious population. Cancer is the leading cause of death in Singapore. The population is well educated and coupled with greater awareness, there is an increasing demand for genetic testing for hereditary cancer syndromes. In Singapore, the Singapore Cancer Action Network (SCAN) guidelines for referral for genetic testing serves as a guide for clinicians on appropriate referral. We examined the important factors in genetic counselling in such a diverse population, such as acknowledgement of psychosocial impact of BRCA1/2, cultural sensitivity and upskilling of healthcare professionals. Access to genetic services in Singapore is widely available, though the number of patients who undergo testing is lower due to need for out-of-pocket costs and lack of funding from government agencies and insurance companies. The delivery of clinical care and research accrual is performed concurrently in our centre. All patients undergo pre-test counselling before giving informed consent for germline genetic testing and post-test counselling for interpretation of test results. Patients who test positive for BRCA1/2 continue to be on follow up with the cancer genetics clinic for risk-management. Predictive testing is discussed and facilitated for all at-risk relatives. Challenges faced by cancer genetics professionals in Singapore include the high rate of variant of uncertain significance (VUS) and low predictive testing rates. We hold regular support group activities for patients to seek mutual support and to raise overall awareness of BRCA1/2. We believe our comprehensive cancer genetics service serves as a useful model for other Asian countries looking to set up their own unit. We continue to aspire to empower patients, family members and healthcare professionals with cancer genetics knowledge to improve personal and public health.

Stroke Care Services in Singapore During COVID-19 Pandemic-A National Perspective.

Stroke is a significant cause of admission to Singapore's acute care hospitals. Because of the current COVID-19 pandemic, there have been major changes in the stroke care system. On calling for the public ambulance, those suspected to have COVID-19 infection are taken to the National Center for Infectious Diseases. Otherwise, on arrival at the emergency room, all cases with fever or respiratory symptoms [COVID-19 suspect patients (CSPs)] are evaluated separately by staff wearing full personal protective equipment (PPE). Triage is not delayed. CSPs needing hyperacute therapies are sent to a specially prepared scanner; if not, imaging is deferred to the latter part of the day. CSPs are managed in isolation rooms, and sent to the acute stroke unit (ASU) if two consecutive COVID-19 swabs are negative. Investigation and rehabilitation are done within the room. ASU rounds are attended by essential members, communication by electronic means. Multidisciplinary team rounds have largely ceased, and discussions are via electronic platforms. Patient transfer and staff movement are minimized. All hospital staff wear face-masks, infection control is strictly enforced. Visitors are not allowed; staff make daily calls to update families. Mild stroke patients may be sent home with rehabilitation advice. Out-patient rehabilitation centers are closed. Patients return for out-patient visits only if needed; medications are sent to their home, and nurses make essential home visits. Stroke support and rehabilitation activities have started on-line. Continuing medical education activities are mainly by webinars. Stroke research has been severely hampered. Overall, evidence-based stroke care is delivered in a re-organized manner, with a clear eye on infection control.

Adoption of Exclusive and Pooled TNC Services in Singapore and the US

On-demand mobility services provided by transport network companies (TNCs) have experienced significant growth in their adoption and diversification of services in major metropolitan cities around the world. This study analyzed primary data from Singapore to explore the sociodemographics of TNC users and determine who among TNC users is more likely to pool their trips and what modes these services are replacing. We compared these results with a comprehensive literature review of similar studies of TNC users in the metropolitan US. We found that the sociodemographics of TNC users in general are similar in Singapore and the US: younger, highly educated, and higher income individuals are more likely to have used TNC services. On the other hand, when differentiating by type of TNC service, we found that younger individuals from households that do not own a car are more likely to have pooled in Singapore, whereas employment is an important predictor in the US. We also found differences in mode substitution; whereas TNC trips in the US primarily induce additional trips or replace trips by public and non-motorized transport, in Singapore they primarily replace personal/private vehicle trips. In Singapore, we explored mode substitution by exclusive and pooled TNC services separately, and found that pooled trips draw more from public and nonmotorized transport, whereas exclusive trips replace more personal/private vehicle trips. These results suggest that people in Singapore view exclusive and pooled TNC services as distinct travel options that may be more closely related to other private or public transport, respectively. Differences between Singapore and the US highlight the importance of accounting for local context and suggest that the quality of all travel alternatives in the urban area will affect the mode substitution of TNC trips.

Evolving Practice Patterns in Singapore's Public Sector Ophthalmology Centers During the COVID-19 Pandemic.

Coronavirus disease 19 (COVID-19) was first reported in Wuhan, China, in December 2019, and has since become a global pandemic. Singapore was one of the first countries outside of China to be affected and reported its first case in January 2020. Strategies that were deployed successfully during the 2003 outbreak of severe acute respiratory syndrome have had to evolve to contain this novel coronavirus. Like the rest of the health care services in Singapore, the practice of ophthalmology has also had to adapt to this rapidly changing crisis. This article discusses the measures put in place by the 3 largest ophthalmology centers in Singapore's public sector in response to COVID-19, and the challenges of providing eye care in the face of stringent infection control directives, staff redeployments and “social distancing.” The recently imposed “circuit breaker,” effectively a partial lockdown of the country, has further limited our work to only the most essential of services. Our staff are also increasingly part of frontline efforts in the screening and care of patients with COVID-19. However, this crisis has also been an opportunity to push ahead with innovative practices and given momentum to the use of teleophthalmology and other digital technologies. Amidst this uncertainty, our centers are already planning for how ophthalmology in Singapore will be practiced in this next stage of the COVID-19 pandemic, and beyond.

Impact of seasonal influenza on polyclinic attendances for upper respiratory tract infections in Singapore.

PurposeThe burden of influenza on primary health-care services is not well established in tropical countries, where there are no clearly defined influenza seasons. We aimed to estimate the association between influenza infection activity and polyclinic attendance rates for upper respiratory tract infections (URTIs) in the Singapore population.MethodsWe used generalized additive time series models to estimate the association between the proportion of respiratory tests positive for influenza infection in Singapore reported to the World Health Organization every week, and the population rate of polyclinic attendances in Singapore for physician-diagnosed URTI, which includes influenza-like illness (ILI), for six years from 2012 through 2017. Where data were available, we controlled for other infections that can cause fever or respiratory symptoms.ResultsInfluenza, dengue fever and chickenpox (varicella) were positively associated with acute URTI polyclinic attendances. The estimated URTI polyclinic attendance rates attributable to influenza, dengue fever and chickenpox were 618.9 (95% confidence interval [CI]: 501.6–736.3), 153.3 (95% CI: 16.5–290.2) and 1751.5 (95% CI: 1246.3–2256.8) per 100 000 population per year, respectively.ConclusionInfluenza poses a considerable burden on primary health-care services in Singapore. However, a substantial number of polyclinic attendances due to febrile infections such as dengue fever and chickenpox appear to be recorded as URTI in the polyclinic database. These associations require further investigation.

M215. FACTORS ASSOCIATED WITH CLOZAPINE RESPONSE AND RESISTANCE IN SCHIZOPHRENIA

BackgroundClozapine remains the only antipsychotic with unique efficacy in treatment resistant schizophrenia (TRS). Considerable ongoing research and clinical efforts have focused on reducing barriers to clozapine use in a bid to increase rates of clozapine use to improve outcomes in TRS. However, less than half of individuals with TRS respond to clozapine, with the remainder categorised as clozapine resistant (CRS) or Ultra-resistant. It is important to deepen understanding on the development of CRS so we can identify them early, attempt to prevent/delay its onset and also explore novel treatments. In the present study, we sought to compare clozapine responders from CRS and identify factors which might be associated with CRS.MethodsThis study was conducted at the Institute of Mental Health, the only psychiatric facility with clozapine services in Singapore. Individuals with TRS on clozapine for at least 12 weeks and the capacity to give informed consent were enrolled into the study. Each participant underwent a clinical assessment on the Structured Clinical Interview DSM-IV-TR (SCID), Positive and Negative Syndrome Scale (PANSS) and Social Occupational Functioning Assessment Scale (SOFAS). We applied the Treatment Response and Resistance In Psychosis consensus criteria to define clozapine response and resistance. Brief Neurocognitive Assessment was done using the digit sequencing and symbol coding tasks from the Brief Assessment of Cognition in Schizophrenia (BACS). A fasting sample of blood was collected; assays for clozapine and norclozapine were performed using high performance liquid chromatography. To be classified as CRS, a participant must meet the below criteria: (i) not meeting symptom remission criteria on the PANSS using the Remission in Schizophrenia Working Group criteria, (ii) moderate and lower level of functioning on the SOFAS, and (iii) at least 12 weeks of clozapine treatment and plasma clozapine levels ≥ 350 ng/ml.ResultsA total of 91 participants were enrolled in this study and 67 (73.6%) met criteria for CRS. 1 in 4 clozapine responders had plasma clozapine levels not exceeding 350 ng/ml. There were no significant differences in age, sex, smoking status, age at onset of illness, clozapine adherence, antipsychotic polypharmacy rates and duration of clozapine use between clozapine responders and CRS. Compared to clozapine responders, individuals with CRS had statistically significantly lower BMI (26.4 vs. 23.4, p=0.008) lower rates of employment (79.2% vs. 35.8%, p<0.001), and poorer cognitive function in both digit sequencing (-0.86 vs. -1.60, p=0.011) and symbol coding (-1.09 vs. -1.88, p=0.002) tasks. In a multivariate logistic regression model with age, sex, age at onset, BMI and cognition, only BMI (OR=0.88, p=0.043) and symbol coding (OR=0.48, p=0.019) were significant variables predicting clozapine resistance.DiscussionOur study highlighted a high rate of CRS and suggests that poorer cognitive function, specifically in processing speed, might be associated with the development of clozapine resistance in schizophrenia. Additionally, it was interesting to note that a higher BMI was associated with clozapine response; this lends weight to existing metabolic and lipid hypotheses of schizophrenia.

Use of telephone intake for family history taking at a cancer genetics service in Asia.

Family history taking is a fundamental part of genetic counseling, and however, it is also a time-consuming process. To cope with the increasing demands at the Cancer Genetics Service in Singapore, alternative methods to collect patients' family history were implemented to reduce the duration of the initial consultation and increase the clinic's capacity. Two interventions were performed in this study, where a family history questionnaire and telephone intakes (telephone calls to collect patient family history) were implemented prior to a cancer genetics consultation. The primary outcome of this study is the duration of the initial consultation in relation to both interventions while the secondary outcome is the clinic attendance rate before and after implementing the telephone intake. The impact of interventions was evaluated with a Plan-Do-Study-Act (PDSA) methodology. The use of a family history questionnaire could not be evaluated due to poor patient response while the telephone intake was found to be feasible among the local population. Two improvements were observed after the implementation of telephone intake: (a) a significant reduction in the duration of the initial consultation from 60 to 45min (p=.001) and (b) a significant increase of 29.7% in clinic attendance (p=.01). This study demonstrates that collecting family history information ahead of genetic counseling via telephone intake is a useful measure in improving clinic capacity, which potentially resulting in optimization of clinical resources.

Adult neurodevelopmental services in Singapore: A sociodemographic and clinical profile at a tertiary psychiatric hospital.

IntroductionThe Adult Neurodevelopmental Service in Singapore is the first service of its kind in South‐East Asia for adults with intellectual disability (ID) and/or autism spectrum disorder (ASD). However, few studies have documented and compared the sociodemographic characteristics and clinical needs of this subpopulation group.MethodsInitial assessments conducted from 1 January 2015 to 31 December 2016 were retrospectively reviewed for this descriptive study.ResultsA total of 272 patients were included in the study (mean age 28.3 ± 11.5; 200 males, 72 females). Adults with ID comprised the largest percentage (52.9%), followed by those with ASD (30.2%), and then those with co‐occurring ASD and ID (16.9%). The ASD subgroup had the highest proportion of individuals with employment, postsecondary school education, functional capabilities, and a psychiatric disorder. In comparison, adults with only ID and adults with co‐occurring ASD and ID shared similar lower levels of education and employment, and had a higher proportion of individuals with epilepsy and aggressive behavior.DiscussionIn this study, adults with ASD had a unique social profile with different clinical needs compared to adults with only ID or to adults with co‐occurring ASD and ID. Adults with only ID and those with co‐occurring ASD shared many of the same social characteristics and high clinical needs. The analysis of these profiles will be useful in developing services that better meet the needs of this complex group.

The Neonatal Transport Service in Singapore: A 5-Year Review

The Neonatal Transport Service in Singapore: A 5-Year Review

Navigating the challenges of the COVID-19 outbreak: Perspectives from the radiation oncology service in Singapore

In December 2019, pneumonia of unknown cause was reported by China to WHO. The outbreak was found to be caused by a coronavirus which was officially named “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2), and the disease caused by it was named ‘COVID-19’. The first case in Singapore was confirmed on 23rd January 2020. With lessons learnt from the SARS epidemic in 2003 and the H1N1 flu pandemic in 2009, Singapore was much better prepared to deal with the virus outbreak. The government has taken swift measures to contain and break the chain of transmission. Healthcare workers face the challenge of keeping patients and staff safe from the disease. There is a higher risk of mortality of COVID-19 in cancer patients and hence unique considerations for a radiation oncology department operating in an infectious disease outbreak. This article is the recommendations and adapted workflow from the two National Cancer Centres in Singapore with the endorsement by the working committee of the Chapter of Radiation Oncology, Academy of Medicine, Singapore. It highlights the challenges that radiation oncology departments in Singapore face and the appropriate recommended responses. This includes interventions, business continuity plans and workflow in managing a COVID-19 positive patient on radiotherapy.

Perspectives on Palliative Care Among Duchenne Muscular Dystrophy Patients and Their Families in Singapore

With better medical care, patients with Duchenne muscular dystrophy (DMD) now live longer but face more complex medical and social needs. This study described the perceptions of DMD patients and their families of disease-specific palliative care services in Singapore. A multicentre, cross-sectional study involving DMD patients and their families was carried out. Structured questionnaires were administered to them to collect data on their understanding of palliative care, health services accessed and desired by them and quality of life. A total of 30 pairs of DMD patients and their caregivers responded. Most patients were >13 years old (70%) and non-ambulant (86%). Most of them and their families (70%) were also not aware of palliative care and support services that were available to them in Singapore. Additionally, they perceived greater financial assistance and better transport services as resources that could better meet their care needs. The presence of scoliosis and need for ventilatory support were associated with lower quality of life in patients. There is a need to improve awareness and provision of palliative care services for DMD patients in Singapore where discussion of end-of-life care is often considered taboo. Prevention and correction of scoliosis and provision of appropriate ventilatory support may improve quality of life in DMD patients.

Conscious sedation service for geriatric and special-care dentistry: A health policy brief

Background: Geriatric and special care dentistry (GSD) involves oral health care for seniors and individuals with disabilities. Due to ethical issues, finances, waiting times, treatment versatility and so on, conscious sedation (CS) may have a place to optimise the delivery of care. Objectives: This article identifies considerations for implementing CS in GSD services in Singapore. Methods: Taking the form of a health policy brief, this review (a) defines the situation for patients with special-care needs and justified the need for dental CS, (b) makes reference to practices from countries with established dental CS services, (c) states and evaluates available CS techniques for the GSD centre in Singapore and (d) discusses action plans and considerations for implementation. Results: Demographic analysis revealed that 23.8% of the GSD patients could have benefitted from CS, or 44.7% of all patients who required behavioural management. The key advantages of CS included enhanced safety, more teeth saved and a reduction in general anaesthesia wait, amongst others. Conventional dental CS techniques included midazolam via various routes, nitrous oxide and ketamine. To establish a CS service, key points of consideration need to be conceptualised first, such as adequate training, perception of patients and providers, operational costs, facilities and developing guidance specific for oral health professionals. Conclusion: A local CS service will be beneficial for GSD patients in view of the challenges faced. A group of experts and stakeholders is needed to provide practical consensus.

Perceptions on site-specific advanced practice roles for radiation therapists in Singapore - A single centre study.

Perception of the radiation oncologists (ROs) and radiation therapists (RTTs) on site-specific advanced practice (SSAP) roles for RTTs, the establishment of SSAP in radiotherapy and the possible implication on current services in Singapore were assessed. Opinions of ROs and RTTs on management support, driving forces, restraints and implication upon successful establishment of SSAP were obtained. Main findings include strong RO's support for SSAP development and RTTs' requisition for fair opportunities on role development. Other potential benefits include RTTs' career advancement, job satisfaction and retention. Enhancement of inter-professional relationship, service quality and patient satisfaction is anticipated with greater communication and collaboration.

The Changing Epidemiology of Serious Trauma in the Elderly Population: An Increasing Concern of a Tertiary Hospital in Singapore

Although trauma is often seen in the young, there is a recent shift in this trend as more elderly patients are hospitalised for traumatic injuries. This study examined serious trauma in young and elderly patients and hypothesised that the increase in incidence of elderly serious trauma has led to greater burden of care in hospitals and health services. Details of trauma patients admitted with an Injury Severity Score ≥9 or to the intensive care unit or high dependency unit of a tertiary acute hospital between 2004 and 2015 were retrospectively reviewed. Patients ≥65 years old who sustained low-impact trauma that resulted from same-level falls with isolated hip fractures or compression fractures of the vertebral column were excluded. Patients were classified as either elderly (≥65 years old, n = 5074) or young (<65 years old, n = 9088) and their baseline characteristics, complications rate and length of hospital stay were evaluated. Elderly patients ≥65 years old accounted for 51.2% of seriously injured patients after 2014 and their numbers are increasing at an annual rate of 16.5%. They also experienced longer hospital stay in the general ward than younger patients. The number of elderly trauma patients were thrice that of all trauma patients seen and they also required longer hospitalisation. This trend has led to greater burden of care in hospitals and health services in Singapore.

Home-based tele-rehabilitation presents comparable positive impact on self-reported functional outcomes as usual care: The Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) randomised controlled trial

Introduction The aim of this research was to evaluate the impact of a novel tele-rehabilitation system on self-reported functional outcomes compared to usual care during the first three months after stroke. Methods A parallel, two-arm, evaluator-blinded, randomised controlled trial was conducted. Adults aged ≥40 years who had suffered a stroke within four weeks of the start of the study were recruited from the general community. The intervention group received access to a novel tele-rehabilitation system and programme for three months. The primary outcome measures utilised were the frequency and limitation total scores of the Late-Life Function and Disability Instrument (LLFDI) at three months. Results A total of 124 individuals were recruited. The mean differences in the LLDFI frequency and limitation total scores at three months comparing the intervention and control groups were –3.30 (95% confidence interval (CI) –7.81 to 1.21) and –6.90 (95% CI –15.02 to 1.22), respectively. Adjusting for the respective baseline covariates and baseline Barthel Index also showed no significant difference between interventions in the LLFDI outcomes. Discussion The intervention and control groups self-reported similar improvements in functional outcomes. Tele-rehabilitation may be a viable option to provide post-stroke rehabilitation services in Singapore while reducing barriers to continue rehabilitation conventionally after discharge from hospital and encouraging more participation.

Biopsychosocial experiences and coping strategies of elderly ESRD patients: a qualitative study to inform the development of more holistic and person-centred health services in Singapore

BackgroundAs the incidence and prevalence rates of end stage renal disease (ESRD) rise globally, a disproportionate increase has been observed in the elderly population. Singapore has the fifth highest incidence of treated ESRD worldwide, with the upward trend of ESRD being most apparent among those aged 70 years and older. Although it is well-documented that ESRD patients suffer an impaired quality of life compared to the general population, there is limited research focusing on the unique experiences and needs of elderly ESRD patients in Asian populations. To address the knowledge gap, this study seeks to explore the impact of ESRD and dialysis on the quality of life of elderly (≥70 years old) ESRD patients in Singapore and examine the coping strategies utilised by these patients.MethodsThis qualitative study involved semi-structured, in-depth interviews with 7 peritoneal dialysis patients, 5 haemodialysis patients, 4 patients on non-dialysis supportive care and 7 caregivers in Singapore. Interviews were conducted in English, Chinese, and Malay and fully transcribed. QSR NVivo 11 software was used for analysis.ResultsParticipants reported that ESRD and dialysis had an impact on three highly interconnected areas of their quality of life: (a) biological/physical (general symptoms, neuromuscular problems, skin problems and poor sleep quality); (b) psychological (depressive symptoms, anxiety and fears, stress and negative self-perceptions); and (c) social (increased dependence on family and loss of social life). There were four key strategies that participants used to cope with these biopsychosocial challenges: (a) family support (financial, practical and emotional support); (b) religious/spiritual support (experiencing gratitude/contentment, the power of prayer and belonging to a faith community); (c) avoidance (cognitive avoidance and distraction techniques); and (d) acceptance (positive thinking and problem solving).ConclusionsThis study has provided insights into the biopsychosocial impact of ESRD and dialysis, as well as cultural and religious factors that shape the experiences and coping mechanisms of elderly ESRD patients and caregivers in Singapore, which can be used to further the development and implementation of more holistic and person-centred services to help each patient achieve a better quality of life.

Home based primary care services in Singapore

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Investigating user perception on autonomous vehicle (AV) based mobility-on-demand (MOD) services in Singapore using the logit kernel approach

The rapid development of autonomous vehicles (AV) in recent years has drawn the attention of numerous countries in terms of its feasibility for use and deployment as individually-owned vehicles or for large-scale fleet planning and deployment as a mobility-on-demand (MOD) service. Singapore is no exception to this global trend and in her pursuit to be smart and car-lite, numerous efforts are made to have AV trials in place and test out their potential deployment in the city state. As one of the many prerequisites of AV planning, public perception on AV plays a vital role when designing any potential AV deployment scheme. As such, a stated preference survey comprising both online survey and field interviews/surveys, was performed island-wide to understand how commuters in Singapore perceive about different AV-based MOD modes. The logit kernel model is adopted to determine how different preference attributes and key demographic indicators can affect the use of AV-based MOD services over other existing first- and last-mile connection modes. The model results have identified how demographics such as gender, age, housing type, education level and income level can influence the travel mode choice. Also, the impacts brought by individuals’ stated preferences over convenience, privacy and familiarity of ride-hailing apps are also investigated. Such findings can provide useful insight in planning future car-lite towns and implementing AV-based MOD services in these towns.

Acceptability of HIV Pre-exposure Prophylaxis (PrEP) and Opinions on PrEP Service Delivery Among Men Who Have Sex With Men in Singapore: A Qualitative Study.

PrEP is effective in preventing HIV transmission among at-risk HIV-negative MSM. A qualitative descriptive study with five focus group discussions (N = 33) involving a purposively recruited sample of Singaporean MSM was conducted from August 2016 to April 2017 to understand local perspectives on potential barriers and motivators to the adoption of PrEP, prior to the implementation of PrEP services in Singapore. Knowledge of PrEP was high, and many viewed PrEP as an attractive alternative to condoms for HIV prevention. Concerns about PrEP included the cost of PrEP and related services, the frequency of PrEP-related clinic visits, fear of side effects, and the stigma associated with using PrEP. Participants felt PrEP was best provided by MSM-friendly providers, and more needed to be done to increase awareness of the effectiveness of PrEP. Access to PrEP for MSM in Singapore has to be affordable, patient-centered, and convenient to maximize the potential benefits of PrEP.

Utilisation patterns of helpline and Web chat services among gamblers in Singapore.

We evaluated the utilisation of a helpline and Web chat system by the public for gambling-related services in Singapore over a period of 12 months. The profile of callers, call characteristics and actions taken were descriptively analysed using aggregate data. The majority of helpline calls and Web chats were from gamblers aged 40-49 years (23.3%, n = 644). Gamblers made 85.4% (n = 8,010) of the calls to the helpline and 73.3% (n = 546) of the Web chats. About four-fifths of the gamblers were Chinese (79.5%, n = 6,381) and employed full time (79.9%, n = 4,125). Table games (67.6%, n = 2,605) were the most popular gambling activity reported by callers, 55.8% of which involved local casinos. Enquiries were mostly casino related (92.4%, n = 5,739). Approximately 1,827 calls were received per month during the study period and 185 referrals were made to the clinic, 80.5% of whom sought treatment.