Profiles of women presenting for abortions in Singapore at the National University Hospital: focus on married women

INTRODUCTION@#In this study, we aimed to identify the differences in sociodemographic variables and reasons for termination of pregnancy (TOP) between married women and single/divorced women. We hope that this study can guide future policies and interventions to reduce the incidence of unsupported pregnancies in this profile group of women.@*METHODS@#We retrospectively evaluated the sociodemographic data of 802 women who underwent an abortion for social reasons at our institution in Singapore from January 2016 to September 2018. We compared the sociodemographic variables, reasons for and methods of TOP between married and single/divorced women.@*RESULTS@#We analysed data from 524 married women (65.3%) and 278 single/divorced women (34.7%). Married women were more likely to be of older age (29.5 years vs. 24.5 years, P < 0.001), had more living children and higher educational qualifications. The top two cited reason for abortions among married women were having enough children (42.0%) and the inability to afford another child (18.7%). Multivariate analysis showed that women aged >19 years and having more living children were independently associated with recurrent TOPs. Having a tertiary education was noted to be associated with less recurrent TOPs.@*CONCLUSION@#The most common reasons married women cited for having TOP include having enough children and the lack of financial capacity to afford another child. Recommendations to support women ought to be personalised and comprehensive in addressing their needs rather than offering a standardised support method. Greater emphasis should be placed on post-TOP family planning counselling to reduce repeated TOP.

Understanding cannabis use in Singapore: profile of users and drug progression

INTRODUCTION@#Cannabis has consistently been the third most commonly abused drug among drug arrestees in Singapore over the past few years. Accordingly, this study aimed to understand the profile of cannabis users in Singapore and explore the effects of cannabis use on drug progression.@*METHODS@#A total of 450 participants who had used cannabis at least once in their lifetime were recruited from the National Addictions Management Service, prisons, the Community Rehabilitation Centre and halfway houses from August 2017 to May 2018. A face-to-face questionnaire was administered and descriptive analyses were conducted.@*RESULTS@#The mean participant age was 40.9 ± 14.51 years, and 93.1% of them were male. The participants generally initiated cannabis use during adolescence, at a mean onset age of 16.5 ± 4.46 years. Most (89.6%) were introduced to cannabis by peers. Approximately half of them (46.9%) had used cannabis before other illicit drugs and 42.1% of them had used heroin as the succeeding drug.@*CONCLUSION@#In Singapore, cannabis use is often initiated during adolescence, largely under peer influence. Cannabis users may progress to other illicit drugs, particularly heroin, later in life.

Improved population coverage of the human papillomavirus vaccine after implementation of a school-based vaccination programme: the Singapore experience

INTRODUCTION@#Cervical cancer has a high disease burden in Singapore, and it is strongly associated with human papillomavirus (HPV) infections. Despite constant efforts to encourage vaccination, local HPV vaccine uptake remains low. Universal mass vaccination is a proven cost-effective method to reduce the cervical cancer disease burden. This paper reviews the newly implemented school-based HPV vaccination programme in Singapore and the factors that led to its success.@*METHODS@#Fully subsidised HPV vaccinations were offered to all Secondary 1 female students on an opt-in basis, starting as a rollout dose in 2019. One-time catchup vaccination was also offered to female students in Secondary 2-5. Eligible recipients were identified using enrolment data provided by Ministry of Education schools. A total of 19,144 students across 139 schools were offered the rollout dose, and 20,854 students across 140 schools were offered the catchup doses.@*RESULTS@#High vaccine uptake rates of 80.6%-87.3% were noted with the introduction of the school-based programme, translating to high vaccine coverage of 90.3%-93.4%. Only a small proportion of students (1.5%-1.9% per cohort) opted out. The rate of reported side effects, which were commonly known effects, was low at one in 1000. Among the students who reported side effects, those who received the second vaccine dose did so uneventfully.@*CONCLUSION@#High HPV vaccine coverage was achieved after implementation of the school-based immunisation programme. Timely assessment of knowledge lapses and targeted intervention, strong partnerships with stakeholders, constant on-site adaptation and positive social influence contributed to its success. This model can be applied to future school health programmes.

Efficacy and safety of ustekinumab in the treatment of moderate to severe plaque psoriasis in Singapore

INTRODUCTION@#Ustekinumab is a human monoclonal antibody that binds to the p40 subunit of both interleukin (IL)-12 and IL-23, and it is approved for the treatment of moderate to severe plaque psoriasis. In this study, we assessed the efficacy and safety of patients receiving ustekinumab for psoriasis.@*METHODS@#This retrospective study included all adults with chronic plaque psoriasis who were prescribed ustekinumab in a tertiary dermatologic centre between December 2009 and December 2015. Efficacy end points included a proportion of patients achieving at least 50% and 75% improvement from baseline psoriasis area and severity index (PASI) and body surface area (BSA) at Weeks 4 and 16.@*RESULTS@#A total of 99 patients were prescribed ustekinumab; 69% of these were Chinese, followed by 15% Indians and 9% Malays. 31 patients had documented PASI scores and 55 patients had documented BSA improvements. In patients with recorded PASI scores, 29 (93.5%) of 31 patients achieved PASI 50, and 21 (67.7%) of 31 achieved PASI 75 at week 16. In patients with recorded BSA, 43 (78.2%) of 55 had at least 50% BSA improvement, and 31 (56.4%) of 55 achieved 75% BSA improvement at 16 weeks. Regarding safety, no patient experienced tuberculosis reactivation. A total of 11 (11%) of 99 patients had latent tuberculosis infection and were treated with prophylactic isoniazid. No patient experienced serious adverse events. No cardiovascular events, cutaneous malignancies or deaths were reported over six years.@*CONCLUSION@#Ustekinumab is safe and efficacious in the treatment of patients with moderate to severe plaque psoriasis in a multiethnic Asian population.

Concordance of self-reporting of diabetes compared with medical records: A comparative study using polyclinic data in Singapore

INTRODUCTION@#Studies of concordance between patients' self-report of diseases and a criterion standard (e.g. chart review) are usually conducted in epidemiological studies to evaluate the agreement of self-reported data for use in public health research. To our knowledge, there are no published studies on concordance for highly prevalent chronic diseases such as diabetes and pre-diabetes. The aims of this study were to evaluate the concordance between patients' self-report and their medical records of diabetes and pre-diabetes diagnoses, and to identify factors associated with diabetes concordance.@*METHOD@#A cross-sectional, interviewer-administered survey was conducted on patients with chronic diseases after obtaining written consent to assess their medical notes. Interviewers were blinded to the participants' profiles. Concordance was evaluated using Cohen's kappa (κ). A multivariable logistic regression model was used to identify factors associated with diabetes concordance.@*RESULTS@#There was substantial agreement between self-reported and medical records of diabetes diagnoses (κ=0.76) and fair agreement for pre-diabetes diagnoses (κ=0.36). The logistic regression model suggested that non-Chinese patients had higher odds of diabetes concordance than Chinese patients (odds ratio [OR]=4.10, 95% confidence interval [CI] 1.19-14.13, P=0.03). Patients with 3 or more chronic diseases (i.e. multimorbidity) had lower odds of diabetes concordance than patients without multimorbidity (OR=0.21, 95% CI 0.09-0.48, P<0.001).@*CONCLUSION@#Diabetes concordance was substantial, supporting the use of self-report of diabetes by patients with chronic diseases in the primary care setting for future research. Pre-diabetes concordance was fair and may have important clinical implications. Further studies to explore and improve health literacy and patient-physician communication are needed.

Current treatment landscape for obesity in Singapore

The rising prevalence of obesity in Singapore is a harbinger for a corresponding increase in obesity-related complications such as type 2 diabetes mellitus (T2DM) and coronary heart disease. Obesity is a complex disease driven by multiple factors, and hence, treatment cannot follow a 'one-size-fits-all' approach. Lifestyle modifications involving dietary interventions, physical activity and behavioural changes remain the cornerstone of obesity management. However, similar to other chronic diseases such as T2DM and hypertension, lifestyle modifications are often insufficient on their own, hence the importance of other treatment modalities including pharmacotherapy, endoscopic bariatric therapy and metabolic-bariatric surgery. Weight loss medications currently approved in Singapore include phentermine, orlistat, liraglutide and naltrexone-bupropion. In recent years, endoscopic bariatric therapies have evolved as an effective, minimally invasive and durable therapeutic option for obesity. Metabolic-bariatric surgery remains the most effective and durable treatment for patients with severe obesity, with an average weight loss of 25%-30% after one year.

Weight bias and stigma in healthcare professionals: a narrative review with a Singapore lens

Addressing weight stigma is essential to obesity management as it causes inequalities in healthcare and impacts the outcomes of health. This narrative review summarises systematic review findings about the presence of weight bias in healthcare professionals, and interventions to reduce weight bias or stigma in these professionals. Two databases (PubMed and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) were searched. Seven eligible reviews were identified from 872 search results. Four reviews identified the presence of weight bias, and three investigated trials to reduce weight bias or stigma in healthcare professionals. The findings may help further research and the treatment, health and well-being of individuals with overweight or obesity in Singapore. Weight bias was prevalent among qualified and student healthcare professionals globally, and there is a lack of clear guidance for effective interventions to reduce it, particularly in Asia. Future research is essential to identify the issues and inform initiatives to reduce weight bias and stigma among healthcare professionals in Singapore.

Understanding cancer predisposition in Singapore: What's next

Knowledge of an underlying genetic predisposition to cancer allows the use of personalised prognostic, preventive and therapeutic strategies for the patient and carries clinical implications for family members. Despite great progress, we identified six challenging areas in the management of patients with hereditary cancer predisposition syndromes and suggest recommendations to aid in their resolution. These include the potential for finding unexpected germline variants through somatic tumour testing, optimal risk management of patients with hereditary conditions involving moderate-penetrance genes, role of polygenic risk score in an under-represented Asian population, management of variants of uncertain significance, clinical trials in patients with germline pathogenic variants and technology in genetic counselling. Addressing these barriers will aid the next step forward in precision medicine in Singapore. All stakeholders in healthcare should be empowered with genetic knowledge to fully leverage the potential of novel genomic insights and implement them to provide better care for our patients.

Frailty prevalence and its associations in a subacute geriatric ward in Singapore

INTRODUCTION@#Our aim was to study the prevalence of frailty and its associated factors in a subacute geriatric ward.@*METHODS@#This was a cross-sectional study of 167 participants between June 2018 and June 2019. Baseline demographics and participants' Mini Nutritional Assessment, Geriatric Depression Scale, Mini Mental State Examination, Charlson's Comorbidity Index and LACE index scores were obtained. Functional measurements such as modified Barthel's Index scores and hand grip strength (HGS) were taken. Frailty was assessed using the Clinical Frailty Scale (CFS) and the FRAIL scale. Data on history of healthcare utilisation, medications, length of stay, selected blood investigations and presence of geriatric syndromes were also collected.@*RESULTS@#The prevalence of pre-frailty (CFS 4) and frailty (CFS ≥ 5) was 16.2% and 63.4%, respectively. There were significant associations between CFS and age (pre-frail vs. non-frail: odds ratio [OR] 1.14, 95% confidence interval [CI] 1.04-1.25, P = 0.006; frail vs. non-frail: OR 1.08, 95% CI 1.01-1.15, P = 0.021), HGS at discharge (frail vs. non-frail: OR 0.90, 95% CI 0.82-0.99, P = 0.025), serum albumin (frail vs. non-frail: OR 0.90, 95% CI 0.82-0.99, P = 0.035) and the presence of urinary incontinence (frail vs. non-frail: OR 3.03, 95% CI 1.19-7.77, P = 0.021).@*CONCLUSION@#Frailty is highly prevalent in the subacute geriatric setting and has many associated factors. In this study, independent factors associated with frailty were age, HGS at discharge, serum albumin and urinary incontinence. This has implications for future resource allocation for frail older inpatients and may help direct further research to study the effectiveness of frailty-targeted interventions.

Consensus statement on Singapore integrated 24-hour activity guide for children and adolescents

INTRODUCTION@#Lifestyle activities, such as regular physical activity, are important for good metabolic health and the prevention of non-communicable diseases. Epidemiological studies highlight an increase in the proportion of overweight children in Singapore. A workgroup was formed to develop recommendations to encourage children and adolescents (aged 7-17 years) to adopt a holistic approach towards integrating beneficial activities within a daily 24-hour period for good metabolic and general health.@*METHODS@#The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision framework was employed to formulate the public health question, assess the evidence and draw conclusions for the guide. The evidence for international 24-hour movement guidelines, and guidelines for physical activity, sedentary behaviour, and sleep and eating habits were reviewed. An update of the literature review from August 2018 to end of September 2020 was conducted through an electronic search of Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases.@*RESULTS@#Ten consensus statements were developed. The statements focused on the overall aim of achieving good metabolic health through integration of these activities and initiatives: light and moderate- to vigorous-intensity physical activity on a regular basis; muscle- and bone-strengthening activities; limiting sedentary behaviour; regular and adequate sleep; good eating habits and choosing nutritionally balanced foods and drinks; practise safety in exercise; and aiming to achieve more or all aforementioned recommendations for the best results.@*CONCLUSION@#This set of recommendations provides guidance to encourage Singapore children and adolescents to adopt health-beneficial activities within a 24-hour period.

Prevalence and correlates of psychological distress and coronavirus anxiety among hospital essential services workers in Singapore

INTRODUCTION@#The COVID-19 pandemic has affected almost all populations, with frontline workers experiencing a higher risk of mental health effects compared to other groups. Although there are several research studies focusing on the mental health effects of the pandemic on healthcare workers, there is little research about its impact on workers in outsourced hospital essential services. This study aims to examine the prevalence and correlates of psychological distress and coronavirus anxiety among staff working in 3 outsourced hospital essential services-housekeeping, porter service and maintenance services.@*METHODS@#A cross-sectional study was conducted among outsourced hospital essential services workers in a tertiary hospital. Data on demographics, medical history, lifestyle factors, psychosocial factors and mental well-being were collected using self-administered questionnaires. Robust logistic regression was used to determine risk factors associated with psychological distress and dysfunctional anxiety related to COVID-19.@*RESULTS@#A total of 246 hospital essential services workers participated in the study. The prevalence of psychological distress was 24.7%, and dysfunctional anxiety related to COVID-19 was 13.4%. Social support and workplace support were found to be independently associated with a lower risk of psychological distress, and social connectivity was associated with a lower risk of dysfunctional anxiety related to COVID-19.@*CONCLUSION@#These findings highlight the crucial roles of communities and workplaces in combating the mental health consequences of the pandemic. Public health programmes that aim to tackle the emerging mental health crisis in hospital essential services workers should incorporate strategies to address psychosocial factors, in addition to traditional self-care approaches.

Prevalence, risk factors and parental perceptions of gastroesophageal reflux disease in Asian infants in Singapore

INTRODUCTION@#Infant gastroesophageal reflux disease (GERD) is a significant cause of concern to parents. This study seeks to describe GERD prevalence in infants, evaluate possible risk factors and assess common beliefs influencing management of GERD among Asian parents.@*METHODS@#Mother-infant dyads in the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO) cohort were prospectively followed from preconception to 12 months post-delivery. GERD diagnosis was ascertained through the revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R) administered at 4 time points during infancy. Data on parental perceptions and lifestyle modifications were also collected.@*RESULTS@#The prevalence of infant GERD peaked at 26.5% at age 6 weeks, decreasing to 1.1% by 12 months. Infants exclusively breastfed at 3 weeks of life had reduced odds of GERD by 1 year (adjusted odds ratio 0.43, 95% confidence interval 0.19-0.97, P=0.04). Elimination of "cold or heaty food" and "gas producing" vegetables, massaging the infant's abdomen and application of medicated oil to the infant's abdomen were quoted as major lifestyle modifications in response to GERD symptoms.@*CONCLUSION@#Prevalence of GERD in infants is highest in the first 3 months of life, and the majority outgrow it by 1 year of age. Infants exclusively breastfed at 3 weeks had reduced odds of GERD. Cultural-based changes such as elimination of "heaty or cold" food influence parental perceptions in GERD, which are unique to the Asian population. Understanding the cultural basis for parental perceptions and health-seeking behaviours is crucial in tailoring patient education appropriately for optimal management of infant GERD.

Health economics of kidney replacement therapy in Singapore: Taking stock and looking ahead

The prevalence of end-stage kidney disease (ESKD) in Singapore remains high and continues to rise. We continue to face major challenges in containing the rising incidence of ESKD and providing sustainable kidney replacement therapy. Our cost projections provide an insight into the present and future, urging a call to action to augment existing initiatives to address the emergent issues.

Medicolegal aspects of non-rapid eye movement parasomnias

INTRODUCTION@#In a subset of adults with non-rapid eye movement (NREM) parasomnias, clinical variants might be violent in nature and can potentially result in unintentional but considerable harm. As such, there is substantial interest on the forensic ramifications of these sleep behaviours.@*METHODS@#This review examined the diagnostic criteria for parasomnias established in the context of international classification systems; medicolegal case reports; legal frameworks; and court cases in and outside of Singapore, to provide an overview of the implications of NREM parasomnias.@*RESULTS@#Violent or injurious behaviours that occurred in the context of somnambulism, otherwise known as sleepwalking, have challenged traditional legal theories of criminal culpability. Yet little has changed in the application of sleep science to criminal responsibility. In Singapore, the defence of somnambulism has hitherto not been directly raised. Nonetheless, sleep medicine practitioners may increasingly be requested to render their opinions on legal issues pertaining to violent or injurious behaviours allegedly arising during sleep. Although the understanding of NREM parasomnias has improved, there is still a dearth of evidence to support both medical and legal decisions in this area.@*CONCLUSION@#NREM parasomnias come with disquieting legal and forensic implications for adjudicating criminal responsibility. There is a need to critically examine legal perspectives on behaviours occurring during sleep. More reliable empirical studies investigating the pathophysiology of NREM parasomnias can offer clearer diagnostic guidelines and address complex behaviours of NREM that often come with medicolegal implications.

Diagnosis and management of polycystic ovary syndrome: Perspectives of clinicians in Singapore

INTRODUCTION@#To harmonise the diagnostic processes of polycystic ovary syndrome (PCOS) and enable clinicians to provide better patient care, it is critical to understand the knowledge gaps in PCOS diagnosis. We evaluated how clinicians in endocrinology, family medicine, general practice and gynaecology diagnose PCOS.@*METHODS@#This cross-sectional survey involved 208 clinicians from specific subspecialties across various healthcare settings in Singapore.@*RESULTS@#A total of 160 responses were included in the final analysis. Among all the diagnostic criteria, the Rotterdam 2003 criteria was most frequently used (66.3%). More than half of the gynaecologists reported having a standardised workplace protocol while the majority from other specialties reported otherwise. A large percentage of respondents (60.5%) were unable to identify the correct PCOS clinical features, which is concerning. Only 8.8% of respondents used clinical and biochemical hyperandrogenism, menstrual disturbances and pelvic ultrasound to diagnose PCOS without performing unnecessary and incorrect investigations. Most clinicians recognised insulin resistance/type 2 diabetes mellitus and fertility problems as complications while only a few recognised psychological complications. Many clinicians (37.3%) sought standardisation of PCOS diagnosis and management guidelines for improvement in PCOS care and 81.9% of respondents would appreciate standardised educational materials.@*CONCLUSION@#This is the first study to the best of our knowledge that gives an insight into the diagnostic and management processes of PCOS among various healthcare institutions in Singapore. This study calls for greater harmonisation of diagnostic processes and holistic evidence-based management of patients with PCOS through standardised workplace protocols and patient education resources.

Determinants of emergency department utilisation by older adults in Singapore: A systematic review

INTRODUCTION@#Adults aged ≥60 years contribute to disproportionately higher visits to the emergency departments (ED). We performed a systematic review to examine the reasons why older persons visit the ED in Singapore.@*METHODS@#We searched Medline, Embase and Scopus from January 2000 to December 2021 for studies reporting on ED utilisation by older adults in Singapore, and included studies that investigated determinants of ED utilisation. Statistically significant determinants and their effect sizes were extracted. Determinants of ED utilisation were organised using Andersen and Newman's model. Quality of studies was evaluated using Newcastle Ottawa Scale and Critical Appraisal Skills Programme.@*RESULTS@#The search yielded 138 articles, of which 7 were used for analysis. Among the significant individual determinants were predisposing (staying in public rental housing, religiosity, loneliness, poorer coping), enabling (caregiver distress from behavioural and psychological symptoms of dementia) and health factors (multimorbidity in patients with dementia, frailty, primary care visit in last 6 months, better treatment adherence). The 7 included studies are of moderate quality and none of them employed conceptual frameworks to organise determinants of ED utilisation.@*CONCLUSION@#The major determinants of ED utilisation by older adults in Singapore were largely individual factors. Evaluation of societal determinants of ED utilisation was lacking in the included studies. There is a need for a more holistic examination of determinants of ED utilisation locally based on conceptual models of health seeking behaviours.

Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting

INTRODUCTION@#In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting.@*METHODS@#The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process.@*RESULTS@#The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists.@*CONCLUSION@#These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.

The impact of deprescribing interventions on oral proton pump inhibitor utilisation in a Singapore tertiary hospital: A quality improvement initiative

INTRODUCTION@#Proton pump inhibitors (PPIs) are effective treatments for upper gastrointestinal pathologies and short-term courses are well-tolerated. However, indiscriminate use of PPIs is undesirable due to its potential harms. We implemented a series of deprescribing interventions between 2016 and 2017 to curb PPI overutilisation in our institution. The aim of this study was to evaluate the effectiveness and safety of these interventions.@*METHODS@#An institutional PPI deprescribing guide was disseminated by email and educational roadshows were conducted to prescribers. Interrupted time series analysis was used to evaluate the effectiveness of the deprescribing interventions over a 7-year period from 2013 to 2019. To ascertain the safety of PPI deprescribing, we analysed the peptic ulcer disease incidence from 2015 to 2018 and conducted a retrospective chart review of 262 inpatients who were deprescribed PPIs.@*RESULTS@#Following the first intervention, there was a significant decrease in mean oral PPI utilisation by 2,324.46 defined daily doses (DDD) per 1,000 prescriptions (95% confidence interval [CI] -3,542.66, -1,106.26) per month, followed by a month-to-month decrease of 302.61 DDD per 1,000 prescriptions per month thereafter (95% CI -473.95, -131.27). A second targeted educational intervention was only effective in sustaining the decline in the outpatient, but not in the inpatient setting. There were no significant changes in incidence of peptic ulcer disease. In the retrospective chart review, a majority (62.6%) of patients remained deprescribed at 6 months.@*CONCLUSION@#We observed a sustained decrease in PPI utilisation in our institution for more than 12 months following our educational interventions. Cautious deprescribing of PPIs in eligible candidates was found to be safe with low recurrence rates of upper gastrointestinal events.

Submammary placement of implantable cardioverter defibrillators: a Singapore plastic surgeon experience

The use of implantable cardioverter defibrillators (ICDs) in young women has been increasing in recent years owing to greater awareness about inherited cardiac conditions that increase the risk of sudden death. Traditional placement of ICDs in the infraclavicular region among young women often leads to visible scars, a constant prominence that causes irritation from purse or bra straps and can result in body image concerns and device-related emotional distress. In this case series, two women with long QT syndrome required placement of ICDs for prevention of sudden cardiac death. Submammary placement of ICDs was performed in collaboration with electrophysiologists. We describe our local experience and technique in submammary placement of ICDs as well as the challenges faced.

Changes in the prevalence of comorbidity of mental and physical disorders in Singapore between 2010 and 2016

INTRODUCTION@#Few studies have examined the changes in the prevalence of comorbidity of mental and physical disorders in recent years. The present study sought to examine whether the prevalence of comorbidity of mental and physical disorders in Singapore showed any changes between 2010 and 2016.@*METHODS@#We extracted data from two repeated nationally representative cross-sectional surveys conducted among resident adults aged ≥ 18 years in Singapore. Significant changes were tested using pooled multinomial logistic regression analyses.@*RESULTS@#The prevalence of comorbid mental and physical disorders increased significantly from 5.8% in 2010 to 6.7% in 2016. Among those with physical disorders, there were significant increases over time in the prevalence of comorbid generalised anxiety disorder (GAD) (0.1% vs. 0.4%) and obsessive-compulsive disorder (OCD) (1.4% vs. 3.9%) in diabetes mellitus, and alcohol dependence in cardiovascular disorders (0.1% vs. 1.3%). Among those with mental disorders, there were significant increases over time in the prevalence of comorbid diabetes mellitus in OCD (4.1% vs. 10.9%), cancer in major depressive disorder (0.4% vs. 2.4%), and cardiovascular disorders in GAD (0.4% vs. 6.7%) and alcohol dependence (0.9% vs. 11.8%). Significant changes in the overall prevalence of comorbid mental and physical disorders were also observed across age group, education and employment status.@*CONCLUSION@#The prevalence of comorbid mental and physical disorders increased significantly over time. This finding supports the need for more appropriate clinical management with better integration between mental health and general medical care professionals across all aspects of the healthcare system to treat this comorbidity in Singapore.