A practical clinical approach to liver fibrosis

Liver fibrosis is a slow, insidious process involving accumulation of extracellular matrix protein in the liver. The stage of liver fibrosis in chronic liver disease (CLD) determines overall morbidity and mortality; the higher the stage, the worse the prognosis. Noninvasive composite scores can be used to determine whether patients with CLD have significant or advanced fibrosis. Patients with low composite scores can be safely followed up in primary care with periodic reassessment. Those with higher scores should be referred to a specialist. As the epidemic of diabetes mellitus, obesity and non-alcoholic fatty liver diseases is rising, CLD is becoming more prevalent. Easy-to-use fibrosis assessment composite scores can identify patients with minimal or advanced fibrosis, and should be an integral part of decision-making. Patients with cirrhosis, high composite scores, chronic hepatitis B with elevated alanine aminotransferase and aspartate aminotransferase, or deranged liver panel of uncertain aetiology should be referred to a specialist.

Prevalence of overweight and obesity in Chinese preschoolers in Singapore

<p><b>INTRODUCTION</b>This study examines the prevalence of overweight and obesity in 6- to 72-month-old Chinese preschoolers in Singapore using 3 references.</p><p><b>MATERIALS AND METHODS</b>This was a population-based cross-sectional study of 3009 Chinese preschoolers aged 6 to 72 months from southwestern and western parts of Singapore. Overweight and obesity were defi ned by using the Center for Disease Control (CDC) (85th and 95th percentile, respectively), the International Obesity Task Force (IOTF) and the local National Health Group Polyclinics (NHGP), Singapore (90th and 97th percentile, respectively) references.</p><p><b>RESULTS</b>The prevalence of overweight and obesity in 24 to 72 months old Chinese children were 8.1% and 7.1% (the CDC reference), 7.6% and 3.9% (the IOTF reference) and 7.5% and 5.3% (the local reference [NHGP]) respectively. For preschoolers aged 6 to 72 months, the prevalence of overweight and obesity was 7.0% and 5.3%, respectively, using the local reference. An increasing trend in the prevalence of obesity with increasing age was seen in both genders, using the CDC and IOTF references (P ≤0.001 and 0.001, respectively). The boys were more likely to be obese than the girls using the CDC reference (OR = 1.42, 95% CI, 1.02 to 1.97, P = 0.03).</p><p><b>CONCLUSION</b>Our study showed a lower prevalence of overweight and obesity among Chinese preschoolers in Singapore when compared to other countries like the United States, Italy, Chile using the CDC and/or IOTF references. The CDC reference overestimated whereas the IOTF reference underestimated the prevalence of overweight and obesity for our population when compared to using the local NHGP reference.</p>

Postgraduate family medicine training in Singapore--a new way forward

Postgraduate Family Medicine (FM) training is important to train future primary care doctors to provide accessible and cost effective healthcare. In Singapore, a structured postgraduate FM training programme has been available for 20 years. This programme is characterised by involvement of both FM and non-FM doctors, well written modules and a rigorous assessment process. However, challenges faced by both the current healthcare system and training structure underlie the need to review the training structure to ensure its relevancy for future Family Physicians (FPs) to manage the needs of their patients. A workgroup was formed to review the current FM postgraduate programme and to explore the possibility of using the Accreditation Council for Graduate Medical Education (ACGME) framework to enhance our current system. The workgroup felt that broad-based training and comprehensive coverage of topics are areas that are important to retain in any new FM residency programme. Weaknesses identified included a lack of early FM exposure and the need to strengthen formative assessments. New organisational structures such as Family Medicine Centres (FMC) need to be established and the involvement of the private sector in any FM residency progammes could be enhanced. The implementation of the FM Residency Programme in 2011 presented a unique opportunity to realign FM postgraduate education in line with the national objectives and to equip FPs with the necessary knowledge and skills for managing the future healthcare needs of Singaporeans.

Acceptability of medical students by patients from private and public family practices and specialist outpatient clinics

<p><b>INTRODUCTION</b>Previous studies on patient acceptance of medical student teaching were from Western populations and in one setting only. However, there has been no prospective study comparing patient acceptability before and after an actual experience. We studied patient acceptability of medical student teaching in private and public family practices and public hospital specialist outpatient clinics in Singapore, and before and after an actual medical student teaching consultation.</p><p><b>MATERIALS AND METHODS</b>We conducted an anonymous cross-sectional survey from March through October 2007 of Singaporean or permanent resident patients attending 76 teaching private family practices, 9 teaching public family practices and 8 specialty clinics in a teaching public hospital. We used pre-consultation cross-sectional patient surveys in all three settings. For private family practice setting only, post-consultation patient survey was conducted after an actual experience with medical student presence.</p><p><b>RESULTS</b>Out of 5123 patients, 4142 participated in the cross-sectional survey (80.9%) and 1235 of 1519 patients in the prospective cohort study (81.3%). Eighty percent were comfortable with medical students present, 79% being interviewed and 60% being examined. Regarding being examined by medical students, parents of children were least comfortable while patients between 41 to 60 years were most comfortable (adjusted OR = 1.99 [1.55-2.57]). Females were less comfortable with medical student teaching than males. Chinese patients were the least comfortable about being interviewed or examined by medical students among the ethnic groups. Indians were most comfortable with being interviewed by medical students (adjusted OR = 1.38 [1.02-1.86]) but Malays were the most comfortable being examined by them (adjusted OR = 1.32 [1.07-1.62]). Family practice patients were more receptive to medical student teaching than the hospital's specialist outpatients. Common barriers to patient acceptance were lack of assurance of patient privacy, dignity and confidentiality. Actual exposure to medical student teaching did not change levels of patient acceptance.</p><p><b>CONCLUSIONS</b>Compared to similar studies from Western countries, Asian patients appear to be less receptive to medical student teaching than Western patients. Family practice settings offer medical students a more receptive learning environment.</p>

Self-rated health, associated factors and diseases: a community-based cross-sectional study of Singaporean adults aged 40 years and above

<p><b>INTRODUCTION</b>Subjective indicators of health like self-rated health (SRH) have been shown to be a predictor of mortality and morbidity. We determined the prevalence of poor SRH in Singapore and its association with various lifestyle and socioeconomic factors and disease states.</p><p><b>MATERIALS AND METHODS</b>Cross-sectional survey by interviewer-administered questionnaire of participants aged 40 years and above. SRH was assessed from a standard question and categorised into poor, fair, good or excellent. Lifestyle factors, socioeconomic factors and presence of disease states were also assessed.</p><p><b>RESULTS</b>Out of 409 participants, 27.6% rated their health as poor or fair, 53.1% as good and 19.3% as excellent. Smaller housing-type (PRR: 1.64, 95% CI: 1.10- 2.44) and lack of exercise (PRR: 1.54, 95% CI: 1.06-2.22) were found to be associated with poor SRH. Presence of chronic diseases such as coronary artery disease (PRR: 1.89, 95% CI: 1.13-3.17), diabetes mellitus (PRR: 1.85, 95% CI: 1.18-2.91), history of cancer (PRR: 2.15, 95% CI: 1.05-4.41) and depression (PRR: 1.73, 95% CI: 1.13-2.65) were associated with poor SRH.</p><p><b>CONCLUSION</b>Prevalence and factors associated with poor SRH in Singapore was comparable to other developed countries. SRH is an important subjective outcome of health and has the potential for wider use in clinical practice in Singapore.</p>

Characteristics, and disease control and complications of hypertensive patients in primary-care - a community-based study in Singapore

<p><b>INTRODUCTION</b>Hypertension is a common chronic condition usually managed by primary-care practitioners in Singapore. This study assessed the characteristics, control and complications of non-diabetic hypertensive patients managed at government primary healthcare clinics.</p><p><b>MATERIALS AND METHODS</b>A cross-sectional study involving 9 clinics was conducted over 1-week in 2006. Five hundred and six non-diabetic hypertensive patients were systematically sampled from all clinic attendees. Data relating to socio-demographic, lifestyle factors, treatment and complications were collected by interviewer-administered questionnaires and review of clinic medical records. Blood pressure (BP) measurements were taken with validated automated sets following a standard protocol.</p><p><b>RESULTS</b>The prevalence of good BP control (<140/90 mmHg) was 37.7% (95% CI: 33.6% to 41.8%). Ninety seven percent were on medication with about half on monotherapy. Seventy percent of patients had a body mass index (BMI) of 23.0 kg/m(2) or higher, 64% did not exercise regularly and 8% were current smokers. After adjusting for age and lifestyle factors, male hypertensive patients had poorer BP control compared to females. Nineteen percent of patients reported at least 1 complication of hypertension, especially cardiac disease. After multivariate analysis and duration of disease, age and the male gender were associated with the presence of hypertensive complications.</p><p><b>CONCLUSIONS</b>More than half of the patients were not controlled to target levels. Male patients were more likely to have poorer control of hypertension and significantly higher risks of complications. Control of BP could be further improved by lifestyle modifications - weight reduction, promotion of physical activity, healthier eating habits and smoking cessation.</p>

Attitudes towards the elderly among Singapore medical students

<p><b>INTRODUCTION</b>It is important that medical students possess the correct attitude towards the elderly and not have an ageist attitude. This is because they will be caring for an increasing proportion of elderly patients. We thus sought to assess the attitudes of our medical students towards the elderly.</p><p><b>MATERIALS AND METHODS</b>We conducted a cross-sectional study assessing the attitudes towards the elderly of 225 fi rst-year and 135 third-year students using a self-administered questionnaire that incorporated the Kogan's Attitudes Toward Old People Scale (KAOP). Elderly people were defined as those aged 65 years and above for this study.</p><p><b>RESULTS</b>The majority of fi rst- (98.2%) and third-year (99.2%) medical students had positive attitudes towards elderly people (KAOP score above 102). KAOP scores were not significantly different regardless of seniority (medical student year), gender, race, household income, or having a doctor-parent. Although the mean KAOP score of third-year students was higher than that of fi rst-year students, this was not significantly different (P = 0.062).</p><p><b>CONCLUSIONS</b>Medical students in Singapore have a positive attitude towards the elderly. It is important that their medical curriculum continues to have an increasing geriatric component in view of the increasing numbers of older persons that they will be caring for due to the ageing population.</p>

Translating the family medicine vision into educational programmes in Singapore

The core of the Family Medicine (FM) vision is patient-centred care, requiring specific education and vocational training. We traced how FM education started and what have been achieved. FM training began in 1971 with the formation of the College of General Practitioners Singapore. Previously, training consisted of self-directed learning, lunchtime talks and examination preparation courses run by hospital specialists. Formal FM vocational training programmes in the United Kingdom and Australia provided the model for a 3-year programme in 1988. The tripartite relationship between the local university, College of Family Physicians and Ministry of Health, together with a structured training programme, contributed to its success. To date, more than 240 Family Physicians in Singapore have been awarded the Masters in Medicine (FM) degree. The Graduate Diploma in Family Medicine programme (GDFM) was introduced in 2000 for Family Physicians who wished to practice at an enhanced level. This programme has trained 194 doctors since then. Behind the scenes, the following were important developments: counterculture with a difference, tripartite stake-holding, training the trainers and learning from others. For the FM undergraduate programme, our aim is to develop the knowledge base, core values and roles of the Family Physician. Sustaining the value of Family Medicine as a career choice is the enduring vision.

A cross-sectional study of primary-care physicians in Singapore on their concerns and preparedness for an avian influenza outbreak

<p><b>INTRODUCTION</b>During an avian influenza (AI) pandemic, primary-care physicians (PCPs) are expected to play key roles in the prevention and control of the disease. Different groups of PCPs could have different concerns and preparedness level. We assessed the concerns, perceived impact and preparedness for an outbreak among PCPs in Singapore.</p><p><b>MATERIALS AND METHODS</b>A cross-sectional survey of PCPs working in private practice (n=200) and public clinics (n=205) from March to June 2006 with an anonymous self-administered questionnaire on concerns (12- items), perceived impact (10 items) and preparedness (10 items) for an outbreak.</p><p><b>RESULTS</b>Two hundred and eighty-five PCPs responded - 149 (response rate: 72.7%) public and 136 (response rate: 67.3%) private. The majority were concerned about risk to their health from their occupation (95.0%) and falling ill with AI (89.7%). Most (82.5%) accepted the risk and only 33 (11.8%) would consider stopping work. For perceived impact, most felt that people would avoid them (69.6%) and their families (54.1%). The majority (81.3%) expected an increased workload and feeling more stressed at work (86.9%). For preparedness, 78.7% felt personally prepared for an outbreak. Public PCPs were more likely to be involved in infection-control activities and felt that their workplaces were prepared.</p><p><b>CONCLUSIONS</b>Most PCPs felt personally prepared for an outbreak but were concerned about their exposure to AI and falling ill. Other concerns included social ostracism for themselves and their families. Public PCPs appeared to have a higher level of preparation. Addressing concerns and improving level of preparedness are crucial to strengthen the primary-care response for any AI outbreak.</p>

Concerns, perceived impact and preparedness in an avian influenza pandemic--a comparative study between healthcare workers in primary and tertiary care

<p><b>INTRODUCTION</b>With the potential threat of an avian influenza (AI) pandemic, healthcare workers (HCWs) are expected to play important roles, and they encounter significant stress levels from an expected increase in workload. We compared the concerns, perceived impact and preparedness for an AI pandemic between HCWs working in public primary care clinics and a tertiary healthcare setting.</p><p><b>MATERIALS AND METHODS</b>An anonymous, self-administered questionnaire was given to 2459 HCWs working at 18 public polyclinics (PCs) and a tertiary hospital (TH) in Singapore from March to June 2006. The questionnaire assessed work-related and non-work-related concerns, perceived impact on personal life and work as well as workplace preparedness.</p><p><b>RESULTS</b>We obtained responses from 986 PC and 873 TH HCWs (response rate: 74.6% and 76.7%). The majority in both groups were concerned about the high AI risk from their occupation (82.7%) and falling ill with AI (75.9%). 71.9% accepted the risk but 25.5% felt that they should not be looking after AI patients with 15.0% consider resigning. HCWs also felt that people would avoid them (63.5%) and their families (54.1%) during a pandemic. The majority expected an increased workload and to feel more stressed at work. For preparedness, 74.2% felt personally prepared and 83.7% felt that their workplaces were prepared for an outbreak. TH HCWs were more likely to be involved in infection-control activities but the perception of infection-control preparedness in both groups was high (>80.0%).</p><p><b>CONCLUSIONS</b>HCWs in both public primary and tertiary healthcare settings felt prepared, personally and in their workplaces, for a pandemic. Their main concerns were risks of falling ill from exposure and the possibility of social ostracism of themselves and their families. Preparedness levels appeared high in the majority of HCWs. However, concerns of HCWs could affect their overall effectiveness in a pandemic and should be addressed by incorporating strategies to manage them in pandemic planning.</p>

Family medicine education in Singapore: a long-standing collaboration between specialists and family physicians

In many countries, family medicine (FM) training has been conducted mainly by senior family physicians alone. However, FM training in Singapore in the last 30 years has involved specialists working in close collaboration with family physicians. The areas in which specialists are currently involved include the training of FM trainees in tertiary hospitals, the Master of Medicine in Family Medicine [MMed (FM)] and Graduate Diploma in Family Medicine (GDFM) programmes. This close relationship has been crucial in the continuing vocational and professional development of family physicians and in fostering closer collaboration between family physicians and specialists, thus ultimately benefiting patient care.