Place of death and its determinants for patients with cancer in Singapore: an analysis of data from the Singapore Cancer Registry, 2000-2009.

AIMS: To describe the place of death for patients with cancer in Singapore from 2000 to 2009, and determinants of death at home and in in-patient hospice compared to death in hospital. METHOD: Cross-sectional analysis of all patients registered with the Singapore Cancer Registry who had died in the study period (N=52120). Places of death were grouped as homes, in-patient hospices, hospitals and others. For determinants of death at home and in in-patient hospice, covariates adjusted for in logistic regression analyses were age group, gender, ethnic group, primary tumour site, stage at diagnosis, duration and cause of death. RESULTS: In the 10-year period, 52.9% of patients with cancer had died in the hospital, 30.3% died at home and 10.7% in in-patient hospice. Determinants of death at home were older age, female (odds ratio OR 1.23, 95% confidence interval, CI 1.17-1.29), Malay (OR 2.28, 95% CI 2.13-2.44), cancers of the colo-rectum, liver, stomach, pancreas and nasopharynx (compared to lung cancer), duration of illness of 1-5 years (OR 1.40, 95% CI 1.34-1.48), primary cause of death being 'neoplasms' (OR 2.97, 95% CI 2.79-3.17). Determinants of death in in-patient hospice were older age, distant metastasis (OR 1.35, 95% CI 1.21-1.50) and primary cause of death being 'neoplasms' (OR 20.07, 95% CI 16.05-25.09). CONCLUSION: Knowledge about place of death and its determinants will facilitate the planning of healthcare services to enable patients with terminal cancer to die at home and in in-patient hospices, thereby avoiding inappropriate hospitalization at the end of life.

Ethnic differences in Singapore's dementia prevalence: the stroke, Parkinson's disease, epilepsy, and dementia in Singapore study.

OBJECTIVES: To study the prevalence of dementia in Singapore among Chinese, Malays, and Indians. DESIGN: A two-phase, cross-sectional study of randomly selected population from central Singapore with disproportionate race stratification. SETTING: Community-based study. Subjects screened to have cognitive impairment at phase 1 in their homes were evaluated clinically for dementia at phase 2 in nearby community centers. PARTICIPANTS: Fourteen thousand eight hundred seventeen subjects aged 50 and older (67% participation rate). MEASUREMENTS: The locally validated Abbreviated Mental Test was used to screen for cognitive impairment at phase 1. Dementia was diagnosed at phase 2 as per Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Possible Alzheimer's disease (AD) and possible vascular dementia (VD) were diagnosed along the National Institute of Neurological and Communicative Disorders-Alzheimer's Disease and Related Disorders Association and National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neuroscienes criteria, respectively. RESULTS: The overall age- and race-standardized dementia prevalence was 1.26% (95% confidence interval (CI)=1.10-1.45). Prevalence (in 5-year age bands) was 0.08% (50-54), 0.08% (55-59), 0.44% (60-64), 1.16% (65-69), 1.84% (70-74), 3.26% (75-79), 8.35% (80-84), and 16.42% (>/=85). From age 50 to 69, 65% of dementia cases were VD; at older ages, 60% were AD. Logistic regression (adjusted for age, sex, education) showed that Malays had twice the risk for AD as Chinese, and Indians had more than twice the risk for AD and VD than Chinese. CONCLUSION: Singapore's dementia prevalence, primarily influenced by its Chinese majority, is lower than seen in the West. The striking interethnic differences suggest a need for a dementia incidence study and further investigation of underlying genetic and cultural differences between the three ethnic groups in relation to dementia risk.

Screening for dementia in the older Chinese with a single question test on progressive forgetfulness.

OBJECTIVES: To assess the utility of asking for presence of progressive forgetfulness (PF) prior to administering the Abbreviated Mental Test (AMT) when screening for dementia in the community-dwelling elderly Chinese. METHODS: This was a two-phased community-based survey of elderly subjects (>or=50 yrs). In phase one, subjects were asked for PF and administered the AMT. Those having PF or an impaired AMT performance were evaluated clinically for dementia in phase two, which also included a randomly selected sample of 35 subjects with no PF and who passed the AMT. RESULTS: 2,566 subjects completed phase one interview, of which 128 subjects completed phase two. Overall prevalence of PF, failed AMT and dementia were 2.4%, 2.2%, 0.9% respectively. The sensitivity of PF for dementia was 95.7% with specificity of 45.1%. PF was significantly associated with depression in the young-old (50-74 yrs) but not in the old-old (>or=75 yrs) age group, after adjusting for dementia. The probability of subjects (%) in the four possible diagnostic combinations of PF and AMT in the young-old and (old-old) age groups were 0 (0.06) in the no PF/ passed AMT, 0 (0.44) in the no PF/failed AMT, 0.23 (9.2) in the PF/passed AMT and 3.6 (43) in the PF/failed AMT groups. CONCLUSION: In screening for the most common dementias, AMT administration is not required if PF is absent. AMT is also of no added utility for diagnosing dementia in older subjects with PF. Younger subjects with PF should be closely evaluated for depression especially if they passed the AMT, and dementia, if they failed the AMT.

Prevalence of respiratory symptoms in children and air quality by village in rural Indonesia.

AIM: This study compared prevalence of respiratory symptoms in three Indonesian villages and related this to air quality. METHODS: We interviewed caregivers of 382 children, using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, and monitored air quality during the survey period. RESULTS: Respiratory symptom prevalence was highest in Kerinci (40.5%), followed by SP7 (33.3%) and Pelalawan (19.8%). Compared with Pelalawan, adjusted odds ratios were 3.17 (95% confidence interval, 1.43-7.07) for Kerinci, and 2.03 (1.04-3.96) for SP7. Ambient air quality levels were highest in Kerinci for PM10 and hydrocarbon (means: 102.9 microg/m3, 10.5 microg/m3), followed by SP7 (73.7 microg/m3, 6.3 microg/m3) and Pelalawan (26.1 microg/m3, 4.7 microg/m3). CONCLUSIONS: The higher prevalence of respiratory symptoms in Kerinci and SP7 could be the result of higher PM10 and hydrocarbon levels in these locations.

Acute respiratory symptoms in adults in general practice.

BACKGROUND: Community studies have shown that approximately 30% of patients with acute respiratory tract symptoms have no identifiable infective aetiology. This may not be applicable in general practice. OBJECTIVE: The purpose of this study was to determine the infective aetiology in patients who presented to primary care doctors with acute respiratory symptoms. METHODS: A prospective study was carried out in all nine primary care clinics belonging to the National Healthcare Group Polyclinics (NHGPs) in Singapore. The subjects comprised 594 consecutive patients (318 males, 276 females) aged > or = 21 years who presented with complaints of any one of cough, nasal or throat symptoms of <7 days duration. Data collection was through interview using structured questionnaire, physical examination, throat swabs for bacterial culture and nasal swabs for virus identification by immunofluorescence (IF) and polymerase chain reaction (PCR). Additional PCR was performed on a subsample of 100 patients. Patients were followed-up until resolution of symptoms. RESULTS: The aetiological diagnosis by infective agent is as follows: 150 patients (25.2%) had virus infections, of which 90.7% (136/150) were by rhinovirus. Fourteen patients (2.4%) had bacterial infections, of which 10 were due to group G streptococcus. Group A streptococcus was not detected. Nineteen patients with new pathogens were identified by further PCR. These included parainfluenza 4, human coronavirus OC43, adenovirus, enterovirus and Chlamydia pneumoniae. No pathogen could be identified in 49% of patients. There were no differences in clinical presentation and socio-demographic variables between patients who had viral infections and those in whom no pathogen could be identified. CONCLUSION: In about half of patients who presented at NHGPs, no pathogens could be identified even after PCR. A non-infective aetiology could be considered in these patients.

Awareness and health beliefs of women towards osteoporosis.

A population-based survey was conducted to determine the awareness, knowledge of risk factors, and attitudes toward osteoporosis in middle-aged and elderly women in Singapore. Chinese women aged 45 years and above ( n=1,376) living in Teban Gardens (community on the western side of Singapore) were randomly sampled. Household interviews were conducted and questions on socioeconomic status, knowledge of osteoporosis, identification of risk factors for osteoporosis, and health beliefs were assessed. There were 946 (68.8%) women who were postmenopausal and 430 (31.2%) who were not. Fifty-eight percent of the sample had heard of osteoporosis. Women who were younger, better educated, who exercised regularly, or who were single were more likely to have heard of osteoporosis. The main sources of information about osteoporosis were the mass media and friends. The identification of risk factors ranged from fair to good: 85.7% of women identified low calcium intake, 43.7% identified lack of exercise, and 30.5% identified family history of osteoporosis as risk factors for osteoporosis. Most women (79.1%) were concerned about developing osteoporosis but only 15.2% thought that osteoporosis was more serious than cancer. Community-based health education programs on osteoporosis that target a wide audience including the less well educated, could be implemented. Increasing the awareness of osteoporosis and its risk factors may be essential in efforts to decrease the incidence of this disease.

Urinary alpha1-microglobulin as a marker of nephropathy in type 2 diabetic Asian subjects in Singapore.

OBJECTIVE: This study examines urinary alpha(1)-microglobulin as a marker of early nephropathy in type 2 diabetic Chinese, Malays, and Asian Indians in Singapore. RESEARCH DESIGN AND METHODS: A cross-sectional study was performed on 590 consecutive type 2 diabetic patients (296 males, 294 females) who were on routine follow-up at a primary care clinic. Information was obtained from interviews, case notes, and blood and urine samples. Because the distribution of urinary alpha(1)-microglobulin levels was highly skewed, these levels were log-transformed, and geometric means were calculated. There was correction for variability in urine flow by dividing by urine creatinine levels, given as mg/mmol urine creatinine, and adjustment for confounding variables. RESULTS: Urinary alpha(1)-microglobulin was higher in men than in women and was directly related to age, but no ethnic differences were apparent. It was directly related to duration of diabetes, with adjusted geometric means of 1.19 and 1.43 mg/mmol urine creatinine for a duration of <10 and > or =10 years, respectively (P = 0.07). Urinary alpha(1)-microglobulin was highest in patients on insulin, followed by those on oral medication and then those on diet alone (adjusted geometric means: 1.47, 1.36, and 0.86 mg/mmol urine creatinine, respectively; P = 0.01). Levels were also higher in patients with poor glucose control, as measured by HbA(1c), fasting plasma glucose, and 2-h postprandial plasma glucose (P < 0.01 for each). Urinary alpha(1)-microglobulin was directly related to albuminuria, with adjusted geometric means for normoalbuminuria, microalbuminuria, and macroalbuminuria of 1.06, 1.47, and 4.72 mg/mmol urine creatinine, respectively (P < 0.01). However, of patients with normoalbuminuria, 33.6% had raised urinary alpha(1)-microglobulin. Likewise, of patients with normal urinary alpha(1)-microglobulin, 27.6% had albuminuria. CONCLUSIONS: Urinary alpha(1)-microglobulin was related to duration, severity, and control of diabetes. Urinary alpha(1)-microglobulin and albumin were directly related, but in some patients, one was present in the absence of the other. Hence, in addition to albuminuria (which measures glomerular dysfunction), urinary alpha(1)-microglobulin (which measures proximal tubular dysfunction) is useful for the early detection of nephropathy in diabetic subjects.

Sensitivity and specificity of visual acuity screening for refractive errors in school children.

PURPOSE: To examine the optimal cutoff point for the use of the visual acuity test to screen for refractive errors in schoolchildren. METHODS: In a sample of schoolchildren between 7 and 9 years old, visual acuity testing was performed using modified ETDRS charts monocularly without optical aids by trained personnel. Cycloplegic autorefraction was performed in each eye. The screening efficacy of using various cutoff points for referring children for further optometric/ ophthalmic assessment was studied. Myopia was defined as a spherical equivalent of at least -0.5 D, hyperopia a spherical equivalent of at least +2.0 D, and astigmatism a cylinder of at least -1.0 D in at least one eye. The sensitivity, specificity, and predictive values were calculated using each patient as a case; a receiver operator curve was plotted. RESULTS: A total of 1,028 children were tested. A satisfactory sensitivity/specificity profile was obtained using a referral criterion of visual acuity worse than or equal to 0.28 logarithm of the minimum angle of resolution in at least one eye. In this scenario, the sensitivity and specificity of this screening test were 72% (95% confidence interval [CI], 68 to 76) and 97% (95%CI, 95 to 98), respectively. The positive and negative predictive values were 96% (95%CI, 93 to 98) and 78% (95%CI, 75 to 82), respectively. CONCLUSIONS: The modified ETDRS visual acuity chart can be used to predict refractive errors in schoolchildren in Singapore in a sensitive and specific manner using a referral criterion of worse than or equal to 0.28 logarithm of the minimum angle of resolution.

Height and its relationship to refraction and biometry parameters in Singapore Chinese children.

PURPOSE: To examine the association between the anthropometric measurements of height, weight, body mass index (BMI) and refraction and other ocular parameters in Singapore Chinese children. METHODS: In a cross-sectional study of 1449 Chinese schoolchildren, aged 7 to 9 years, from three Singapore schools, height and weight were measured according to standard protocol, and BMI was calculated. Refractive error and corneal curvature measures were determined by autorefraction in eyes under cycloplegia. Axial length, vitreous chamber depth, lens thickness, and anterior chamber depth were measured using A-scan biometry ultrasonography. RESULTS: In comparison with the children with height in the first quartile for a given age and gender, the eyeball length in children in the fourth quartile was 0.46 mm longer, the vitreous chamber depth 0.46 mm deeper, the corneal radius of curvature 0.10 mm greater (i.e., flatter), refraction more negative by 0.47 D (-0.76 D versus -0.29 D), and axial length-to-corneal curvature radius (AL-CR) ratio higher, after analyses controlling for age, gender, parental myopia, reading, school, and weight. The associations of height with refractive error and AL-CR ratio were significant in girls but not in boys. Heavier and more obese children had refractions that were more hyperopic (P = 0.01, P = 0.08), after analyses controlling for age, gender, parental myopia, reading, and school (height was also controlled for if weight was evaluated). This association was present in boys but not in girls. CONCLUSIONS: Controlling for age, gender, parental myopia, reading, school, and weight showed that taller Singapore Chinese children had eyes with longer axial lengths, deeper vitreous chambers, flatter corneas, and refractions that tended toward myopia. In multivariate analysis, eyes in children who were heavier or who had a higher BMI tended to have refractions that were more hyperopic, and eyes in heavier children had shorter vitreous chambers. Differences between the present results and a recent report in Singapore adults suggest either a cohort effect or a potential influence of systemic endocrine or metabolic factors during childhood on refractive development.

Nearwork in early-onset myopia.

PURPOSE: To determine the relationship of nearwork and myopia in young elementary school-age children in Singapore. METHODS: A cross-sectional study of 1005 school children aged 7 to 9 years was conducted in two schools in Singapore. Cycloplegic autorefraction, keratometry, and biometry measurements were performed. In addition, the parents completed a detailed questionnaire on nearwork activity (books read per week, reading in hours per day and diopter hours [addition of three times reading, two times computer use, and two times video games use in hours per day]). Other risk factors, such as parental myopia, socioeconomic status, and light exposure history, were assessed. RESULTS: In addition to socioeconomic factors, several nearwork indices were associated with myopia in these young children. The multivariate adjusted odds ratio of higher myopia (at least -3.0 D) for children who read more than two books per week was 3.05 (95% confidence interval [CI], 1.80-5.18). However, the odds ratios of higher myopia for children who read more than 2 hours per day or with more than 8 diopter hours (1.50; 95% CI, 0.87-2.55 and 1.04; 95% CI, 0.61-1.78, respectively) were not significant, after controlling for several factors. CONCLUSIONS: Children aged 7 to 9 years with a greater current reading exposure were more likely to be myopic. This association of reading and myopia in a young age cohort was greater than the strength of the reading association generally found in older myopic subjects. Whether these results identify an association of early-onset myopia with nearwork activity or other potentially confounding factors is discussed.