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This study estimates the incubation period of COVID-19 among locally transmitted cases, and its association with age to better inform public health measures in containing COVID-19. Epidemiological data of all PCR-confirmed COVID-19 cases from all restructured hospitals in Singapore were collected between 23 January 2020 and 2 April 2020. Activity mapping and detailed epidemiological investigation were conducted by trained personnel. Positive cases without clear exposure to another positive case were excluded from the analysis. One hundred and sixty-four cases (15.6% of patients) met the inclusion criteria during the defined period. The crude median incubation period was 5 days (range 1–12 days) and median age was 42 years (range 5–79 years). The median incubation period among those 70 years and older was significantly longer than those younger than 70 years (8 vis-à-vis 5 days, P = 0.040). Incubation period was negatively correlated with day of illness in both groups. These findings support current policies of 14-day quarantine periods for close contacts of confirmed cases and 28 days for monitoring infections in known clusters. An elderly person who may have a longer incubation period than a younger counterpart may benefit from earlier and proactive testing, especially after exposure to a positive case.
Scholars studying Singapore have given it many labels ranging from a dictatorship and one-party state to an illiberal democracy. In 2015, Mark Tushnet, in a much-discussed article published in the Cornell Law Review, used Singapore as the quintessential prototype of what he calls “authoritarian constitutionalism.” This chapter critically examines and unpacks Tushnet’s model of “authoritarian constitutionalism” and argues that this categorization is neither accurate nor useful. The author argues that Tushnet’s construction of this model is based on flawed premises and variables and that from the perspective of comparative constitutional law, this kind of model-making is unhelpful for scholars seeking to understand the true nature of how constitutions work in different societies.
The psychiatric reactions relating to Human Immunodeficiency Virus (HIV) infection cover the whole range of mental illnesses and psychosocial problems. This poses a challenge to both physicians and psychiatrists and is of immense relevance due to the rising number of HIV patients in Singapore.
To retrospectively examine the psychiatric disorders and related factors associated with HIV infected patients in a general hospital in Singapore.
To review and describe the psychiatric disorders and related factors associated with HIV patients under the care of Tan Tock Seng Hospital and Communicable Disease Centre in Singapore.
A 2-years retrospective descriptive study was performed on all HIV patients who were referred to the Department of Psychological Medicine of Tan Tock Seng Hospital for psychiatric assessment and this includes both inpatient and outpatient referrals. The data for inpatient referrals was obtained through the interdepartmental referral registry and relevant case notes. The data for outpatient referrals was obtained through the attendance and relevant case notes of the HIV psychiatric clinic. The data was collated and analyzed.
Mood disorders were the most common psychiatric disorders diagnosed and antidepressants were the most commonly used psychotropic drugs. Most patients were followed up on an outpatient basis for continuation of treatment.
Many HIV infected patients may have concomitant psychiatric disorders. Clinicians may need to actively identify patients at risk and initiate early psychiatric consult to ensure appropriate care for these treatable disorders.
The air transport industry has seen a rapid growth since the early 1900s. Serving more than 180 cities in over 50 countries, Changi International Airport in Singapore has established itself as a major aviation hub in the Asia Pacific region, with an annual handling capacity of more than 44 million passengers. In recent years, it has been observed that a number of passengers are found to be in a mentally disturbed state at the Changi International Airport. Some of whom are unable to continue in their journey and have to be admitted for further evaluation. The purpose of this descriptive study was to examine the occurrence and the presentation of mental disorders requiring admission at an international airport.
A retrospective study was performed including patients who had been referred for psychiatric observation by the Changi International Airport to a tertiary hospital nearest the airport. The patients were studied in respect to the circumstance of admission, clinical presentation, management and how they continued on their journey.
Most of the patients admitted had a history of a major mental illness, such as schizophrenia and bipolar disorder. In-flight emergencies and serious incidents caused by psychiatric patients were fortunately uncommon.
As air travel becomes more prevalent, it is conceivable that there will be an increasing number of psychiatric patients taking a flight. Although most patients are able to travel uneventfully, there are still a small number of patients who have to be detained and stabilised at a hospital.
Electroconvulsive therapy (ECT) involves the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp to induce a seizure for therapeutic purposes. In 2001, the American Psychiatric Association (APA) task force on ECT concluded that convincing data exists to support use for major depression, bipolar depression and mania, schizophrenia, and schizoaffective and schizophreniform disorders. However, the National Institute for Clinical Excellence in the UK (NICE 2003) does not recommend that ECT be used as a long-term treatment to prevent recurrence of depressive illness, and that it recommends that ECT should not be used in the general management of schizophrenia.
To review and describe the practice of ECT in the largest psychiatric hospital in Singapore.
This was a retrospective descriptive study performed on all patients who were administered electroconvulsive therapy at the Institute of Mental Health in Singapore during the 2-year study period of 1st July 2005 – 30th June 2007. Data was collected from existing medical records on the demographics, indications, frequency and the complications of the patients given ECT. The frequency of missed fits was also determined as measuring the number of missed-fits provided one way of assessing an ECT clinic's efficiency.
The main indications for electroconvulsive therapy at the Institute of Mental Health in Singapore were patients with Schizophrenia or Schizoaffective Disorders with poor response to medications, followed by patients with mood disorders. The rate of complications of ECT and the frequency of missed-fits were found to be low.
One of the major challenges in Asia is the impact of diseases in the aging population. Dementia is a common and disabling disorder in the elderly which has gained growing public health relevance. The Asian populations in developing countries have been known to report a lower prevalence of dementia, partially influenced by their cultural background and traditional societal roles for the elderly. We aim to investigate how living in a developed country with a strong Asian cultural background, influence perceptions on dementia.
We invited in-patients of a tertiary hospital, with no previously diagnosed cognitive impairment, to complete an anonymous, self-filled questionnaire about their perceptions of dementia, societal trends and the current role of elderly in Singapore.
Majority of respondents had strong traditional values and felt a duty of care for elderly within their family. Societal norms still suggests that our elderly would more likely give up position of authority and property for younger members of the family. Our elderly also became significantly less active in society after retirement.
With the rapid development of our society and trend towards nuclear families, the resultant possibility of higher carer stress and pressure for residential placement facilities are likely to grow.
The Lasting Power of Attorney (LPA), under the Mental Capacity Act 2008, came into effect in Singapore on March 2010. as more people become aware of the LPA and the demand for making one rises, it is imperative for healthcare professionals to be knowledgeable about it, in order to provide sound and timely advice to the public.
This study aims to assess the Knowledge, Attitudes and Practices of doctors and medical social workers (MSWs) in Tan Tock Seng Hospital, Singapore, with regards to the making of an LPA.
209 structured questionnaires were distributed and analyzed across seven medical and surgical disciplines between January-April 2011.
Only 8.89% of surgeons, 29.3% of physicians and 29.2% of MSWs have ever encountered an LPA before. 51% of respondents felt that they knew little or nothing at all about the LPA. Only 67% knew the difference between an LPA and an Advanced Medical Directive (AMD). Only 26% were aware of the information sources available for the making of an LPA.
The results of the study revealed limited knowledge and inconsistent attitudes. This resulted in misconceptions, leading to non-standard practices amongst doctors and medical social workers surveyed with regards to the LPA document, in Singapore. It is crucial to address and rectify this deficiency in knowledge. Hopefully in time, this will translate to better practices and the public would be more comfortable approaching their doctors for advice regarding creating a Lasting Power of Attorney for themselves and their loved ones.
Studies have shown the Clock Drawing Test (CDT) to be useful as a screening test between normal, elderly populations and those diagnosed with dementia. However, the results of studies which have looked at the utility of the CDT to help differentiate Alzheimer's dementia
(AD) and other dementias have been conflicting. The purpose of this study was to explore the utility of the CDT in discriminating between patients with AD and other dementias.
A review was conducted using MEDLINE, PsycINFO and Embase. Search terms included clock drawing or CLOX and dementia or Parkinson's Disease or Alzheimer's Disease or Dementia with Lewy Bodies (DLB) or Vascular Dementia (VaD) or Semantic Dementia.
20 studies were selected. In most of the studies included, no significant differences were found in CDT scores between AD and VaD, DLB, and Parkinson's disease dementia (PDD) patients. Frontotemporal dementia (FTD) patients consistently scored higher in the CDT than AD patients. Qualitative analyses of the type of errors seem to suggest a difference between AD and the other types of dementias.
Overall, the CDT score may be useful in distinguishing between AD and FTD patients, but shows limited value in differentiating between AD and VaD, DLB and PDD. Qualitative analysis of the type of CDT errors may be a useful adjunct in the differential diagnosis of the types of dementias.
Schizophrenia is associated with an increased risk of sudden cardiac death, traditionally attributed to prolonged QTc interval and cardiovascular risk factors such as metabolic syndrome. However, defective ion channels are also implicated in schizophrenia. This applies as well for Brugada syndrome (BrS), a rare hereditary cardiac disorder associated with an increased risk of cardiac arrhythmias, which can been provoked by various drugs, including psychotropic.
To screen whether an increased prevalence of suspect Brugada ECG is present in patients with recent onset schizophrenia.
273 subjects with recent onset schizophrenia admitted between 2006 and 2012 and 306 healthy controls, underwent an ECG. All persons who had an ECG suspect for BrS were asked to undergo a provocation test to diagnose/exclude BrS. We checked whether patients had deceased during follow-up.
20/273 patients (7.3%) and 5/306 healthy controls (1.6%) showed an ECG suspect for BrS, with a Relative risk (RR) of 4.8 (p<0.001). Thus far 12 provocation tests have been performed, confirming BrS in three patients (1.1%). Ten patients had deceased during follow-up, of which two due to sudden cardiac death. Patients and controls didn’t differ significantly on average QTc interval.
Conclusion: This study shows that a considerable subset of patients with recent onset schizophrenia have an ECG suspect of Brugada Syndrome, confirming results in a population with chronic schizophrenia (Blom 2014). This may imply that there is a common pathophysiologic mechanism involved in both disorders. Screening for Brugada Syndrome in schizophrenia is relevant to prevent sudden cardiac death.
Speech disturbances manifest in various psychiatric conditions and demonstrate temporal variability in relation to acute and stable symptom periods. They can be externally assessed, which facilitates their potential use as an objective marker of illness stage. Continued research will have positive implications for diagnostics and long-term management in clinical settings.
This was a descriptive study of the prescription trend of anti-psychotics for elderly patients in a general hospital in Singapore.
Elderly patients aged >65 who received at least 1 prescription of anti-psychotics during 2005, 2007, 2009, 2011 and 2013 in Tan Tock Seng Hospital, Singapore, were selected. Data was obtained from the hospital computerized prescription records.
The total number of elderly patients who received anti-psychotics increased from 865 in 2005 to 1990 in 2013. Following the official warning issued by the health sciences authority in 2004 regarding the increased risks of cerebrovascular events in elderly patients taking olanzapine and risperidone, prescriptions for risperidone reduced between 2005 to 2013 (20.74% vs. 11.79%, 95% CI: 0.07–0.10, P < 0.0001). However, the percentage of prescriptions of other atypical anti-psychotics such as quetiapine increased from 27.47% to 58.48% (95% CI: 0.29–0.33, P < 0.0001), in 2005 and 2013 respectively, and prescriptions for olanzapine remained relatively stable at 6.65% in 2005 and 8.94% in 2013 (P > 0.05). With the black box warnings extended to typical anti-psychotics 3 years later, the percentage of prescriptions of typical anti-psychotics decreased between 2005 to 2013, e.g. haloperidol (33.19% vs. 13.39%, 95% CI: 0.17–0.22; P < 0.0001), sulpiride (6.58% vs. 2.83%, 95% CI: 0.03–0.05, P < 0.0001) and chlorpromazine (3.85% vs. 1.85%, 95% CI: 0.01–0.03, P < 0.0001).
After the first safety warning the percentage of prescriptions for risperidone dropped significantly, and there was a significant increase for quetiapine. The percentage of haloperidol, sulpiride and chlorpromazine prescriptions declined after both warnings. Anti-psychotics use in the elderly continues to be prevalent.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
There is limited data on psychological burden following spinal cord injury (SCI) in Singapore.
(1) To describe the prevalence of depression and anxiety at admission for inpatient rehabilitation and (2) describe the baseline characteristics that predict the development of anxiety or depression in patients following SCI.
We retrospectively reviewed medical records of SCI patients at admission from 01-06-2013 to 31-12-2015. The Hospital Anxiety and Depression Scale (HADS), ASIA score and demographics were collated.
A total of 157 subjects were included, 62.4% (n = 98) were male with a mean age of 56.7 years. 43.4% (n = 68) had a traumatic SCI with 73.9% (n = 116) having had spinal surgery. The average length of stay was 46.6 days with most discharged to their own homes. Ten subjects screened positive for anxiety (6.4%) and 16 for depression (10.2%). 13.4% (n = 21) screened positive for anxiety and/or depression. Two third (n = 95) had injuries at the cervical level and 14% (n = 22) scored ASIA A/B. 45.9% (n = 72) was referred to the psychologist. A significantly higher proportion of subjects (P < 0.05) who screened positive had a past psychiatric history, were prescribed antidepressants at admission and during rehabilitation. Significant differences were noted in primary caregiver (nursing home vs. others) following discharge when comparing those that screened positive vs. negative however there were no significant differences between baseline demographics, neurological level and ASIA score.
Psychological burden following SCI is significant. Standardized screening and psychological support is warranted with special attention to those with a past psychiatric history.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Employment is a crucial part of adult life and is associated with improved health outcomes. However, despite the several advantages of hiring individuals with intellectual and development disabilities (IDD), the employment rate for this population is still low. An employment conference was organised to inform participants of successful employment initiatives, and to increase our understanding of local employer challenges regarding the recruitment, hire, and retention of employees with IDD. Descriptive statistics were used to assess common methods of recruitment, potential helpful hiring strategies, and recruitment, hire, and retention challenges, and an ordinal logistic regression was conducted to examine whether responses differed based on demographic variables. The conference was evaluated by gathering data on several facets of participant satisfaction. Findings brought to light several key challenges that can be used to create more targeted interventions and supports. Responses to several questions differed by demographics (such as company size and industry type), which represent important areas for future research to examine. Participants reported being satisfied with the conference, and many indicated that their attitudes had changed towards disability and that they were more likely to employ individuals with IDD in the future. Systematically addressing barriers to employment is essential in order to reduce the employment gap and improve outcomes for individuals with IDD. Ultimately, conferences that aim to educate participants about successful programs and strategies represent a promising practice that can increase employment opportunities for individuals with IDD.
Sparganosis is an important foodborne parasitic zoonosis; however, few reports on the prevalence of snake-infecting plerocercoids from Hunan province in China are available. Therefore, we investigated the prevalence of spargana infection in wild snakes from this region in 2018, and identified an astonishing prevalence rate of 91.7% (344/375). Spargana parasites were found in 99.1% of Zaocys dhumnades, 94.1% of Elaphe carinata and 86.7% of Elaphe taeniura. Parasites exhibited various distributions: 50% were located in muscular tissue, 32.1% in subcutaneous tissue and 17.9% in the coelomic cavity. To identify the specific status of spargana collected from wild snakes, partial mitochondrial cytochrome c oxidase subunit 1 (cox1) gene sequences were amplified, sequenced and analysed. Sequence variations for cox1 among all the examined plerocercoids ranged between 0.0 and 2.9%, with 21 variable sites identified (4.71%, 21/446). Phylogenetic analyses identified that all plerocercoids isolated from Hunan province were Spirometra erinaceieuropaei. This is the first report of S. erinaceieuropaei infection in snakes in Hunan province. The risks and harms of sparganosis should be publicized, and illegal wildlife trade should be controlled.
Patients with severe mental disorders in low-resource settings have limited access to services, resulting in overwhelming caregiving burden for families. In extreme cases, this has led to the long-term restraining of patients in their homes. China underwent a nationwide initiative to unlock patients and provide continued treatment. This study aims to quantify household economic burden in families after unlocking and treatment, and to identify factors associated with increased burden due to schizophrenia.
A total of 264 subjects were enrolled from three geographically diverse provinces in 2012. Subjects were patients with schizophrenia who were previously put under restraints and had participated in the ‘unlocking and treatment’ intervention. The primary outcome was the current household economic burden, obtained from past year financial information collected through on-site interview. Patient disease characteristics, treatment, outcomes and family caregiving burden were collected as well. Univariate and multivariate linear regression were used to construct risk factor models for indirect economic burden.
After participating in the intervention, 85% of patients continued to receive mental health services, 70% used medication as prescribed and 80% were never relocked. Family members reported significantly decreased caregiving burden after receiving the intervention. Mean direct and indirect household economic burdens were CNY963 (US$31.7) and CNY11 724 (US$1670) per year, respectively, while family total income was on average CNY12 108 (US$1913) per year. Greater disease severity and poorer patient psychosocial function at time of study were found to be independent factors related to increased indirect burden.
The ‘unlocking and treatment’ intervention has improved the lives of patients and families. Indirect burden due to disease is still a major economic issue that needs to be addressed, potentially through improving treatment and patient functioning. Our findings contribute to the unravelling and eventual elimination of chronic restraining of mentally ill patients in low-resource settings.
To describe an outbreak of bacteremia caused by vancomycin-sensitive Enterococcus faecalis (VSEfe).
An investigation by retrospective case control and molecular typing by whole-genome sequencing (WGS).
A tertiary-care neonatal unit in Melbourne, Australia.
Risk factors for 30 consecutive neonates with VSEfe bacteremia from June 2011 to December 2014 were analyzed using a case control study. Controls were neonates matched for gestational age, birth weight, and year of birth. Isolates were typed using WGS, and multilocus sequence typing (MLST) was determined.
Bacteremia for case patients occurred at a median time after delivery of 23.5 days (interquartile range, 14.9–35.8). Previous described risk factors for nosocomial bacteremia did not contribute to excess risk for VSEfe. WGS typing results designated 43% ST179 as well as 14 other sequence types, indicating a polyclonal outbreak. A multimodal intervention that included education, insertion checklists, guidelines on maintenance and access of central lines, adjustments to the late onset sepsis antibiotic treatment, and the introduction of diaper bags for disposal of soiled diapers after being handled inside the bed, led to termination of the outbreak.
Typing using WGS identified this outbreak as predominately nonclonal and therefore not due to cross transmission. A multimodal approach was then sought to reduce the incidence of VSEfe bacteremia.
The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural–geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.
In March 2017, the New Jersey Department of Health received reports of 3 patients who developed septic arthritis after receiving intra-articular injections for osteoarthritis knee pain at the same private outpatient facility in New Jersey. The risk of septic arthritis resulting from intra-articular injection is low. However, outbreaks of septic arthritis associated with unsafe injection practices in outpatient settings have been reported.
An infection prevention assessment of the implicated facility’s practices was conducted because of the ongoing risk to public health. The assessment included an environmental inspection of the facility, staff interviews, infection prevention practice observations, and a medical record and office document review. A call for cases was disseminated to healthcare providers in New Jersey to identify patients treated at the facility who developed septic arthritis after receiving intra-articular injections.
We identified 41 patients with septic arthritis associated with intra-articular injections. Cultures of synovial fluid or tissue from 15 of these 41 case patients (37%) recovered bacteria consistent with oral flora. The infection prevention assessment of facility practices identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection practices. No additional cases were identified after infection prevention recommendations were implemented by the facility.
Aseptic technique is imperative when handling, preparing, and administering injectable medications to prevent microbial contamination.
This investigation highlights the importance of adhering to infection prevention recommendations. All healthcare personnel who prepare, handle, and administer injectable medications should be trained in infection prevention and safe injection practices.