Original Article

Chee KG, Puhaindran ME, Chong AK
Correspondence: Dr Chee Kin Ghee, kin_ghee_chee@ttsh.com.sg

ABSTRACT
Introduction Hand surgery is a subspecialty with a dedicated training programme in Singapore. Currently, Singapore is one of two countries in the world that still provides dedicated advanced hand specialty training. As hand surgeons depend on referrals from institutions and general practitioners, appropriate hand surgical referral requires the referring physician to have knowledge and understanding of common hand conditions as well as less common but more urgent surgical conditions, and their available surgical treatments. This study aimed to determine the knowledge of hand surgery and hand surgical conditions among general practitioners.
Methods A questionnaire survey was conducted during a continuing medical education symposium on hand surgery in Singapore. Participants responded to 12 questions on hand trauma by keying the answers into a computer database system. The results were then analysed.
Results A total of 35 general practitioners responded to our survey, and they were able to answer 53% of the questions correctly. We found knowledge gaps among the participants regarding hand surgical conditions, and identified areas where increased education during medical school, postgraduate training and continuing medical education may be beneficial. Areas that were found to be weak included recognising injuries that pose a high risk for developing wound infection, complications of topical steroid injection in trigger finger treatment and hand tumours.
Conclusion Improving hand surgery knowledge among general practitioners not only leads to improved primary care, but it can also facilitate prompt recognition of surgical problems and subsequent referral to appropriate hand surgeons for treatment. This may possibly reduce the load of tertiary institutions in treating non-urgent hand conditions.

Leong L, Chia SE
Correspondence: Dr Lucy Leong, Lucy_Leong@mom.gov.sg

ABSTRACT
Introduction This study aimed to determine the prevalence of modifiable cardiovascular risk factors among health workers (HWs) and non-health workers (NHWs) in a large hospital in Singapore.
Methods A cross-sectional prevalence survey of 3,384 hospital staff was conducted. The study comprised a selfadministered questionnaire, body mass index, systolic and diastolic blood pressure measurements, and laboratory analysis of fasting blood samples of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides and plasma glucose. HWs were doctors and nurses, while NHWs were health administrators, facility staff, clerks and administrative personnel.
Results A total of 3,384 out of 3,987 eligible staff (response rate 84.9%) participated in the survey . The majority of the participants were female (81%, n = 2,755), and 64% (n = 2,179) were 20–39 years old. HWs comprised almost two-thirds of the staff employed (61.3%, n = 2076), of whom 87.7% were female, while 72.5% of NHWs were female. Compared to HWs, NHWs had a higher adjusted (age, ethnic group and gender) prevalence of personal history of diabetes mellitus (adjusted prevalence rate ratio [PRR] 1.64, 95% confidence interval [CI] 1.02–2.64), cigarette smoking (adjusted PRR 1.85, 95% CI 1.48–2.32), obesity (adjusted PRR 1.36, 95% CI 1.05–1.75) and elevated systolic pressure (adjusted PRR 1.74, 95% CI 1.31–2.31).
Conclusion The prevalence of modifiable cardiovascular risk factors in NHWs is higher than that in HWs. Health promotion programmes should address this captive and neglected audience in healthcare organisations.

Madhukumar P, Loh GY, Maung ZT, Chua FS, Chen JJ
Correspondence: Dr Preetha Madhukumar, preetha@nccs.com.sg

ABSTRACT
Introduction Central venous catheters (CVCs) are becoming more popular for delivery of outpatient courses of intravenous therapy such as chemotherapy and long-term antibiotics. The incidence of non-tunnelled type CVC-related infections in patients with solid tumours receiving chemotherapy in an ambulatory setting has not been well studied. We aimed to determine the baseline data on CVC-related infections in this retrospective study conducted from January 2005 to December 2007.
Methods Data on cancer patients with CVCs inserted as outpatients at National Cancer Centre Singapore over a three-year period were collected and analysed retrospectively. Data retrieved from medical records included patients’ demographics, the number of catheter days, cancer type and other medical illnesses. Definitions from the Centre for Disease Control and Prevention for CVC-related infections were used. For data analysis, graphical and quantitative techniques were employed.
Results A total of 88 CVCs were inserted during the study period, with a total of 11,541 catheter days (median 114; range 2–510 days). Infection rate was 0.87 per 1,000 catheter days. The risk of infection was higher when catheters were left in situ for longer periods of time and in patients with solid tumours.
Conclusion The infection rate for non-tunnelled type CVCs is low in our centre. Hence, its use for chemotherapy on an outpatient basis is relatively safe and convenient in oncologic patients.

Keywords: ambulatory care, central venous catheter, chemotherapy, infection
Singapore Med J 2012; 53(8): 513–516

Kaushal J, Bhutani G, Gupta R
Correspondence: Dr Garima Bhutani, garimahuja2010@yahoo.com

ABSTRACT
Introduction This study aimed to compare the effects of the two most commonly prescribed atypical antipsychotics, olanzapine and risperidone, on fasting blood sugar and serum lipid profile of the recipients.
Methods A randomised, comparative, open clinical study was conducted on 60 schizophrenic patients. The patients were divided into two groups, one receiving olanzapine and the other receiving risperidone. The patients were assessed for changes in fasting blood sugar and serum lipid profile (triglycerides [TG], high-density lipoprotein [HDL], low-densitylipoprotein [LDL], very-low-density lipoprotein [VLDL] and total cholesterol) eight weeks after starting treatment. The number of patients positive for fasting blood sugar and lipid profile criteria of metabolic syndrome was calculated by applying the modified National Cholesterol Education Programme Adult Treatment Panel III guidelines (NCEP ATP III) criteria at eight weeks.
Results Patients treated with olanzapine showed a highly significant increase in the observed parameters, whereas those treated with risperidone showed a significant increase in fasting blood sugar, HDL and LDL levels, and a highly significant increase in other parameters. Intergroup comparison was insignificant except for TG, VLDL and total cholesterol levels. More men as compared to women fulfilled the NCEP ATP III criteria for metabolic syndrome in both groups.
Conclusion Olanzapine has a higher propensity to cause derangement of some parameters of lipid profile than risperidone. These parameters include TG, VLDL and total cholesterol levels.

Keywords: hyperlipidaemia, metabolic syndrome, olanzapine, risperidone
Singapore Med J 2012; 53(7):488–492

Wongpakaran T, Wongpakaran N, Sirithepthawee U, Pratoomsri W, Burapakajornpong N, Rangseekajee P, Bookkamana P, Temboonkiat A
Correspondence: Dr Tinakon Wongpakaran, tchanob@med.cmu.ac.th

ABSTRACT
Introduction The aims of this study were two-fold; to investigate the validity and reliability of the Thai version of the Inventory of Interpersonal Problems (IIP) and to compare the characteristics of the interpersonal problems experienced in a non-clinical sample and psychiatric outpatients.
Methods A total of 689 subjects (452 non-clinical sample and 237 psychiatric outpatients) completed the IIP-32 and IIP-64, Symptom checklist-90 (SCL-90) and 16 Personality Factor (16 PF) Questionnaire, after which a four-week retest was carried out. Cronbach’s alpha was used for internal consistency and the intra-class correlation coefficient was used to determine test-retest reliability. Factor analysis of the IIP sub-scales and Pearson’s correlation were used for construct and concurrent validity.
Results Both versions of the IIP showed good internal consistency. Factor analysis revealed two factors that corresponded to the circumplex property. The expected correlation between the SCL-90 and 16 PF subscales reflected the level of concurrent validity. There was a significant difference in the cold, socially-inhibited and self-sacrificing subscales between the non-clinical and clinical samples, while major depressive disorder was found to have a significantly higher score in the subscales of the control dimension, i.e. the non-assertive, socially inhibited and self-sacrificing subscales, than the neurotic and non-clinical groups, whereas, the neurotic group differed from the normative sample in terms of the affiliation axis.
Conclusion The IIP-64 and IIP-32 demonstrated their reliability and are suitable for use in either clinical or non-clinical setting.

Keywords: clinical, IIP, interpersonal problems, non-clinical
Singapore Med J 2012; 53(7):481–487

Yu ZL, Yeoh LY, Seow YY, Luo XC, Griva K
Correspondence: Dr Griva Konstadina, psygk@nus.edu.sg

ABSTRACT
Introduction It is challenging for dialysis patients to maintain adherence to their medical regimen, and symptoms of depression are prevalent among them. Limited data is available about adherence and depression among patients receiving peritoneal dialysis (PD). This study aimed to examine the rates of treatment non-adherence and depression in PD patients.
Methods A total of 20 PD patients (response rate 71.4%; mean age 64.4 ± 11.6 years) were assessed using the Beliefs about Medicines Questionnaire, Self Efficacy for Managing Chronic Disease Scale, Hospital Anxiety and Depression Scale (HAD) and Kidney Disease Quality of Life-Short Form. A self-reported adherence (PD exchanges, medication and diet) scale developed for the study was also included. Medical information (e.g. most recent biochemistry results) was obtained from chart review.
Results The mean self-reported scores indicated an overall high level of adherence, although a significant proportion of patients were non-adherent. Among the latter, 20% of patients were non-adherent to medication and 26% to diet due to forgetfulness, while 15% and 26% of patients admitted to deliberate non-adherence to medication and diet, respectively. Treatment modality, employment, self-care status and self-efficacy were associated with overall adherence. Using a cutoff point of 8 for HAD depression and anxiety subscales, 40% of patients were found to be depressed and 30% had symptoms of anxiety.
Conclusion This is the first study to document treatment adherence and depression among PD patients in Singapore. Findings of high prevalence of depression and anxiety, and reports of poor adherence warrant development of intervention programmes.

Keywords: adherence, depression, peritoneal dialysis, quality of life
Singapore Med J 2012; 53(7):474–480

Sidik SM, Arroll B, Goodyear-Smith F, Ahmad R
Correspondence: Dr Sherina Mohd Sidik, sherina@putra.upm.edu.my

ABSTRACT
Introduction Depression affects more women than men in Malaysia. The objective of this paper was to determine the prevalence of depression and its associated factors among women attending a government primary care clinic.
Methods A cross-sectional study was conducted in a government-funded primary care clinic in Malaysia. Consecutive adult female patients attending the clinic during the data collection period were invited to participate. The participants completed self-administered questionnaires (including the validated Patient Health Questionnaire [PHQ-9], which was translated into the Malay language).
Results A total of 895 female patients participated in the study (response rate 87.5%). The prevalence of depression (PHQ-9 scores ≥ 10) was 12.1%. Based on multiple logistic regression analysis, certain stressful life events were found to be associated with depression (p < 0.05). These factors, arranged from highest to lowest risk, were financial problems (odds ratio [OR] 3.7, 95% confidence interval [CI] 2.2–6.2), unhappiness in the parent-child relationship (OR 3.0, 95% CI 1.2–7.5), history of serious illness (OR 2.4, 95% CI 1.1–5.2), unhappiness in family relationships (OR 2.3, 95% CI 1.1–4.7) and unhappiness at work (OR 2.2, 95% CI 1.1–4.3) (p < 0.05).
Conclusion The prevalence of depression among participants in this study was clinically significant and corresponded with the findings of other international studies. Factors associated with depression need to be highlighted and addressed accordingly. Clinicians in Malaysia should be aware of this prevalence when making diagnoses in primary care.

Keywords: depression, Malaysia, prevalence, primary care, women
Singapore Med J 2012; 53(7):468–473

Tan LL, Seng KH
Correspondence: Dr Tan Lay Ling, lay_ling_tan@cgh.com.sg

ABSTRACT
Introduction In tandem with our ageing population, it is observed there is a growing trend of elderly patients presenting for the first time with psychotic symptoms. Clinical experience suggests differences in the phenomenology of late-onset psychosis in our Asian context compared to studies done in the West. This study aimed to analyse the characteristics and psychopathology of first presentation psychosis in our local elderly and to determine the treatment outcome over a 12-month period.
Methods A total of 64 subjects with first presentation psychosis were consecutively recruited. Those with a nonaffective, non-organic psychotic disorder were evaluated using the Positive and Negative Symptoms Scale, the Clinical Global Impression Scale, Mini-Mental State Examination and the Beck’s Depression Inventory.
Results Of the 64 subjects recruited, 55 were enrolled in the study. 59.3% (n = 32) of the subjects were diagnosed to be suffering from very-late-onset schizophrenia-like psychosis, followed by delusional disorder in 31.5% (n = 17). The remaining 11.1% (n = 6) were diagnosed to have late-onset schizophrenia. The sample showed a high preponderance of women, with 88.9% reporting persecutory-type delusions. The majority of them were married and 80% of the subjects were living with relatives. Treatment was effective in ameliorating symptoms, but there was a high loss to follow-up of male subjects (81.8%).
Conclusion This descriptive study found sociodemographic and phenomenological similarities to other studies of late-onset psychosis in the West, except that social isolation and partition delusions were not prominent.

Keywords: late onset, psychopathology, schizophrenia
Singapore Med J 2012; 53(7):463–467

Feng L, Chong MS, Lim WS, Ng TP
Correspondence: A/Prof Ng Tze Pin, pcmngtp@nus.edu.sg

ABSTRACT
Introduction This study aimed to determine the stratified normative data by age and education for a modified version of the Mini-Mental State Examination (MMSE) test from a large sample of community-dwelling Chinese older adults in Singapore, and to examine the MMSE’s value in detecting early cognitive impairment.
Methods We studied 1,763 Chinese older adults with normal cognitive function and 121 Chinese older adults with early cognitive impairment (Clinical Dementia Rating global score 0.5). Normative MMSE values were derived for each of the 15 strata classified by age (three groups) and education level (five groups). Receiver operating characteristic curve analysis was conducted for the whole sample and each of the three education subgroups (no education, primary, secondary and above).
Results Education level and age significantly influenced the normative values of MMSE total scores in Chinese older adults with normal cognitive function. For the purpose of detecting early cognitive impairment, an optimal balance between sensitivity (Se) and specificity (Sp) was obtained at a cutoff score of 25, 27 and 29 for each of the three education groups, respectively. For the whole sample, the optimal cutoff point was 26 (Se 0.61, Sp 0.84, area under curve 0.78).
Conclusion Age and education level must be taken into account in the interpretation of optimal cutoffs for the MMSE. Although widely used, the MMSE has limited value in detecting early cognitive impairment; tests with better performance should be considered in clinical practice.

Keywords: cognitive impairment, dementia, Mini-Mental State Examination, sensitivity and specificity
Singapore Med J 2012; 53(7):458–462

Ngo H, Shin JY, Nhan NV, Yang LH
Correspondence: Dr Lawrence H Yang, lhy2001@columbia.edu

ABSTRACT
Introduction Intellectual disabilities are as prevalent in East Asian countries as in the West (0.06%–1.3%). Widespread discrimination against intellectual disabilities in Asia may initiate stigma that places unfair restrictions on the social life of these individuals and their caregivers. We utilised established stigma frameworks to assess the extent to which a child’s intellectual disability contributes to the social exclusion of caregivers in Vietnam.
Methods A mixed quantitative and qualitative approach was employed to examine the experience of social life restriction among parents of children with intellectual disabilities. The child’s disability level and restrictions on caregivers’ social experiences were assessed among 70 mothers and fathers recruited from schools in Hue City, Vietnam. Qualitative responses describing social exclusion were also recorded.
Results Caregivers reported elevated levels of social exclusion. As hypothesised, parents of children with greater intellectual disability experienced more restrictions on their social life (Beta = 0.79, 95% confidence interval 0.27–1.30, standard error = 0.26, p < 0.01). Qualitative analyses indicated that the threatening of core cultural norms (inability to be employed or married upsets community harmony) initiated labelling, social exclusion and efforts to keep the condition secret or withdraw from others.
Conclusion This study is among the first to demonstrate the impacts of intellectual disabilities on caregivers’ social  functioning in Asia. The findings illustrate how traditional Asian norms initiate stigma, which in turn restricts key social interactions among caregivers. Psycho-educational interventions may address the social domains in which caregivers are impacted and encourage sustained help-seeking among caregivers for their children.

Keywords: Asia, culture, disability, family, stigma
Singapore Med J 2012; 53(7):451–457