Current situation, future vision and enablers of nursing home oral healthcare in Singapore: Dentists' perspectives

OBJECTIVES

To address the following research questions: (i) What is the current situation and future vision on oral healthcare service in nursing homes (NHs) in Singapore? (ii) What are the enablers to achieve the future vision? (iii) How do views differ between dentists with and without clinical experiences in NHs?

BACKGROUND

Oral healthcare services in NHs need to reflect the perspectives of a diverse range of stakeholders and establish shared goals, however there is scarce evidence of in-depth dentists' insights.

MATERIAL AND METHODS

Dentists were purposively recruited. Focus group discussions with 4-5 participants each were conducted via teleconferencing. Data were analysed thematically.

RESULTS

The participants (n = 19, median 36.0 years) recognised the need of comprehensive reform of the oral healthcare paradigm in NHs: symptomatic care to preventive care, disease-oriented care to person-centred care and more active collaborative care. Overall, five domains of enabling factors emerged: (1) to improve general system of oral healthcare in NHs, (2) to increase the number of dentists engaging in NHs, (3) to improve the quality of dental practice, (4) to improve the quality of daily oral care and (5) to promote seniors' cooperative attitude to oral healthcare. There was a noticeable difference in the perception on how to encourage dentists to serve in NHs.

CONCLUSION

There is a need for a comprehensive reform of the oral healthcare paradigm for seniors in NHs in Singapore. A multi-tiered strategy using both top-down and bottom-up approaches is required.

Dentists' perspectives on structural and system barriers hindering oral healthcare provision in residential care facilities

OBJECTIVES

Oral healthcare service is not well integrated with existing healthcare policy in nursing homes (NHs) globally. This qualitative study aimed to identify dentists' perspectives on structural and system barriers that hinder oral healthcare (OHC) provision to seniors in NHs in Singapore and to understand the consequences of these barriers.

METHODS

Nineteen dentists (8 males and 11 females, 36.0 [IQR: 32.0-48.5] years old) were recruited through combination of purposive and snowball sampling. Four focus group discussions were conducted via teleconferencing, and each discussion had 4-5 anonymised participants. Sessions lasted 90-120 min and were audio-recorded and transcribed verbatim. Thematic analysis was conducted on data collected using NVivo software (Version12, QRS International).

RESULTS

Participants agreed that the current OHC system for seniors in NHs is not well developed. The challenges dentists faced were categorised in three themes: [1] general oral healthcare system level; [2] local nursing home setting level; and [3] geriatric oral healthcare education level. These challenges are complexly intertwined and have contributed to several consequences such as a shortage of dentists in NHs and their diminished motivation to serve. It has also limited the quality of dental service they are able to provide in NHs, contributing to the current poor access of dental services for seniors in NHs.

CONCLUSIONS

Dentists in Singapore face many structural and systemic barriers in providing OHC to seniors in NHs, some of which are unique to the local context. Newfound understanding of these barriers and its consequences will be helpful in developing strategic approaches to overcome these challenges.

Perception of nurses applying silver diamine fluoride to children's teeth: A mixed methods study

BACKGROUND

No studies have evaluated the unique potential of nurse-led silver diamine fluoride (SDF) application for children to bridge the gap in interprofessional collaboration.

AIM

To investigate the attitudes, beliefs and perceptions of nurses regarding nurse-led SDF application at the well-child visit and identify possible barriers and make recommendations.

DESIGN

Mixed methods design involving a questionnaire and semi-structured individual interviews were conducted.

RESULTS

All eligible nurses (n = 110) completed the questionnaire, and 16 were interviewed. Questionnaire responses highlighted that nurses were not confident in providing oral health services (score: <3 of 5) beyond oral hygiene advice (score: ≥3.9 of 5) but believed that they should be providing these services for individuals with difficulty accessing care. Interviews reflected that most nurses viewed oral health care as an important part of paediatric health but were limited by knowledge, time and manpower. Most were willing to expand their job scope to include SDF application with formal education and training, competency assessments and approaches to counter time limitations.

CONCLUSION

Where nurses are already providing basic oral healthcare, nurse-led SDF application could be the next step. Findings suggest that systemic changes should include strategies to empower and motivate nurses to apply SDF at the well-child visit.

A customized table-top aging simulation exercise to augment gerodontology teaching

While aging simulation suits have been used in healthcare education to promote empathy for older adults, little has been published on learning outcomes specific to geriatric dental patients. We designed a seminar utilising a customised ageing simulation suit to help dental students empathise with several disabilties their older adult patients may face.

Development of a dental diet-tracking mobile app for improved caries-related dietary behaviours: Key features and pilot evaluation of quality

Objective

Diet significantly contributes to dental decay (caries) yet monitoring and modifying patients' diets is a challenge for many dental practitioners. While many oral health and diet-tracking mHealth apps are available, few focus on the dietary risk factors for caries. This study aims to present the development and key features of a dental-specific mobile app for diet monitoring and dietary behaviour change to prevent caries, and pilot data from initial user evaluation.

Methods

A mobile app incorporating a novel photo recognition algorithm and a localised database of 208,718 images for food item identification was developed. The design and development process were iterative and incorporated several behaviour change techniques commonly used in mHealth. Pilot evaluation of app quality was assessed using the end-user version of the Mobile Application Rating Scale (uMARS).

Results

User feedback from the beta-testing of the prototype app spurred the improvement of the photo recognition algorithm and addition of more user-centric features. Other key features of the final app include real-time prompts to drive actionable behaviour change, goal setting, comprehensive oral health education modules, and visual metrics for caries-related dietary factors (sugar intake, meal frequency, etc.). The final app scored an overall mean (standard deviation) of 3.6 (0.5) out of 5 on the uMARS scale.

Conclusion

We developed a novel diet-tracking mobile app tailored for oral health, addressing a gap in the mHealth landscape. Pilot user evaluations indicated good app quality, suggesting its potential as a useful clinical tool for dentists and empowering patients for self-monitoring and behavioural management.

Ventilating my thoughts on severe asthma exacerbations

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Functional Dentition, Chronic Periodontal Disease and Frailty in Older Adults-A Narrative Review

BACKGROUND

The likelihood of experiencing the impact of chronic disease rises with age, and cumulative functional deficits over time increase the risk of frailty in older adults. The exact causes of frailty are not clear, and research is needed to identify appropriate intervention measures to reduce risk of developing frailty in old age.

OBJECTIVE

To review the evidence on the relationship between frailty, dental status and chronic periodontitis and to determine if improvements in oral health of older adults can contribute to reversal of frailty.

RESULTS

The oral cavity is the entry point to the gastro-intestinal tract, and natural teeth facilitate efficient mastication of food prior to swallowing and subsequent digestion. The loss of natural teeth, which is gradual and cumulative over the life course, is associated with diminished nutritional intake, especially in older adults. Furthermore, chronic periodontitis has been postulated as a risk factor for frailty. The evidence supporting a strong relationship between oral health status and frailty is not clearcut. Cross sectional studies suggest an association with missing teeth and chronic periodontal inflammation. However, there are very few longitudinal studies and accordingly, it is not currently possible to claim a causal relationship. As yet, there is no evidence to suggest that improvements in oral health contribute to reversal of frailty.

CONCLUSION

Longitudinal studies with robust designs are required to better inform the relationship across functional dentition, chronic periodontitis and frailty in older adults.

Theory-derived intervention to improve oral health of older adults: study protocol for a randomised controlled trial

INTRODUCTION

Changing health behaviours is an important and difficult task. Despite growing interest in behavioural theories and models, there is a paucity of research examining their validity in explaining oral health behaviours, and there is a need for interventional studies to assess their effectiveness in improving oral health. This study aims to test the explanatory power of the dominant psychological theories, develop theory-derived intervention and evaluate its effectiveness in improving oral health of older adults.

METHODS AND ANALYSIS

440 community dwelling older adults will be recruited. To be eligible for this trial, one needs to be 55-79 years old, having at least 8 natural teeth, and with no life-threatening disease, impaired cognitive function, or radiotherapy in the head and neck region. At the initial visit, each participant will be required to complete a detailed questionnaire which collects information on sociodemographic background, oral health behaviours and domains of three psychological theories and models: (1) health belief model, (2) theory of planned behaviour and (3) social cognitive theory. The theory or model that best explains the health behaviours will be selected for designing the oral health intervention. The effectiveness of the theory-derived intervention will be evaluated in a randomised controlled trial. Participants will be randomly assigned to two groups, receiving theory-derived intervention and conventional health education, respectively. At baseline and at 12 and 24 months post intervention, each participant will complete a short questionnaire and undergo an oral examination (dental check-up). The effectiveness of the interventions will be evaluated using behavioural outcomes (diet, toothbrushing, interdental cleaning) and clinical outcomes (oral hygiene, dental caries and periodontal conditions).

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of National University of Singapore (Ref: NUS-IRB-2020-417). Findings will be presented in international conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04946292.

Periodontal disease and systemic health: An update for medical practitioners

INTRODUCTION

Chronic periodontal disease is a highly prevalent dental condition affecting tooth-supporting tissues. Scientific evidence is accumulating on links between periodontal disease and various systemic conditions. This narrative review provides a holistic yet succinct overview that would assist medical practitioners to deliver integrated care for better clinical outcomes.

METHOD

Scientific evidence on associations between periodontal disease and systemic conditions was synthesised and critically appraised. Key findings of latest prospective cohort studies, randomised clinical trials, and meta-analysis were closely assessed and compiled.

RESULTS

A bidirectional relationship has been established, indicating that diabetes and periodontal disease are closely linked and amplify one another, if not successfully controlled. Existing evidence also supports the associations of periodontal disease with cardiovascular diseases and adverse pregnancy outcomes. Successful treatment of periodontal disease and dental prophylaxis has been shown to improve clinical outcomes in these systemic conditions. Other systemic conditions associated with periodontal disease include respiratory diseases, Alzheimer's disease, rheumatoid arthritis and chronic kidney disease. Although the underlying mechanisms remain to be fully elucidated, it is generally accepted that the inflammatory burden of chronic periodontal disease has an important systemic impact.

CONCLUSION

Oral-systemic links are multifaceted and complex. While evidence linking periodontal disease with a variety of systemic conditions is still emerging, the nature of the relationship is becoming clearer. The updated understanding of these associations warrants the attention of medical experts and policymakers for a concerted effort to develop a patient-centric, integrated model for the treatment of comorbid dental and medical conditions.

When e-learning takes centre stage amid COVID-19: Dental educators' perspectives and their future impacts

INTRODUCTION

The COVID-19 pandemic has necessitated an unprecedented shift from face-to-face teaching to e-learning. Previous surveys revealed the negative impact of COVID-19 on dental education and the physical and psychological well-being of dental students. This qualitative study aimed to investigate the perspectives of dental educators towards e-learning during the pandemic and the impact of this experience on their future adoption of e-learning.

MATERIALS AND METHODS

Semi-structured interviews with dental educators from the National University of Singapore were conducted over Zoom. Audio recordings were transcribed verbatim and subjected to thematic analysis. Data saturation was reached. Consolidated criteria for reporting qualitative research (COREQ) was followed.

RESULTS

Fifteen out of 22 (68%) eligible dental educators were interviewed. Educators had minimal prior e-learning experience. They encountered difficulties in engaging students, assessing students' understanding and adapting their teaching. A practical challenge was to ensure the well-rounded training of competent dentists with adequate patient-interaction skills through e-learning. Self-motivation of the audience, class size, type of teaching and complexity of the material were perceived as factors influencing the suitability of the e-learning format. Educators reported an increased confidence after this emergency e-learning experience. Some considered sustaining or expanding e-learning in their future teaching practice and highlighted the need for continued investment and institutional support, training on the pedagogy of e-learning modalities and curriculum redesign to accommodate blended learning approaches.

CONCLUSIONS

Although the shift to e-learning during the COVID-19 pandemic presented a myriad of challenges, dental educators gained experience and confidence which may accelerate the pace of future e-learning adoption and innovation.

A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2

SUMMARY

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death.

RECOMMENDATIONS

Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.

Teaching pediatric behavior management in student dentists with constructive video feedback from faculty

PURPOSE

The range of child behaviors encountered in real-life situations far exceeds that of any classroom-based simulated scenarios. For such reasons, clinical training with real-time clinical supervisor's feedback is optimal for learner-centricity. This study aimed to objectively evaluate the effect of video feedback on the student dentist's ability to manage behaviors in children.

METHODS

Third-year dental student volunteers were randomly allocated to two groups: control and intervention. They were video recorded for three pediatric dental treatment sessions and received standard feedback for all sessions. Additionally, the intervention group received two constructive 1-on-1 feedback sessions after the first and second video sessions. Students' application of behavior management techniques for all recorded treatment sessions was scored with a study-specific objective scale (maximum score: 20; larger score indicating better performance) by two independent and blinded evaluators. A self-administered student questionnaire elicited subjective feedback on the intervention.

RESULTS

There was a significant difference (p = 0.008) between behavior management scores when comparing all pre-intervention sessions (10.74 ± 3.55) and all post-intervention sessions (13.57 ± 2.96). The intervention significantly improved these techniques: 1. Providing specific feedback - positive reinforcement and descriptive praise (p = 0.006) and 2. Distraction - Using imagination with stories and singing (p = 0.035). The feedback sessions (4.29 ± 0.54) were perceived to be significantly (p = 0.032) more effective than having the students view the videos on their own (3.76 ± 0.87).

CONCLUSION

Video feedback improved the behavior management scores of student dentists. The faculty feedback sessions were found by student dentists to improve confidence and the techniques for managing children.

Parental perspectives towards sugar-sweetened beverages and polices: a qualitative study

PURPOSE

This qualitative study aimed to understand parental perception of (1) sugar-sweetened beverages (SSB) and implications of SSB on health; (2) their role in shaping their children's consumption of SSB; (3) the influences on SSB consumption of their children; and (4) potential government policies targeted at controlling SSB consumption.

METHODS

English-speaking parents of pre-schoolers aged 2-6 years were recruited. Semi-structured interviews based on the knowledge, attitude, practice framework were conducted, and transcripts were subjected to thematic analysis based on inductive approaches. Recruitment continued until data saturation was reached.

RESULTS

Twenty parents participated in the study and themes addressing the objectives identified. (1) There were misconceptions regarding the healthfulness of certain non-packaged SSB such as traditional remedies and juices. Some were unaware about the association between SSB and dental caries. (2) The need to reduce and restrict sugar consumption for overall and oral health reasons was well-recognised, but the extent of control varied. (3) Multiple stakeholders including pre-schools, grandparents and domestic helpers were involved in shaping children's diet. Children's sugar intake was also influenced by environmental factors, such as the ubiquitously available SSB, targeted marketing and high cost of healthy alternatives. (4) Participants were less accepting towards SSB taxation than the ban of SSB sales.

CONCLUSION

Despite the awareness of the types of SSBs and the general/oral health implications of sugar consumption, misconceptions exist. Although most parents possessed the knowledge and attitude, this did not translate into the practice of reducing sugar consumption in their children. There was no SSB reduction policy that had overwhelming acceptability.

Quantitative proteomics analysis identifies salivary biomarkers for early detection of pregnancy loss in a Singaporean cohort-A pilot study

PURPOSE

Early pregnancy loss (EPL) is one of the most common complications encountered in clinical practice. As most of EPLs occur relatively early on during pregnancy, they are often misunderstood as an expected menstrual cycle. Thus, it is essential to investigate the diagnostic biomarkers for monitoring pregnancy loss for continuous non-invasive monitoring of EPL.

EXPERIMENTAL DESIGN

Unstimulated saliva was collected from 10 subjects with EPL and a matched cohort of healthy pregnant women as controls. Samples were analyzed using iTRAQ analysis, and ELISA was performed to validate results.

RESULTS

Enrichment analysis of the 38 differentially abundant proteins identified that regulation of nucleobase, nucleoside, nucleotide, and nucleic acid metabolism was significantly affected in EPL. The nucleosome assembly pathway was significantly underrepresented in EPL and was associated with depletion of histone proteins (H2B, H3, and H4). These results were validated with ELISA experiments. A depletion of histones can impair nucleosome assembly and cause the nuclear machinery to fail.

CONCLUSION

Regulation of nucleosome is critical for the maintenance of genome stability and epigenetic information, lack of which may lead to pregnancy loss. Thus, assessing and monitoring salivary histone levels in patients with threatened miscarriage can be a quick and easy method of obtaining periodic diagnostic information that can speed up treatment decisions.

CLINICAL RELEVANCE

There is considerable uncertainty regarding the prognosis of threatened pregnancy, making it stressful for expecting mothers and healthcare professionals. Most EPLs are often misunderstood or ignored as an expected menstrual cycle. Thus it is essential to develop screenings and rapid detection devices using a medium that can be non-invasive and self-performed for continuous monitoring. Using saliva, we have identified that the nucleosome assembly gets affected in EPL with depletion of histone proteins (H2B, H3, and H4). With further verification, these findings can help saliva be utilized as a medium to determine which patients will/will not progress to miscarriage and at what point of their pregnancy. Assessing and monitoring EPL using salivary diagnostics can be a quick and easy method of obtaining periodic diagnostic information that can speed up treatment decisions. Hence, these findings need to be investigated further to improve the prediction of outcomes in women with threatened pregnancy.

Salivary Proteomic Profiling Identifies Role of Neutrophil Extracellular Traps Formation in Pregnancy Gingivitis

Pregnancy gingivitis peaks during mid-pregnancy and resolves transiently towards the postpartum period. However, the role of maternal immune response in orchestrating gingival inflammation has not yet been fully understood. Hence, in this study, we examined the salivary protein profile during the three trimesters of pregnancy, in context to pregnancy gingivitis, employing iTRAQ-based quantitative proteomics. Unstimulated saliva was collected from 10 subjects in each trimester of pregnancy and postpartum period. Samples were analysed using iTRAQ analysis and ELISA and SEM was performed to validate results. Neutrophil mediated immune response was overrepresented in all three trimesters of pregnancy, despite the decrease in phagocytic responses during the second and third trimesters. ELISA showed a significantly higher Neutrophil Extracellular Traps (NETs) formation in the third trimester of pregnancy coinciding with the resolution of pregnancy gingivitis. The NETs-associated proteins (neutrophil elastase and myeloperoxidase) showed a positive correlation with estrogen hormones, which was also highest during the third trimester. Sex hormone-driven NETs formation could be the mainstay of defence that contributes to the remission of pregnancy gingivitis. This study has provided a new insight into the role of immune-modulation in pregnancy gingivitis, which will aid development of new therapeutics for managing pregnancy gingivitis in future.

Correlation between microbial host factors and caries among older adults

Background

There is little knowledge about factors which may affect oral health among older adults. The objective of this study was to determine the relationship between Streptococcus mutans (MS) and Lactobacilli (LB) counts and caries among older adults.

Methods

In this community-based observation study, 141 participants aged 60 years and above were recruited from the west district of Singapore. Alongside the clinical examination, saliva samples were collected to determine Streptococcus mutans (MS) and Lactobacilli (LB) counts, as well as to record salivary flow rate and buffering capacity of saliva.

Results

Of the 141 participants, 63.8% were female and 94.3% were of Chinese ethnicity. The mean DMFT was 11.08 (s.d. 8.27). 9.9% of participants had at least one decayed tooth, 52.5% had minimum one missing tooth and 86.5% had at least one filled tooth. 67.4% had MS counts of ≥ 10⁵ while LB counts were ≥ 10⁵ for 48.2%. 83.7% had normal salivary flow or hypersalivation (> = 1 mL/min), the buffering capacity of the saliva was alkaline in 61% of the participants. Multivariate analysis showed that participants who had high MS counts were less likely to have a DMFT < 12 [OR (95% CI), 0.29 (0.11–0.77)] whereas participants who had high LB counts were less likely to have a DMFT ≤ 14 [OR (95% CI), 0.45 (0.20–1.002)].

Conclusion

Our study showed a positive correlation between MS and LB counts and caries experience in older adults. The mean DMFT was on the low side in our sample despite having a relatively high MS count. This suggests that there are many other factors which vary according to host environment, physiological and biological conditions that may affect MS and LB counts in the oral cavity.

Clinical relevance

Our study supports the knowledge that the aetiology of dental caries among older adults is a complex process and it would be wrong to consider caries as a same problem with the same solution for all age groups.

Subgingival Microbiota during Healthy Pregnancy and Pregnancy Gingivitis

INTRODUCTION

Previous studies have largely explored the microbial composition and pathogenesis of pregnancy gingivitis. However, the patterns of microbial colonization during pregnancy in the absence of pregnancy gingivitis have rarely been studied. Characterization of the oral microbiome in pregnant women with healthy gingiva is an important initial step in understanding the role of the microbiome in progression to pregnancy gingivitis.

OBJECTIVES

In this study, we compared the oral microbiome of pregnant women without gingivitis (healthy pregnancy) with pregnant women having gingivitis and nonpregnant healthy women to understand how pregnancy modifies the oral microbiome and induces progression to pregnancy gingivitis.

METHODS

Subgingival plaque samples were collected from Chinese pregnant women with gingivitis (n = 10), healthy pregnant women (n = 10), and nonpregnant healthy women (n = 10). The Illumina MiSeq platform was used to perform 16S rRNA gene sequencing targeting the V4 region.

RESULTS

The alpha and beta diversity was significantly different between pregnant and nonpregnant women, but minimal differences were observed between pregnant women with and without gingivitis. Interestingly, the oral bacterial community showed higher abundance of pathogenic taxa during healthy pregnancy as compared with nonpregnant women despite similar gingival and plaque index scores. However, when compared with overt pregnancy gingivitis, pathogenic taxa were less abundant during healthy pregnancy. PICRUSt analysis (phylogenetic investigation of communities by reconstruction of unobserved states) also suggested no difference in the functional capabilities of the microbiome during pregnancy, irrespective of gingival disease status. However, metabolic pathways related to amino acid metabolism were significantly increased in healthy pregnant women as compared with nonpregnant women.

CONCLUSION

The presence of pathogenic taxa in healthy pregnancy and pregnancy gingivitis suggests that bacteria may be necessary for initiating disease development but progression to gingivitis may be influenced by the host environmental factors. More efforts are required to plan interventions aimed at sustaining health before the appearance of overt gingivitis.

KNOWLEDGE TRANSFER STATEMENT

The results of this study draw attention to the importance of oral health maintenance during pregnancy, as women without any prenatal oral conditions are predisposed to the risk of developing pregnancy gingivitis. Hence, it is important to incorporate comprehensive assessment of oral health in the prenatal health care schedules. Pregnant woman should be screened for oral risks, counseled on proper oral hygiene and expected oral changes, and referred for dental treatment, when necessary.

Factors affecting dental service utilisation among older Singaporeans eligible for subsidized dental care - a qualitative study

Background

The World Health Organization has highlighted the paucity of research into the oral health needs of older adults. In Singapore, until recently, publically funded/subsidized oral health care for adults has been limited to basic primary care at government-funded polyclinics. Access to a more comprehensive range of subsidized care in the private sector was widened through the government-funded Community Health Assistance Scheme (CHAS) in 2012 and Pioneer Generation (PG) scheme in 2015. Little is known about the attitude to dental service utilization among older adults in Singapore since then.

Methods

We conducted semi-structured individual interviews with 25 participants above 65 years of age who were eligible for subsidized dental care plans. Participants were recruited from a public teaching hospital and a public primary care clinic in Singapore. The duration of each interview was 15–30 min. Interviews were transcribed verbatim and the transcripts were analyzed thematically using a phenomenological approach.

Results

Pertinent themes emerged related to four major areas: (a) general awareness towards oral health, (b) life course perspective of oral health, (c) barriers to visit the dentist, (d) shaping dental service utilisation behaviours through provision of financial subsidies for dental care. Most participants perceived a strong relationship between oral health and systemic health. However, there were erroneous traditional beliefs such as oral health is not part of physical health and edentulous participants did not need to visit a dentist. Fear, anxiety, previous negative experience and lack of knowledge were barriers to visiting the dentist. Trust and convenience were considerations for patients when deciding whether to switch from public to private dental services where CHAS/PG were only available.

Conclusion

Our study provided important insights regarding oral health perceptions and beliefs of older people residing in the community which may affect their dental service utilization. This further highlights the importance of understanding the concerns of this group when implementing healthcare policies for elderly in Singapore. The findings of our study will serve as a baseline for future studies in Singapore and inform studies in other countries that implement targeted schemes for older adults.

Managing tooth pain in general practice

Tooth pain is a common presentation in primary care, with 32.4% of Singaporeans experiencing pain from dental caries in their lifetime. Some systemic conditions can have oral presentations, and oral conditions may be associated with chronic disease. A good history and examination is key in delineating odontogenic from non-odontogenic causes of tooth pain. Primary care physicians should accurately diagnose and assess common dental conditions and make appropriate referrals to the dentist. Common non-odontogenic causes of orofacial pain can be mostly managed in primary care, but important diagnoses such as acute coronary syndrome, peritonsillar abscess and temporal arteritis must not be missed. Ibuprofen has been shown to be effacious, safe and cost-effective in managing odontogenic pain. Antibiotics are indicated when there is systemic or local spread of dental infection. Without evidence of spread, antibiotics have not been shown to reduce pain or prevent subsequent dental infections.

Oral Health in Pregnant Chinese Women in Singapore: A Call to Go beyond the Traditional Clinical Care

Objective: To examine the correlations among oral health knowledge, attitude, practices and oral disease among pregnant Chinese women in Singapore. Methods: A descriptive correlational study was conducted in pregnant Chinese women in Singapore. A questionnaire was used to collect data of oral health knowledge, attitude and practices. Plaque index scores were used to assess the oral health of subjects. Results: A total of 82 pregnant women participated in the study, out of whom 38% showed adequate oral health knowledge, nearly half of them achieved adequate and oral health attitude and practice scores while 34% had good Plaque index scores. The lower income group had higher experience of self-reported dental problems during pregnancy than those in the higher income group (p = 0.03). There were significant positive correlations between scores of oral health practice, attitude and oral health knowledge levels. The plaque index scores negatively correlated with the oral health practice scores (p = 0.02). Conclusions: Our findings provided evidence that oral health knowledge, attitude and practices among Chinese pregnant women were not optimal which implies the importance of promoting their oral health during pregnancy through the improvement of knowledge and attitudes. This would facilitate formulation and implementation of appropriate oral health promotion policies.

APOE*E2 allele delays age of onset in PSEN1 E280A Alzheimer's disease

Alzheimer's disease (AD) age of onset (ADAOO) varies greatly between individuals, with unique causal mutations suggesting the role of modifying genetic and environmental interactions. We analyzed ~50 000 common and rare functional genomic variants from 71 individuals of the 'Paisa' pedigree, the world's largest pedigree segregating a severe form of early-onset AD, who were affected carriers of the fully penetrant E280A mutation in the presenilin-1 (PSEN1) gene. Affected carriers with ages at the extremes of the ADAOO distribution (30s-70s age range), and linear mixed-effects models were used to build single-locus regression models outlining the ADAOO. We identified the rs7412 (APOE*E2 allele) as a whole exome-wide ADAOO modifier that delays ADAOO by ~12 years (β=11.74, 95% confidence interval (CI): 8.07-15.41, P=6.31 × 10(-8), PFDR=2.48 × 10(-3)). Subsequently, to evaluate comprehensively the APOE (apolipoprotein E) haplotype variants (E1/E2/E3/E4), the markers rs7412 and rs429358 were genotyped in 93 AD affected carriers of the E280A mutation. We found that the APOE*E2 allele, and not APOE*E4, modifies ADAOO in carriers of the E280A mutation (β=8.24, 95% CI: 4.45-12.01, P=3.84 × 10(-5)). Exploratory linear mixed-effects multilocus analysis suggested that other functional variants harbored in genes involved in cell proliferation, protein degradation, apoptotic and immune dysregulation processes (i.e., GPR20, TRIM22, FCRL5, AOAH, PINLYP, IFI16, RC3H1 and DFNA5) might interact with the APOE*E2 allele. Interestingly, suggestive evidence as an ADAOO modifier was found for one of these variants (GPR20) in a set of patients with sporadic AD from the Paisa genetic isolate. This is the first study demonstrating that the APOE*E2 allele modifies the natural history of AD typified by the age of onset in E280A mutation carriers. To the best of our knowledge, this is the largest analyzed sample of patients with a unique mutation sharing uniform environment. Formal replication of our results in other populations and in other forms of AD will be crucial for prediction, follow-up and presumably developing new therapeutic strategies for patients either at risk or affected by AD.

Can MRI replace CT in evaluating semicircular canal dehiscence?

BACKGROUND AND PURPOSE

Patients with symptoms of semicircular canal dehiscence often undergo both CT and MR imaging. We assessed whether FIESTA can replace temporal bone CT in evaluating patients for SC dehiscence.

MATERIALS AND METHODS

We retrospectively reviewed 112 consecutive patients (224 ears) with vestibulocochlear symptoms who underwent concurrent MR imaging and CT of the temporal bones between 2007 and 2009. MR imaging protocol included a FIESTA sequence covering the temporal bone (axial 0.8-mm section thickness, 0.4-mm spacing, coronal/oblique reformations; 41 patients at 1.5T, 71 patients at 3T). CT was performed on a 64-row multidetector row scanner (0.625-mm axial acquisition, with coronal/oblique reformations). Both ears of each patient were evaluated for dehiscence of the superior and posterior semicircular canals in consensual fashion by 2 neuroradiologists. Analysis of the FIESTA sequence and reformations was performed first for the MR imaging evaluation. CT evaluation was performed at least 2 weeks after the MR imaging review, resulting in a blinded comparison of CT with MR imaging. CT was used as the reference standard to evaluate the MR imaging results.

RESULTS

For SSC dehiscence, MR imaging sensitivity was 100%, specificity was 96.5%, positive predictive value was 61.1%, and negative predictive value was 100% in comparison with CT. For PSC dehiscence, MR imaging sensitivity was 100%, specificity was 99.1%, positive predictive value was 33.3%, and negative predictive value was 100% in comparison with CT.

CONCLUSIONS

MR imaging, with a sensitivity and negative predictive value of 100%, conclusively excludes SSC or PSC dehiscence. Negative findings on MR imaging preclude the need for CT to detect SC dehiscence. Only patients with positive findings on MR imaging should undergo CT evaluation.

Theory and action for effective condom promotion: illustrations from a behavior intervention project for sex workers in singapore

Acquired immunodeficiency virus (AIDS) and sexually transmitted diseases (STD) control programs targeted at sex workers have focused on condom use. Reasons for non-condom use among female brothel-based sex workers in Singapore were found to be low self-efficacy, lack of condom negotiation skills, and barriers such as fear of annoying clients. Green's PRECEDE framework and Bandura's self-efficacy theory were applied to develop a project aimed at equipping sex workers with negotiation skills, overcoming barriers to condom use, and gathering support from brothel keepers and peers. The experimental group showed significant improvements in negotiation skills and outcome behavior of always refusing sex without a condom, that were supported by a decline in gonorrhea incidence. This article describes the application of behavior change and health education theories to achieve reduction in gonorrhea risk.

Do Parents Talk to Their Adolescent Children about Sex?—Findings from a Community Survey in Singapore

Introduction: Sexually transmitted infections have increased sharply among adolescents both locally and internationally in recent years. Parents play an important role in their children’s sexual health development. An integral part of this includes effective parent-child sexuality communication. Materials and Methods: A nationwide cross-sectional community-based household survey was conducted in Singapore between August 2008 and March 2009 to assess parents’/caregivers’ attitudes and practices regarding caregiver-child sexuality communication. With an overall response rate of 81.4%, 1169 questionnaires from parents/caregivers of children aged 10 to 17 years were analysed. Results: Almost all (94.2%) the caregivers were parents. A majority (>80%) of caregivers considered talking to their children about sexuality issues such as abstinence, consequences of premarital sex and condom use as important. However, a significantly lower percentage (about 60%) felt comfortable and confident doing so. Only 8.3% among them discussed sexual health issues with their children very often, 37.2% sometimes, 22.0% seldom/hardly ever (once or twice) and 32.5% never, in the past year. In the multivariate analysis, caregiver-child sexuality communication was significantly associated with caregivers’ relationship to children, ethnicity, educational level, and their perceived levels of comfort and confidence in sexuality communication. Conclusion: Caregivers generally felt it was important but were significantly much less comfortable and confident talking about sexuality issues with their children, which leads to a lower frequency of caregiver-child sexuality communication. Educational programmes on adolescent sexual health targeting parents/caregivers are needed. They must be equipped with skills and provided with resources to enable them to talk to their adolescent children about sexuality. Key words: Abstinence, Condom use, Confidence level, Importance, Parent-child sexuality communication

Do parents talk to their adolescent children about sex?--findings from a community survey in Singapore

INTRODUCTION

Sexually transmitted infections have increased sharply among adolescents both locally and internationally in recent years. Parents play an important role in their children's sexual health development. An integral part of this includes effective parent-child sexuality communication.

MATERIALS AND METHODS

A nationwide cross-sectional community-based household survey was conducted in Singapore between August 2008 and March 2009 to assess parents'/caregivers' attitudes and practices regarding caregiver-child sexuality communication. With an overall response rate of 81.4%, 1169 questionnaires from parents/caregivers of children aged 10 to 17 years were analysed.

RESULTS

Almost all (94.2%) the caregivers were parents. A majority (>80%) of caregivers considered talking to their children about sexuality issues such as abstinence, consequences of premarital sex and condom use as important. However, a significantly lower percentage (about 60%) felt comfortable and confident doing so. Only 8.3% among them discussed sexual health issues with their children very often, 37.2% sometimes, 22.0% seldom/hardly ever (once or twice) and 32.5% never, in the past year. In the multivariate analysis, caregiver-child sexuality communication was significantly associated with caregivers' relationship to children, ethnicity, educational level, and their perceived levels of comfort and confidence in sexuality communication.

CONCLUSION

Caregivers generally felt it was important but were significantly much less comfortable and confident talking about sexuality issues with their children, which leads to a lower frequency of caregiver-child sexuality communication. Educational programmes on adolescent sexual health targeting parents/caregivers are needed. They must be equipped with skills and provided with resources to enable them to talk to their adolescent children about sexuality.

Enzyme replacement therapy for mucopolysaccharidosis VI (Maroteaux-Lamy syndrome): experience in Hong Kong

Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome) is a very rare inherited lysosomal storage disease. We evaluated the efficacy and safety of weekly infusions of recombinant human arylsulfatase B as enzyme replacement therapy for two patients in whom this condition was advanced. The primary outcome variables were the distance walked in a 6-minute walk test, forced vital capacity, and ejection fraction. The secondary outcome variables were the number of stairs climbed in a 3-minute stair climbing test, joint mobility, urinary glycosaminoglycan excretion, auto-continuous positive airway pressure study and liver size. After 24 weeks of treatment, patient A walked 40 m (36%) and patient B walked 66 m (58%) more in the walk test than at baseline. After 48 weeks, in patient A the corresponding improvements were 142 m (129%) in the walk test and 33 stairs (60%) in the 3-minute stair climbing test, and in patient B the respective improvements were 198 m (174%) and 77 stairs (140%). There was a significant decline in urinary glycosaminoglycan excretion and improvement in range of motion of joints in both patients. The auto-continuous positive airway pressure study revealed improvements in patient A, while other efficacy variables remained static. There were no drug-related adverse events or allergic reactions reported during and after the infusions of recombinant human arylsulfatase B. Recombinant human arylsulfatase B significantly improves endurance and reduces urinary glycosaminoglycan excretion. The drug is generally safe and well tolerated.

A qualitative study on HPV vaccination from a nursing perspective in Hong Kong

OBJECTIVE

To identify the perception on human papillomavirus (HPV) vaccination among female nursing students in Hong Kong.

DATA SOURCES

Data were collected through focus group discussions and semi-structured in-depth interviews. All participants (n=28) were female nursing students of a university in Hong Kong. Tape recordings of individual interviews and focus group discussions were transcribed verbatim in Chinese, translated into English, and analyzed according to Colaizzi's phenomenological analysis.

STUDY DESIGN

Four major themes emerged from the data: nursing students' understanding about HPV vaccine, nursing students' attitude on HPV vaccine, nursing students' perspective on HPV vaccination promotion, and nursing role on HPV vaccination.

CONCLUSIONS

Government should take initiative in promotion with vaccine suppliers. The awareness and knowledge of HPV and HPV vaccination among women should be increased in order to raise the positive attitude of women towards HPV vaccination and prevention of cervical cancer. Health professionals should work together on HPV promotion among women and increase the HPV vaccination rates. Moreover, further studies regarding attitude and awareness of HPV vaccination among women in different age groups are needed in order to identify more associated factors affecting their perceptions towards HPV vaccination.

Brain-derived neurotrophic factor gene polymorphisms and mirtazapine responses in Koreans with major depression

Brain-derived neurotrophic factor (BDNF) is a candidate molecule for influencing the clinical response to antidepressant treatment. The aims of this study were to determine the relationship between the Val66Met polymorphism in the BDNF gene and the response to mirtazapine in 243 Korean subjects with major depressive disorder (MDD). The reduction in the Hamilton Depression score over the 8-week treatment period was not influenced by BDNF V66M genotypes. A marginal effect of genotype on somatic anxiety score was observed at baseline (P = 0.047 in the dominant model). However, genotype-time interaction had no effect on somatic anxiety score after the 8-week a treatment period. Plasma BDNF levels tended to increase during mirtazapine treatment, although without statistical significance (P = 0.055). After 8 weeks of mirtazapine treatment, plasma BDNF levels were higher in Met allele homozygotes (1499.7 ± 370.6 ng/mL) than in Val allele carriers (649.7 ± 158.5 ng/mL, P = 0.049). Our results do not support the hypothesis that the Val66Met promoter polymorphism in the BDNF gene influences the therapeutic response to mirtazapine in Korean MDD patients. However, our data indicate that this polymorphism results in increased plasma BDNF after mirtazapine treatment.

Is the worldwide epidemic of obesity a communicable feature of globalization?

Globalization has a major impact on both economic and social determinants in public health. The current worldwide epidemic in obesity needs to be considered in the context of globalization as a communicable rather than non-communicable process. There is increasing evidence that global trends in lifestyle, eating behavior and cultural adaptation contribute to the rapid increase in obesity around the world. Thus, obesity may be defined as a "socially-contagious" feature of globalization. Furthermore, infectious agents are being identified that may cause obesity by central mechanisms or by modulating adipocyte function or at least by contributing to the chronic inflammatory milieu of the metabolic syndrome. Therefore, globalization may indeed form a critical platform for these pathogens to fuel the obesity epidemic. Understanding obesity in the light of globalization as a communicable disorder will allow outlining better avenues of prevention and treatment.

Tuberculosis culture testing at a tertiary care hospital: options for improved management and use for treatment decisions

SETTING

Chris Hani Baragwanath Hospital, a tertiary care hospital in Johannesburg, South Africa.

OBJECTIVES

To determine the proportion of patients with positive Mycobacterium tuberculosis cultures and whether those who were positive were on treatment.

DESIGN

Tuberculosis (TB) culture results were obtained from the laboratory for a 3-month period. Positive results were checked against registrations at the hospital TB Care Centre (TBCC). The treatment status of non-registered patients was obtained from various records at the hospital, district clinics and from home visits.

RESULTS

Overall, 3909 patients had 5404 samples sent for culture. Of these, 708 patients (18%) had at least one positive culture. The positive yield from 2749 adult sputum samples was 33% and ranged from 6% to 40% for different extra-pulmonary specimens. Among 1160 children, the yield varied from 0% to 12%, with 12% in sputum and gastric washing specimens. Of the 708 culture-positive patients, 429 (61%) patients were registered at the TBCC and were known to have started TB treatment. Of the 279 subjects not registered (39% overall), 100 (36%) died. Only 67 of the 179 survivors were confirmed on treatment, 40 were not on treatment and 72 could not be traced.

CONCLUSIONS

Large numbers of TB culture tests were performed, some inappropriately. Study findings highlight inadequacies in the management of culture-confirmed TB at this hospital.

Framingham Risk Scores and Anthropometric Measurements in Predicting Cardiovascular Risks among Malay Men

Framingham Risk Scores is an established method to predict an individual's 10-year risk for coronary heart disease (CHD). It provides a more precise delineation of risk which might lead to appropriate selection of therapy and opportunities for patient education and motivation. A Healthy Lifestyle Project was initiated to decrease the modifiable risk factors for CHD in a worksite in Kuala Lumpur. The participants were Malay men (n=186) working as security guards in a public university. Their mean age was 46.6 + 6.6 years. The majority had secondary education and were married. The participants' 10-year risks based on the Framingham Risk Scores were 55.4%, 39.8% and 4.8% respectively for categories of low (< 10%), intermediate (10 to 20%) and high (>20%) risk. Their Framingham Risk Scores were then correlated with anthropometric measurements such as the Body Mass Index (BMI), waist circumference and waist-hip-ratio (WHR). All the anthropometric measurements had weak but significant correlation with the Framingham Risk Scores (WHR: r=0.26; waist circumference: r=0.23; BMI: r=0.16). In conclusion, 44.6% of our participants had more than 10% risk in developing CHD in the coming ten years. Hence, they are suitable target candidates for the promotion of a healthy lifestyle such as smoking cessation, weight control, healthy dietary patterns and increased physical activities. Indicators of abdominal obesity like WHR or waist circumference may be used to complement the Framingham Risk Scores for the prediction of CHD risk in this population.

Cryptococcal pneumonia in African miners at autopsy

SETTING

Deceased miners from South Africa whose cardiorespiratory organs were submitted for autopsy for compensation for occupational lung diseases from 1996 to 2000.

OBJECTIVES

To 1) calculate the prevalence of cryptococcal pneumonia in 8421 autopsied miners, a population with a high prevalence of human immunodeficiency virus (HIV) infection; 2) document the association of cryptococcal pneumonia with other pulmonary infection; 3) document the association of cryptococcal pneumonia with a clinical diagnosis of cryptococcal meningitis; and 4) determine the accuracy of the clinical diagnosis of cryptococcal pneumonia.

DESIGN

Case series of 589 black miners with histological evidence of cryptococcal pneumonia at autopsy, defined as the presence of cryptococcal organisms in the lung parenchyma, identified by staining of the mucinous capsule.

RESULTS

The incidence of cryptococcal pneumonia at autopsy was 7%. Ninety-seven of the 589 cases (16.5%) had a concomitant respiratory infection, most commonly Pneumocystis jirovecii pneumonia (51.5%), followed by mycobacterial infection (42.3%). In life, cryptococcal meningitis was diagnosed in 46.9% and cryptococcal pneumonia in only 2.7%.

CONCLUSION

Although tuberculosis remains the most common HIV-associated respiratory disease in Africa, it is important to consider the diagnosis of cryptococcal pneumonia in acquired immune-deficiency syndrome (AIDS) patients, and to bear in mind the possibility of dual pathology.

The dental awareness of nursing home staff in Singapore - a pilot study

OBJECTIVE

The aim of this pilot study was to assess the oral health knowledge among staff working in a local nursing home managed by a voluntary welfare organisation.

METHOD

A self-administered questionnaire was completed by 53 nursing staff working in a home with 270 residents. The questionnaire was structured to assess the staff's knowledge of dental caries, periodontal disease and the care and use of dentures.

RESULTS

99.6% of the respondents felt that oral health care of the elderly was very important. However, only 45.3% of them attributed the cause of dental caries to the frequent intake of sugar. Bacteria in dental plaque was identified by 88.7% of them as the main cause of periodontal disease while 96.2% of them indicated that dentures should be cleaned at least once a day and rinsed after every meal.

CONCLUSION

The staff of this nursing home demonstrated positive knowledge of periodontal disease and denture care. However, their knowledge of dental caries revealed substantial room for improvement. This could signal an area for future staff training and development. Such efforts would help establish a team of caregivers who can improve the oral health and quality of life for residents in the nursing home.

Fetal myocardial performance in pregnancies complicated by gestational impaired glucose tolerance

OBJECTIVE

To determine fetal myocardial performance in pregnancies complicated by mild gestational impaired glucose tolerance (GIGT).

METHODS

Ultrasound examinations were performed in 37 pregnant women with mild GIGT (36 did not require insulin) and in 44 controls at 18-24, 26-30 and 34-37 weeks of gestation. The thickness of the fetal ventricular walls and interventricular septum were measured by M-mode echocardiography. Using conventional Doppler echocardiography, the mitral and tricuspid early (E) and late (A) diastolic velocities and the ventricular myocardial performance index (MPI) were determined.

RESULTS

The fetuses of women with GIGT had a greater abdominal circumference (P = 0.02), a larger amniotic fluid index (P = 0.03), and a tendency to be heavier (P = 0.058) at the third scan. There were no significant differences in myocardial thickness, mitral and tricuspid E and A velocities, and E/A ratios between study and control groups. The left and right ventricular MPIs, while similar between the two groups in the first and second scans, had decreased significantly by late gestation in the GIGT fetuses (P for trend = 0.018 and 0.014, respectively) and were significantly lower than those of the control group (P = 0.002 and 0.0008, respectively).

CONCLUSIONS

Fetuses of women with mild GIGT lack the ventricular hypertrophy and diastolic dysfunction that is common in fetuses of diabetic mothers, and they have a decreased MPI late in gestation. Published by John Wiley & Sons, Ltd.

An epidemiological and knowledge, attitudes, beliefs and practices study of sexually transmitted infections in older men

INTRODUCTION

This study was conducted to determine the disease patterns of sexually transmitted infections (STI) in older men, as well as to gather information on their knowledge, attitudes, beliefs and sexual practices.

METHODS

A prospective study was carried out from January to June 2005 in men aged 50 years or older who attended the Department of STI Control clinic.

RESULTS

There were 104 men enrolled. The majority (92.3 percent) were Chinese, and 62.5 percent were aged between 50 and 59 years, 25.9 percent between 60 and 69 years, and 11.5 percent aged 70 years or older. The patients were predominantly heterosexual, and had fairly low levels of education--85.6 percent of the patients had received primary or secondary school level of education. Majority (79.8 percent) of the men had been sexually active in the preceding six months, and 37.3 percent had paid sex during that time. 29.8 percent of men reported having taken drugs such as sildenafil (Viagra, Pfizer, New York, NY, USA) or similar drugs such as vardenafil (Levitra, Bayer, Wuppertal, Germany) or tadalafil (Cialis, Eli Lilly, Indianapolis, IN, USA). 56.7 percent of the men had active infections, with non-gonococcal urethritis (15.4 percent), genital warts (12.5 percent) and gonorrhoea (10.6 percent) being the commonest. Generally, condom usage was accepted as an effective way to prevent transmission of STI. However, many of the men surveyed felt that condom usage reduced their sexual pleasure, and 38.5 percent felt that condoms were inconvenient. There were also areas of human immunodeficiency virus (HIV) knowledge that were lacking. Most patients listed the media as their main source of knowledge about STI and HIV.

CONCLUSION

Older males attending the clinic remain at significant risk of STI and targeted educational efforts are warranted.

Tuberculosis at Chris Hani Baragwanath Hospital: an intervention to improve patient referrals to district clinics

SETTING

A study in 2001 described the process of managing tuberculosis (TB) at Chris Hani Baragwanath hospital, the numbers of patients diagnosed and poor outcomes of referring patients to clinics in the adjacent sub-districts. The present study describes and evaluates an intervention to address the problems.

OBJECTIVES

To describe the intervention process (education and referral of TB patients) and the subsequent results over a 2-year period from 2003 to 2005.

METHODS

The process of establishing the system and how it was evaluated at district clinics in Johannesburg are described.

RESULTS

In the first 2 years of operation, August 2003 to July 2005, 13,138 patients were registered. Extra-pulmonary tuberculosis (EPTB) was diagnosed in 34%. Of the 46% tested for human immunodeficiency virus (HIV), 93% were positive. Successful referral to clinics was achieved for 94% of patients.

CONCLUSIONS

Very large numbers of patients are diagnosed with TB at Chris Hani Baragwanath Hospital. A TB care centre has successfully addressed important referral, education and registration requirements for the comprehensive management of TB with links to clinics. It is suggested that this model be applied at other hospitals.

Seroprevalence of HSV-1 and 2 among sex workers attending a sexually transmitted infection clinic in Singapore

We studied the seroprevalence of herpes simplex virus (HSV)-1 and 2 in sex workers attending a sexually transmitted infection clinic in Singapore and examined their knowledge and attitudes towards HSV infection. A total of 300 participants were recruited. Questionnaires were administered and blood was taken and analysed, using the HerpeSelect 1 and 2 Elisa IgG assays (type-specific serological test). HSV-1 serology was positive in 230 (76.7%), negative in 67 (22.3%) sex workers and indeterminate in three (1.0%) sex workers. HSV-2 serology was positive in 237 (79.0%) and negative in 63 (21.0%) sex workers. On univariate analysis, there was significant association between HSV-2 seropositivity and increasing age, nationality (locals) (P<0.001) and marital status (P<0.01). Adjusting for age, marital status and condom use, HSV-2 prevalence increased significantly with duration of years of practice of sex work. Most of the respondents (86.0%) were aware that HSV could be spread through sex without a condom and about two-thirds of them were aware that HSV could be spread in the absence of symptoms. In conclusion, HSV-2 is a common infection among sex workers in Singapore with the risk increasing with years of practice.

Pneumocystis jirovecii pneumonia in African miners at autopsy

SETTING

Deceased miners from South Africa whose cardio-respiratory organs were submitted for autopsy for compensation for occupational lung diseases from 1996 to 2000.

OBJECTIVES

1) To document the incidence of Pneumocystis jirovecii pneumonia (PJP) in autopsied miners; 2) to compare the incidence of PJP over a 5-year period; 3) to record the incidence of concomitant lower respiratory tract infection in a group of PJP-infected deceased miners coming to autopsy from 1996 to 2000; and 4) to describe the accuracy of the in-life diagnosis of PJP in this group.

DESIGN

Case series of 328 deceased Black miners with histological evidence of PJP at autopsy.

RESULTS

Of the 328 miners with PJP at autopsy, 107 (32.6%) had a concomitant respiratory infection, the most common being cryptococcal pneumonia (46.7%), followed by bacterial pneumonia (34.6%) and pulmonary tuberculosis (13.1%). Overall, Pneumocystis pneumonia was unsuspected prior to death in 89% of cases; however, diagnostic accuracy in life improved from 7% in 1996 to 21% in 2000.

CONCLUSION

The high rate of undiagnosed PJP is cause for concern. Clinicians should have a heightened awareness for PJP in Africa, particularly as the disease is treatable at low cost and effective prophylaxis is available.

Teaching community, occupational and family medicine at the National University of Singapore: past, present and future

INTRODUCTION

We describe how the curriculum of community, occupational and family medicine (COFM) has evolved in response to social and educational forces and local health needs. Challenges in the teaching of the curriculum are also discussed.

CURRICULUM

The COFM Department aims to produce medical undergraduates and graduates with the skills to critically appraise evidence, prevent and manage diseases, and promote health in the community and primary healthcare setting. Its teaching programmes consist of the medical undergraduate programme and the Master of Medicine programmes in Occupational Medicine, Public Health and Family Medicine. The undergraduate modules consist of evidence-based medicine, public health in the community, disease prevention and control, occupational medicine practice, health promotion and behaviour, and communication with patients. The university's first completely online module on SARS was jointly implemented by the Department and the Centre for Instructional Technology for the entire student population last year. The COFM curriculum has shifted from giving students factual information through lectures to developing students' critical thinking and problem-solving skills through small group teaching, case studies and community health projects. Innovative assessment methods such as open-book examinations; objective structured communication stations with simulated patients; and evaluation of students' participation in group work are used to assess students' skills in problem-solving, communication and teamwork respectively.

CONCLUSION

While the Department has made significant progress in developing a relevant and updated curriculum based on appropriate learning and assessment approaches, it will strive to do more to develop students' critical thinking skills by using newer approaches.

Tuberculosis at Chris Hani Baragwanath Hospital: numbers of patients diagnosed and outcomes of referrals to district clinics

SETTING

Chris Hani Baragwanath Hospital, in Johannesburg. South Africa is experiencing a serious epidemic of tuberculosis (TB), with a measured rate of 500 cases per 100,000 population. Patients in public hospitals are referred for treatment to district clinics or to specific TB hospitals.

OBJECTIVES

To measure numbers of patients diagnosed with TB, and to describe the type of disease and referral outcomes.

METHODS

A descriptive study of patients diagnosed with TB in a tertiary hospital. Data in patient files were collected for medical and paediatric patients, and patients were interviewed by researchers who visited clinics to check if referred patients had attended.

RESULTS

In the 8-week study period, 1291 patients were diagnosed with TB: 74% had pulmonary disease and 80% of those tested for HIV were positive; 19% died in hospital, and 21% required transfer to a TB hospital. Only half of the patients referred to clinics attended within 2 weeks.

CONCLUSIONS

Patients with advanced TB are commonly seen at this hospital. Notifications were an inadequate record and an unacceptable proportion of patients were lost between hospital and clinics. This study has recommended that opportunities for education and discussion must be provided if patients are to reach clinics successfully.

Genotype C hepatitis B virus infection is associated with an increased risk of hepatocellular carcinoma

BACKGROUND

Identification of risk factors for the development of hepatocellular carcinoma (HCC) is important for HCC surveillance in chronic hepatitis B virus (HBV) infection. Our aim was to study the independent risk factors and effect of HBV genotypes on HCC development in a prospective longitudinal cohort of chronic hepatitis B patients.

PATIENTS AND METHODS

Chronic hepatitis B patients recruited since 1997 were prospectively followed up for the development of HCC. HCC was diagnosed by a combination of alpha fetoprotein, imaging, and histology. Liver cirrhosis was defined as ultrasonic features of cirrhosis together with hypersplenism, ascites, varices, and/or encephalopathy.

RESULTS

In total, 426 patients were followed up for 1664 person years; median 225 (range 12-295) weeks. Forty nine (11%) patients had underlying clinical liver cirrhosis. A total of 242 (57%) and 179 (42%) patients had HBV genotypes C and B, respectively. Twenty five patients developed HCC in a median follow up of 121 (range 14-236) weeks. The overall incidence of HCC was 1502 cases per 100 000 person years. On multivariate analysis, clinical liver cirrhosis and HBV genotype C infection were independently associated with HCC development, with an adjusted relative risk of 10.24 (95% confidence interval (CI) 4.39-23.89; p<0.001) and 2.84 (95% CI 1.05-7.72; p = 0.040), respectively. Patient age, sex, hepatitis B e antigen (HBeAg) status, alanine aminotransferase (ALT) levels, and basal core promoter mutations did not predict HCC development. Patients infected with HBV genotype C tended to have persistently positive HBeAg or fluctuating HBeAg status and higher ALT levels during the follow up period.

CONCLUSION

Genotype C HBV infection is an independent risk factor for HCC development in addition to liver cirrhosis.

Willingness to donate blood samples for genetic research: a survey from a community in Singapore

Studies on the public's willingness to donate blood specimens for genetic research are few and are conducted mainly among Western countries. Little is known about the Asian community's willingness to participate in genetic research. A community-based survey was conducted on 548 adult Singaporeans to examine their willingness to donate blood samples for genetic research and its associated factors. The response rate was 70.3%. About 49.3% (95% CI, 45.1-53.5%) were willing to donate blood for genetic research. In the multivariable Cox regression analysis, willingness was significantly associated with belief in the benefits of genetic research; intention to participate in government studies; having no fear of pain, blood, injections, and needles; and non-concern about the loss of confidentiality. Reasons against donating blood were fear of pain, blood, injections, and needles (38.1%); no self-benefits (24.8%); fear of finding out about having a disease (22.3%); fear of discrimination (18.7%); and concerns about weakness (15.1%) and weight gain (9.4%). Public education programs to promote participation in genetic research should stress its benefits and address people's fears and concerns.