The Certificate of Cause of Death (CCOD) is an important legal document. The statutory duty of completing the CCOD is imposed upon a licensed medical practitioner by the Registration of Births and Deaths Act. The family physician is often in the best position to certify the cause of death when the death occurs in the community. Medical practitioners are permitted to issue CCODs ONLY when the cause of death is known and natural and if the deceased is not in statutory care. Deaths that are reportable to the Coroner include deaths from unnatural causes, iatrogenic events, or if circumstances surrounding the death are unknown or suspicious. Proper certification of cause of death is essential to avoid problems with the authorities and added grief to the family of the deceased. However, with better understanding of the process of completing the CCOD, the family physician can more confidently perform this duty and render a final professional service to their patients.

Androgen Antagonists ; therapeutic use ; Anilides ; therapeutic use ; Antineoplastic Agents, Hormonal ; therapeutic use ; Bone Neoplasms ; complications ; secondary ; Goserelin ; therapeutic use ; Humans ; Male ; Middle Aged ; Nitriles ; therapeutic use ; Prostatic Neoplasms ; complications ; drug therapy ; Purpura, Thrombotic Thrombocytopenic ; drug therapy ; etiology ; Tosyl Compounds ; therapeutic use

INTRODUCTION: While waist circumference (WC) is widely used as an index for visceral fat accumulation and purportedly the primary pathology responsible for the metabolic syndrome (MS), its proposed cut-off value varies depending on the disparate diagnostic criteria used as well as on the gender, race and ethnic group being evaluated. Due to the strong association between MS and central obesity, waist circumference should be incorporated into the routine physical exam when assessing cardiovascular disease and diabetes risk. Currently however, there is no standard location for the measurement of WC. On literature review, we found no scientific rationale for preferring any one WC site to the others hence, this study.
OBJECTIVE: This study aims to (1) determine waist circumference measurement var iat ions among MS patients, (2005 NCEP-ATP III/AHA/NHLB criteria), at three levels: (A) umbilical level, (B) midline level (between the inferior margin of the ribs and the superior border of the iliac crest) and (C) level of the superior border of the iliac crest.
RESEARCH DESIGN AND METHODS: Across - sectional analytical study among adult patients, aged 40 to 69 years, diagnosed with MS using 2005 NCEP-ATP III/AHA/ NHLB criteria seen at the Philippine General Hospital, as part of the Asia-Oceania Survey on Metabolic Syndrome and Diabetes initiated by the Japan Diabetes Society.
RESULTS: A total of 187 MS individuals were included in the study (56% females). Both males and females were obese stage 1 (25.5 kg/m2 and 26.7 kg/m2 respectively). The mean WC measurements at level A in men was 92.9 cm (81.36 - 104.44 cm) and 93.83 cm (83.4 - 104.26 cm) in women; at level B, the mean WC in men was 90.73 cm (75.49 - 105.97 cm) and 91.51 cm (80.62 - 102.4 cm) in women; and at level C, the mean WC in men was 93.5 cm (81.97 - 105.03 cm) and 95.12 cm (85.11 - 105.13 cm) in women. Results showed that WC measurements at three levels did not significantly differ among MS patients when stratified to age and sex. However, when waist circumference was measured at three levels among all patients with MS, there was significant difference in WC taken at level B and level C (Sig = 0.009). Waist circumference at level A was similar and less variable to WC level B than WC at levelC.
CONCLUSIONS: Among patients with MS as defined by NCEPATP III/AHA/NHLB criteria, waist circumference at level B (midpoint level between the lower ribs and superior border of the iliac crest) was smaller than waist circumference at level A (umbilical level) and smaller than level C (superior border of the iliac crest) (WCB < WCA < WCC). There was greater variability in mean WC measurements at level B and level C. Mean WC measurements at level A (umbilical level) and level B (midpoint level) were similar and less variable and may be a better waist circumference measurements to level C (superior border of the iliac crest).

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Adenosine Triphosphate ; Asia ; Cardiovascular Diseases ; Diabetes Mellitus ; Ethnic Groups ; Hospitals, General ; Intra-abdominal Fat ; Japan ; Metabolic Syndrome X ; Obesity ; Obesity, Abdominal ; Philippines ; Umbilicus ; Waist Circumference ;

INTRODUCTION: Effectiveness of COVID-19 control interventions relies significantly on behavioural modifications of its population. Differing adoption rates impacts subsequent COVID-19 control. Hence, positive and sustained behavioural modification is essential for disease control. We describe the adoption rates of behavioural modifications for Singapore's "circuit-breaker" (CB), the national public health response to the COVID-19 crisis, among the general population in the community. METHODS: We conducted an interrupted-time series study using retrospective secondary data. We compared the proportion of Singaporeans who reported adopting specific behaviour modifications before, during and after CB. Behaviours of interest were working from home, performing hand hygiene, using face mask in public, and avoiding crowded areas. We compared change in incidence rates for community COVID-19 cases among the general population across the same time periods. RESULTS: There was an increase in face mask usage (+46.9%, 95% confidence interval [CI] 34.9-58.8, CONCLUSION Community incidence of COVID-19 in Singapore decreased during CB and remained low after CB. Use of face masks and social-distancing compliance through working from home increased during CB. However, it is unlikely to influence other sources of COVID-19 such as imported cases or within foreign worker dormitories.
Adoption ; COVID-19 ; Humans ; Retrospective Studies ; SARS-CoV-2 ; Singapore/epidemiology*

INTRODUCTION: In the past decades, the prevalence of childhood overweight and obesity has increased worldwide. Childhood obesity has been associated with wide range of serious health complications and increased risk of premature adult illnesses. Non-alcoholic Fatty Liver Disease (NAFLD) was of concern because of limited data among children. The study aims to determine the prevalence and demographic /clinical factors associated with NAFLD among overweight and obese children.

METHODOLOGY: The study was a cross-sectional study among overweight and obese participants aged 2-18 years old. A total of 96 subjects were included. Frequencies and percentages of clinical characteristics were determined. Chi-square, linear correlation and logistic regression analysis for different factors were performed.

RESULTS: Among the 92 subjects, 26 (28%) were overweight while 66 (72%) were obese. The M:F ratio was 1.8:1 and majority belonged to 6-10 years old (44%). As to socioeconomic class, the rity (59%) were from the low-income group. The overall prevalence of NAFLD among overweight and obese subjects was 29.3%. None of the clinical factors (age, gender, socioeconomic status, BMI, waist circumference, actual caloric intake, and dietary fat consumption) were significantly associated with NAFLD. Analysis of biochemical factors revealed that alanine aminotransferase, aspartate aminotransferase, serum triglycerides and total cholesterol were found to be associated with NAFLD. Among which AST and ALT were identified predictors of NAFLD.

CONCLUSION: There was high prevalence of NAFLD among overweight and obese children. Screening among the pediatric population may aid on early identification and prevent its progression. ALT, AST, serum triglycerides and total cholesterol were independently related wih NAFLD. AST and ALT were identified predictors of NAFLD.

Human ; Overweight ; Obesity ; Child Nutrition Disorders ; Philippines ; Cross-sectional Studies

INTRODUCTIONWeight management programmes (WMPs) can help overweight individuals lose weight, and thus prevent complications associated with obesity. Herein, we describe the demographic profile, clinical characteristics, motivations and expectations, and outcomes of patients enrolled in a nonsurgical WMP.

METHODSThis was a retrospective study of consecutive patients with a body mass index (BMI) of > 23 kg/m2 enrolled in the four-month WMP at the Health For Life Clinic, Alexandra Hospital, Singapore, between 1 and 31 August 2009. Demographic data, medical history and source of referral were recorded. Details on personal motivations and weight loss goals were obtained from the completed self-administered questionnaires of the WMP participants. Weight, waist circumference, fat percentage and BMI were measured at the start and end of the WMP. A weight loss of ≥ 5% was deemed as a successful outcome.

RESULTSA total of 58 patients (mean age 37.2 years) were included in our study. Of these 58 patients, 58.6% were of Chinese ethnicity and 55.2% were male. Many patients (32.8%) attributed their weight gain to work- or study-related stress, and a minority to poor eating habits (12.1%) or a lack of exercise (10.3%). Patients' motivations included a desire for better health (53.4%) and better fitness (15.5%). However, only 53.4% patients scored their motivation as high (i.e. a score of > 7). The mean expected weight loss was 9.9 kg at 4 months, and 14.1 kg at 12 months. Among the 40 patients (69.0%) who completed the programme, the mean percentage weight loss was 1.8 ± 4.3%. A weight loss of ≥ 5% was achieved by 8 (13.8%) patients.

CONCLUSIONAlthough the patients in our study cohort were young and educated, only a portion of them appeared to be highly motivated to lose weight, despite joining the WMP. There is a need for patients to be guided on how to set realistic weight loss goals.

Adult ; Aged ; Body Mass Index ; Female ; Humans ; Male ; Middle Aged ; Motivation ; Obesity ; psychology ; therapy ; Overweight ; psychology ; therapy ; Retrospective Studies ; Singapore ; Surveys and Questionnaires ; Treatment Outcome ; Weight Loss ; Weight Reduction Programs ; methods ; Young Adult

INTRODUCTIONSensori-neural hearing loss (SNHL) is a frequent complication of conventional radiotherapy for head and neck tumours, especially nasopharyngeal carcinoma. To manage radiation-induced ototoxicity appropriately, an understanding of the cellular and molecular basis of this complication is necessary.

MATERIALS AND METHODSA medline search of relevant literature was done, focusing on the radiation-induced cellular and molecular processes that lead to hair cell death in the cochlea.

RESULTSRadiation-induced SNHL occurs in the cochlea, with the retro-cochlear pathways remaining functionally intact. By simulating radiotherapy regimes used clinically, radiation-induced cochlear cell degeneration in the absence of damage to the supporting structures and blood vessels has been demonstrated in animals. This could be due to apoptotic cochlear cell death, which has been shown to be associated with p53 upregulation and intra-cellular reactive oxygen species (ROS) generation. Oxidative stress may initiate the upstream processes that lead to apoptosis and other cell death mechanisms.

CONCLUSIONSA model of radiation-induced SNHL based on a dose and ROS-dependent cochlear cell apoptosis, is proposed. This model supports the feasibility of cochlear implantation, should one be clinically indicated. It can explain clinical observations such as radiation-induced SNHL being dose-dependent and affects the high frequencies more than the lower frequencies. It also opens up the possibility of preventive strategies targeted at different stages of the apoptotic process. Antioxidants look promising as effective agents to prevent radiation-induced ototoxicity; they target upstream processes leading to different cell death mechanisms that may co-exist in the population of damaged cells.

Animals ; Cell Death ; Cell Line ; Cochlea ; radiation effects ; Genes, p53 ; Hair Cells, Auditory ; radiation effects ; Hearing Loss, Sensorineural ; etiology ; genetics ; physiopathology ; Humans ; Mice ; Radiation Injuries ; complications ; Reactive Oxygen Species ; metabolism

INTRODUCTIONThe use of opioids in chronic non-cancer pain (CNCP) is controversial, as it presents both benefits and risks. There is currently no available data on the incidence, prescription pattern, functional outcomes and adverse effects of opioids in patients with CNCP in Singapore. This study aimed to address the aforementioned deficit.

METHODSAll records of patients who were prescribed strong opioids (for > 3 months per year) for the management of CNCP over a two-year period were retrospectively analysed. Factors including type of opioid, indications for opioid prescription, uncontrolled side effects, functional status, coexisting psychological issues and suspicion of aberrant drug-seeking behaviour were studied.

RESULTSOut of the 1,389 new patients who visited the centre, 42 (3.0%) with CNCP received strong opioids for more than three months a year. The most commonly prescribed opioid was methadone (42.9%). The principal diagnosis for opioid prescription was spinal pain (38.1%). Ten patients had severe side effects. 15 patients saw improvement in activities of daily living scores. Although ten patients returned to work, one stopped following the commencement of opioids. Aberrancy was seen in 5 (11.9%) patients, while 19 (45.2%) had psychological issues and 10 (23.8%) required psychiatric co-management.

CONCLUSIONOpioids are not a panacea for chronic pain. Therefore, functional outcomes should be considered more important end points than mere reductions in pain scores. A multidisciplinary team approach is essential for the effective management of patients with CNCP who are on opioids.

Adult ; Aged ; Aged, 80 and over ; Analgesics, Opioid ; administration & dosage ; Chronic Pain ; diagnosis ; drug therapy ; etiology ; Dose-Response Relationship, Drug ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Pain Clinics ; statistics & numerical data ; Pain Measurement ; Prescription Drugs ; Retrospective Studies ; Singapore ; Treatment Outcome ; Young Adult

INTRODUCTIONPeritoneal mesothelioma is a rare neoplasm. Due to the limited understanding of its biology and behaviour, peritoneal mesothelioma poses a diagnostic and management challenge. The management of peritoneal mesothelioma has been controversial; systemic chemotherapy, palliative surgery and cytoreductive surgery (CRS) with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) have been described.

MATERIALS AND METHODSThis study shares our experience with cytoreductive surgery and HIPEC for 5 out of the 6 cases of peritoneal mesotheliomas treated surgically, at a single institution in Singapore over the past 2 years. Computed tomography (CT) scans, positron emission tomography (PET)-CT scans and tumour markers were performed preoperatively but were not conclusive for the disease. All 6 cases presented to the Department of Surgical Oncology at National Cancer Centre Singapore, were diagnosed by histology of intraoperative biopsies. The combination of aggressive cytoreductive surgery and HIPEC was performed in 5 patients, with abandonment of procedure in 1 with extensive disease, who was treated with systemic chemotherapy instead.

RESULTSMedian duration of surgery, median length of hospital stay, and median follow-up duration were 7.04 hours, 11 days, and 15 months respectively. One postoperative morbidity relating to chemical peritonitis required exploratory laparotomy with good outcome. There were no mortality. All patients are alive at the last follow-up with no evidence of recurrences at 4 to 31 months from the time of their surgery.

CONCLUSIONPeritoneal mesothelioma is a rare disease that requires early diagnosis and can be effectively treated by CRS and HIPEC in selected group of patients.

Adult ; Antineoplastic Combined Chemotherapy Protocols ; administration & dosage ; Chemotherapy, Cancer, Regional Perfusion ; methods ; Cryosurgery ; methods ; Female ; Follow-Up Studies ; Humans ; Hyperthermia, Induced ; methods ; Male ; Mesothelioma ; diagnosis ; therapy ; Middle Aged ; Peritoneal Neoplasms ; diagnosis ; therapy ; Positron-Emission Tomography ; Tomography, X-Ray Computed

INTRODUCTIONThe use of complementary and alternative medicine (CAM) in Singapore for a variety of conditions has been reported to be high. However in Asian chronic pain patients, there is no data on their use of CAM and its perceived benefits.

MATERIALS AND METHODSA cross-sectional survey of 210 patients was carried out in Pain Management Centre. Patients were interviewed directly on their use of CAM. The outcomes were prevalence of CAM use, the types of CAM used, the perceived efficacy and factors influencing its use.

RESULTSThe prevalence of CAM users in chronic pain is 84%. The most common class of CAM is traditional Chinese medicine (68%) the subset of which, acupuncture, was most frequently utilised (49% of patients using CAM). In univariate analyses, ethnicity was significantly linked to CAM use but not gender, age, education level and income (P = 0.027). Specifically for neck pain, it was significant that patients were more likely to see a chiropractor, to use massage, to take take vitamins and ginseng to alleviate their symptoms. With upper limb pain, it was the use of Tui na, massage and seeing a TCM practitioner. For abdominal pain, it was the use of herbal medicines. The majority felt that CAM helped with their pain (72%) although less expressed satisfaction with CAM (64%). Reasons for using CAM included: having more control over their pain; fewer side effects; safety and lower costs compared to conventional medicine.

CONCLUSIONThe use of CAM in chronic pain patients is higher than the general population. Most felt that it improved their pain. As part of multimodal therapy, CAM may have a role in the management of chronic pain.

Adolescent ; Adult ; Chronic Pain ; therapy ; Complementary Therapies ; utilization ; Female ; Humans ; Male ; Middle Aged ; Singapore ; Socioeconomic Factors ; Young Adult