OBJECTIVE: To determine the prevalence, factors associated with and patterns of concomitant Chinese medicine (CM) with Western treatment use among patients with rheumatoid arthritis (RA) in a tertiary referral centre (Singapore General Hospital) in Singapore. METHODS: We conducted a cross-sectional interviewer-administered survey of a consecutive sample of patients with RA in Singapore General Hospital centre regarding their CM use including data on patient demographics, disease characteristics, concomitant use of CM and reasons, concerns and disclosure patterns from March to August 2015. Univariate and multivariate logistic regression analyses were performed to determine the associations of CM use. RESULTS: Prevalence of CM use among the 258 patients surveyed (male: female 42: 216; Chinese: Malay: Indian 191: 29: 34; mean age: 61 years; mean duration of RA: 10 years) was 46.1% (119/258). On multivariate analysis, Chinese ethnicity (OR, 95% CI: 4.11, 1.49-11.36), Chinese speakers (OR, 95% CI: 2.35, 1.03-5.54), middle-income group (OR, 95% CI: 2.53, 1.01-6.31) and greater learned helplessness (OR, 95% CI: 1.13, 1.04-1.22) were significantly associated with CM use. More CM users disclosed their CM use to CM physicians (87.3%, 96/110), sought advice from them on treatment interactions (59.4%, 57/96) and how best to combine treatments (49.0%, 47/96) than did so with rheumatologists (42.0%, 50/119; 40.0%, 20/50; and 42.0%, 21/50, respectively). Forty-two percentage (29/69) of patients who concealed CM use from rheumatologists because their rheumatologists did not specifically enquire about CM use. CONCLUSIONS Concomitant CM use among patients with RA treated in a tertiary referral centre in Singapore is high but voluntary disclosure is low. The associations identified can help doctors identify and enquire about CM use, minimizing potential adverse interactions.
Arthritis, Rheumatoid/epidemiology* ; Cross-Sectional Studies ; Ethnicity ; Female ; Humans ; Male ; Medicine, Chinese Traditional ; Middle Aged ; Prevalence

The ongoing pandemic in Singapore is part of a global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To control the spread of COVID-19 and prevent the healthcare system from being overwhelmed, 'circuit breaker' measures were introduced between 7 April and 1 June 2020 in Singapore. There is thus a crucial need for innovative approaches to the provision and delivery of healthcare in the context of safe-distancing by harnessing telemedicine, especially for patients with chronic diseases who have traditionally been managed in tertiary institutions. We present a summary of how the Virtual Monitoring Clinic has benefited the practice of our outpatient rheumatology service during the COVID-19 pandemic. The virtual consultations address the need for safe-distancing by limiting face-to-face appointments and unnecessary exposure of patients to the hospital where feasible. This approach ensures that the patients are monitored appropriately for drug toxicities and side-effects, maintained on good disease control, and provided with patient education.
Ambulatory Care/methods* ; Antirheumatic Agents/therapeutic use* ; COVID-19 ; Delivery of Health Care ; Humans ; Nurse Practitioners ; Pharmacists ; Rheumatic Diseases/drug therapy* ; Rheumatology/methods* ; SARS-CoV-2 ; Singapore ; Telemedicine/organization & administration* ; Tertiary Care Centers

INTRODUCTION: To describe the maternal and fetal outcomes in systemic lupus erythematosus (SLE) pregnancies followed-up in a single tertiary referral centre. METHODS: We performed a retrospective cohort study of 75 SLE pregnancies who were followed up in Singapore General Hospital over a 16-year period from 2000 to 2016. Adverse fetal and maternal outcomes including preterm delivery, miscarriages, fetal growth restriction, congenital heart block, neonatal lupus, pre-eclampsia and SLE flares were obtained from the medical records. RESULTS: The mean age at conception was 32 years old (SD 3.8). The mean SLE disease duration was 5.9 years (SD 5.2). The majority (88%) had quiescent SLE disease activity at baseline. Most pregnancies resulted in a live birth (74.7%). The mean gestational age at birth was 37.4 weeks (SD 3.4). Adverse fetal outcomes occurred in 53.3%. Preterm delivery (33.9%), miscarriages (20%) and fetal growth restriction (17.3%) were the most frequent adverse fetal outcomes. There was 1 neonatal death and SLE flares occurred in a third (33%). In the subgroup of SLE pregnancies with antiphospholipid syndrome, there were higher SLE flare rates (40%) and adverse fetal outcomes occurred in 8 pregnancies (80%). There were no predictive factors identified for all adverse fetal and maternal outcomes. In the subgroup analysis of preterm delivery, anti-Ro (SS-A) antibody positivity and hydroxychloroquine treatment were associated with a lower risk of preterm delivery. CONCLUSION Although the majority had quiescent SLE disease activity at baseline, SLE pregnancies were associated with high rates of adverse fetal and maternal outcomes.

This was a systematic review of the literature on the association between obesity and the outcome of inflammatory rheumatic diseases. We conducted a literature search using PubMed®, Embase and PsycINFO®. Articles were classified into three categories based on the effects of obesity on the outcomes of inflammatory rheumatic diseases. The subject population, country, type of studies, number of patients, measurement of obesity and outcomes assessed were presented. Quality was appraised using Kmet et al's criteria. 4,331 articles were screened and 60 were relevant to the objective. Obesity had a negative, positive and neutral association with outcomes of inflammatory rheumatic diseases in 38 (63.3%) studies with 57,612 subjects, 11 (18.3%) studies with 3,866 subjects, and 11 (18.3%) studies with 3,834 subjects, respectively. In most studies, the disease population had been diagnosed with rheumatoid arthritis (RA). Tumour necrosis factor-α inhibitors were mostly associated with negative outcomes. More studies examining subjects outside Europe and North America and diseases other than RA are warranted.

Clinical practice guidelines (CPGs) have become ubiquitous in every field of medicine today but there has been limited success in implementation and improvement in health outcomes. Guidelines are largely based on the results of traditional randomised controlled trials (RCTs) which adopt a highly selective process to maximise the intervention's chance of demonstrating efficacy thus having high internal validity but lacking external validity. Therefore, guidelines based on these RCTs often suffer from a gap between trial efficacy and real world effectiveness and is one of the common reasons contributing to poor guideline adherence by physicians. "Real World Evidence" (RWE) can complement RCTs in CPG development. RWE-in the form of data from integrated electronic health records-represents the vast and varied collective experience of frontline doctors and patients. RWE has the potential to fill the gap in current guidelines by balancing information about whether a test or treatment works (efficacy) with data on how it works in real world practice (effectiveness). RWE can also advance the agenda of precision medicine in everyday practice by engaging frontline stakeholders in pragmatic biomarker studies. This will enable guideline developers to more precisely determine not only whether a clinical test or treatment is recommended, but for whom and when. Singapore is well positioned to ride the big data and RWE wave as we have the advantages of high digital interconnectivity, an integrated National Electronic Health Record (NEHR), and governmental support in the form of the Smart Nation initiative.
Big Data ; Electronic Health Records ; Evidence-Based Medicine ; Guideline Adherence ; Humans ; Practice Guidelines as Topic ; Practice Patterns, Physicians' ; Pragmatic Clinical Trials as Topic ; Precision Medicine ; Singapore

INTRODUCTIONAlthough research is widely considered to be a relevant and essential skill to resident development, the actual participation rate of residents in research remains low, and the factors associated with participation are unclear.

METHODSWe examined the participation rate of junior residents in research, and their attitudes and perceived barriers toward research, via an anonymised survey carried out from October to November 2013. The residents were from an established Accreditation Council for Graduate Medical Education-accredited internal medicine residency training programme in Singapore.

RESULTSThe overall response rate was 64.1% (82/128 residents). The most frequently cited barrier was lack of time. Only a third of the residents surveyed were actively participating in research. Those with postgraduate qualifications were more likely to be involved in research (odds ratio 4.71, p = 0.015). Among the 82 residents, 40.2% reported an interest in research as part of their career; these were mainly graduates from overseas universities or postgraduates. A belief that research is an intrinsically valuable activity distinguished residents who chose research as a career path from those who were undecided (p = 0.004). The belief that research is a means to better clinical practice also divided those who chose research from those who rejected it (p = 0.02).

CONCLUSIONOur findings suggest that specific beliefs determine the level of research activity and career interest among residents. Novel strategies may be incorporated in training programmes to improve the interest and participation of residents in research, and to facilitate the development of academic clinicians.

INTRODUCTIONThe Short Form-12 version 2 (SF-12v2) is a shorter version of the Short Form-36 version 2 (SF-36v2) for assessing health-related quality of life. As the SF-12v2 could not be resolved into the physical- and mental-component summary score (PCS and MCS, respectively) in the general population of Singapore, this study aims to determine and validate the Singapore SF-12 version 2 (SG-12v2).

MATERIALS AND METHODSThe SG- 12v2 was generated using the same methodology as the SF-12v2. Bootstrap analysis was used to determine if the SG-12v2 were significantly different from the SF-12v2. Content validity was assessed using percentage of variance (R²) of the Singapore version of SF-36v2 PCS and MCS explained by the SG-12v2 items. Agreement between the SF-36v2 and the SG-12v2 was assessed using Bland-Altman diagrams. Criterion validity was demonstrated if effect size differences between SF-36v2 and SG-12v2 were small (Cohen's criteria). Known-group validity of SG-12v2 was reported for participants with and without chronic diseases.

RESULTSFive items differed between the SG-12v2 and SF-12v2. Bootstrap analysis confirmed that SG-12v2 and SF-12v2 were significantly different. The SG12v2 explained 94% and 79% of the R² of the SF-36v2 PCS and MCS, respectively. Agreement was good and effect size differences were small (<0.3). Participants with chronic diseases reported lower SG-12v2 scores compared to participants without chronic diseases.

CONCLUSIONThe SG-12v2 offers advantage over the SF-12v2 for use in the general population of Singapore. The SG-12v2 is a valid measure and will be particularly useful for large population health surveys in Singapore.

Asian Continental Ancestry Group ; Chronic Disease ; Ethnic Groups ; Health Status ; Health Surveys ; Humans ; Quality of Life ; Reproducibility of Results ; Singapore

INTRODUCTIONThe aim of this study is to report normative data for the Short-Form 36 version 2 (SF-36v2) for assessing health-related quality of life, in the Singapore general population.

MATERIALS AND METHODSData for English and Chinese-speaking participants of the Singapore Prospective Study Programme were analysed. The SF-36v2 scores were norm-based with the English-speaking Singapore general population as reference and reported by age (in decades), gender and ethnicity as well as for the 5 most prevalent chronic medical conditions. Scores were reported separately for the English and Chinese language versions.

RESULTSA total of 6151 English-speaking (61.5% Chinese and 19.2% Malay) and 1194 Chinese-speaking participants provided complete data. Mean (SD) age of all participants was 49.6 (12.58) years with 52.4% being women. In both languages, women reported lower scores than men on all scales. Among the chronic medical conditions, stroke had the largest impact on all English SF-36v2 scales and on 3 Chinese SF-36v2 scales (role-physical, general health and social functioning).

CONCLUSIONWe have provided detailed normative data for the Singapore English and Chinese SF-36v2, which would be valuable in furthering HRQoL research in Singapore and possibly the region.

Adult ; Female ; Health Surveys ; standards ; statistics & numerical data ; Humans ; Language ; Male ; Middle Aged ; Prospective Studies ; Quality of Life ; Singapore ; Young Adult

INTRODUCTIONWhether fi nal height is associated with quality of life and mental health is a matter of epidemiological and medical concern. Both social and biological explanations have been previously proposed. This study aims to assess the associations in ethnic Chinese in Singapore.

MATERIALS AND METHODSA cross-sectional study of 4414 respondents aged at least 21 years seen at a major polyclinic was performed. Socioeconomic and behavioural features of the sample and the Singapore population of similar ages were comparable. Height was measured by clinic nurses using an ultrasonic height senor. Participants were interviewed for socioeconomic, behavioural, health and quality of life information. Clinical morbidity data was collected from the participants' treating physicians. The SF-6D utility index and its Mental Health domain were the main endpoints. Linear and ordinal logistic regression models were used to analyse the utility index and the Mental Health scores, respectively.

RESULTSHaving adjusted for age and gender, the Mental Health domain (P <0.01) was associated with height but the utility index was not. Further adjustment for health, socioeconomic and behavioural covariates made little difference. Analyses based on height categories showed similar trends.

CONCLUSIONAdult height has a positive association with mental health as measured by the SF-6D among ethnic Chinese in Singapore. Socioeconomic status and known physical health problems do not explain this association. Adult height had no association with SF-6D utility index scores.

Adult ; Aged ; Aged, 80 and over ; Body Height ; ethnology ; China ; ethnology ; Cross-Sectional Studies ; Female ; Health Behavior ; Health Status ; Health Surveys ; Humans ; Linear Models ; Logistic Models ; Male ; Mental Health ; ethnology ; Middle Aged ; Quality of Life ; Singapore ; epidemiology ; Socioeconomic Factors ; Surveys and Questionnaires ; Young Adult

The incidence of chikungunya infection in Singapore has been on the rise since the first reported case in 2006. Acute polyarthritis, a common manifestation among affected patients, may precede fever and present with debilitating arthritis to rheumatologists, orthopaedists, internists and primary care physicians. The diagnosis of chikungunya infection requires careful history taking and a high index of suspicion, with supporting evidence from the reverse transcription-polymerase chain reaction or the chikungunya IgM serology test. Treatment of chikungunya arthritis usually involves non-steroidal anti-inflammatory drugs. Rarely, polyarthritis in chikungunya may persist even after resolution of the acute infection, necessitating treatment with disease-modifying anti-rheumatic drugs. In this article, we present the different manifestations of chikungunya arthritis in our local setting and review the literature.
Aged ; Alphavirus Infections ; complications ; Anti-Inflammatory Agents, Non-Steroidal ; therapeutic use ; Arthritis ; drug therapy ; virology ; Chikungunya Fever ; Chikungunya virus ; Female ; Humans ; Male ; Middle Aged