Novel approach to analysis of the immune system using an ungated model of immune surface marker abundance to predict health outcomes.

Traditionally, the immune system is understood to be divided into discrete cell types that are identified via surface markers. While some cell type distinctions are no doubt discrete, others may in fact vary on a continum, and even within discrete types, differences in surface marker abundance could have functional implications. Here we propose a new way of looking at immune data, which is by looking directly at the values of the surface markers without dividing the cells into different subtypes. To assess the merit of this approach, we compared it with manual gating using cytometry data from the Singapore Longitudinal Aging Study (SLAS) database. We used two different neural networks (one for each method) to predict the presence of several health conditions. We found that the model built using raw surface marker abundance outperformed the manual gating one and we were able to identify some markers that contributed more to the predictions. This study is intended as a brief proof-of-concept and was not designed to predict health outcomes in an applied setting; nonetheless, it demonstrates that alternative methods to understand the structure of immune variation hold substantial progress.

Symptom clusters of subjective cognitive decline amongst cognitively normal older persons and their utilities in predicting objective cognitive performance: structural equation modelling.

BACKGROUND AND PURPOSE: Prior literature on subjective cognitive decline (SCD) has mostly focused on memory complaints. It is uncertain whether the other non-memory complaints are equally relevant and can be used, alongside memory complaints, to identify populations at high risk of cognitive impairment. How the memory and non-memory complaints of SCD cluster with each other amongst community-dwelling individuals was investigated, and the differential utility of the symptom clusters of SCD in predicting objective cognitive performance was evaluated. METHODS: This study included 736 participants who were ≥60 years and had normal cognition, using the baseline data of an ongoing cohort study. Participants completed baseline assessments which comprised an SCD scale, a global cognitive measure and neuropsychological tests. Symptom clusters of SCD - as identified from exploratory and confirmatory factor analyses - were included in structural equation models to predict baseline changes in neuropsychological tests. RESULTS: The symptoms of SCD were split into two distinct factors, of which factor 1 was reported much more frequently than factor 2. Each standard deviation (SD) increment in factor 1 led to a 0.16-0.50 SD increase in global cognition, immediate memory, visuospatial abilities, language, attention and delayed memory (P < 0.05). In contrast, each SD increment in factor 2 worsened some of the cognitive domains by 0.18-0.37 SD. CONCLUSIONS: The various complaints of SCD can have different implications amongst cognitively normal older persons and may possibly be classified into age-related symptoms and pathological symptoms. The findings highlight the need for caution when selecting SCD measures, and illustrate the potential utility of SCD subtypes to inform on the underlying neurobiology.

Prospective study on the effects of orthotic treatment for medial knee osteoarthritis in Chinese patients: clinical outcome and gait analysis.

OBJECTIVE: To evaluate the effectiveness of various orthotic treatments for patients with isolated medial compartment osteoarthritis. DESIGN: Prospective cohort study with sequential interventions. SETTING: University-affiliated hospital, Hong Kong. PATIENTS: From December 2010 to November 2011, 10 patients with medial knee osteoarthritis were referred by orthopaedic surgeons for orthotic treatment. All patients were sequentially treated with flat insole, lateral-wedged insole, lateral-wedged insole with subtalar strap, lateral-wedged insole with arch support, valgus knee brace, and valgus knee brace with lateral-wedged insole with arch support for 4 weeks with no treatment break. Three-dimensional gait analysis and questionnaires were completed after each orthotic treatment. MAIN OUTCOME MEASURES: The Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analogue scale scores, and peak and mean knee adduction moments. RESULTS: Compared with pretreatment, the lateral-wedged insole, lateral-wedged insole with arch support, and valgus knee brace groups demonstrated significant reductions in WOMAC pain score (19.1%, P=0.04; 18.2%, P=0.04; and 20.4%, P=0.02, respectively). The lateral-wedged insole with arch support group showed the greatest reduction in visual analogue scale score compared with pretreatment at 24.1% (P=0.004). Addition of a subtalar strap to lateral-wedged insoles (lateral-wedged insole with subtalar strap) did not produce significant benefit when compared with the lateral-wedged insole alone. The valgus knee brace with lateral-wedged insole with arch support group demonstrated an additive effect with a statistically significant reduction in WOMAC total score (-26.7%, P=0.01). Compliance with treatment for the isolated insole groups were all over 90%, but compliance for the valgus knee brace-associated groups was only around 50%. Gait analysis indicated statistically significant reductions in peak and mean knee adduction moments in all orthotic groups when compared with a flat insole. CONCLUSIONS: These results support the use of orthotic treatment for early medial compartment knee osteoarthritis.

Asymptomatic grade-2 central chondrosarcoma of the distal femur with non-aggressive radiological features.

This paper discusses the case of a 57-year-old man with an incidental finding of a radiologically non-aggressive chondroid lesion and concomitant osteonecrosis in the left distal femur. The final resected specimen showed a grade-2 chondrosarcoma. This case illustrates that long-term follow-up is necessary for non-aggressive chondroid lesions. If surgical management is considered, resection with an adequate margin is superior to intralesional curettage.

A sarcoma of 23 years' duration: symptom duration is not a reliable parameter to exclude malignancy.

This report describes a 31-year-old woman with a 23-year history of a right buttock mass that was otherwise asymptomatic, but was proven to be a low-grade fibromyxoid sarcoma (a fully malignant soft tissue tumour with a potential for distant metastasis). This case illustrates that a long-standing tumour does not necessarily imply a benign pathology. A vigilant approach should be taken for any tumours that are of significant size (larger than 5 cm).

Simultaneous cardio-cerebral infarction: a meta-analysis.

BACKGROUND/INTRODUCTION: Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse. AIM: We aimed to summarize the reported cardio-cerebral infarction cases in the literature. DESIGN: Meta-analysis. METHODS: Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors. RESULTS: A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported. DISCUSSION/CONCLUSION: The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.

Arthroscopic treatment of popliteal cyst.

OBJECTIVE: To review the results of arthroscopic treatment of popliteal cysts in our centre and analyse outcomes including complications. DESIGN: Retrospective study. SETTING: University teaching hospital, Hong Kong. PATIENTS: From July 2007 to July 2009, 11 patients with symptomatic popliteal cysts were treated arthroscopically. All of them had preoperative magnetic resonance imaging to confirm the diagnosis, identify the valvular opening, and the associated intra-articular pathology. We used the Rauschning and Lindgren criteria for evaluation. RESULTS: Intra-articular pathology like cartilage degeneration and meniscus tear were commonly associated with popliteal cysts. All patients achieved symptomatic improvement after treatment and the recurrence rate was low. No major complications were encountered. We failed to identify (and correct) any valvular opening in one patient. CONCLUSION: From our experience, we conclude that arthroscopic treatment of popliteal cyst with correction of the valvular opening and treatment of associated intra-articular pathology is effective and safe.

Tea Consumption and Depression from Follow Up in the Singapore Longitudinal Ageing Study.

OBJECTIVES: Experimental evidence suggest that tea polyphenols have anti-depressant effect and tea consumption may reduce the risk and severity of depression. We investigated whether tea consumption was associated with changes in depressive symptoms over time among Asian older adults. DESIGN: Population-based prospective cohort study with mean 4 years of follow up. SETTING: Singapore Longitudinal Ageing Study (SLAS) of community-living older persons. PARTICIPANTS: 3177 participants overall (mean age 67 years) and 3004 participants who were depression-free at baseline. MEASUREMENTS: Baseline tea consumption which include Chinese (black, oolong or green) tea or Western (mixed with milk) tea and change in Geriatric Depression Scale (GDS) measure of depression. Incident depression was defined by GDS≥5, and GDS depression improvement or deterioration by GDS change of ≥4 points. Estimated odds ratio and 95% confidence intervals (OR, 95%CI) were adjusted for baseline age, sex, ethnicity, education, housing type, single/divorced/widowed, living alone, physical and social activity, smoking, alcohol, number of comorbidities, MMSE, and baseline GDS level. RESULTS: Compared to non-tea drinkers, participants who consumed ≥3 cups of tea of all kinds were significantly less likely to have worsened GDS symptoms: OR=0.32, 95% CI=0.12, 0.84. Among baseline depression-free participants, the risk of incident GDS (≥5) depression was significantly lower (OR=0.34, 95%CI=0.13, 0.90) for daily consumption of all types of tea, and Chinese (black, oolong or green) tea (OR=0.46, 95%CI=0.21,0.99). CONCLUSION: This study suggests that tea may prevent the worsening of existing depressive symptoms and the reduce the likelihood of developing threshold depression.

Obesity Measures and Definitions of Sarcopenic Obesity in Singaporean Adults - the Yishun Study.

OBJECTIVES: Due to the lack of a uniform obesity definition, there is marked variability in reported sarcopenic obesity (SO) prevalence and associated health outcomes. We compare the association of SO with physical function using current Asian Working Group for Sarcopenia (AWGS) guidelines and different obesity measures to propose the most optimal SO diagnostic formulation according to functional impairment, and describe SO prevalence among community-dwelling young and old adults. DESIGN: Obesity was defined according to waist circumference (WC), percentage body fat (PBF), fat mass index (FMI), fat mass/fat-free mass ratio (FM/FFM), or body mass index (BMI). SO was defined as the presence of both obesity and AWGS sarcopenia. Muscle function was compared among phenotypes and obesity definitions using ANOVA. Differences across obesity measures were further ascertained using multiple linear regressions to determine their associations with the Short Physical Performance Battery (SPPB). SETTING: Community-dwelling adults 21 years old and above were recruited from a large urban residential town in Singapore. PARTICIPANTS: 535 community-dwelling Singaporeans were recruited (21-90 years old, 57.9% women), filling quotas of 20-40 participants in each sex- and age-group. MEASUREMENTS: We took measurements of height, weight, BMI, waist and hip circumferences, body fat, muscle mass, muscle strength, and functional assessments. Questionnaire-based physical and cognitive factors were also assessed. RESULTS: Overall prevalence of SO was 7.6% (WC-based), 5.1% (PBF-based), 2.7% (FMI-based), 1.5% (FM/FFM-based), and 0.4% (BMI-based). SO was significantly associated with SPPB only in the FMI model (p<0.05), and total variance explained by the different regression models was highest for the FMI model. CONCLUSIONS: Our findings suggest FMI as the most preferred measure for obesity and support its use as a diagnostic criteria for SO.

Nutritional Status and Risks of Cognitive Decline and Incident Neurocognitive Disorders: Singapore Longitudinal Ageing Studies.

BACKGROUND: Studies suggest that nutritional interventions using the whole diet approach such as the Mediterranean diet may delay cognitive decline and dementia onset. However, substantial numbers of older adults are non-adherent to any ideally healthy dietary pattern and are at risk of malnutrition. OBJECTIVE: The present study investigated the relationship between global malnutrition risk and onsets of cognitive decline and neurocognitive disorders (NCD), including mild cognitive impairment (MCI) or dementia in community-dwelling older adults. METHODS: Participants aged ≥ 55 years in the Singapore Longitudinal Ageing Studies (SLAS) were assessed at baseline using the Elderly Nutritional Indicators for Geriatric Malnutrition Assessment (ENIGMA) and followed up 3-5 years subsequently on cognitive decline (MMSE drop ≥ 2) among 3128 dementia-free individuals, and incident neurocognitive disorders (NCD) among 2640 cognitive normal individuals. RESULTS: Individuals at high nutritional risk score (≥ 3) were more likely to develop cognitive decline (OR=1.42, 95%CI=1.01-1.99) and incident MCI-or-dementia (OR=1.64, 95%CI=1.03-2.59), controlling for age, sex, ethnicity, low education, APOE-e4, hearing loss, physical, social, and mental activities, depressive symptoms, smoking, alcohol, central obesity, hypertension, diabetes, low HDL, high triglyceride, cardiac disease, and stroke. Among ENIGMA component indicators, low albumin at baseline was associated with cognitive decline and incident NCD, and 5 or more drugs used, few fruits/vegetables/milk products daily, and low total cholesterol were associated with incident NCD. CONCLUSION: The ENIGMA measure of global malnutrition risk predicts cognitive decline and incident neurocognitive disorders, suggesting the feasibility of identifying vulnerable subpopulations of older adults for correction of malnutrition risk to prevent neurocognitive disorders.

Malnutrition and Sarcopenia in Community-Dwelling Adults in Singapore: Yishun Health Study.

OBJECTIVES: To determine the overlapping prevalence of malnutrition and sarcopenia and the association between parameters of malnutrition with muscle mass and strength in a community-dwelling Singaporean adult population. DESIGN: This was a cross-sectional study. SETTING: Large north-eastern residential town of Yishun in Singapore. PARTICIPANTS: Random sampling of community-dwelling Singaporeans aged 21-90 years old (n=541). MEASUREMENTS: Anthropometry, body composition and handgrip strength (muscle strength) were measured. Sarcopenia was identified using dual-energy x-ray absorptiometry scan (muscle mass). Nutritional status was measured using Mini Nutritional Assessment (MNA-SF). Other questionnaires collected included physical activity and cognition. Associations between nutritional status with sarcopenia as well as with muscle mass and strength were analysed using multinomial logistics and linear regressions. RESULTS: The overall population-adjusted prevalence of those at nutritional risk and malnourished were 18.5% and 0.1% respectively. More than a third of participants (35%) who were at nutritional risk were sarcopenic. Malnourished participants were all sarcopenic (100%, N=2) whereas those who were sarcopenic, 27.0% (N=37) were at nutritional risk/malnourished. Being at nutritional risk/malnourished was significantly associated with 2 to 3 times increased odds of sarcopenia in multivariate analyses adjusting for age, gender, physical activity level and cognition, and fat mass index. Favourable MNA parameter scores on food intake and BMI were positively associated with greater muscle mass and handgrip strength (p<0.05). CONCLUSION: Given the overlapping clinical presentation of malnutrition and sarcopenia, community screening protocols should include combination screening of nutritional status and sarcopenia with appropriate interventions to mitigate risk of adverse health outcomes.

Development, Validation and Field Evaluation of the Singapore Longitudinal Ageing Study (SLAS) Risk Index for Prediction of Mild Cognitive Impairment and Dementia.

BACKGROUND: Mild cognitive impairment (MCI) is a critical pre-dementia target for preventive interventions. There are few brief screening tools based on self-reported personal lifestyle and health-related information for predicting MCI that have been validated for their generalizability and utility in primary care and community settings. OBJECTIVE: To develop and validate a MCI risk prediction index, and evaluate its field application in a pilot community intervention trial project. DESIGN: Two independent population-based cohorts in the Singapore Longitudinal Ageing Study (SLAS). We used SLAS1 as a development cohort to construct the risk assessment instrument, and SLA2 as a validation cohort to verify its generalizability. SETTING: community-based screening and lifestyle intervention Participants: (1) SLAS1 cognitively normal (CN) aged ≥55 years with average 3 years (N=1601); (2) SLAS2 cohort (N=3051) with average 4 years of follow up. (3) 437 participants in a pilot community intervention project. MEASUREMENTS: The risk index indicators included age, female sex, years of schooling, hearing loss, depression, life satisfaction, number of cardio-metabolic risk factors (wide waist circumference, pre-diabetes or diabetes, hypertension, dyslipidemia). Weighted summed scores predicted probabilities of MCI or dementia. A self-administered questionnaire field version of the risk index was deployed in the pilot community project and evaluated using pre-intervention baseline cognitive function of participants. RESULTS: Risk scores were associated with increasing probabilities of progression to MCI-or-dementia in the development cohort (AUC=0.73) and with increased prevalence and incidence of MCI-or-dementia in the validation cohort (AUC=0.74). The field questionnaire risk index identified high risk individuals with strong correlation with RBANS cognitive scores in the community program (p<0.001). CONCLUSIONS: The SLAS risk index is accurate and replicable in predicting MCI, and is applicable in community interventions for dementia prevention.

The influence of childhood atopic dermatitis on health of mothers, and its impact on Asian families.

This study examines maternal perceptions of paediatric atopic dermatitis (AD) on family and determines risk factors including severity of AD, maternal physical and mental health (MH), quality of life of patients and sociodemographics which predict a negative family impact. A cross-sectional assessment using the Dermatitis Family Impact Questionnaire Scale to assess the impact of AD on family, Infant's Dermatitis Quality of Life Index (<5-yrs old) or Children's Dermatitis Life Quality Index (5-17 yrs old) was used to measure health-related quality of life (HRQOL) of paediatric patients with AD. A 12-item Short-Form Health Survey (SF-12) was used to assess physical and MH of their mothers. Risk factors of adverse family impact were assessed using multiple regression analysis. One hundred and four patients with AD and their mothers were studied. Their mean ages (+/-s.d.) were respectively 6.4 +/- 4.3 and 37.2 +/- 6.6 yrs. In multiple regression analysis, Severity Scoring of Atopic Dermatitis (SCORAD) appeared to be associated with negative family impact and the association remained significant after adjustment for bio-psycho-social factors and HRQOL of patients. The association remained insignificant after adjustment for physical and MH of the mothers. Our results show that the severity of paediatric AD leads to negative family impact through reduction of physical and MH of the mothers, and is independent of patients' HRQOL and sociodemographics. The current approach for managing paediatric AD in Asian society could include early multidisciplinary intervention, aiming at enhancing physical and MH of mothers while minimizing negative impact on family and social isolation. Further research will be welcomed as the results of this study mainly applied to Asian society which could be different to populations from other geographic areas.

Interethnic differences in dementia epidemiology: global and Asia-Pacific perspectives.

The burden of dementia will continue to rise globally, particularly in developing countries, many of which lie in the Asia-Pacific region. It was initially thought that both prevalence and incidence of dementia showed little geographic variation. More recent work has suggested differences: migrant populations attain rates between their homelands and adopted countries, and higher rates have been found in African Americans and Hispanics compared to Caucasian Whites, and also among native Australians. The only interethnic studies in the Asia-Pacific region were performed in Singapore, which showed lower standardized prevalence among ethnic Chinese compared to ethnic Malays and Indians, independent of vascular risk factors. There was conflicting information about the relative frequencies of Alzheimer's disease and vascular dementia between ethnic groups in Singapore. More research, with careful attention to potential cultural confounders, is needed to further explore and better understand interethnic differences in dementia epidemiology.

Diagnostic performance of the Chinese Frontal Assessment Battery in early cognitive impairment in an Asian population.

BACKGROUND: The Frontal Assessment Battery (FAB) has been shown to be useful in evaluating frontal dysfunction. There is a paucity of studies validating cutoffs in the early cognitive impairment. We aim to validate the Chinese FAB in Asian subjects with mild cognitive impairment (MCI) and early dementia. METHODS: Eighty subjects with MCI and mild dementia and 100 cognitively healthy community subjects were studied. ROC analysis was done to determine the Chinese FAB's optimal cutoff scores for age- and education-adjusted subgroups. RESULTS: Chinese FAB scores were significantly lower in early cognitive impairment compared with cognitively normal controls. The optimal cutoff score was 12/13 (sensitivity 92%, specificity 78.7%). A similar cutoff score was obtained following age-adjustment and for subjects with <6 years' education. Of note, the optimal cutoff for subjects with ≥6 years' education was 13/14 (sensitivity 91.8%, specificity 70.3%), an improved diagnostic performance compared to the earlier reported 11/12 cutoff. In comparison, the Mini-Mental Status Examination (MMSE) had lower rule-out accuracy (77% sensitivity, 91.2% specificity). The combination of the Chinese FAB and MMSE was superior to either test in isolation. CONCLUSION: The education-adjusted Chinese FAB has good diagnostic performance, which can supplement the MMSE in early cognitive impairment evaluation with construct differences observed between the Chinese FAB and MMSE.

Osteomalacia: a case series of patients with atypical clinical orthopaedic presentations.

Osteomalacia is uncommon in an affluent subtropical city like Hong Kong, where sunlight exposure is adequate and nutritional support is good. We present three patients who had osteomalacia with different presentations. A 74-year-old male with oncogenic osteomalacia presented with multiple bone pain. His biochemical markers returned to normal 4 days postoperatively after resection of a second toe giant cell tumour of tendon sheath. A 62-year-old woman with a history of liver problem and proximal muscle weakness was admitted with atraumatic fracture of the left distal humerus due to osteomalacia. An 81-year-old vegetarian woman with inadequate sun exposure complained of multiple bone pains. Subsequent investigation revealed dietary- and sunlight-deficient osteomalacia with multiple bony abnormalities including marked femur bowing.

Risk Factors of Progression to Frailty: Findings from the Singapore Longitudinal Ageing Study.

OBJECTIVES: To investigate risk factors of incident physical frailty. DESIGN: A population-based observational longitudinal study. SETTING: Community-dwelling elderly with age 55 years and above recruited from 2009 through 2011 in the second wave Singapore Longitudinal Ageing Study-2 (SLAS-2) were followed up 3-5 years later. PARTICIPANTS: A total of 1297 participants, mean age of 65.6 ±0.19, who were free of physical frailty. MEASUREMENTS: Incident frailty defined by three or more criteria of the physical phenotype used in the Cardiovascular Health Study was determined at follow-up. Potential risk factors assessed at baseline included demographic, socioeconomic, medical, psychological factors, and biochemical markers. RESULTS: A total of 204 (15.7%) participants, including 81 (10.87%) of the robust and 123 (22.28%) of the prefrail transited to frailty at follow-up. Age, no education, MMSE score, diabetes, prediabetes and diabetes, arthritis, ≥5 medications, fair and poor self-rated health, moderate to high nutritional risk (NSI ≥3), Hb (g/dL), CRP (mg/L), low B12, low folate, albumin (g/L), low total cholesterol, adjusted for sex, age and education, were significantly associated (p<0.05) with incident frailty. In stepwise selection models, age (year) (OR=1.07, 95%CI=1.03-1.10, p<0.001), albumin (g/L) (OR=0.85, 95%CI=0.77-0.94, p=0.002), MMSE score (OR=0.88, 95%CI=0.78-0.98, p=0.02), low folate (OR=3.72, 95%CI=1.17-11.86, p=0.03, and previous hospitalization (OR=2.26, 95%CI=1.01-5.04,p=0.05) were significantly associated with incident frailty. CONCLUSIONS: The study revealed multiple modifiable risk factors, especially related to poor nutrition, for which preventive measures and early management could potentially halt or delay the development of frailty.

The Long-Term Impact of Functional Disability on Hospitalization Spending in Singapore.

Singapore is one of the fastest-aging populations due to increased life expectancy and lowered fertility. Lifestyle changes increase the burden of chronic diseases and disability. These have important implications for social protection systems. The goal of this paper is to model future functional disability and healthcare expenditures based on current trends. To project the health, disability and hospitalization spending of future elders, we adapted the Future Elderly Model (FEM) to Singapore. The FEM is a dynamic Markov microsimulation model developed in the US. Our main source of population data was the Singapore Chinese Health Study (SCHS) consisting of 63,000 respondents followed up over three waves from 1993 to 2010. The FEM model enables us to investigate the effects of disability compounded over the lifecycle and hospitalization spending, while adjusting for competing risk of multi-comorbidities. Results indicate that by 2050, 1 in 6 elders in Singapore will have at least one ADL disability and 1 in 3 elders will have at least one IADL disability, an increase from 1 in 12 elders and 1 in 5 elders respectively in 2014. The highest prevalence of functional disability will be in those aged 85 years and above. Lifetime hospitalization spending of elders aged 55 and above is US$24,400 (30.2%) higher among people with functional disability compared to those without disability. Policies that successfully tackle diabetes and promote healthy living may reduce or delay the onset of disability, leading to potential saving. In addition, further technological improvements may reduce the financial burden of disability.

Differential item functioning of the Geriatric Depression Scale in an Asian population.

BACKGROUND: The Geriatric Depression Scale (GDS) is widely used for screening and assessment of major depressive disorder (MDD). Screening scales are often culture-specific and should be evaluated for item response bias (synonymously differential item functioning, DIF) before use in clinical practice and research in a different population. In this study, we examined DIF associated with age, gender, ethnicity and chronic illness in a heterogeneous Asian population in Singapore. METHODS: The GDS-15 and Structured Clinical Interview for DSM-IV diagnosis of MDD were independently administered by interviewers on 4253 non-institutionalized community living elderly subjects aged 60 years and above who were users of social service agencies. Multiple Indicator Multiple Cause latent variable modelling was used to identify DIF. RESULTS: We found evidence of significant DIF associated with age, gender, ethnicity and chronic illness for 8 items: dropped many activities and interests, afraid something bad is going to happen, prefer staying home to going out, more problems with memory than most, think it is (not) wonderful to be alive, feel pretty worthless, feel (not) full of energy, feel that situation is hopeless. LIMITATIONS: The smaller number of minority Indian and Malay subjects and the self-report of chronic medical illnesses. CONCLUSIONS: In a heterogeneous mix of respondents in Singapore, eight items of the GDS-15 showed DIF for age, gender, ethnicity and chronic illness. The awareness and identification of DIF in the GDS-15 provides a rational basis for its use in diverse population groups and guiding the derivation of abbreviated scales.

The association between maternal depression and frequent non-routine visits to the infant's doctor--a cohort study.

BACKGROUND: Perinatal depression is common, but women typically do not seek help for it. We studied its association with frequent non-routine physician visits, which may be a form of help-seeking behaviour. METHODS: A prospective cohort study of women in their 34th to 38th week of pregnancy at the outpatient obstetrics clinic at a Singapore tertiary hospital was done. Screening was done using the Edinburgh Postnatal Depression Scale and diagnosis of major or minor depressive disorder was made using the SCID-IV. At 6 to 12 months' post-partum, women were screened and interviewed again for depression and asked to report the frequencies with which they had brought their infants to the doctor on non-routine visits in the preceding 6 weeks. Four hundred and seventy-one of the 559 patients recruited before delivery were re-interviewed. RESULTS: After adjusting for confounders, women who had brought their infants for three or more non-routine visits to the infant's doctor had a significantly higher prevalence of depression (32.6%) than those with fewer visits (13.6%) (OR 2.87, 95% CI 1.41 to 5.85, p=0.004). The relative risk reduction for women who did not bring their infants for frequent non-routine visits was 0.583 (95% CI 0.44 to 0.73, p=0.002). They were also more likely to have poorer perceived emotional support from their families. LIMITATIONS: These included use of self-reported doctor visits, and relatively high educational levels of the participants. CONCLUSIONS: Doctors should have a high index of suspicion for enquiring about depression and emotional support in mothers who bring their infants for frequent non-routine visits.