Subthreshold depression and cognitive impairment but not demented in stroke patients during their rehabilitation.

BACKGROUND: Subthreshold depression (sD) and cognitive impairment but not demented (CIND) in stroke patients are associated with poorer rehabilitative outcomes. Their diagnosis can easily be operationalized using validated scales. AIM: The aim of the study was to ascertain the prevalence of depressive symptoms and cognitive impairment in stroke patients during three crucial stages of the rehabilitative process, viz. upon admission, upon planned discharges from rehabilitation hospitals and at 6 months post-stroke, using validated scales like the Geriatric Depression Scale and Abbreviated Mental Test (recommended by the British Geriatric Society). Their baseline risk factors were also ascertained. RESULTS: On admission, the prevalence of depressive symptoms and cognitive impairment was 60% and 54% respectively. The prevalence upon planned discharges and 6 months post-stroke, respectively, of depressive symptoms was 38% and 34% and that of impaired cognition was 33% and 40%. Baseline independent correlates at 6 months post-stroke depressive symptoms were: recurrent stroke (OR 3.34); on admission cognitive impairment (OR 4.78) and ADL dependence (OR 5.28). And that of cognitive impairment were: increasing age (OR 8.07); post-stroke dysphagia (OR 4.58); on admission cognitive impairment (OR 23.95) and on admission depressive symptoms (OR 3.50). CONCLUSIONS: Continuous screening and appropriate intervention, especially at baseline, would significantly decrease the burden posed by stroke patients with such psychological impairments in the community.

Appropriate use of personal protective equipment among healthcare workers in public sector hospitals and primary healthcare polyclinics during the SARS outbreak in Singapore.

BACKGROUND: Singapore was affected by an outbreak of severe acute respiratory syndrome (SARS) from 25 February to 31 May 2003, with 238 probable cases and 33 deaths. AIMS: To study usage of personal protective equipment (PPE) among three groups of healthcare workers (HCWs: doctors, nurses, and administrative staff), to determine if the appropriate PPE were used by the different groups and to examine the factors that may determine inappropriate use. METHODS: A self-administered questionnaire survey of 14,554 HCWs in nine healthcare settings, which included tertiary care hospitals, community hospitals, and polyclinics, was carried out in May-July 2003. Only doctors, nurses, and clerical staff were selected for subsequent analysis. RESULTS: A total of 10 236 valid questionnaires were returned (70.3% response); 873 doctors, 4404 nurses, and 921 clerical staff were studied. A total of 32.5% of doctors, 48.7% of nurses, and 77.1% of the administrative staff agreed that paper and/or surgical masks were "useful in protecting from contracting SARS". Among this group, 23.6% of doctors and 42.3% of nurses reported working with SARS patients. The view that a paper and/or surgical mask was adequate protection against SARS was held by 33.3% of doctors and 55.9% of nurses working at the A&E unit, 30.5% of doctors and 49.4% of nurses from medical wards, and 27.5% of doctors and 37.1% of nurses from intensive care units. Factors which predicted for agreement that paper and/or surgical masks were protective against SARS, included HCW's job title, reported contact with SARS patients, area of work, and Impact Events Scale scores. CONCLUSION: A variety of factors determine appropriate use of personal protective equipment by HCWs in the face of a major SARS outbreak.

A study on the prevalence of hepatitis B surface antigen among Chinese adult males in Singapore.

A study was conducted in Singapore on 8829 Chinese men aged 35 years or more to determine whether the prevalence of hepatitis B surface antigen (HBsAg) positivity is associated with the source from which the subjects were recruited, or with occupation as an indicator of socioeconomic status. The HBsAg prevalence rates were significantly different (p less than 0.0001) among the five source groups: 8.3% in healthy blood donors, 7.8 in other healthy subjects, 9.2 in non-hepatic outpatients, 10.3 in hospital non-hepatic patients who were not gravely ill, and 11.2 in hospital non-hepatic patients who were gravely ill. After statistical adjustment by multiple logistic regression for age and occupation, the odds ratio (using 'other healthy subjects' as the reference group) ranged from 0.98 (95% CL = 0.65-1.47) for healthy blood donors to 1.42 (95% CL = 0.95-2.12) for hospital non-hepatic patients who were gravely ill. The HBsAg prevalence rates were also significantly different (p less than 0.0001) among occupations: 8.5% in professional, technical and administrative personnel, 9.7 in clerical, sales and services personnel, 10.3 in agricultural and factory workers and unskilled labourers, and 10.5 among the unemployed and retired. After statistical adjustment for age and source groups, the odds ratio (using professional, technical and administrative subjects as the reference group) ranged from 1.07 (95% CL = 0.99-1.17) for the unemployed and retired subjects, to 1.19 (95% CL = 0.93-1.53) for agricultural and factory workers and unskilled labourers.

Knowledge and concerns of newly diagnosed NIDDM patients in Singapore.

This paper describes the findings of a questionnaire survey of the knowledge and concern of 152 newly diagnosed NIDDM patients presenting at the Government Polyclinic (primary health care centre). This study is part of a project on outpatient diabetic care in Singapore. It was found that 23.7% of the subjects had no education and 51.3% had only primary school education. More than eighty percent of the subjects understood the importance of diet control and weight control in their condition. More than half of the subjects, 61% of males and 52.7% of females were aware that diabetes could not be cured and that once diabetes is controlled, that medication cannot be stopped and that one must still take the medication even if one feels well. Less than 30% knew about the interpretation of blood and urine sugar findings. The two major concerns amongst the subjects were complications and the need for long-term medication. These findings will be incorporated into the next phase of the project where a health education programme for NIDDM patients will be developed and evaluated.

A SAS procedure for exact probability testing of difference between sample and population proportion.

Statistical testing of the hypothesis that the proportion of subjects in a defined population having a certain attribute (proportion of "positives" in a population, P) is equal to some specified value (P0) is frequently encountered in biomedical research. For example, a study might be carried out to statistically test whether the postoperative wound infection rate in patients having undergone an operation with a "new" surgical procedure is 20%, the same value that has been observed for the "established" surgical procedure. The significance test for this hypothesis (e.g., test H0: P = 0.20 against HA: P not equal to 0.20) is usually based on the normal theory approximation method. However, when the sample size is "small", especially if P0 is close to 0 or 1, the normal theory method can yield grossly unreliable results. In contrast, the significance test based on the exact binomial probability procedure always yields reliable results. A computer program coded in SAS is described herein to perform this exact probability test procedure.

Health and morbidity profiles of older adults in Singapore and their health care needs.

Before setting up the first Senior Citizens' Health Care Centre (SCHCC), a survey was done to establish the health and morbidity profiles of older adults in the community and their health care needs. Community volunteers personally interviewed 1,697 persons aged 55 years and above, living in three areas in Singapore. The response rate was 75%. The respondents' general characteristics, the prevalence rate of chronic diseases, their functional and mobility status, utilisation of the health services and how the chronic diseases affected their activities of daily living (ADL) were studied. Among the respondents, 2.1% required nursing care, 4.2% were unable to climb stairs, and 23.3% were on long-term medications. As compared to the younger age groups, those 75 years and above reported more difficulties with mobility (semi-ambulant 6.5%, bedridden 1.8%), more needed assistance in ADL (bathing 4.8%, toiletting 4.7%, dressing 3.0%, and feeding 2.4%) and a higher percentage required nursing care (3.6%). Services that would benefit the frail elderly are reported in this paper.

Awareness and acceptance of hepatitis B vaccination in Clementi, Singapore.

Hepatitis B Virus infection, a public health problem in Singapore, can be effectively controlled by vaccination. This paper reports on a study conducted in 1988/89 to ascertain the awareness and uptake rate of Hepatitis B vaccination. A list of children born between November 1986 and May 1987 in the catchmen zone of the Clementi Maternal and Child Health (MCH) Clinic was obtained. Out of a total of 257 children, 226 (87.9%) responded to our study in May 1988 which was part of a larger community health survey carried out by a group of medical students. The vaccination uptake rate was 23%. The awareness of the parents on Hepatitis B virus infection and vaccination was assessed using a standardised questionnaire. About two-thirds were aware of the main modes of Hepatitis B transmission, 46.5% were aware of the long-term consequences of Hepatitis B infection and 6.6% thought that the vaccine was not safe from serious side effects. A follow-up survey of the respondents was carried out in August 1989. The Hepatitis B vaccination uptake had increased to 48.3%. The immunisation status showed a correlation with the ethnic group, father's occupation and awareness score of respondents. The more than two-fold increase in uptake rate can be attributed to a reduction in the cost of Hepatitis B vaccination and a vigorous nation-wide education programme during the preceding year.

Clinical aspects of health screening for senior citizens.

Out of a total of 1,224 subjects aged 55 years and above who attended the Senior Citizens' Health Care Centres for health screening, new medical conditions were picked up for the first time in 472 subjects, giving an overall pick-up rate of 38.6%. This rate increased with age rising from 29.4% among those aged 55-64, to 45.8% among those aged 65-74 and to 51.4% in the 75 years and above. This trend was found to be of statistical significance (p greater than 0.001). The objective of the health screening programme in the Senior Citizens' Health Care Centres is to detect geriatric problems early in order to take adequate steps to prevent disability and dependency states, so that the elderly may continue to live at home. In this paper, we studied the 472 subjects with abnormal medical conditions. The pick-up rates (per 100) of medical conditions were as follows: cataract 13.8, other eye conditions 6.5, deafness 4.5, other ear conditions 2.7, diabetes mellitus 2.5, hypertension 2.2 and osteoarthritis 1.6. The socio demographic profile and the medical conditions of the 472 subjects were also studied, with implications on their quality of life in future. We recommend that physicians specifically screen for diabetes mellitus, hypertension, eye and ear abnormalities in all asymptomatic elderly, during periodic health check ups.

Health screening for the elderly--the Singapore Senior Citizens' Health Care Centres' experience 1986-1989: an overview.

A systematic health screening programme for the elderly aged 55 years and above was implemented in the first Senior Citizens' Health Care Centre (SCHCC) in 1986. This programme was expanded to two more SCHCCs by 1989. The first 1,224 clients aged 55 years and above, who attended this programme in the first three SCHCCs were studied in this paper. The characteristics of the elderly who voluntarily attended the SCHCCs for health screening were studied with respect to their referrals, socio demographic status, whether they had regular physician care, the existing medical problems and the new medical problems picked up at health screening. Of those screened, 49.6% were referred for the programme by relatives and self, and 28.2% by community centres, thus, showing that community and family supported the programme. Only 7.2% of referrals to the screening programme came from general practitioners and 4% from polyclinic doctors. It is interesting to note that 40% of clients had no regular physician care. About two thirds (57.2%) had one or more existing chronic medical conditions or disability at the time of screening. The majority with existing conditions had hypertension (24.8%) and diabetes (15.5%). Other existing conditions were ischaemic heart disease (6.2%), cataract (3.9%) and asthma (3.6%). The pick-up rate of medical conditions among the clients at the time of health screening was 38.6% for the whole group. This showed a rising trend from the younger to the older age groups being 29.4% in the age group 55 to 64, to 45.8% in the age group 65 to 74, and 51.4% in the age group 75 years and above (p less than 0.001). Some of the topical issues related to a health screening programme for the elderly have been discussed.

Disability, rehabilitation and after-care of stroke patients after discharge from hospital, Singapore 1983-84.

135 new onset stroke patients admitted over a nine-month period to a medical unit in Singapore were studied with emphasis on their rehabilitation and community care after discharge. Follow-up visits were made to 79 survivors at third month after onset. 16.7% of the patients made apparently complete recoveries, 20.3% remained slightly disabled, 21.5% moderately disabled, and the remaining 41.8% severely disabled. Sixty-five patients were staying in private households at third month follow-up. The main care-givers were usually female relatives. These informal carers assisted a large proportion of patients in various activities of living: 62.0% in dressing, 54.4% in walking and toileting, 30.4% in feeding, and 22.8% in turning in bed. The study establishes the need to develop and strengthen supportive services to enable disabled stroke patients to be cared for in their own homes. These include the home nursing service, elderly day care service, home help service, and meals-on-wheel service.

Is improvement in impaired cognition and depressive symptoms in post-stroke patients associated with recovery in activities of daily living?

BACKGROUND AND PURPOSE: Depression and cognitive impairment after stroke are associated with physical functional outcomes, but there are limited data on whether depressive symptoms and cognitive status and improvements independently influence functional status and recovery. METHODS: In a 6-month prospective cohort study of 141 post-acute stroke patients, demographic and clinical data on admission, and neurological, cognitive, depressive symptoms and functional variables on admission and at 6 months after stroke were measured using the National Institute of Health Stroke Scale (NIHSS), Abbreviated Mental Test (AMT), Geriatric Depression Scale (GDS) and Barthel Index (BI). RESULTS: On multivariate analysis, severe activities of daily living (ADL) dependence at 6 months was significantly less likely associated with higher baseline AMT score denoting better cognitive status (OR=0.68, 95% CI 0.48-0.97 per score point) and with greater AMT change score denoting greater cognitive improvement (OR=0.61, 95% CI 0.41-0.91 per change score point); it was also more likely with higher baseline NIHSS scores denoting severe neurological impairment, (OR=1.74, 95% CI 1.13-2.63 per point score), NIHSS change score [denoting lesser neurological improvement (OR = 1.83, 95% CI 1.13-2.93 per unit change score)], but was not associated with baseline or change scores of GDS. Greater magnitudes of functional recovery [BI change score (standardized beta)] were associated with better baseline depressive symptoms (-0.21) and improvement (-0.31), but not with cognitive status or improvement, in the presence of other significant variables, neurological status (-0.89) and improvement (-0.65), lower baseline physical functional status (-0.85) and younger age (-0.23). CONCLUSIONS: These data suggest that improving depressive symptoms in stroke patients may accelerate functional recovery, but the level of physical functioning achieved post-stroke is determined by neurological and cognitive factors, consistent with the evidence that improvement of depressive symptoms through therapeutic intervention is limited by cognitive impairment.

Determinants of length of stay during post-stroke rehabilitation in community hospitals.

INTRODUCTION: Length of stay (LOS) in hospitals is the largest contributor of direct stroke care cost. Rehabilitation accounts for 16 percent of healthcare cost in the six-month post-stroke period. It is important to determine factors extending LOS in rehabilitation hospitals to identify focus areas of cost-control strategies. The aim of the study was to ascertain the predictors of LOS of post-stroke patients admitted into two community hospitals offering rehabilitation. METHODS: An observational cohort study was conducted on 200 stroke patients admitted from acute hospitals into two community hospitals. Data collected included baseline sociodemographical variables, and the National Institute of Health Stroke Scale, Abbreviated Mental Test, Geriatric Depression Scale and Barthel Index were used to assess neurological impairment, cognitive impairment, depressive symptoms and functional disability, respectively. Medical complications (defined as new or exacerbated medical problems that generated additional physician evaluation, a change in medication or additional medical intervention), after patients were admitted to the community hospitals until discharged, were recorded. The outcome variables measured were length and cost of stay. RESULTS: The mean LOS in our study was 34.4 (standard deviation [SD] 18.4) days, and the mean cost of hospital stay was S$2,410.83 (SD S$2,167.26). Length and cost of hospital stay were significantly correlated (r equals 0.52; p-value is less than 0.01). On multiple linear regression analysis, the significant variables positively associated with LOS were medical complications and functional dependence on admission. Significant variables negatively associated with LOS were unplanned discharge and recurrent strokes. CONCLUSION: Medical complication is a key reversible determinant of increased LOS of post-stroke patients receiving rehabilitation in community hospitals. Strategies for prevention, early detection and treatment of medical complications during stroke rehabilitation are discussed.

Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients.

BACKGROUND: Length of hospital stay (LOHS) is the largest determinant of direct cost for stroke care. Institutional discharges (acute care and nursing homes) from rehabilitation settings add to the direct cost. It is important to identify potentially preventable medical and non-medical reasons determining LOHS and institutional discharges to reduce the direct cost of stroke care. AIM: The aim of the study was to ascertain the total direct cost, LOHS, frequency of institutional discharges and their determinants from rehabilitation settings. METHODOLOGY: Observational study was conducted on 200 stroke patients in two rehabilitation settings. The patients were examined for various socio-demographic, neurological and clinical variables upon admission to the rehabilitation hospitals. Information on total direct cost and medical complications during hospitalization were also recorded. The outcome variables measured were total direct cost, LOHS and discharges to institutions (acute care and nursing home facility) and their determinants. RESULTS: The mean and median LOHS in our study were 34 days (SD = 18) and 32 days respectively. LOHS and the cost of hospital stay were significantly correlated. The significant variables associated with LOHS on multiple linear regression analysis were: (i) severe functional impairment/functional dependence Barthel Index < or = 50, (ii) medical complications, (iii) first time stroke, (iv) unplanned discharges and (v) discharges to nursing homes. Of the stroke patients 19.5% had institutional discharges (22 to acute care and 17 to nursing homes). On multivariate analysis the significant predictors of discharges to institutions from rehabilitation hospitals were medical complications (OR = 4.37; 95% CI 1.01-12.53) and severe functional impairment/functional dependence. (OR = 5.90, 95% CI 2.32-14.98). CONCLUSION: Length of hospital stay and discharges to institutions from rehabilitation settings are significantly determined by medical complications. Importance of adhering to clinical pathway/protocol for stroke care is further discussed.

History of blood transfusion, tattooing, acupuncture and risk of hepatitis B surface antigenaemia among Chinese men in Singapore.

To determine whether a history of blood transfusion, tattooing, and acupuncture is associated with an increased risk of hepatitis B surface antigenaemia, a study of 6,328 Chinese men between 35 and 65 years of age was undertaken in Singapore. The age-adjusted odds ratios were 1.44 (95% CI: 1.14, 1.83) for blood transfusion, 1.14 (95% CI: 0.80, 1.63) for tattooing, and 0.88 (95% CI: 0.71, 1.11) for acupuncture. Using no history of any of the three percutaneous procedures as reference, the age-adjusted odds ratio for blood transfusion only was 1.40, 95% CI: 1.07, 1.84, and for blood transfusion plus tattooing was 2.59, 95% CI: 1.18, 5.70. The proportion of HBsAg positive cases attributable to blood transfusion and tattooing, as measured by the population attributable risk, are 4.1 and 0.7 per cent, respectively.