BACKGROUND: Non-Hodgkin's lymphoma has increased in incidence in many countries, particularly in the West. Advances in diagnostic methods and the understanding of the disease over time pose a challenge to the interpretation of these trends. The aim of this study was to determine if the disease has increased in Singapore, a newly industrialized Asian country, and to examine the possible factors that may account for any observed changes.
METHODS: Data from the population-based Singapore Cancer Registry for the period 1968 to 1992 were reviewed to determine time trends based on sex and ethnic group. The Poisson regression model was fitted to the cross-tabulated data to obtain the adjusted incidence density ratios.
RESULTS: A total of 1988 cases of non-Hodgkin's lymphoma were included in the analysis. There was an overall increase in incidence among both Chinese and Malaysians. However, the rate of increase was greater in females (age-standardized rate from 1.8 per 100,000 in 1968-1972 to 4.5 per 100,000 in 1988-1992) than in males (3.2 per 100,000 to 5.9 per 100,000 in the same time periods). Between ethnic groups, Malay females were at higher overall risk compared with their Chinese counterparts (incidence density ratio 1.32; 95% confidence interval, 1.08-1.61). Although a substantial proportion of patients diagnosed with Hodgkin's disease between 1968 and 1972 were reclassified on review, using present criteria, as having non-Hodgkin's lymphoma, it is unlikely that this, and other recent changes in histologic interpretation, could have accounted for an increase of this magnitude.
CONCLUSIONS: Non-Hodgkin's lymphoma has increased in incidence among the Chinese and Malay populations in Singapore. The pattern of increase differs from that of the common cancer sites, and suggests the need to look for environmental and genetic factors that have not yet been elucidated.
The current status and directions for changes of issues related to quality care in health services in Asian countries--Malaysia, China, Singapore, Japan and Korea are overviewed. In countries with public sector dominated health care systems such as Malaysia. China and Singapore, governmental leadership in quality care is prominent along with legislative backup. Japan and Korea have private sector dominated health care systems and quality care activities are mainly carried out by non-governmental organisations. Hospital accreditation programs are in the developing stages in most countries, although China and Korea started in 1980. Most Asian countries are at the initial stages in quality care activities and focus has been placed on education and training. Asian countries are not exempted from efforts to enhance quality care activities and a new horizon in quality health care is emerging.
Hong Kong, Taiwan, Singapore, and Malaysia are initiating health care reform to meet the changing demands of populations with improved socioeconomic status and access to modern technologies and who are living longer than in previous generations. Hong Kong, in particular, is facing a unique set of circumstances as its people prepare for the transition in 1997 from a British colony to a Special Administrative Region of China. While spending only 4% of its gross domestic product on health care, it has a large and regulated public hospital system for most inpatient medical care and a separate, loosely regulated private health care system for most outpatient medical care. In 1993 the Secretary for Health and Welfare of Hong Kong initiated a year-long process to debate the pros and cons of 5 fundamental programs for health care reform. After a year of open consultation, options were chosen. We describe the Hong Kong health care system, the fundamental changes that have been adopted, and lessons for reformers in the United States.
"This article discusses international migration from Java in the past and present and the role brokers have played in stimulating this movement. It describes legal and clandestine labor migration to Singapore, Malaysia, and Saudi Arabia, the influence of employment brokers on the process, and the organization of the recruitment networks. The involvement of brokers is crucial but not always beneficial for the migrants. Migrants are dependent on the brokers and risk exploitation. In the case of movement to Saudi Arabia, there is a linkage with religious institutions and the Islamic pilgrimage."
As growth potential in the U.S. market declines and regulatory constraints increase, providers of health-related services may look increasingly to international opportunities as a way to supplement the lost domestic market. In this article, critical factors bearing on the decision to compete in international markets are identified. Existing theories of multinational competition are expanded to provide a framework for analyzing international competition. Applied in the context of the proprietary hospital industry, the critical factors governing both the selection of foreign markets and mode of entry are proposed to be host country receptivity and market growth potential.
The mortality from coronary artery disease (CAD) in Indians is more than three times that in the Chinese and Malays of Singapore. Serum total and HDL cholesterol as well as apolipoprotein (Apo) AI, AII and B levels were determined in a group of 349 newborns (cord blood) from both sexes in these three ethnic groups in order to examine if a trend is reflected at birth. Both serum LDL cholesterol and Apo B levels were low in the newborn, while HDL cholesterol and Apo AII levels were almost the same as in adults. Serum Apo AI levels were also low in newborns. No consistent difference as to ethnic group or sex was observed in any of the parameters investigated, except that the females had significantly higher levels of serum Apo AI in all the ethnic groups. Serum total and HDL cholesterol levels in Singapore newborns were comparable to those reported in Caucasians and Asians. The trends of incidence of CAD were not reflected in the lipid profiles studied at birth.
"A recent conference sponsored by the United Nations Center for Regional Development (UNCRD) in Nagoya, Japan examined the growing importance of labor migration for four major Asian labor importers (Japan, Hong Kong, Malaysia, and Singapore) and five major labor exporters (Bangladesh, Korea, Pakistan, Philippines, and Thailand).... The conference concluded that international labor migration would increase within Asia because the tight labor markets and rising wages which have stimulated Japanese investment in other Asian nations, for example, have not been sufficient to eliminate migration push and pull forces...."
"This article provides some empirical information pertaining to the benefits and costs of foreign labor to Singapore and subjects to critical analysis some of Pang and Lim's hypotheses concerning the costs of labor importation presented in a previous article.... The article concludes with a discussion of the real cost to Malaysia of Singapore's labor importation policies and its potential for disruption of Malaysia's development plans."
Coagulation, fibrinolytic activity and platelet function were studied in 104 Asian women volunteers who received 150 mg of depot medroxyprogesterone acetate intramuscularly every three months for two years or more. The results were compared with those in matched controls. There was a paucity of change in coagulation factors. The fibrinogen levels were increased and prothrombin time was shortened. The fibrinolytic activity, as shown by the euglobulin clot lysis time, was significantly increased. This latter change contrasts with the many reports concerning Caucasian women and may reflect an increase in fibrinolytic potential in Asian women.
STUDY OBJECTIVE: The aim of the study was to examine cardiovascular risk factors to see how these might explain differences in cardiovascular disease mortality among Chinese, Malays, and Indians in the Republic of Singapore.
DESIGN: The study was a population based cross sectional survey. Stratified systematic sampling of census districts, reticulated units, and houses was used. The proportions of Malay and Indian households were increased to improve statistical efficiency, since about 75% of the population is Chinese.
SETTING: Subjects were recruited from all parts of the Republic of Singapore.
SUBJECTS: 2143 subjects aged 18 to 69 years were recruited (representing 60.3% of persons approached). There were no differences in response rate between the sexes and ethnic groups.
MEASUREMENTS AND MAIN RESULTS: Data on cardiovascular risk factors were collected by questionnaire. Measurements were made of blood pressure, serum cholesterol, low and high density lipoprotein cholesterol, fasting triglycerides and plasma glucose. In males the age adjusted cigarette smoking rate was higher in Malays (53.3%) than in Chinese (37.4%) or Indians (44.5%). In both sexes, Malays had higher age adjusted mean systolic blood pressure: males 124.6 mm Hg v 121.2 mm Hg (Chinese) and 121.2 mm Hg (Indians); females 122.8 mm Hg v 117.3 mm Hg (Chinese) and 118.4 mm Hg (Indians). Serum cholesterol, low density lipoprotein cholesterol and triglyceride showed no ethnic differences. Mean high density lipoprotein cholesterol in males (age adjusted) was lower in Indians (0.69 mmol/litre) than in Chinese (0.87 mmol/litre) and Malays (0.82 mmol/litre); in females the mean value of 0.95 mmol/litre in Indians was lower than in Chinese (1.05 mmol/litre) and Malays (1.03 mmol/litre). Rank prevalence of diabetes for males was Indians (highest), Malays and then Chinese; for females it was Malays, Indians, Chinese.
CONCLUSIONS: The higher mortality from ischaemic heart disease found in Indians in Singapore cannot be explained by the major risk factors of cigarette smoking, blood pressure and serum cholesterol; lower high density lipoprotein cholesterol and higher rates of diabetes may be part of the explanation. The higher systolic blood pressures in Malays may explain their higher hypertensive disease mortality.
The prevalence of hepatitis B virus markers in 121 men and 239 women prostitutes was studied. Of 33 (9.7%) with hepatitis B surface antigen (HBsAg), nine (27.3%) also had hepatitis Be antigen, which was more prevalent in men than women. Antibodies to HBsAg (anti-HBs) and to hepatitis B core antigen (anti-HBc) were found in about 71% of men and women prostitutes. Hepatitis B virus markers were more prevalent in men than in women prostitutes. Compared with other people, prostitutes had a significantly greater prevalence of hepatitis B virus markers. This study strongly suggested the importance of sexual transmission of infection with hepatitis B virus in a country where infection is endemic.
A study of race-related distribution of hepatitis B markers was conducted in 458 children admitted consecutively to Singapore General Hospital. The positive rates for hepatitis B surface antigen (HBsAg) in Chinese, Malays and Indians were 11.2, 8.0 and 12.2% respectively and the corresponding figures for anti-HBs were 30.2, 12.0 and 14.6%. In Chinese children HBsAg prevalence was shown to be sex-related, being higher in males than females. The percentages of Chinese children positive for anti-HBs and anti-HBc were also higher than those of the Indians. This study confirmed that Singapore children were exposed to hepatitis B infection from early life. All three races were equally susceptible to this infection.
Previously, perceived competence of and attraction toward targets categorized by race showed in-group bias and no bias, respectively. Consequently, previous investigators regarded intergroup perception as a compromise between the norms of in-group bias and fair-mindedness. An alternative hypothesis for such findings is that attraction is not as relevant a dimension for intergroup discrimination as is competence. To test contrasting predictions of these hypotheses, the present authors asked participants from the majority and minority groups in Singapore (ns = 320) to evaluate either competence of or attraction toward one of the five targets. Consistent with the hypothesis that intergroup perception is a compromise, both dimensions yielded a uniform but weak in-group bias. The participants' equating of the in-group with one out-group further illustrated fair-mindedness. The authors discussed implications of the findings.
As little is known about health-related quality of life (HRQoL) in Asians with anxiety disorders, we assessed HRQoL in Singaporeans with anxiety disorders and identified factors influencing their HRQoL. Outpatients with anxiety disorders (n = 119) attending a hospital psychiatric clinic completed the Short Form 36 Health Survey (SF-36), Beck Anxiety Inventory (BAI) and General Health Questionnaire (GHQ-12). SF-36 score reduction from population norms (quantified as the number of standard deviations below the mean) in these subjects was compared with existing data on Singaporeans with various medical conditions and Americans with panic disorder (PD). Factors influencing HRQoL were examined using stepwise multiple linear regression models. SF-36 score reduction in these subjects (0.3-1.4 SD) was greater than that in Singaporeans with systemic lupus erythematosus or thyroid cancer survivors for seven scales but similar to that in Americans with PD (0.5-1.7 SD). BAI and GHQ-12 scores, presence of PD/generalized anxiety disorder, presence of chronic medical conditions, being married or increasing age accounted for 19-61% of the variance in six selected SF-36 scales. In conclusion, it can be said that Singaporeans with anxiety disorders experience clinically important reductions in HRQoL; both clinical and socio-demographic factors influence HRQoL in such subjects.
Study site: Neuroscience Psychiatric Clinic, tertiary referral hospital, Singapore
There is still substantial uncertainty concerning the association between Chlamydia pneumoniae and ischemic heart disease. This may partly be explained by the adjustment for potential confounders in different population studies. This is the first study in Singapore to look at the association of C. pneumoniae seropositivity with ischemic heart disease in a multivariate analysis. A random sample of 714 persons aged between 35 and 69 years was selected from the participants of the Singapore National Health Survey conducted in 1998. Data on clinical measurements and conditions were collected using biochemical tests and interviewer-based questionnaires. Ischemic heart disease was defined by the Rose questionnaire and included history suggestive of angina and/or myocardial infarction. Immunoglobulin G antibodies for C. pneumoniae were detected using an indirect microimmunofluorescence test, and seropositivity was defined as IgG titers > or = 1:16. There were no statistically significant differences in the prevalence rates of seropositivity to C. pneumoniae among the three ethnic groups, that is, Chinese (80.4%), Malays (74.0%), and Asian Indians (73.2%). There was no association between seropositivity and ischemic heart disease after adjustment for age alone (OR 1.00, 95% CI 0.54-1.83) or for age, sex, and other risk factors of atherosclerosis (OR 0.99, 95% CI 0.53-1.84). C. pneumoniae Immunoglobulin G seropositivity was not associated with an increased risk of ischemic heart disease as defined by the Rose angina questionnaire in Singapore.
Rheumatoid arthritis (RA) is a chronic arthritic condition that can lead to deformities and disabilities. Although numerous studies reported the association of human leukocyte antigen (HLA)-DRB1*04 and RA, other genes, e.g. cytokines genes, may contribute towards disease susceptibility. Interleukin-18 (IL-18) is a proinflammatory cytokine postulated to play a role in the acute and chronic inflammatory phases of RA. The IL-18 protein expression seems to be regulated by two single-nucleotide polymorphisms (SNPs) located at positions -607 and -137 in the promoter region of the gene. It is postulated that specific alleles may be associated with susceptibility to the development of RA. In the present study, we described the IL-18 gene promoter region genotypes and combined genotypes (-607/-137) in 106 RA patients and 273 unrelated healthy controls to evaluate the contributions of these alleles to RA predisposition in Chinese, Malays, and Indians. The genotyping were performed using sequence-specific polymerase chain reactions. Rheumatoid factors were assayed by enzyme-linked immunosorbent assay. Biodata were obtained through chart review. The controls had significantly higher frequency of AA genotype at position -607 when compared to RA patients. No significant differences were observed in the distribution of either allelic or genotypic frequencies at position -137. There was no association between the genotypes and the presence of rheumatoid factors. This study did not find evidence of a genetic susceptibility factor but demonstrated the novel finding that the AA genotype at position -607 is associated with a protective effect against development of RA in Chinese individuals. This protection may be mediated through inhibition of cyclic (Adenosine 3', 5'-cyclic monophosphate) AMP-responsive element (CRE)-binding protein by the disruption of the CRE consensus sequence.
There are many crucial determinants of the individual outcome and benefit of a university education including the stressful interplay of cultural and socioeconomic factors which are of growing importance in the inflationary 1970's. An epidemiological study of university students from 1969-1972 in Canada, 1973-1974 in Britain, and 1975 in Singapore, attempted to identify stresses leading to mental ill-health in these students. Singapore was chosen as an example of a culture bridging the developed Northern and developing Southern nations of the world. Cultural differences affecting the results of the study are discussed as is the role of social change.