BackgroundLow-wage migrant workers are vulnerable to healthcare inequities. We sought to identify potential barriers to healthcare and risk factors for mental health issues in non-domestic migrant workers in Singapore, and identify high-risk subgroups.MethodsA cross-sectional, interviewer-administered survey of 433 non-domestic migrant workers was conducted at subsidised clinics and a foreign worker dormitory from July to August 2016. Questions assessed healthcare usage patterns, affordability issues, barriers to care and psychological distress using a validated screening scale (Kessler-6).FindingsBangladeshi workers surveyed were more likely to be single, have more financial dependents, a lower level of education and salary and pay higher agent fees (p<0.01). 61.4% of workers reported that they had insurance, but had poor understanding of whether it covered inpatient/outpatient expenses. The majority of workers had not, or were not sure if they had, received information about company-bought insurance (72.4%). Among those who had, most reported that information was not in their native language (67.7%). Non-specific psychological distress was found in 21.9%, as estimated by the Kessler-6 scale. Multivariate analysis found that psychological distress was independently associated with Bangladeshi nationals (OR 2.98, 95% CI 1.58 to 5.62; p=0.001) and previous experience of financial barriers to healthcare (OR 3.86, 95% CI 2.25 to 6.62; p<0.0001).InterpretationWe identified gaps in non-domestic migrant workers' knowledge of healthcare coverage, and substantial financial barriers to healthcare. The Bangladeshi population in our study was at higher risk of such barriers and psychological distress. These represent areas for further research and intervention.

ObjectivesTo estimate the prevalence of HIV-associated neurocognitive disorders (HAND) among HIV patients in a multiethnic South Asian population, describe the pattern of neurocognitive impairment in HAND and the factors associated with HAND.DesignA cross-sectional survey of HIV-positive outpatients and inpatients.SettingThe sole referral centre for HIV/AIDS treatment in Singapore.ParticipantsInclusion criteria were HIV positive, age between 21 and 80 years old and at least 3 years of education. Exclusion criteria included concomitant delirium, serious systemic disease or major psychiatric illness. 265 patients did not meet criteria or declined to participate. The final sample size was 132.Outcome measuresThe primary outcome measure was cognitive impairment based on performance on the Montreal Cognitive Assessment, International HIV Dementia Scale and Instrumental Activities of Daily Living. The secondary outcome measure was the classification of impairment based on the 2007 updated research nosology for HAND.ResultsThe prevalence of HAND was 22.7% of which 70% (15.9% of total) were asymptomatic neurocognitive impairment, 23.3% (5.3% of total) were mild neurocognitive disorder and 6.7% (1.5% of total) were HIV-associated dementia. Increasing age (OR 1.104, 95% CI 1.054 to 1.155, p<0.001), less education (OR 0.78, 95% CI 0.69 to 0.89, p<0.001) and low baseline CD4 count (OR 0.15, 95% CI 0.03 to 0.74, p=0.019) were associated with HAND. Delayed recall, language and abstract thinking were the domains most commonly affected, but impairment in visuospatial ability (RC 3.013, 95% CI 1.954 to 4.073, p<0.001) and attention (RC 2.205, 95% CI 1.043 to 3.367, p<0.001) were most strongly associated with HAND.ConclusionHAND is common among HIV patients in a South Asian sample, most of whom are asymptomatic. Older patients with less education and severe illness at diagnosis are at highest risk of HAND. Delayed recall is most commonly affected, but visuospatial dysfunction is most strongly associated with prevalent HAND.

Sleep disturbance, independent of psychological distress, is an important prognostic factor of functional and social outcomes after mild traumatic brain injury.

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Introduction: Psychosis is a prominent neuropsychiatric symptom of Parkinson’s disease (PD) and is associated with negative outcomes, such as poorer quality of life and greater rate of functional impairment. Early identification of patients with PD at risk of developing psychosis facilitates appropriate management to improve outcomes. However, this phenomenon has not been examined locally. This study aimed to examine the prevalence of PD-associated psychosis in the local setting, identify any associated risk factors, as well as characterise the cognitive trajectory of patients with PD with psychosis. Methods: A retrospective cohort of 336 patients with PD, who presented to the National Neuroscience Institute, Singapore, in 2006 and 2007 and attended follow-up visits through to 2013 was analysed. The data analysed included scores from clinician assessments of cognitive function, disease severity and presence of psychotic symptoms, conducted when clinically appropriate during patients’ medical visits. Survival analysis and logistic and linear regression analysis were performed. Results: Psychosis was diagnosed in 63 patients with PD, indicating a prevalence of 18.8% for PD-associated psychosis. Incidence of psychosis in PD was calculated to be 40 per 1,000 person-years. No significant association was found between demographic variables and the odds of developing psychosis in PD. Regression analyses found that the presence of psychosis significantly predicted greater cognitive decline and disease severity. Conclusion: Psychosis has a significant presence among the PD population in Singapore, possibly serving as an indicator of more rapid cognitive decline and progression of PD severity.

Introduction:Migrant workers comprise about one-fifth of Singapore's resident population and form a substantial and vital component of the nation's workforce. However, limited data is available regarding the barriers that migrant workers face in accessing healthcare from the healthcare providers' perspective. Methods:We conducted a survey on doctors working in four restructured hospitals in Singapore, to assess what they perceived to be barriers faced by migrant workers in accessing healthcare. We also assessed the doctors' understanding of migrant-health-related policies in Singapore. Results:A total of 427 survey responses were collected. Most respondents were senior doctors (senior residents or consultants) who had been practising medicine for a median of ten years.Among doctors, the most common perceived barriers to migrant workers accessing healthcare were related to culture/language (92.3%) and finances (healthcare cost) (81%). Of the six questions asked pertaining to migrant healthcare policy in Singapore, the respondents achieved a median of four correctly answered questions (interquartile range 3-5), and 55% were unaware or unsure of available resources for migrant workers. Conclusion:Our study identified healthcare providers' perceived barriers to the delivery of healthcare to migrant workers, which corroborate previously published data reported by migrant workers themselves. Further efforts should be directed toward diminishing these barriers and increasing the literacy of migrant health among healthcare workers.

Background Practical screening strategies are necessary to detect neurocognitive impairment of all severities in HIV populations, which remains prevalent despite highly active antiretroviral therapy and requires full neuropsychological testing for diagnosis. We aimed to develop a brief and clinically feasible battery to screen for HIV-associated neurocognitive disorders (HAND) in resource-limited settings even where English is not the native language. Methods A total of 53 outpatients were recruited from a multi-ethnic Southeast Asian HIV-positive cohort. Performance on a neuropsychological protocol was used to define cognitive impairment, of which 28 patients (52.8%) were identified with HAND. Receiver operating characteristic analysis was used to determine the best combinations of cognitive tests for the screening battery. Results 3 different combinations of cognitive tests that required minimal literacy, time to administer, and administrator training were found to classify HAND with fair accuracy. Montreal Cognitive Assessment (MoCA), in combination with tests of psychomotor coordination, verbal learning and speed processing, yielded area under curve scores of above 0.75, the primary outcome of receiver operating characteristic analysis. Conclusion The 3-test combinations presented in this study appear to be promising screening options for HAND in HIV-infected patients. The addition of 2 tests to MoCA improves the overall accuracy while retaining its convenience, giving more potential for the inclusion of cognitive screening in routine clinical care. Further validation of the batteries in specific settings is warranted to determine specific screening cut-offs to a global cognitive score.

There have been some small studies that suggest a link between autism spectrum disorders and criminal offending either through cognitive defi cits [1] or circumscribed interests [2]. Only a handful of case reports exist about sexual offending in individuals with autistic disorder or Asperger ' s syndrome. In contrast, there is a more substantial body of literature that links sexual offending to intellectual disability [3] or acquired brain injury [4]. Of greater interest is that there are even fewer reports about recovery from autistic disorder with or without specifi c treatment [5]. A case is reported here about improvement in certain autistic characteristics in a boy previously diagnosed with autism, after an acquired brain injury, and the unusual coexistence of sexual offending.The patient is the eldest of two children and was born via emergency Caesarean section because of pre-labour rupture of membranes. His parents described him as being an easy child in the fi rst year, and achieved milestones of head lifting, turning over and walking at appropriate times. Between the ages of two and fi ve, he was not able to communicate using speech, pointing or gesturing. He cried and screamed when his needs were not met. Also, he did not play or interact with other children, and did not engage in imaginary or imitative play. He did not play with toys as they were meant to be played and was only interested in spinning the wheels of vehicle toys. He was then diagnosed with autistic spectrum disorder between the ages of four and fi ve. He learnt to talk at the age of fi ve but only managed short phrases and would not spontaneously initiate conversation with another person. He still did not interact with other children even though he was at a childcare centre. A circumscribed interest in vehicles and their wheels continued and he had stereotyped movements of banging doors and other furniture. He attended special needs schools where he was assessed to have mild intellectual disability with an IQ of 65.