Original Article

GWM Cham, E Seow
Correspondence: Dr Gregory Cham, wai_ming_cham@notes.ttsh.gov.sg

ABSTRACT
Aim To determine the pattern and frequency of elder abuse presenting to an urban Emergency unit in Singapore.
Method The survey was conducted from May 1994 to December 1997. The patients consisted of adults who were 65 years or older who presented to the Emergency Department with non-accidental trauma or complained of other acts of cruelty.
Result 17 cases of elder abuse were found, out of a total of 62,826 elderly patients. The frequency of elder abuse presenting to the Emergency Department was 0.03%. Elder abuse makes up 2.9% of all cases of family violence involving adults in this period. The average age was 74.6 years old. There was a predominance of Chinese females. In 58.8% the assailants were the daughter-in-law or son. 70.5% were ambulatory. Most (76.4%) had a chronic medical illness, commonly hypertension, diabetes mellitus, or both. Blunt musculoskeletal trauma, head or maxillofacial injuries were the commonest injuries encountered.
Conclusion Elder abuse is a significant subset of Family Violence. It may be more widespread than thought. Awareness of its occurrence is a first step in halting its progression.

Keywords: elder abuse, domestic violence, family violence, profile, emergency
Singapore Med J 2000; 41(12): 571-574

JHK Kua, G Parker, C Lee, AF Jorm
Correspondence: Dr J H K Kua

ABSTRACT
Objectives To compare responses to a mental health literacy survey assessing the likely outcome of three major mental disorders by primary health practitioners (OPD doctors and GPs) and by psychiatrists in Singapore.
Methods We used two vignettes of Major Depression and Schizophrenia developed in an Australian study. In addition, a third vignette of Mania was developed locally and included. The respondents were required to choose one of the set of prognostic options if the patients received or did not receive professional help, to rate the likely impact of the disorder, and to assess the likelihood of the patient being discriminated against. Psychiatrists' responses were obtained by surveying staff at Woodbridge Hospital, while the primary health practitioners were required to respond to a postal survey.
Results The response rate for the psychiatrists was 70% (69/99), while the Primary health practitioners had an overall response rate of 38% (264/691). The response from OPDs being 51% (77/151) and that of the GPs being 35% (189/540). There was evidence of disorder specificity, with schizophrenia judged as having the worst outcome and depression the best outcome in response to treatment. There was also evidence of group specificity, with the psychiatrists most optimistic and the OPD doctors least optimistic about the outcome following professional intervention. The majority of both the primary health practitioners and the psychiatrists judged that patients would be discriminated against, more so for schizophrenia and mania than for depression. Compared to the OPD doctors, a lower percentage of GPs felt that the patients would be discriminated against.
Conclusion Primary health practitioners in Singapore hold more negative views than Singapore psychiatrists about the outcome of professional intervention for three major psychiatric disorders. This finding has implications for education and training for primary health practitioners as well as for treatment of psychiatric patients in the primary health setting.

Keywords: primary health practitioners, psychiatrists, mental health literacy, outcome, discrimination
Singapore Med J 2000; 41(11): 542-547

P Lee, CBE Chee, YT Wang
Correspondence: Dr Lee Pyng, lee_pyng@notes.ttsh.gov.sg

ABSTRACT
Introduction Management of spontaneous pneumothorax (SP) is variable and the initial management of SP is often undertaken by frontline junior medical staff.
Objectives To assess if medical education in the principles of SP management is adequate and to determine if practice variability exists among different disciplines.
Methods A validated questionnaire survey on the knowledge and practice of the junior medical staff posted to a general hospital from May to December 1998 was performed. 138 doctors posted to the various departments: medical (n = S9), surgical (n = 46) and emergency (n = 33) were surveyed.
Results The response rate was 95%. 73% surveyed had experience inserting chest tubes (CT). Of the 27% (n = 37) who had never inserted CT, 41% were medical officers. Our results showed adequate knowledge pertaining to initial management of primary SP (PSP). The preferred site and method for CT insertion was the 5th intercostal space, anterior axillary line and open method. There was significant practice variability in the CT size, method of insertion and CT removal sequence among the disciplines (p < 0.05). However a significant proportion of staff (49%) chose to observe or aspirate an acutely breathless patient with a 10% secondary SP (SSP) instead of CT insertion.
Conclusion While knowledge in PSP appears adequate, management of SSP and practical training in CT insertion must be emphasized as it is a simple procedure that is potentially life-saving.

Keywords: pneumothorax, spontaneous, education, practice variability
Singapore Med J 2000; 41(11): 538-541

AS Devnani
Correspondence: Dr A S Devnani, devnani@kb.usm.my

ABSTRACT
Aim To describe an appliance used for equalisation of severe congenital lower limb length discrepancy for patients who refuse to undergo any operative correction but wish to walk and look better.
Method The appliance which is a combination of an ischial bearing brace and a below knee prosthesis was fitted to four patients, aged between 12 and 31 years, with congenital shortening of the lower limb ranging between 17 to 27 centimetres. The diagnosis was proximal femoral focal deficiency in 2 patients, hypoplastic femur in 1 and tibial hemimelia in the fourth patient. The appliance could accommodate existing deformities of the knee, ankle and foot without any operative correction as well as equalise the lower limb length. It is modular in construction and could be easily assembled from off-the-shelf components.
Result The appliance improves the gait as well as the appearance, could be fitted to the patient without the prior need of operative correction and could be well disguised under any loose fitting garment. Four patients with severe congenital shortening of the leg have used it for over three years and are pleased with it. It requires little maintenance.
Conclusion The appliance is useful for patients with severe congenital shortening of the lower limb who refuse to undergo operative correction.

Keywords: severe congenital shortening, refuse operation, new appliance
Singapore Med J 2000; 41(11): 534-537

CL Chiu, YK Chan, GSY Ong, AE Delilkan
Correspondence: Dr C L Chiu

ABSTRACT
Background To compare the maintenance and recovery characteristics of sevoflurane and isoflurane anaesthesia in Malaysian patients.
Method This is a prospective, open labelled, randomized, controlled study. Sixty unpremedicated ASA I or II patients (aged 18-50 years), scheduled for elective breast lump excision were randomly allocated to receive either isoflurane or sevoflurane for the maintenance of anaesthesia following fentanyl and propofol intravenous induction. The systolic, diastolic, mean arterial blood pressure and heart rate were measured. The speed of recovery was measured by time to eye opening, time to following simple command, and time to correctly giving own names and address. The incidence of postoperative complication was also recorded.
Results The trend of systolic blood pressure was significantly higher in the isoflurane group as compared to the sevoflurane group for the duration of anaesthesia (p < 0.001, by ANOVA for repeated measurement) but the trend of heart rate was similar for both groups. The recovery time was faster in the isoflurane group. [mean time of eye opening (SD) = 6.8 (2.2) vs 10.7 (4.4) min, p < 0.001; mean time of sticking tongue out (SD) = 7.9 (2.9) vs 11.5 (4.7) min, p < 0.01; mean time of giving own name (SD) = 7.8 (2.7) vs 11.8 (4.8) min, p < 0.001, mean time of giving own address (SD) = 8.4 (2.9) vs 12.0 (4.7) min, p < 0.01]. No major adverse effects were encountered postoperatively and the incidences of minor adverse effects were low in both groups.
Conclusion We concluded that sevoflurane is a safe alternative to isoflurane but in these short procedures, awakening time was surprisingly slower than after isoflurane.

Keywords: Anaesthesia general; anaesthesia inhalational; isoflurane; maintenance; recovery; sevoflurane
Singapore Med J 2000; 41(11): 530-533

BP Khoo, YC Giam
Correspondence: A/Prof Y C Giam

ABSTRACT
A common dilemma faced by the clinician in the outpatient clinic is in distinguishing a drug eruption from a viral exanthem in a child. This is further confounded by multiple drugs frequently prescribed for common childhood ailment. Therefore many children are wrongly labelled as having drug allergy or mistakenly sent for allergy testing. This retrospective study seeks to address this common problem.
Method The case records of children aged 12 and below clinically diagnosed as having drug eruptions, seen from January 1995 to December 1997 in the National Skin Centre, were reviewed.
Results One hundred and eleven children were seen. The indications for drug prescribed were upper respiratory tract infection (47%), fever (18%) and chest infection (10%). The common discriminating drugs prescribed were amoxycillin/ampicill in in 59%, paracetamol in 36% and cotrimoxazole in 19% of patients. In general, the drug eruption took place within 1 day in 39%, by the 2nd day in 10% and by the 3rd to the 7th day in 13% of patients. Drug eruption patterns seen were urticaria/angioedema (45%), maculopapular rash (32%) and fixed drug eruption (12%). Drug allergy was confirmed in 8 patients (7%), while it was deemed probable in 22%, possible in 31% and unlikely in 41% of patients.
Conclusion A detailed drug history, knowledge of the various drug eruption patterns and drug specific reaction rates, and appropriate oral rechallenge test, are essential factors to the successful management of a child with drug eruption. Radioallergosorbent test (RAST) and patch test may be useful in some cases.

Keywords: children, drug history, drug eruption patterns, oral rechallenge, drug-specific reaction rates
Singapore Med J 2000; 41(11): 525-529

SY Tan, WB Chan, WC Cheng, A Hargarty, KT Lim, R Quaife
Correspondence: R Quaife

ABSTRACT
The aim of the present work was to examine the efficacy of using FISH for the rapid prenatal diagnosis of common chromosome aneuploidies. A total of 100 analyses over a six month period were included in the study. Diagnosis was possible in all cases. A mosaic for trisomy 21 proved, by comparison with an extensive analysis of long term cultures, to be an apparent false positive. Otherwise the technique was reliable, accurate and relatively straightforward to perform. Results could be available within 24 hrs. In most cases an additional long term full analysis was also done, so as to exclude rarer aneuploidies and structural rearrangements. This methodology is seen as a useful addition to the prenatal diagnostic repertoire.

Keywords: Chromosome, Aneuploid, FISH, Prenatal, Probe
Singapore Med J 2000; 41(10): 493-497

KVS Liew, TC Lau, CH Ho, TK Cheng, YS Ong, SC Chia, CC Tan
Correspondence: Dr Kenneth V.S.Liew

ABSTRACT
Aim of Study To perform a retrospective study, with the help of literature review, of the management of patients with pyogenic liver abscess in a general hospital.
Method A retrospective study of 73 consecutive patients treated at TanTock Seng Hospital between January 1994 and December 1997 was conducted to determine the demographic, clinical, laboratory, radiological and microbiological characteristics of these patients, as well as the management strategies employed.
Results Liver abscess was more common in males, occurring more frequently in the right hepatic lobe. Most patients presented with non-specific clinical and biochemical features. A raised alkaline phosphatase level was the most common biochemical abnormality found in about two-thirds of patients. Ultrasonography was not as sensitive as computed tomographic scans in detecting abscesses. Klebsiella pneumoniae was the most common etiological agent detected in cultures of blood and abscess aspirates. All patients were treated with intravenous antibiotics. Twenty-two (30%) needed percutaneous catheter drainage and five (7%) required surgical management. There was no hospital mortality in our series. Prolonged hospitalisation was associated with advanced age, degree of loculation within the abscess, concomitant diabetes mellitus and Klebsiella septicaemia.
Conclusion Pyogenic liver abscesses require a high index of suspicion for early diagnosis. When appropriate therapy in the form of antibiotics in combination with percutaenous drainage or surgery is administered, mortality is very low. However, significant morbidity is still a problem, particularly in the elderly, diabetic patient.

Keywords: Pyogenic liver abscess, Klebsiella pneumoniae, percutaneous catheter drainage
Singapore Med J 2000; 41(10): 489-492

SG Ling, CCM Boey
Correspondence: Dr Ling Shih Gang

ABSTRACT
A descriptive study was carried out on patients admitted for febrile convulsion over a two-year period to determine rate of lumbar puncture (LP) refusal, factors associated with LP refusal and outcome of such patients. From 77 patients indicated and requested for LP, 19 (25%) patients refused the procedure. Refusal of LP was significantly more common among the Malay ethnic group (p = 0.01) but not significantly associated with age,gender or whether the patient was admitted for a first or recurrent febrile convulsion. Half of the patients who refused LP had to be started empirically on antibiotics for meningitis. Patients who refused LP were also 8.5 times more likely to discharge themselves "at own risk" (AOR), compared to other patients with febrile convulsion (p = 0.004). In conclusion, LP refusal is a common problem in the local setting and is a hindrance to the proper management of patients with fever and seizure. Appropriate measures must be carried out to educate the public, particularly those from the Malay ethnic group on the safety and usefulness of the procedure. Reasons for patients discharging AOR following LP refusal also need to be addressed and problems rectified.

Keywords: discharge against medical advice, febrile seizure, meningitis, parents, spinal tap
Singapore Med J 2000; 41(10): 485-488

KM Fock, HS Ng, TM Ng, NM Law, CC Lim
Correspondence: A/Prof Fock Kwong Ming

ABSTRACT
Dual therapy has been reported to produce H.pylori eradication rate of 75-80%. This study is designed to determine the efficacy of omeprazole 20 mg bd in combination with amoxycillin 500 mg tid (Group A), amoxycillin 750 mg tds (Group B) and clarithromycin 500 mg tid (Group C) in Singapore. One hundred and forty-eight patients with H. pylori positive duodenal ulcers between ages of 22 and 69 were enrolled from two centres. There were 48 patients in Group A, 50 patients in Group B and 50 patients in Group C. The medication was given for 14 days. The patients were re-evaluated with an upper GI endoscope 4 weeks after cessation of treatment. Successful eradication was defined as H.pylori negative on histology and culture. Based on intention to treat analysis, the eradication rate was 47.8% in Group A, 68% in Group B and 66% in Group C. The difference between Group A and B were statistically significant (p = 0.04). Based on all patient treated analysis, the eradication rate was 57.5% in Group A, 70.7% in Group B and 75% in Group C. The difference in eradication rates was not statistically significant. Adverse events were reported in 21% of all patients with no difference in the adverse event rate between all groups. The eradication rate achieved with dual therapy in this study was similar to that attained in Western population. Higher dose amoxycillin regime gives a significantly higher eradication than a lower dose amoxycillin.

Keywords: Omeprazole, amoxycillin, clarithromycin, Helicobacter pylori
Singapore Med J 2000; 41(10): 482-484