Original Article

ON Nagi, MS Dhillon, A Aggarwal, SS Gill
Correspondence: Dr O N Nagi

ABSTRACT
Background/Aim of Study Fractures of the medial condyle of humerus are uncommon in adults. The aims of this study were (i) to highlight the rarity of this injury, (ii) to focus on the problems in management of cases which present late, and (iii) to compare the results of surgical excision of medial condyle with those of internal fixation.
Methods Seven adult medial humeral condyle fractures were seen over a 10-year period. Four cases were surgically fixed within three weeks of the injury; one case refused operation. Two cases which presented late, one with an isolated trochlear fracture, and another Milch type I fracture comminution and compounding, were treated by excision of the condyle and supervised post excision physiotherapy.
Results All six operated cases regained good function. The two patients with excised condyle had no significant instability and had good range of movements. The results were comparable to those managed by open reduction and internal fixation.
Conclusion Medial condyle fractures presenting early (within 3 weeks), should be managed by accurate open reduction and rigid fixation: non operative management leads to relatively poor results. In late/neglected cases, or those with extensive comminution, open reduction and fixation may lead to stiff and painful elbow, whereas excision of the condylar fragment does not lead to instability.

Keywords: Medial condyle, Humerus, Fracture, Adults
Singapore Med J 2000; 41(7): 347-351

J Cheah
Correspondence: Dr Jason Cheah, tscheah@singnet.com.sg

ABSTRACT
A critical or clinical pathway defines the optimal care process, sequencing and timing of interventions by healthcare professionals for a particular diagnosis or procedure. It is a relatively new clinical process improvement tool that has been gaining popularity across hospitals and various healthcare organisations in many parts of the world. It is now slowly gaining momentum and popularity in Asia and Singapore. Clinical pathways are developed through collaborative efforts of clinicians, case managers, nurses, and other allied healthcare professionals with the aim of improving the quality of patient care, while minimising cost to the patient. Clinical pathways have been shown to reduce unnecessary variation in patient care, reduce delays in discharge through more efficient discharge planning, and improve the cost-effectiveness of clinical services. The approach and objectives of clinical pathways are consistent with those of total quality management (TQM) and continuous clinical quality improvement (CQI), and is essentially the application of these principles at the patient's bedside. However, despite the growing popularity of pathways, their impact on clinical outcomes and their clinical effectiveness remains largely untested and unproven through rigorous clinical trials. This paper begins with an overview of the nature of clinical pathways and the analysis of variances from the pathway, their benefits to the healthcare organisation, their application as a tool for CQI activities in direct relation to patient care, and their effectiveness in a variety of healthcare settings. The paper describes an evaluation of the impact of a clinical pathway on the quality of care for patients admitted for uncomplicated acute myocardial infarction (AMI) through an analysis of variances. The author carried out a one year evaluation of a clinical pathway on uncomplicated AMI in Changi General Hospital (CGH) to determine its effectiveness and impact on a defined set of outcomes. A before and after nonrandomized study of two groups of patients admitted to the Hospital for uncomplicated AMI was done. A total of 169 patients were managed on the clinical pathway compared to 100 patients in the control (historical comparison) group. Outcomes were compared between the two groups of patients. Restriction and matching of study subjects in both groups ensured that the patients selected were comparable in terms of severity of illness. The results showed that the patients on the clinical pathway and the comparison group were similar with respect to demographic variables, prevalence of risk factors and comorbidities. There was a statistically significant reduction in the average length of stay after implementation of the clinical pathway. This was achieved without any adverse effect on short term clinical outcomes such as in-hospital mortality, complication rate and morbidity. There were no significant difference in readmission rates at 6 months after discharge. The paper concludes that clinical pathways, implemented in the context of an acute care general hospital, is able to significantly improve care processes through better collaboration among healthcare professionals and improvements in work systems.

Keywords: Processes of care, variance analysis, evidence-based medicine, multidisciplinary
Singapore Med J 2000; 41(7): 335-346

F Lateef, SH Lim, V Anantharaman, CS Lim
Correspondence: Dr Fatimah Lateef

ABSTRACT
The Pre-hospital Defibrillation Program in Singapore has in some cases demonstrated a lower amplitude of Ventricular Fibrillation (VF) than considered the norm. The Electrode Skin Impedance (ESI) refers to the skin impedance determined between two electrodes placed at specific positions on the body surface. The objective of this prospective study was to measure the ESI of patients at 5 Hz and 2 kHz frequencies, and assess its change with time from the application of electrodes, the difference between the ESI at two different sets of electrode placement positions and correlation with patient factors. Patients who were 25 years or older and not critically ill had their ESI measured with a modified Heart-Save 911 defibrillator, using signal frequencies at 5 Hz and 2 kHz, at 10 seconds, 1 and 2 minutes after electrodes application. Two sets of positions were used; Position 1 where an electrode is placed in the right infra-clavicular region and another just lateral to the apex beat on the left and Position 2, which represents the mirror image of Position 1. 36 each of male and female patients were studied. The mean age and weight were 59.9 +/- 13.5 years and 56.8 +/- 24.1 kg respectively. There was no significant correlation between the ESI and patients' body weight or sex. However, there was a significant decrease in the ESI with time from application of electrodes at both Positions (p < 0.05) with the two different frequencies. The ESI was lower when measured at lower frequencies and higher when taken at higher frequencies, but there was no statistically significant difference between the two mirror-image positions used. Thus, with lower frequency, the ECG amplitude of VF recorded on the automated external defibrillator could be enhanced.

Keywords: ventricular fibrillation, skin impedance, ECG amplitude
Singapore Med J 2000; 41(7): 331-334

ATJ Goon, SH Tan, LSW Khoo, T Tan
Correspondence: Dr Anthony Goon Teik Jin

ABSTRACT
Aim of Study To study the efficacy of tetracycline (or doxycycline) and nicotinamide in the treatment of less extensive bullous pemphigoid.
Methods An open trial of 11 patients with bullous pemphigoid. Treatment was initiated with tetracycline 1.5-2 g/day and nicotinamide 1.5-2 g/day and gradually tapered down. Doxycycline was substituted for tetracycline in patients who could not tolerate tetracycline due to gastrointestinal side effects or headache.
Results 6 out of 11 patients achieved complete response (> 90% decrease in lesions) while another 2 had partial response (50-90% decrease in lesions).
Conclusion Tetracycline/doxycycline and nicotinamide is a useful alternative treatment for localized bullous pemphigoid, especially in those whose concurrent medical illnesses preclude the use of systemic corticosteroids.

Keywords: Bullous pemphigoid, tetracycline, nicotinamide
Singapore Med J 2000; 41(7): 327-330

M Kurien, A Stanis, A Job, Brahmadathan, K Thomas
Correspondence: Dr Mary Kurien, kurien_mary@hotmail.com

ABSTRACT
Introduction The diagnostic test of swabbing the surface of the tonsil as a culture specimen for the determination of the organism responsible for the tonsil infection is still in practice, despite controversy. To date there has been no reports of establishing the reliability and validity of this common diagnostic test by appropriate statistical test of Likelihood ratios taking into consideration the specificity and sensitivity.
Aims To assess the reliability and validity of throat swab in the diagnosis of bacterial microflora in chronic tonsillitis.
Patients and Methods A prospective study of 40 patients clinically diagnosed to have chronic tonsillitis undergoing tonsillectomy was undertaken. The reliability of the throat surface swab was then assessed and validated with the reference (gold) standard of tonsil core culture.
Results The likelihood ratio of this diagnostic test being positive (LR +ve) was 0.84 to similar and 1.3 to general organism pathogen.
Conclusion Routine culture of the throat by surface swab in the accurate diagnosis of bacterial flora in chronic tonsillitis is neither reliable nor valid. The clinical implications of this investigation which is still very popular is discussed.

Keywords: Throat swab, tonsil core culture, gold standard, reliability, validity, sensitivity, specificity, likelihood ratio
Singapore Med J 2000; 41(7): 324-326

Z Amin
Correspondence: Zubair Amin, zubair@kkh.com.sg

ABSTRACT
Background Learning preference refers to one's choice of specific learning situations or environments over the other. It is one of the factors needed to be considered in planning curriculum and in designing instructional units.
Objectives The primary objectives of this study were to characterize the learning preference of recent medical graduates of the National University of Singapore (NUS) and to identify any possible gender differences. This study is likely to be first of its kind in this learner population.
Instrument Rezler's Learning Preference Inventory.
Methods Rezler's Learning Preference Inventory was administered among twenty-eight 1997 graduates (male 16, female 12) of NUS. The independent variable was the gender and the dependent variables were the scores in each of the learning categories: abstract, concrete, teacher-structured, student-structured, interpersonal, and independent.
Analysis Frequency distribution of the learning preferences was counted manually. Independent samples t-test was used to compare two groups of dependent variables.
Results Ninety-two percent female and sixty-nine percent male respondents preferred concrete learning. Only one male respondent and none of the female respondents preferred abstract learning. Among all the respondents, differences between concrete and abstract categories reached statistical, as well as meaningful, significance (p < 0.0001 and mean score difference of 19.9). Differences between student-structured and teacher-structured, and between interpersonal and independent categories did not reach statistical significance (p value of 0.51 and 0.78 respectively). Female respondents generally showed a trend towards greater preference for concrete and teacher-structured learning than their male counterparts.
Conclusion The learning preferences of recent graduates of the NUS is characterized by high inclination towards concrete learning. The results can be utilized in designing instructional methods for this group of learners.

Keywords: Learning Preference, Rezler’s Learning Preference Inventory, Curriculum Planning, and Instructional Unit Design
Singapore Med J 2000; 41(7): 317-323

EJ Lim, SC Peh
Correspondence: E J Lim, limej@medicine.med.um.edu.my

ABSTRACT
Background 47 patients with non-Hodgkin's lymphoma (NHL) were studied retrospectively to determine their marrow and blood changes at diagnosis.
Methods The blood counts, blood films, marrow smears, trephine and tissue biopsies of patients at diagnosis were reviewed. The scheme proposed by the International Lymphoma Study Group (REAL) was utilised for lymphoma subclassification.
Results and Conclusion 21.3% had lymphoblastic lymphoma, 21.3% had peripheral T-cell lymphoma (unspecified), 29.8% had diffuse large B-cell NHL, 10.6% had Burkitt's lymphoma and 17% had others. The incidences of anaemia, one or more abnormal counts, lymphocytopenia, increased marrow reticulin and marrow eosinophilia at diagnosis were 66%, 85.1%, 41.3%, 40.9% and 44.7% respectively. Marrow involvement was present in 46.8% of the patients, with diffuse infiltration noted in 71.4% of these cases. Abnormal counts and anaemia were common in all the NHL subtypes. In lymphoblastic lymphoma, the common haematological abnormalities were peripheral atypical lymphocytes and diffuse marrow involvement. In peripheral T-cell lymphoma (unspecified), common features were peripheral lymphocytopenia, increased marrow reticulin and eosinophilia. In diffuse large B-cell NHL, peripheral lymphocytopenia, peripheral myeloid precursors and/or nucleated red cells and marrow involvement were common. In Burkitt's lymphoma, diffuse marrow involvement and eosinophilia were common. No significant differences were noted between most of the haematological parameters of B and T-NHLs. In comparison with other reports, we recorded higher overall incidences of anaemia and diffuse marrow involvement, and a lower incidence of marrow infiltration in peripheral T-cell lymphoma (unspecified).

Keywords: Non-Hodgkin’s lymphoma, marrow, peripheral blood
Singapore Med J 2000; 41(6): 279-285

Hai C Lim, BL Quah, V Balakrishnan, HC Lim, V Tay, SC Emmanuel
Correspondence: Hai C Lim

ABSTRACT
Aim of the Study To evaluate the feasibility of an improved visual acuity screening program for Singapore 4-year-old preschool children and to draw up an appropriate referral criteria as well as evaluating the rates and outcomes of these referrals.
Method A total of 450 children aged 4 to 4 1/2 years, who attended 3 polyclinics of the Family Health Service (FHS) for their 4-year-old Developmental Health Screening during the study period from 1/4/1997 to 30/6/1997 were recruited for the study. Children who were tested with Snellen (or Sloan) visual acuity chart resulting in visual acuity of 6/9 or worse, or failed to pass the 3 mm medium plate at 30 cm distance (300 seconds of arc) in the Frisby Stereotest, or were found to have strabismus, or were untestable in either visual acuity test or stereotest were offered referral to ophthalmologists in the hospitals for specialist assessment.
Result 82.7% of the 450 children were successfully screened with Snellen (or Sloan) chart while 91.6% were successfully screened with Frisby Stereotest. In all, 180 children were evaluated by ophthalmologists. Majority of the children were referred because of their abnormal visual acuity test while only 2 children were referred for failing stereotest alone. Among the 180 children referred, 63 (35.0%) were found to have refractive errors for which spectacles were prescribed. Eight children had amblyopia and 2 children had strabismus which were not detected at the polyclinic screening. The untestable children evaluated had significantly higher abnormality rate (37.5%) than that of children who had 6/9 vision (8.8%) therefore they should be offered referral for further evaluation. There was high "refused referral" rate of 39.0%. Parents of children who were untestable or had 6/9 vision were found to be more likely to refuse offer of referral. If these two groups of children were excluded, the "refused referral" rate dropped to 13.3%. When the referral criteria for visual acuity was reset at 6/12 instead of 6/9, the referral rate dropped from 39.6% to a more manageable 26.7% and the positive predictive value improved from 35.4% to 48.3% and none of the children with amblyopia were missed being screened-out.
Conclusion The study confirmed the feasibility of doing visual acuity screening at 4 to 41/2 year-old. The referral criteria for abnormal visual acuity should be set at 6/12. The efficacy of adding Frisby stereotest needs further evaluation.

Keywords: Preschool, Visual acuity, Frisby stereotest, Referral criteria
Singapore Med J 2000; 41(6): 271-278

S Ozgocmen, B Karaoglan, OB Cimen, ZR Yorgancioglu
Correspondence: Dr S Ozgocmen, sozgocmen@hotmail.com

ABSTRACT
Aim of Study To determine the site-specific relationship between grip strength and hand bone mineral density (BMD) measured with dual energy x-ray absorptiometry (DXA) in healthy women. The correlation of hand BMD and BMD at axial sites has also been assessed.
Method Twenty-nine healthy housewives, aged 30-70, were included in the study. Women were grouped according to their menopausal status (12 premenopausal and 17 postmenopausal). Grip strength of the dominant hand was measured using a Jamar dynamometer. BMD of the antero-posterior spine, femoral neck, trochanter, and Ward's triangle were measured with DXA. For the hand BMD measurements, the analysis software, which was modified from the software of small animals and developed for hand BMD measurements, was used.
Results Hand BMD moderately correlated with grip strength in postmenopausal women. There was no significant correlation between grip strength and hand BMD in premenopausal women. Significant positive correlations were determined between the hand BMD and BMD at axial sites.
Conclusion Grip strength may be an independent indicator of hand BMD in postmenopausal women, and also a site-specific relationship. Hand BMD measurements may indirectly reflect the BMD of axial sites especially in postmenopausal women.

Keywords: hand, bone mineral density, grip strength
Singapore Med J 2000; 41(6): 268-270

N Baral, BC Koner, P Karki, C Ramaprasad, M Lamsal, S Koirala
Correspondence: Dr Nirmal Baral, nirmalbaral@hotmail.com

ABSTRACT
Aim of the Study The present study was designed to (a) evaluate the implications of revised WHO diagnostic criteria on prevalence of abnormal glucose tolerance, (b) compare glycated hemoglobin level amongst healthy, impaired glucose tolerance (IGT), impaired fasting glucose (IFG) and diabetic subjects and (c) evaluate the assay of glycated hemoglobin in screening IGT, IFG from normal subjects.
Methodology Hospital based, cross-sectional study. Plasma glucose and glycated hemoglobin (gHb) were estimated by glucose oxidase and affinity chromatography method respectively.
Results The crude prevalence of IFG, IGT and diabetes were 9%, 18% and 5.29% respectively with no significant difference between Mongol and non-Mongol population. Newly introduced IFG group falsely incorporate 12% diabetic subjects and fails to detect 83% IGT subjects as impaired glucose metabolism. The gHb level is raised in IGT and diabetic group but not in IFG group.
Conclusion The assay of gHb may be used to screen abnormal glucose tolerance but paired estimation of fasting glucose increases the reliability of diagnosis. The level of gHb in mild carbohydrate intolerance mostly depend on the level of rise in post prandial glucose (where the variation is wide, as in IGT) but not on the narrow variance in fasting plasma glucose level as found in IFG.

Keywords: Glycated hemoglobin (gHb), Impaired fasting glucose (IFG), Diabetes mellitus, Impaired glucose tolerance (IGT)
Singapore Med J 2000; 41(6): 264-267