Original Article

NC Tan, S Goh, H Leong, CJ Ng, V Thai, WF Siew, S Emmanuel, TK Lim
Correspondence: T K Lim, mdclimkt@nus.edu.sg

ABSTRACT
Background It has been suggested that resources for asthma intervention should be focused mainly on patients in the community who experience a high burden of disease. These are who patients who have acute exacerbations which require urgent treatment.
Aim To assess the morbidity and identify deficiencies in the treatment of patients who present for urgent treatment of acute exacerbations to primary care clinics.
Patients Adult patients who received urgent treatment for acute exacerbation of bronchial asthma
Setting 4 primary care polyclinics.
Methods A cross-sectional survey of consecutive patients which related regular preventive treatment to current asthma activity. Poor asthma control was defined as step 2 or higher (American National Asthma Education and Prevention Program, report II, 1997) or > or = 2 emergency room visits in 6 months.
Results There were 116 patients of whom 53% were women. The mean (SD) age was 45(15) years and duration of current exacerbation 3 (3) days. The acute symptoms were successfully treated in 93% of patients. Quick relief medication was used regularly in 91% and inhaled corticosteroids (ICS) in 55%. Oral salbutamol was prescribed in 14% of patients. The asthma was poorly controlled in 54%. In the poorly controlled group 33% were not on regular ICS treatment and 64% were not receiving "add on" medication.
Conclusion Patients treated for acute asthma in primary care clinics: (1) were older and had less acutely severe exacerbations than those who presented to emergency rooms, (2) over half had poorly controlled asthma and (3) a third of patients with poor asthma control were inadequately treated.

Keywords: asthma, treatment, guidelines, morbidity
Singapore Med J 2000; 41(6): 259-263

LY Chen, KY Ho, KH Phua, Community Medicine GI Study Group
Correspondence: Dr Khek Yu Ho, mdchoky@nus.edu.sg

ABSTRACT
Background/Aim of Study Data on the epidemiology of bowel frequency and functional bowel disorders in the East are limited. The aims of this study were to determine the most common bowel frequency and the prevalence of functional bowel disorders in Singaporean adults.
Methods A cross sectional study, using a reliable and valid questionnaire was carried out in a random sample of residents aged 16 years and above in Bishan, 68% responded (n = 271).
Results The most common (59.0 +/- 6.5%) bowel frequency was once a day with 96.8 +/- 5.6% of individuals having bowel frequency between 3 times/week and 3 times/day. The prevalences of irritable bowel syndrome, chronic constipation and chronic diarrhoea were 3.2 +/- 2.3%, 7.3 +/- 3.5% and 6.9 +/- 3.4%, respectively. Women were found to have a lower bowel frequency (p < 0.001) and a higher prevalence of chronic constipation (11.3 +/- 6.0% vs. 3.6 + 3.5%, p < 0.05) than men.
Conclusion Normal bowel frequency may be defined as bowel movements between 3 times per week and three times per day. The prevalence of irritable bowel syndrome in the general population of Singapore was low compared with those reported in the West.

Keywords: bowel frequency, functional bowel disorder, irritable bowel syndrome, constipation, diarrhoea
Singapore Med J 2000; 41(6): 255-258

CSC Cheok, YG Ang, WM Chew, HY Tan
Correspondence: CPT(DR) C S C Cheok

ABSTRACT
A small proportion of servicemen enlisting for compulsory National Service in Singapore experience problems adjusting to military life. This paper aims to profile the servicemen who experience such problems. There is a paucity of literature addressing this issue internationally and none published locally. Servicemen who were referred to the Psychological Medicine Branch of the Singapore Armed Forces within six months of enlistment were retrospectively studied. In the work year July 1995 to June 1996, 77 cases were seen. The main classes of diagnoses were stress-related disorders, anxiety, mood and psychotic disorders. The main stressor was problems adapting to the military environment. There were 10 cases of parasuicide, significantly less than US Army statistics. At Operationally Ready Date, 20.7% were able to hold a combat vocation, similar to the US Army situation. This paper hopes to document the local figures and act as a reference for evaluating future therapies and policies.

Keywords: Military, Psychiatry, Adjustment Disorder, Singapore, Outcome
Singapore Med J 2000; 41(5): 218-220

ME Khadadah, BO Onadeko, HT Mustafa, KEH Metwali
Correspondence: Dr M E Khadadah, mousaa@hsc.kuniv.edu.kw

ABSTRACT
Aim of the Study The recognition and management of severe acute asthma have attracted considerable attention since the seventies because of the morbidity and mortality that may accompany the condition. Recognition and appropriate management of severe acute asthma is essential. Admission to intensive care, intubation and ventilation risks versus benefit have been argued. We highlight these controversies by documenting our experience and comparing it to others in the literature
Methodology We prospectively document our experience over a two-year period in the management of severe asthma in the intensive Care Unit (ICU). Patients were established asthmatics, who came in severe exacerbation. Attention was paid to the duration of onset of acute attack, time to presentation, spirometric and blood gas data, the type of treatment given, factors responsible for complications and mortality were identified. The findings in this study were compared with those in similar studies in the literature.
Results A total of 30 patients were studied. Twenty-one patients were ventilated and 9 were not. 82% had a history of asthma longer than 5 years. The duration of symptoms before admission to ICU was very short (one day or less in 57%). Hypercapnia was significantly higher in intubated patients. The duration of stay in ICU and hospital was longer for intubated patients (P<0.02). Complications were higher in intubated patients.
Conclusion ICU care provides an excellent setting for management of acute severe asthma. The reported high morbidity and mortality in ICU can be improved. Without ICU care the mortality and morbidity increases,so physicians should not hesitate to admit asthmatics early to ICU.

Keywords: Asthma, Hypercapnia, Mortality, Morbidity, ICU
Singapore Med J 2000; 41(5): 214-217

KSG Chua, KH Kong, YC Lui
Correspondence: K S G Chua

ABSTRACT
Purpose of Study This study investigated the effects of intramuscular Botulinum toxin A (BTX-A) in 7 ambulatory chronic hemiplegic subjects (5 male, 2 female) who had spastic hemiplegic foot drop.
Basic Procedures An open label study involving intramuscular injections of Botulinum toxin A (dilution 10 U/0.1 ml) was performed in ambulatory chronic hemiplegics. Tone as measured by the Modified Ashworth Scale (MAS), passive ankle joint range of motion (PROM), briskness of ankle reflexes, gait velocity, motor functional status and effects on the use of walking aids were measured at baseline, 3 and 12 weeks post-injection.
Main Findings All subjects except I showed a significant decrease in MAS from 3.43 +/- 0.54 at baseline to 2.0 +/- 1.15 at 3 weeks post-injection, which was maintained during the 3 month study duration. The median change in PROM was 17.0 degrees (SD 12.1 degrees) at 3 weeks and 5.0 degrees (SD 7.1 degrees) at 12 weeks (p = 0.25) Gait velocity and Modified Barthel Index mobility scores which measured motor functional status were not significantly altered post-injection. The injections were generally well-tolerated and there were no serious adverse side effects.
Principal Conclusion Although significant decreases in muscle tone were observed and maintained after intramuscular Botulinum toxin A during the 3 month study period, this regional intervention did not significantly influence functional status, gait velocity and the use of ambulatory aids.

Keywords: Spasticity, Botulinum toxin A, Plantar flexors, Hemiplegia, Foot-drop
Singapore Med J 2000; 41(5): 209-213

CH Chui, AS Jacobsen
Correspondence: Dr A S Jacobsen

ABSTRACT
Aim of Study To examine the role of laparoscopy in the evaluation of the non-palpable undescended testes in paediatric patients.
Method A review of all laparoscopies performed for the evaluation of the non-palpable undescended testes in a children's hospital over a 12-month period was conducted. Special attention was paid to the patients' age, the location of the testes at the time of laparoscopy, the subsequent surgical procedures and the complications.
Results Sixteen boys underwent laparoscopy to localise 20 nonpalpable testes. 12 patients had unilateral disease while 4 had bilateral disease. 15 non-palpable testes were intraabdominal, 3 had inguinal testicular remnants and 2 had 'vanished'. A contralateral inguinal hernia was incidentally found in one patient. A patient with epididymal-gonadal non-union was not apparent at laparoscopy. There were no post-laparoscopic complications in all 16 patients.
Conclusion Laparoscopy is safe and accurate in the evaluation of non-palpable testes in children. The accurate localisation of intraabdominal testes facilitates the development of an optimal surgical strategy.

Keywords: diagnostic laparoscopy, cryptochidism
Singapore Med J 2000; 41(5): 206-208

PH Tang, HP Chia, LL Cheong, D Koh
Correspondence: Prof David Koh, cofkohd@nus.edu.sg

ABSTRACT
Background Androgenetic alopecia is the most common form of hair loss. It affects a large number of the local male population, with 1,812 men seeking treatment for hair loss at the sole dermatological tertiary referral centre in Singapore in 1994. The aim of this study was to assess the prevalence of male androgenetic alopecia in the community.
Methods A questionnaire-based cross-sectional survey with a one-stage sampling method was conducted. Each male was diagnosed clinically and the severity graded according to the Norwood Criteria. The survey area was in Bishan East, a housing estate with 8,004 households. A total of 335 households were selected for the survey.
Results The household response rate was 84%. Within these households, 254 out of 378 men participated in the study (67% response rate). The prevalence of androgenetic alopecia was found to be 63%. The prevalence of the condition increased with age, from 32% among young adults aged 17 to 26 years to 100% among those in their 80s. Proportionately more Indians (87%) were affected compared to Chinese (61%). 81% of the respondents with androgenetic alopecia did not seek help as they did not view it as a problem. Of those seeking treatment, 74% used non-medical methods of unproven effectiveness.
Conclusion There is a high prevalence of androgenetic alopecia in the community in Singapore. Age specific prevalence and racial differences correlate well with both Western and local studies respectively.

Keywords: androgenetic alopecia, community prevalence, race, epidemiology
Singapore Med J 2000; 41(5): 202-205

F Lateef, V Anantharaman
Correspondence: Dr F Lateef, f_lateef@hotmail.com

ABSTRACT
Objective This is a prospective cohort study done over a period of one year to look at hypotension that developed in the local Acute Myocardial Infarction (AMI) patients given Streptokinase (SK).
Method Suitable patients with AMI (those with ischaemic chest pain most severe within the last 8 hours, ST-segment elevation and no contraindications) were selected for thrombolysis with SK given as the standard dose of 1.5 mega-units diluted in 100 mls of normal saline and infused over 60 minutes. (Group A). The AMI patients who did not receive SK (Group B), were analysed separately and acted as "controls", as it was not possible to withhold thrombolytic therapy in a group of patients in a completely randomised fashion. The pulse, non-invasive blood pressure and electrocardiogram were monitored and recorded.
Results Of 120 patients analysed, 70 received SK (Group A) and 50 (Group B) did not due to a variety of reasons. There was no statistically significant difference in the sex, age and body weight distribution as well as the initial mean arterial blood pressure (MAP) in the two groups. The MAP showed a statistically significant decrease at 15 minutes (105.6 to 81.4 mmHg, 95%CI: 13.965, 28.178) and 30 minutes (105.6 to 89.6 mmHg, 95%CI: 10.929, 19.814) after the commencement of SK in Group A patients. When analysed separately, the decrease in MAP was also statistically significant at 15 minutes (95%CI: 4.263, 22.014) for those with anterior AMI and both at 15 (95%CI: 19.112, 41.299) and 30 minutes (95%CI: 1.191, 28.716) for those with inferior AMI. There was no statistically significant decrease noted in Group B patients and the door-to-needle time for Group A patients was 37.2+/-6.0 minutes. The SK infusion time for Group A patients who developed hypotension was prolonged to 95.3+/-14.1 minutes.
Conclusion Hypotension was more commonly noted in the AMI patients given SK. The MAP tend to decrease in the first 30 minutes after commencing the SK infusion. It is thus possible to conclude that the hypotension was at least partly due to SK and is probably a rate-related phenomenon.

Keywords: hypotension, Streptokinase, door-to-needle time
Singapore Med J 2000; 41(4): 172-176

K Shamsuddin, M Abdul Haris
Correspondence: Dr K Shamsuddin

ABSTRACT
Objectives To measure the prevalence of cigarette smoking among male secondary school children and assess their family influence especially that of their fathers' smoking habits on their current smoking habits.
Methodology A cross-sectional study was carried out in Kota Bharu, Kelantan in April 1997 where 460 male form four students, aged 15-16 years were randomly selected from six secondary schools. Data on smoking habits, sociodemographic profile and family characteristics particularly parents and siblings' smoking habits, perceived parental supervision and communication were collected through self-administered questionnaires.
Results The prevalence of cigarette smoking among male secondary school children was 33.2%. Crude analysis shows family factors, fathers' and siblings' smoking habits, and lack of parental supervision were significantly associated with the students' current smoking habit. Among students who smoked compared to non-smokers, father's smoking habit gives a crude Odds Ratio = 1.8, 95% C.I. 1.08 - 3.16. Further analysis shows that the effect of their father's smoking habit on the student's current smoking habit is still significant after controlling for other familial and non-familial factors including parental supervision, academic performance, reported influence of cigarette advertisement, having friends who smoked and the student's poor knowledge of the ill-effects of smoking and other factors (Odds Ratio = 1.9, 95% C.I 1.05 - 3.32). In conclusion, family factors especially the father's smoking habit is an important factor that influences a student's current smoking habit and the presence of negative role models within the home need to be seriously considered in any cigarette smoking prevention programs among secondary school adolescents.

Keywords: smoking, male students, adolescents, family influence, father’s smoking habit
Singapore Med J 2000; 41(4): 167-171

KK Yeo, TT Yeo, CY Chan, YY Sitoh, J Teo, SY Wong
Correspondence: Dr T T Yeo

ABSTRACT
Aim To assess the usefulness of stereotactic brain biopsies in AIDS patients with cerebral lesions in Singapore.
Methods A total of 10 patients with AIDS and cerebral lesions underwent stereotactic brain biopsies in the Department of Neurosurgery, Tan Tock Seng Hospital (TTSH) between September 1997 and September 1998. The patients were referred from the Communicable Diseases Centre (CDC), TTSH. These patients either failed a trial of therapy for toxoplasmosis encephalitis (TE) or had CT/MRI scans which did not suggest TE. Four were CT-guided and six were MRI-guided stereotactic biopsies. The Radionics Cosman-Robert-Wells (CRW) stereotactic apparatus was used for all cases.
Results The male to female ratio was 9:1. Histological diagnosis from biopsy was lymphoma (5), metastatic adenocarcinoma (1), TE (1), abscess (1), encephalitis (1) and granulomatous tissue (1-presumed tuberculosis).
Conclusion The early experience is that stereotactic brain biopsy is useful in patients with AIDS and cerebral lesions. The etiology is confirmed in the majority of cases and impacts on management decisions and prognostication.

Keywords: stereotactic brain biopsy, HIV, cerebral lesions
Singapore Med J 2000; 41(4): 161-166