Original Article

S Nordin, MD Ros, WI Faisham
Correspondence: Dr S Nordin, nordins@kb.usm.my

ABSTRACT
We have studied residual limb length inequality following femoral shaft fractures in 62 children. From 61.2% of the children who had shortening of more than 1 cm at union, 34.21% still maintained the shortening at the completion of study. The longitudinal femoral overgrowth occurred significantly during the first 18 months of the fracture in 77.4% of the children, with an average of 1.17 cm. Children with proximal-third fractures and those who sustained the fractures before eight years of age have higher capability to correct the limb length disparity.

Keywords: Femoral fractures, Residual overgrowth, Clinical measurement
Singapore Med J 2001; 42(12): 563-565

PW Eu, C Lee, G Parker, J Loh
Correspondence: Dr Eu Pui Wai, pui_wai_eu@imh.com.sg

ABSTRACT
The disability profile of persons with schizophrenia in Singapore and how disability levels vary in patients cared for in the community and in the long-stay wards of a state mental hospital were studied using the Life Skills Profile (LSP). The inter-rater reliability of the LSP assessed by the intraclass correlation coefficient (ICC), was lower than in the Australian studies. The test-retest ICCs for the total LSP score and the five subscale scores were satisfactory for the hospitalised subjects and for the community psychiatric nurse subjects, but generally poor for the community care facility subjects. The average ICCs were lower compared to the Australian study. Female hospitalised subjects but not male hospitalised subjects returned higher disability scores on all LSP scales compared to community subjects. This study provided some preliminary data on the usefulness and validity of the LSP in a multi-ethnic Asian setting like Singapore. If the LSP is used as a measure of disability in schizophrenia, it would appear that ratings should only be made by those who know the subject well, and that raters should be formally trained mental health professionals.

Keywords: schizophrenia, disability, Life Skills Profile, community care, long-stay
Singapore Med J 2001; 42(12): 559-562

MIC Chen, JKT Chua, CC Lee, YS Leo, G Kumarasinghe
Correspondence: Dr Lee Cheng Chuan, lee_cheng_chuan@ttsh.com.sg

ABSTRACT
Aim To identify epidemiological, clinical and laboratory features of serologically-proven typhus in the local setting.
Method & Results Retrospective study looking at rickettsial serologies done over a six-month period and collection of the epidemological, clinical, laboratory and treatment response data from the case notes of the patients with an ordered rickettsial serology. Twenty of the 35 cases had a positive serology. Of these 20 patients, 18 were already clinically diagnosed as having murine typhus. All except one were males and all were migrant workers. Majority of the patients were construction workers staying in containers where rats abound. The most consistent clinical features were high fever (100%) for a median period of seven days, headache (94%) and cough (47%). The white cell count was usually normal (74%) but thrombocytopenia was common (68%). Transaminitis was also common (90%) with the AST component higher than the ALT in half of the cases. Response to doxycycline therapy was rapid and most (88%) were afebrile by 72 hours.
Conclusion Typhus (notably murine type) can be confidently diagnosed from consistent clinical features supported by epidemiological and laboratory clues. Early recognition with the prompt treatment response will result in shorter hospital stay with decreased cost. Serological testing may only prove useful in difficult situations when the clinical diagnosis is less clear.

Keywords: rickettsial, typhus, murine, scrub
Singapore Med J 2001; 42(12): 553-558

AKY Ong, PA Tambyah, S Ooi, G Kumarasinghe, C Chow
Correspondence: Dr Paul Ananth Tambyah, mdapat@nus.edu.sg

ABSTRACT
Singapore is a modern urban city and endemic typhus is thought to be a disease of the past. This may be due to lack of specific serological testing as indirect immunoperoxidase testing using specific rickettsial antigens (U.S. Army Medical Research Unit, Institute of Medical Research, Kuala Lumpur, Malaysia) has only recently become available. In the last fourteen months, twenty-one cases of endemic typhus were diagnosed in patients hospitalised for acute febrile illnesses at the National University Hospital. We conducted a case control study to define the clinical and laboratory features of endemic typhus in Singapore.
Method Demographic, clinical and laboratory data were reviewed for cases and twenty-one age and sex matched controls who had negative serologic tests as part of a work-up for fever of unknown origin.
Results Apart from a higher initial temperature (39 degrees C vs 37.9 degrees C (p < 0.001)) and ALT(p = 0.002), cases and controls had similar presentations of fever, myalgia, headache, cough, normal WBC and platelet counts. Singapore residents and migrant workers were represented in both groups (p = ns).
Conclusion Endemic typhus remains an important cause of acute febrile illness in Singaporein both the local and migrant worker populations. The presentation is similar to other causes of acute febrile illnesses and the diagnosis will be missed unless it is specifically sought.

Keywords: endemic typhus, rickettsial disease, fever of unknown origin
Singapore Med J 2001; 42(12): 549-552

LKP Yap, SH Tan, WH Koo
Correspondence: Dr W H Koo, whkoo@doverpark.org.sg

ABSTRACT
Aim of Study To review the use of hypodermoclysis in a local Hospice.
Method A review of all hypodermoclysis carried out over a six-month period was conducted. Special attention was paid to the reason for starting and stopping the drip, duration of the drip, complications, the type and amount of solution infused.
Results Fifty-one (19%) out of 266 patients received hypodermoclysis during their stay. This constituted 5.9% of total patient-days in the study period. Vomiting and drowsiness were the main reasons for the use of drip. The commonest reason for stopping the drip was patient demise. Complications seen were drip site redness (16%), extravasation (15%) and bleeding (2.5%) There was no overt clinical sepsis in any of the patients.
Conclusion Hypodermoclysis is an easy and convenient means of providing hydration. The availability of a standard protocol with clearer guidelines on its use will help to reduce procedure-related complications and promote wider adoption of the practice.

Keywords: hypodermoclysis, butterfly needle, hydration, hospice, standard protocol
Singapore Med J 2001; 42(11): 526-529

K Sim, C Rajasoorya, KN Sin Fai Lam, LS Chew, YH Chan
Correspondence: Dr K Sim, kang_sim@imh.com.sg

ABSTRACT
This study seeks to determine the prevalence of psychiatric morbidity within a medical intensive care unit, examine its correlation with the various physiological parameters and delineate any clinical predictors for psychiatric morbidity. Seventy-seven patients who gave informed consent were administered the General Health Questionnaire (GHQ), Acute Physiological And Chronic Health Evaluation II (APACHE II) and thyroid function tests were performed. A high prevalence of psychiatric morbidity was found (36.4%). However, no statistically significant association was found between psychiatric morbidity and gender, age, APACHE II scores and thyroid function indices. Nevertheless, it is hoped that the index of suspicion for psychiatric morbidity can be raised in order to optimise the clinical management of patients within this setting.

Keywords: psychiatric, morbidity, medical, intensive care, APACHE II
Singapore Med J 2001; 42(11): 522-525

L Wong, ASA Tan
Correspondence: Dr Lisa Wong

ABSTRACT
Aim of Study To evaluate the 50 g glucose challenge test as a screening tool for gestational diabetes in pregnant women with no risk factors, to determine the prevalence of gestational diabetes in this population and to determine the perinatal outcomes of pregnancy according to the glucose challenge test.
Methodology A descriptive prospective study. A total of 146 patients with no risk factors who booked a particular obstetrician and delivered between May 1996 and April 1997 were recruited. Pregnancy outcomes were assessed by the gestation and mode of delivery, neonatal outcomes included birth weights, apgar scores and other neonatal complications.
Results The detected incidence of gestational diabetes was 8.2%. With the threshold plasma glucose level at 7.1 mmol/l, 53 women or 36% needed to undergo the 75 g oral glucose tolerance test and 12 women were found to have gestational diabetes. The diagnostic yield was 22.6%. With 7.8 mmol/l as the threshold value, 28 women or 20% needed the oral glucose tolerance test and eight women with gestational diabetes were detected. The diagnostic yield was 28.6%. Perinatal outcome for these diabetic women who were well-controlled during pregnancy was similar to the rest of the women with normal glucose challenge test.
Conclusion The 50 g glucose challenge test is a useful screening test for diabetes in Singaporean women with no risk factors. A threshold value at 7.8 mmol/l with a smaller number of women requiring the 75 g oral glucose challenge test may be more acceptable.

Keywords: Glucose challenge test, gestational diabetes
Singapore Med J 2001; 42(11): 517-521

HH Tan, SC Lim
Correspondence: Dr Tan Hwee Huan, gecthh@sgh.com.sg

ABSTRACT
An adult presenting with diabetes is usually assumed to have type 2 diabetes. Since the 1980s, type 2 diabetic subjects who had failed sulphonylurea therapy soon after diagnosis have been thought to be actually slowly progressive type I patients. This diabetes sub-type is currently referred to as latent autoimmune diabetes in adults (LADA). Early recognition of such patients has important clinical implications. To assist local doctors in the recognition of such patients, we performed a retrospective study to profile and highlight distinctive features of thirteen LADA patients. We found that these patients were mostly females with a mean body mass index of 17.2 kg/m2, diagnosed with type 2 diabetes in their fourth decade of life and becoming insulin dependent after a mean of 2.5 years.

Keywords: latent autoimmune diabetes in adults, anti-GAD antibodies
Singapore Med J 2001; 42(11): 513-516

WRW Lee, S Emmanuel, HS Lim, AC Thai, WLS Chew, LG Goh, HC Lau, CH Lee, PC Soon, JA Tambyah, YT Tan, LN Jorgensen, A Chua, JP Yeo, for the Diabcare Singapore Local Working Group & the Diabetic Society of Singapore
Correspondence: Dr Warren Lee, warren@kkh.com.sg

ABSTRACT
The Diabcare-Asia Singapore 1998 project was carried out using data from 22 centres collected on paper forms to provide an overview of diabetes management and metabolic control status in 1697 diabetic patients from both primary health care clinic (PHC) (67%) and restructured hospital (RH) (33%) settings. PHC patients were on average older than RH patients (61.3 +/- 11.2 years vs 51.5 +/- 17.7 years), and had a shorter duration of diagnosed diabetes (9.2 +/- 6.8 years vs 12.0 +/- 8.5 years). The mean body mass index (BMI) for PHC patients was 25.5 +/- 4.4 kg/m2 vs 24.5 +/- 4.2 kg/m2 for RH patients. Proportionately more PHC than RH patients were overweight (BMI >25 kg/m2) (49% vs 42%). Patients with type I diabetes constituted 3.5% of PHC vs 18.1% of the RH cohort. HbA1c information was available for 92.5% of RH vs 69% of PHC patients. HbA1c measurements were <1% above ULN in 50% of PHC vs 37% of RH patients, while FBG was >7.8 mmol/l in >61% of all patients. Proteinuria (>500 mg/24 hrs) was reported in 13% of PHC vs 26% of RH patients tested. Microalbuminuria (20-300 mg/l) was noted in 36% of 171 RH patients tested. Oral hypoglycaemic agents were used as sole therapy in 83.5% of PHC vs 43% of RH patients. Eye, feet, renal and severe late complications were more commonly reported by RH than PHC patients. There is a variation in the patient profiles and care between PHC and RH patients.

Keywords: diabetes mellitus, glycaemic/metabolic control, complications, primary health care, restructured hospital
Singapore Med J 2001; 42(11): 508-512

WRW Lee, HS Lim, AC Thai, WLS Chew, S Emmanuel, LG Goh, HC Lau, CH Lee, PC Soon, JA Tambyah, YT Tan, LN Jorgensen, A Chua, JP Yeo, for the Diabcare Singapore Local Working Group & the Diabetic Society of Singapore
Correspondence: Dr Warren Lee, warren@kkh.com.sg

ABSTRACT
The Diabcare-Singapore project was carried out in 22 clinics (general hospitals, GH and primary healthcare centres, PHC) to provide an overview of diabetes management and metabolic control status. Data from 1697 diabetic patients were collected on paper forms and analysed centrally. Type 2 diabetes mellitus patients constituted 91.4% and type I patients constituted 8.1% of population. The proportion of type I patients was greater in GH (18.1%) vs PHC (3.4%). The mean age (+/- SD) was 58.1 +/- 14.4 years and mean duration of diabetes was 10.1 +/- 7.5 years. Mean body mass index (BMI) was 25.1 +/- 4.4 kg/m2 and more than half (53%) of patients were overweight (BMI >25 kg/m2). Mean HbA1c and FBG levels were 8.0 (1.9% and 9.1 +/- 3.1 mmol/l. A total of 51% of patients had HbA1c (1% above the Upper Limits of Normal (ULN). Fasting blood glucose (FBG) was >7.8 mmol/l in 61% of patients. The majority (70%) had satisfactory levels of fasting lipids (triglycerides, total cholesterol and HDL-cholesterol). Only 19.7% practised home blood glucose self-monitoring, while 99% reported receiving some diabetes education. Sixteen percent of patients had abnormal levels of protein (>500 mg/24 h) in the urine, 3% had elevated serum creatinine levels and 36% had microalbuminuria. Retinopathy (12%), cataract (16%) and neuropathy (12%) were commonly reported diabetic complications. The data revealed suboptimal glycaemic control in about half of patients studied.

Keywords: diabetes mellitus, Singapore, demographic profile, HbA1c, metabolic control
Singapore Med J 2001; 42(11): 501-507