Original Article

MG Caleb
Correspondence: M G Caleb, mcgeorge88@hotmail.com

ABSTRACT
Massive pulmonary embolism with shock remains a highly fatal disease. We present twelve cases of massive embolism over the last seven years that required emergent surgery. Five patients suffered haemodynamic collapse and all died despite heroic attempts at salvage. A better outcome can only be achieved in this sub-category of patients with a rapid confirmatory diagnosis and appropriate thrombolysis and early referral to a cardiothoracic surgeon.

Keywords: Massive, pulmonary embolism, emergent surgery, haemodynamic collapse
Singapore Med J 2002; 43(1): 25-27

L Chew, C Cheah, Y Koh
Correspondence: Dr L Chew, chew_ling@hpb.gov.sg

ABSTRACT
A postal survey was conducted in 4,479 private companies with at least 50 employees in 1998 to determine the prevalence and the scope of workplace health promotion programme in these companies in Singapore. The self-administered questionnaire mailed to the study population covered five areas viz, organisational details, workplace health policies, health promotion and related activities, workplace health facilities and the source of assistance for the programme. The overall response was 49.5%. Parkinson's definition of workplace health promotion was used in the analysis to determine the prevalence of the programme. The data was collated on DBase IV and analysed using SPSS computer programmes. About one third of the respondents covering an estimated 26% of the private sector workforce had a comprehensive workplace health promotion programme as defined by Parkinson. This prevalence was a function of workforce size and industry type. Workplaces with larger workforce size (p<0.001) and those from the manufacturing and human/health service sectors (p<0.001) were more likely to have such programmes compared to their smaller counterparts and other industries respectively. The management remained the main driver behind these programmes. Many of the programmes were centred around health promoting policies and facilities with emphasis on occupational healthl safety and smoking issues. A significant proportion of workplaces surveyed had in place a comprehensive workplace health promotion programme. However, more could still be done to encourage its uptake such as training for facilitators, consultation, grant provision etc. Small workplaces remained an untapped market for such programmes.

Keywords: workplace health promotion, prevalence, private companies, Singapore
Singapore Med J 2002; 43(1): 18-24

LC Ong, YN Lim, A Sofiah
Correspondence: Professor Ong Lai Choo, onglc@mail.hukm.ukm.my

ABSTRACT
Purpose To determine the relationship between spinal lesion level and functional outcome in children with spina bifida.
Methods Prospective observational study of 66 children who attended the Spina Bifida Clinic from 1994-1997. Data were obtained from serial physical examination and parent interview to determine mobility status, neurosensory deficits, continence and school placement.
Results Eighteen (27.3%) had high-level (thoracic and thoracolumbar), 27 (40.9%) intermediate (low lumbar) and 21 (31.8%) low-level (sacral) lesions. Children with high-level lesions experienced more mobility problems (independent ambulation, balance and use of appliances), than those with intermediate or low-level lesions (p<0.001). 58.8% of children with low-level lesions used diapers, compared with those with high (90%) or intermediate (100%) level lesions (p = 0.005), but there were no significant differences in the incidence of soiling or urinary incontinence among all three groups. There were no significant differences among the three groups in terms of school placement, skin breakdown, epilepsy or visual defect.
Conclusion Although there is good correlation between the level of the lesion and mobility in children with spina bifida, other measures of functional outcome like continence and school placement are more difficult to predict. These data are important for realistic counselling of families with newborns with spina and planning long term rehabilitation resources.

Keywords: spina bifida, outcome, children
Singapore Med J 2002; 43(1): 12-17

VS Doshi, JH Say, SH-Y Young, P Doraisamy
Correspondence: Dr Doshi Shashikant Vina, Vina_Doshi@cgh.com.sg

ABSTRACT
Aim The aim of this study was to look at the type and frequencies of complications after an acute stroke in an inpatient rehabilitation setting. We also looked at the type of complications which required the transfer of patient care back to the primary referring physician.
Materials and Methods A retrospective review of case notes of patients transferred to the rehabilitation team was conducted. The study period was a six-month period from the beginning of January 2001 to the end of June 2001. A list of complications was made. Each pre-determined complication was then defined. The frequency of each complication was then calculated.
Results A total of 140 case notes were reviewed. The overall complication rate was 54.3%. The more common complications, in order, from highest to lowest frequencies, were: constipation (complicating 22.9% of strokes); acute retention of urine (ARU, 20.9%); urinary tract infections (UTI, 14.3%); depression (9.3%); and limb pain (8.6%). Females were more likely to have UTI (p=0.038), ARU (p=0.002) and depression (p=0.018). Patients 65 years and above were more likely to suffer multiple complications although the results did not reach statistical significance (p=0.055). The care for eight patients (5.7% of patients with complications) had to be transferred back to the primary referring team or physician.
Conclusion Complications post stroke are common. Some patients required transfer of care back to the primary referring physician. A pro-active approach is ideal in all post stroke patients, in order to identify and treat any complications early, thereby, improving outcome and reducing costs.

Keywords: stroke, complications, inpatient, stroke rehabilitation
Singapore Med J 2003; 44(12): 643-652

MH Kam, SG Tan
Correspondence: Mr Tan Seck Guan, gsutsg@sgh.com.sg

ABSTRACT
Objective To audit retrospectively all long saphenous vein stripping performed or supervised intra-operatively by a single surgeon over a seven-year period.
Patients One hundred and twenty-four patients (156 limbs) operated primarily in standard surgeon-supervised operations, were audited.
Methods All patients were questioned via telephone interviews, and those with symptoms or recurrent varicosities were recalled for clinical review and investigations by the surgeon.
Results Eighty-seven cases presented with lower limb pain, 36 with eczema and 27 with ulcer. Eighty-one percent of operations were performed for symptomatic varicose veins and 19% were done for cosmesis. There were 153 limbs with varicosities, 121 of these had documented long saphenous vein reflux preoperatively. One hundred and sixteen limbs resolved post-operatively, five did not resolve, and four recurred. Incompetent perforators and short saphenous veins were the commonest causes of non-resolution and recurrence. Complications, including five cases of saphenous nerve paraesthesias, were temporary and met with full resolution eventually.
Conclusion A 96% success rate is possible after high tie, stripping of the long saphenous vein with multiple avulsions of varicosities. Recurrence is 3% over the period of follow-up.

Keywords: varicose veins, varicosities, long saphenous vein, short saphenous vein, venous reflux, vein stripping
Singapore Med J 2003; 44(12): 639-642

CE Tan, LM Loh, ES Tai
Correspondence: Dr Tan Chee Eng, ce_tan@sgh.com.sg

ABSTRACT
A substantial number of physicians in Asian countries believe that Asian patients need lower doses of statins to achieve therapeutic lipid target because of the smaller size of patients. This belief is deep rooted and we looked at the SGH Lipid Clinic to determine if our experience bears out this belief. Between 1996 and August 2000, the Lipid Unit treated a total of 841 patients, of which 548 patients (77.5% Chinese, 12.1% Malays, 7.6% Asian Indians; 49.6% males, 50.4% females; 54.7% diabetics, 45.3% non-diabetic) were on statins alone. These patients had > or =2 coronary risk factors, diabetes mellitus or documented coronary heart disease. The pre-treatment lipid levels or the worst lipid levels available were entered as the baseline lipid values (mean LDL-C: 5.38+1.5 mmol/l). Duration of therapy ranged from six months to five years. The choice and titration of statins were determined by attending physicians. The median statin dose (Simvastatin equivalent) was 20.0 mg with 52.5% requiring 20 mg or more. Statin dose did not differ between diabetic and non-diabetic subjects. The median statin dose was 15 mg for the lower two tertiles and 20 mg for the upper tertile; this difference did not achieve statistical significance. The reduction in LDL cholesterol was 41.5% (40.1-42.8) and total cholesterol was 33.0% (32.9-34.1). Only 25% of our patients achieved LDL cholesterol of less than 2.6 mmol/l whilst 77.5% had LDL cholesterol less than 3.4 mmol/l. Our experience at the Lipid Clinic suggests that the Asian patients require similar statin doses to achieve target cholesterol levels.

Keywords: asian patients, statins, LDL cholesterol, Body mass index, diabetes mellitus
Singapore Med J 2003; 44(12): 635-638

JSC Chen, N Walford, YL Yan, CL Ong, GSH Yeo
Correspondence: Dr Jeanette Chen, jeanchensc@yahoo.co.uk

ABSTRACT
Objectives The objectives of this study are to discuss the use of ultrasonography for the diagnosis of foetal intralobar sequestration (FILS) antenatally and the management options available for these pregnancies.
Methods This is a retrospective review of six cases of FILS diagnosed antenatally by two dimensional (2D) and colour Doppler ultrasonography out of a total of 31,508 deliveries over a two-year period at the KK Women's and Children's Hospital.
Results The incidence of FILS in this hospital was 1 in 5,251 deliveries. 2D ultrasonography showed an echogenic lung in all cases. FILS was confirmed by the demonstration of a systemic vessel leading to the affected lung on colour Doppler examination. After counselling, four terminated their pregnancies during mid-trimester, while two continued their pregnancies to term. Confirmation of the terminated cases was by post-mortem. In the two pregnancies that continued, regular growth scans were done to monitor the progression of the condition. Computed tomography confirmed the diagnosis post-delivery. Both were well but one had a resection of the sequestrated lung although he was asymptomatic. Histology also confirmed the diagnosis.
Conclusion FILS is a rare anomaly. 2D and colour Doppler ultrasonography are used to diagnose the condition antenatally. Termination of the pregnancy is not always indicated, as there are favourable outcomes from FILS.

Keywords: echogenic lungs, intralobar sequestration, Colour Doppler Ultrasonography, foetal anomalies
Singapore Med J 2003; 44(12): 630-634

K Mamun, CYE Goh-Tan, LL Ng
Correspondence: Dr K Mamun, kaysar_mamun@cgh.com.sg

ABSTRACT
Aim To assess the prescribing practice, use and potential adverse effects of psychoactive medications in Singapore nursing homes.
Methods From a list of existing 24 voluntary welfare organisation (VWO) run nursing homes, four homes with the largest bed capacity were selected from the eastern zone of Singapore. When contacted, two homes agreed to participate in the study. Medical records of all residents aged 65 years and above were reviewed to obtain demographic information, clinical diagnoses and medication orders. Two geriatricians and one psychogeriatrician reviewed the psychoactive medications used in these nursing homes.
Results A Total of 384 residents were enrolled in the study. Mean age of the participants was 79.1 years (65-107); 60.7% were female and 92.4% were Chinese. Dementia was documented for 131 (34.1%) residents, depression for 50 (13%) residents. Residents were on an average of 5.2 (0-14) medications. A total of 309 psychoactive medications were prescribed for the residents. Fifty-nine (63%) antipsychotics, 42 (65%) Benzodiazepines, 65 (61%) antidepressants, 10 (77%) others sedatives and 31 (100%) anticonvulsants were deemed inappropriate. Lack of documented indication, potential adverse drug reaction, drug-drug interaction and therapeutic duplication were the most common medication related problems observed in this study.
Conclusion Majority of the nursing home residents were on psychoactive medications. Residents with dementia were more likely to be on psychoactive medications. Statistically significant association was observed between the use of inappropriate psychoactive medications and the diagnosis of dementia. Better documentation of clinical diagnoses and indications, and regular medication review for potential adverse drug reactions would improve the quality of care in Singapore nursing homes.

Keywords: psychoactive medications, nursing home, current practice, elderly, Singapore
Singapore Med J 2003; 44(12): 625-629

DL Lim, BY Thong, SY Ho, et al
Correspondence: Dr Dawn Li-Chern Lim, paelimd@nus.edu.sg

ABSTRACT
Objectives To describe the clinical features, disease complications, treatment modalities and overall outcome of 39 local patients with Primary Immunodeficiency Diseases (PID) in Singapore over the last 11 years.
Methods Paediatric and adult patients who presented to the The Children's Medical Institute, National University Hospital, Tan Tock Seng Hospital and KK Women's and Children's Hospital between January 1990 and December 2000 were identified. Their diagnoses were categorised into six groups according to the IUIS (International Union of Immunological Societies, affiliated to World Health Organisation) classification: antibody deficiencies, combined immunodeficiencies, immunodeficiencies associated with other major defects, congenital phagocytic defects, complement deficiencies and other well-defined immunodeficiency syndromes. Patients were selected from screening of inpatients with discharge diagnoses associated with primary immunodeficiency and of patients undergoing tests for immunodeficiency. Patient data were collated from case files and compiled using a standard questionnaire.
Results There were 39 Singaporean patients diagnosed and treated for PID during the study period. The age at diagnosis ranged from three weeks to 69 years. Antibody deficiency (41%) was the most common form of PID. Seven patients had a family history of PID. Recurrent bacterial respiratory tract infections were the most common clinical manifestation. Associated conditions included autoimmune diseases, allergies and malignancies. Infection was the commonest cause of mortality. Eighteen patients (46.2%) with antibody or combined deficiencies received regular intravenous immunoglobulin (IVIG) as the primary treatment modality. Two children successfully received sibling-matched haematopoietic stem cell transplantation (HSCT).
Conclusion Antibody deficiencies are the most common form of PID in Singapore. Treatment with antibiotics, IVIG and HSCT are the main therapeutic modalities currently available. Early referral to an immunologist is needed to achieve good outcomes.

Keywords: Epidemiology, intravenous immunoglobulin, haematopoietic stem cell transplantation, gene therapy
Singapore Med J 2003; 44(11): 579-586

WJ Chng, MK Tan, Ponnudurai Kuperan
Correspondence: Dr Chng Wee Joo, chngwj@nuh.com.sg

ABSTRACT
Background FFP is often inappropriately used despite existence of guidelines. An audit was conducted with the aim of making recommendations to reduce inappropriate use.
Materials and Methods A retrospective review of blood bank and electronic medical records of patients given FFP from October to December 2001 in an acute general hospital was undertaken. The criteria set by the College of American Pathologists in 1994 were used as the standards.
Results Nine hundred and thirty-two units of FFP were used during the study period for 359 transfusion episodes. Only 98 (27%) episodes were deemed appropriate. Percentage of inappropriate requests was similar across specialties. FFP used in the setting of inadequately prolonged coagulation profiles or absence of bleeding or surgical intervention was the commonest reasons for inappropriate use.
Conclusion Our results showed significant proportion of FFP used outside of established international criteria. There may be many reasons for this and we suggest that a continual system of staff education and administrative intervention may help to reduce the inappropriate usage.

Keywords: fresh frozen plasma, audit, guidelines
Singapore Med J 2003; 44(11): 574-578