Original Article

H Tiwari, A Kumar, SK Kulkarni
Correspondence: Prof S K Kulkarni, skpu@yahoo.com

ABSTRACT
Introduction The present pilot study was conducted in order to establish the drug-prescribing trend of anti-hypertensive agents at the Panjab University Health Centre in India.
Methods A pilot study of six-month duration was conducted at the Panjab University Health Centre. The information was collected from the patients attending the outpatient department through a random sample method. World Health Organisation-based prescription-auditing proforma was used for data collection.
Results This study revealed that most of the male patients were on monotherapy (60 percent). In the monotherapy category, four classes of drugs were used. These were calcium channel blockers (48.1 percent), beta-blockers (46.2 percent), ACE inhibitors (3.9 percent) and diuretics (1.9 percent). Among monotherapy drugs, calcium channel blockers were prescribed most whereas diuretics were least used. Among those who were treated with drug combinations, 92.1% received two drugs and 7.9 percent received three drugs. In combination therapy, a two-drug combination consisting of beta-blockers and calcium channel blockers was given to the majority of the patients. Overall, 57.8 percent patients were treated with a single anti-hypertensive drug and 42.2 percent were treated with anti-hypertensive drug combinations.
Conclusion The present study represents the current prescribing trend for anti-hypertensive agents and it highlights certain shortcomings in the existing prescribing practice. There is a considerable scope for improvement, particularly the under-utilisation of diuretics in the present prescribing pattern of anti-hypertensive drugs.

Keywords: anti-hypertensive drugs, drug utilisation, hypertension, prescribing pattern, prescription monitoring
Singapore Med J 2004; 45(3): 117-120

OC Ezechi, P Mabayoje, LO Obiesie
Correspondence: Dr Oliver C Ezechi, oezechi@yahoo.co.uk

ABSTRACT
Introduction Rupture of the gravid uterus is a grave obstetric complication that is associated with high maternal and perinatal mortality rates. In Nigeria, the incidence remains high and continue to increase because of poverty, illiteracy, unavailability of manpower, poor supply of medical equipment and consumables, and dwindling health care funding.
Methods A 10-year retrospective review of all cases of ruptured uterus seen at the Obafemi Awolowo University teaching hospital complex in Ile Ife, Nigeria was conducted.
Results A total of 61 cases of ruptured uterus from 16,683 deliveries were recorded, giving a ratio of 1 in 273. Predisposing or aetiological factors for rupture were: prolonged labour (91.8 percent), grand multiparity (50.8 percent), injudicious use of oxytocin (41.0 percent), uterine scar (26.2 percent), obstetric manipulation (4.9 percent) and abnormal lie (14.8 percent). Fifty-six patients had surgery, of which 14 (25.0 percent) had total abdominal hysterectomy, 16 (28.6 percent) had subtotal hysterectomy, 15 (26.8 percent) had repair of the rupture and bilateral tubal ligation, and 13 (19.6 percent) had repair only. Thirteen maternal deaths occurred with a case fatality rate of 21.3 percent.
Conclusion Ruptured uterus remains a problem in Nigeria, with primary health centres and mission houses being identified as major contributors to this condition. They primarily failed in the recognition of abnormalities in the antepartum and/or intrapartum periods, with delays in referral and the injudicious use of oxytocin.

Keywords: grandmultipara, injudicious use of oxytocin, maternal mortality, prolonged labour, ruptured uterus
Singapore Med J 2004; 45(3): 113-116

Y Imran, W Zulmi, AS Halim
Correspondence: Dr Imran Yusof, drimran@kb.usm.my

ABSTRACT
Introduction Immediate recognition of anastomotic failure is important to ensure the viability of the vascularised fibular graft. The problems associated with post-operative bone scanning and angiography for immediate detection of anastomotic failure have been described.
Methods We report the effectiveness of using a skin paddle as an indicator of the vascularised fibular graft viability in 13 cases which had undergone various types of long bone reconstruction using fasciocutaneous free vascularised fibular graft.
Results Early detection of anastomotic failure in 100 percent of the patients (4 out of 4) with 92 percent (12 out of 13 patients) success rate shows the effectiveness of this method.
Conclusion The skin paddle offers the best method of post-operative monitoring of fibular graft viability.

Keywords: graft viability, skin paddle, vascularised fibular graft
Singapore Med J 2004; 45(3): 110-112

YK Ong, YH Goh, YL Lee
Correspondence: Dr Ong Yew Kwang, ykong@pacific.net.sg

ABSTRACT
Introduction The disease pattern and management of peritonsillar infections in Singapore General Hospital are studied. Other objectives are to determine if a seasonal variation exists and to examine the role of routine bacterial cultures and interval tonsillectomy.
Methods This is a retrospective review of the management and outcome of patients with peritonsillar infections who were admitted acutely to Singapore General Hospital over a three-year period.
Results Of 185 patients studied, 151 (81.6 percent) had peritonsillar abscess or quinsy and 34 (18.4 percent) had peritonsillar cellulitis. There were 139 males and 46 females, with a racial predisposition among Malays (p value is less than 0.0005). There may be a seasonal variation with a bi-annual trend, though no correlation with upper respiration tract infections was noted. Treatment consisted mainly of incision and drainage (66 percent) or needle aspiration (34 percent). No significant difference in the length of stay was noted in patients receiving penicillin alone, penicillin with metronidazole, or broad-spectrum antibiotics (p value is equal to 0.062). Fourteen (7.6 percent) patients had recurrences, all of which occurred after the first month. Two patients (1 percent) had bilateral quinsy.
Conclusion Peritonsillar infections remain a common admitting diagnosis to the Otolaryngology department. A single episode of infection should no longer be an indication for tonsillectomy as the incidence of recurrence is low.

Keywords: antibiotics, peritonsillar cellulitis, peritonsillar infections, quinsy, tonsillectomy
Singapore Med J 2004; 45(3): 105-109

TC Wong, IS Rikhraj
Correspondence: Dr Inderjeet Singh, gooisr@sgh.com.sg

ABSTRACT
Antegrade intramedullary nailing of femoral shaft fractures is a tried and tested treatment modality that has yielded consistently high union rates. Retrograde nailing is controversial as the approach violates the knee joint. We report two cases in which both patients had an arthrodesis of the hip and subsequently suffered a femoral shaft fracture distal to the implant. We feel that this would be an indication for retrograde nailing.

Keywords: arthrodesis, femoral shaft fractures, hip arthrodesis, Intramedullary nailing, retrograde interlocking nailing
Singapore Med J 2004; 45(2): 85-87

HY Wu, JJ Chin, HMH Tong
Correspondence: Dr Wu Huei Yaw, huei_yaw_wu@ttsh.com.sg

ABSTRACT
Introduction This study sets out to determine the usefulness of a questionnaire to screen for hearing impairment, assess the psychosocial impact of hearing handicap and survey older persons' attitudes towards hearing aid usage.
Methods Subjects were recruited from a Geriatric Medicine unit over a six-month period. A questionnaire was administered, followed by an otoscopic examination and audiometric testing.
Results Sixty-three patients were included in the study. Fifty-two (83%) patients had hearing impairment, of which 34 were moderately severe and 18 were mild. Of the six questions used in hearing screening, the question on self-perception was the most specific (91%). Administering the remaining five questions on activities of daily living improved the questionnaire's sensitivity from 58% to 73%, although the specificity was reduced from 91% to 64%. Of the 30 patients with self-perceived and audiometrically-confirmed hearing impairment, about 40% reported negative psychosocial impact as a result of the handicap. 66.7% were not keen to consider using hearing aid, even if recommended. The willingness to use hearing aids was correlated to patients' functional status (p=0.002) but not to the severity of hearing impairment (p=0.157).
Conclusion Self-perception of hearing problems in the elderly is a strong indicator of hearing impairment. Introducing additional culturally-relevant questions based on activities of daily living improves the detection rate of hearing impairment. Although hearing loss impacts negatively on psychosocial well-being, most elderly subjects are unwilling to consider the use of hearing aids. There is a need to educate the elderly on the importance of intervention in order to reduce their handicap and improve their quality of life.

Keywords: audiometric testing, hearing aids, hearing impairment, psychosocial impact, questionnaire
Singapore Med J 2004; 45(2): 79-84

M Ong, JTL Choo, E Low
Correspondence: Dr M Ong, mikeong@pacific.net.sg

ABSTRACT
Introduction Active Hearing Defenders are established hearing protectors with in-built electro-acoustics that shut-off ambient noise while allowing effective communication between users.
Methods A blinded, self-controlled trial was conducted among naval servicemen to compare the effectiveness of two types of active hearing defenders (Howard-Leight Thunder TM and COM-55) in relation to passive hearing defenders in an operational environment.
Results Subjects felt that the active hearing defenders were more comfortable, durable, and that the active hearing defenders helped them work better. When subjects were tested with a speech discrimination battery (Central Institute of the Deaf, Spondee Word lists), there was a significant difference (p value of 0.04, using the Kruskall-Wallis ANOVA test) between the two active and the passive defenders. However, no significant difference was found between the two types of active hearing defenders.
Conclusion Active hearing defenders are an acceptable and efficacious means of hearing protection in noisy environments.

Keywords: active hearing defenders, hearing conservation programme, noise induced deafness, passive hearing defenders, speech discrimination battery
Singapore Med J 2004; 45(2): 75-78

HAMN Ahasan, AA Mamun, SR Karim, MA Bakar, EA Gazi, CS Bala
Correspondence: Dr H A M Nazmul Ahasan, supto@bttb.net.bd

ABSTRACT
Introduction Puffer fish is available in Bangladesh and is occasionally eaten by some people. Ignorance regarding its proper cooking process may lead to serious health hazards, including fatality.
Methods An unusual catastrophic event happened recently in Khulna, Bangladesh that drew nationwide attention. Eight families were affected.
Results Thirty-seven patients were admitted with a history of consumption of puffer fish. Peri-oral paraesthesia (24), weakness of both lower limbs (22), paraesthesia all over the body (18), headache (15), difficulty in respiration (14), nausea and vomiting (8), blurring of vision (7), and vertigo (6) were common clinical presentations. Twenty-two patients developed ascending paralysis of limbs and involved the respiratory muscles in 17 patients. Eight patients died due to respiratory failure while the rest improved.
Conclusion Health personnel should have sufficient knowledge regarding the clinical manifestations, complications and management of puffer fish poisoning. During its preparation, organs that contain the highest level of tetrodotoxin should be removed. Since there is no specific treatment, people should be made aware of the potential risk of eating puffer fish, about the warning symptoms and signs of puffer fish poisoning, and when to seek medical help.

Keywords: paralytic complications, poisoning, puffer fish, respiratory failure, tetrodotoxin
Singapore Med J 2004; 45(2): 73-74

YM Tan, WK Wong, LLPJ Ooi
Correspondence: Dr Tan Yu-Meng, gsutym@sgh.com.sg

ABSTRACT
Introduction Debate currently exists regarding the appropriate surgical strategy for emergency treatment of gallstone ileus. This relates to the need for definitive biliary tract surgery after relief of mechanical obstruction. Our study reviews treatment by enterolithotomy alone and enterolithotomy combined with definitive biliary tract surgery and fistula closure to determine if there is advantage of one treatment option over the other.
Methods The clinical, operative and follow-up data on 19 consecutive patients treated by emergency surgery for gallstone ileus from January 1992 to December 2000 was retrospectively reviewed.
Results There were 15 women and four men, with a mean age of 74.6 (range 62-91) years. Pre-operative diagnosis was made in only nine of 19 patients. Enterolithotomy alone (E group) was performed in seven patients and enterolithotomy with cholecystectomy and fistula closure (E+C group) in 12 patients. In the E group, more patients had significant co-morbidity as identified by poorer American Society of Anesthesiologists (ASA) status, poorer pre-operative status (shock at presentation) than in the E+C group. Operative time was significantly shorter in the E group. However, there were no significant differences in morbidity, and both groups had zero mortality.
Conclusion Both procedures can be carried out safely and with zero mortality. Relief of obstruction remains the mainstay of treatment. The better surgical option in our series is enterolithotomy alone. It is safe in both low and high-risk patients, and requires a shorter operating time as it is technically less demanding. In the longer term, the remnant fistula also does not appear to lead to further complications.

Keywords: biliary-enteric fistula, emergency surgery, gallstone, gallstone ileus, intestinal obstruction
Singapore Med J 2004; 45(2): 69-72

M Leow, J Lim, TC Lim
Correspondence: Dr M Leow, mgtlpg@hotmail.com

ABSTRACT
The purpose of this paper is to report the use of the superior gluteal artery perforator (SGAP) flap in the closure of sacral pressure sores here in Singapore. This fasciocutaneous flap is a refinement of the musculocutaneous flap which is popularly used for the closure of sacral sores. There were minimal complications. This is a reliable flap and gives the option of further reconstructive possibilities should a recurrence occur.

Keywords: fasciocutaneous, pedicled, sacral pressure sores, superior gluteal artery perforator (SGAP) flap
Singapore Med J 2004; 45(1): 37-39