Original Article

Joshi VD, Chen YM, Lim JFY
Correspondence: Dr Veena Dhanajay Joshi, veena.d.joshi@singhealth.com.sg

ABSTRACT
Introduction In Singapore, few studies have been done on the factors that the general public considers to be most important in the healthcare system. We conducted this pilot study to determine the factor structure, reliability and validity of statements in a healthcare survey questionnaire as predictors of public perception of a good healthcare system.
Methods Data on public perceptions of healthcare from a national survey of 1,434 adult Singaporeans was analysed using a principal component analysis and regression, to obtain the factors and predictors. The survey employed 31 statements on healthcare quality, cost, access and the role of the individual vis-à-vis society, which participants ranked on a five-point Likert scale.
Results The exploratory factor analysis identified six critical factors (F): National healthcare financing framework (F1), Service at public institutions (F2), Service at private institutions (F3), Individual responsibility for health (F4), Affordability at public institutions (F5), and Affordability at private institutions (F6). These factors explained 54 percent of variance, and Cronbach’s alpha ranged from 0.5 to 0.72, except for F1. Regression analysis showed an association of public perception of good healthcare in Singapore with the following factors: F2 (odds ratio [OR] 1.79, 95 percent confidence interval [CI] 1.48–2.16, p-value is less than 0.0001); F3 (OR 1.29, 95 percent CI 1.10–1.52, p-value is less than 0.0001); F5 (OR 1.52, 95 percent CI 1.27–1.83, p-value is less than 0.0001); F1 (OR 1.31, 95 percent CI 1.08–1.59, p-value is 0.01); F4 (OR 1.33, 95 percent CI 1.16–1.54, p-value is less than 0.0001); but not with F6.
Conclusion This pilot study provides a practical, reliable and valid first perception second level matrix to assess the Singapore healthcare system. Further snapshot surveys to assess perceptions of the healthcare system should be conducted with questionnaires abridged to include only these five identified critical factors.

Keywords: healthcare system, Singapore healthcare system
Singapore Med J 2009; 50(10): 982-989

Wu AYT, Low LP
Correspondence: Dr Akira Y T Wu, akirawu@pacific.net.sg

ABSTRACT
Introduction Elevated blood pressure is a principal risk factor for cardiovascular and renal diseases. Early detection and adequate treatment of hypertension are essential components in the primary prevention of these end-stage events. Microalbuminuria is recognised as an early marker of renal disease and increased cardiovascular risk. Screening alerts physicians to implement timely intervention strategies to delay disease progression and minimise consequent complications. Although the value and significance of microalbuminuria screening has been widely documented, its use is still suboptimal.
Methods Survey forms were sent to randomly-selected general practitioners in Singapore to capture their self-reported attitudes and practices regarding microalbuminuria screening in the management of hypertension.
Results Results from this survey revealed that microalbuminuria screening was practised by 88 percent of the physicians surveyed; however, only 56 percent of hypertensive patients without risk factors were screened. Quantitative analysis of urine samples was the preferred screening method of 90 percent of the physicians surveyed.
Conclusion A concerted effort should be made to address the lack of public awareness on the importance of screening for microalbuminuria. Continuing medical education should also emphasise the usefulness of surrogate markers in the therapeutic prevention of end-organ damage in hypertensive patients. There is also a need to form a consensus guideline on microalbuminuria screening, to aid in the standardisation of practice.

Keywords: cardiovascular risk factor, health screening, hypertension, microalbuminuria, renal disease
Singapore Med J 2009; 50(10): 976-981

Kong KH, Chua SGK
Correspondence: Dr Keng He Kong, keng_he_kong@ttsh.com.sg

ABSTRACT
Introduction Although lower extremity deep vein thrombosis (DVT) is a common complication after an acute stroke, there is little local data documenting this condition in stroke patients undergoing rehabilitation. The purpose of this study was to determine the frequency and risk factors of DVT in ischaemic stroke patients admitted to a rehabilitation unit.
Methods This was a prospective observational single-centre study of ischaemic stroke patients with lower limb paresis admitted to a rehabilitation centre. The screening protocol consisted of quantitative D-dimer assay (DDA) within 24–48 hours of rehabilitation admission followed by duplex Doppler ultrasonography (DUS) of the paretic lower extremity if the DDA level was elevated (equal or greater than 0.34 µ/ml).
Results 212 patients (167 Chinese, 27 Malays, 17 Indians and one Eurasian) were screened at a mean of 23.2 days post-stroke. 121 (57.1 percent) patients had an elevated DDA, and all underwent ultrasonography. The incidence of lower limb DVT was 5.2 percent (11), consisting of four proximal and seven distal. DVT was significantly related to total anterior circulation infarct (odds ratio 3.69, 95 percent confidence interval 1.04–3.05, p-value is 0.043), but not to age, gender, race, severity of lower limb weakness, and ambulatory and functional status. No patients had clinical pulmonary embolism during rehabilitation.
Conclusion Locally, asymptomatic lower limb DVT based on a screening protocol of DDA and selective DUS, is uncommon in ischaemic stroke patients admitted to rehabilitation. Future research efforts could include a detailed evaluation of DDA’s role as a screening tool for DVT in the stroke population, by comparing it to an established gold standard like venography.

Keywords: D-dimer, deep vein thrombosis, stroke, rehabilitation
Singapore Med J 2009; 50(10): 971-975

Bhardwaj R
Correspondence: Dr Rajeev Bhardwaj, rajeevbhardwaj_dr@yahoo.com

ABSTRACT
Introduction Total occlusion of the abdominal aorta is unusual, posing diagnostic and therapeutic problems. The outcome of surgery involving the abdominal aorta depends upon the presence of coronary artery disease (CAD). Hence, the purpose of this study was to determine the prevalence of CAD in patients with total occlusion of the abdominal aorta.
Methods 74 patients presenting with claudication of both the lower limbs and having bilaterally absent femoral pulsations were subjected to abdominal aortography. Patients who were found to have total occlusion of the abdominal aorta were included in the study. Coronary angiography was done in all the patients.
Results 47 patients were found to have total occlusion of the abdominal aorta. The mean age was 55 years. 37 patients were male and ten were female. All were smokers, 37 were hypertensive and four were diabetic. 11 (23.4 percent) patients were found to have CAD. Single vessel disease was present in eight patients, two-vessel disease in two patients and three-vessel disease in one patient.
Conclusion The study shows that approximately one-fourth of the patients with total occlusion of the abdominal aorta had CAD. A majority of these patients had single vessel disease.

Keywords: abdominal aorta, atherosclerosis, coronary artery disease, total arterial occlusion
Singapore Med J 2009; 50(10): 967-970

Norasyikin AW, Norlela S, Rozita M, Masliza M, Shamsul AS, Nor Azmi K
Correspondence: Dr Norasyikin A Wahab, naw8282kt@gmail.com

ABSTRACT
Introduction Acute coronary syndrome (ACS) is an acute stressful condition which stimulates the hypothalamus-pituitary-adrenal axis that regulates neurovascular and hormonal responses. Functional hypoadrenalism has been shown to be associated with significant morbidity and mortality in the critically-ill patient, but there is to date, no known study done to determine its prevalence in patients with ACS.
Methods 37 patients who fulfilled the diagnostic criteria of ACS were subjected to the low-dose (1 µg) ACTH stimulation test (LDT), followed by a standard-dose (250 µg) ACTH stimulation test (SDT) two hours later.
Results 14 (37.8 percent) patients had ST acute myocardial infarction, eight (21.6 percent) patients had non-ST elevation myocardial infarction, and 15 (40.5 percent) patients had unstable angina. Based on an increment of less than 250 nmol/L post-SDT, no patient had adrenal insufficiency. However, using a similar criteria with the LDT, eight (21.6 percent) patients had adrenal insufficiency. Four patients died during the study and they had very high cortisol levels. The diagnosis of adrenal insufficiency is not associated with any significant morbidity and mortality in our group of patients.
Conclusion Utilising the LDT, adrenal insufficiency is present in 21.6 percent of patients admitted with ACS. However, this is not associated with any significant morbidity and mortality.

Keywords: ACTH stimulation test, acute coronary syndrome, adrenal insufficiency, cortisol
Singapore Med J 2009; 50(10): 962-966

Jim MH, Chan AO, Tse HF, Lau CP
Correspondence: Dr Man-Hong Jim, jimmanh2002@yahoo.com

ABSTRACT
Introduction Compared with anterior wall myocardial infarction, inferior wall myocardial infarction is generally regarded as being low risk. The aim of this study was to elucidate the clinical factors affecting its inhospital outcome.
Methods From January 1997 to March 2006, 546 consecutive patients who suffered from their first inferior wall myocardial infarction were recruited for the study. The demographic, clinical, electrocardiographical and angiographical characteristics, treatment and medications, complications and inhospital deaths were subjected to univariate analysis. The factors that had a p-value of less than 0.1 were included for multivariate logistic regression analysis. A p-value of less than 0.05 was considered significant. The impact of thrombolysis on clinical outcome in various high-risk patient subsets was also examined.
Results An advanced age of more than 74 years, female gender, lateral wall extension, complete atrioventricular block, bundle branch block, and cardiac free-wall rupture were found to be independent predictors of inhospital mortality, whereas the use of thrombolysis was associated with a favourable outcome. On the other hand, right ventricular infarction and precordial ST-segment depression are not predictive of poor outcome. In addition, thrombolysis reduced inhospital mortality in patients with an age above 64 years, male gender, lateral wall extension, haemodynamically-significant right ventricular infarction and complete atrioventricular block.
Conclusion In inferior wall myocardial infarction, independent predictors of poor inhospital outcome are advanced age, female gender, lateral wall extension, complete atrioventricular block, bundle branch block and cardiac free-wall rupture. The use of thrombolysis is generally beneficial, especially in those of the high-risk subsets.

Keywords: acute myocardial infarction, inferior wall myocardial infarction, myocardial infarction, right ventricular infarction, thrombolysis
Singapore Med J 2009; 50(10): 956-961

Haghdoost AA, PoorRanjbar M
Correspondence: Dr Aliakbar Haghdoost, ahaghdoost@kmu.ac.ir

ABSTRACT
Introduction The serum lipid profiles in Muslims change during the fasting month of Ramadan, but it is not clear whether this change is due to changes in their physical activities. In this study, we compared the patterns of the lipid profile changes in those who engaged in regular physical activity with those who did not.
Methods In a randomised trial, we assigned 93 students who took a physical education course into two groups – those who had regular physical activity after Ramadan and those who had physical activity during Ramadan. Venous blood (5 ml) was taken just before, at the end, and 40 days after Ramadan, and the fasting glucose sugar and lipid profile were measured.
Results Fasting with physical activity decreased body weight by 1.2 kg (p-value is 0.03). Fasting blood sugar also decreased by 7 mg/dL during Ramadan, but this drop was observed in both groups. Triglyceride decreased in both groups during Ramadan, but cholesterol levels dropped considerably during and after Ramadan for those who concurrently engaged in physical activity and fasted (-12.24 and -8.4 mg/dL, respectively). The patterns of changes in the high-density lipoprotein (HDL), low-density lipoprotein (LDL) and HDL/LDL values were more or less comparable in both groups (p is greater than 0.5).
Conclusion Usually, people are less physically active during Ramadan, but our findings show that physical activity alone cannot explain the variations in the lipid profile. Other factors, such as changes in the diet and sleeping hours, may have more important roles.

Keywords: fasting, lipid profile, physical activity, Ramadan
Singapore Med J 2009; 50(9): 897-901

Wong CS, Chu YCT, Ma KFJ, Cheng LF
Correspondence: Dr Chun Sing Wong, singsingboy@gmail.com

ABSTRACT
Introduction Spinal cord compression is a very debilitating condition and could be secondary to many causes. Urgent magnetic resonance (MR) imaging of the spine is crucial in making the diagnosis and guiding further management. Our objectives were to assess the nature of MR imaging requests, the diagnostic yield, and the subsequent management according to relevant MR imaging findings.
Methods We focused on all the urgent MR imagings of the spine conducted from July 1, 2007 to December 31, 2007. Clinical data, including the demographical information, presenting symptoms, radiological diagnosis, waiting time for MR imaging and treatment, was reviewed.
Results A total of 33 cases of urgent MR imaging of the spine were performed. Patients were aged 29–85 years, with 18 males and 15 females. Most of them (84.8 percent) presented with neurological symptoms. 84 percent of the MR imaging was performed within 24 hours. 76 percent of the examinations yielded significant cord compression, of which 56 percent were due to vertebral metastasis, while others were due to epidural haematoma (12 percent), infective spondylodiscitis (8 percent), vertebral fracture (8 percent) and disc herniation (16 percent). Of the vertebral metastasis patients, 43 percent had one region imaged. 64 percent of the cord compression patients received surgical treatment or radiotherapy, with a mean waiting time of 1.7 days.
Conclusion The urgent MR imaging spine service was able to react promptly with a high diagnostic yield. One-third of the patients with vertebral metastasis had multiple levels involved, and imaging of the whole spine would be useful.

Keywords: radiotherapy, spinal cord compression, spine imaging, vertebral compression fracture, vertebral metastasis
Singapore Med J 2009; 50(9): 894-896

Baltas CS, Balanika AP, Sgantzos MN, Papakonstantinou O, Spyridopoulos T, Bizimi V, Tsouroulas M, Guglielmi G
Correspondence: Prof Giuseppe Guglielmi, g.guglielmi@unifg.it

ABSTRACT
Introduction We used ultrasonography to detect the presence of biliary sludge or gallstones in Greek patients with complete high spinal cord injury (SCI) above the seventh thoracic segment (T7), within the first six months from injury onset, in order to evaluate the effects of neurological instability and dysfunction of the sympathetic nervous system (SNS) on the gallbladder function in the early post-SCI phase.
Methods We evaluated 78 asymptomatic patients (57 males, 21 females; mean age 34.8 (range 19–56) years) with complete high SCI located above the T7 segment, and 78 healthy subjects (59 males, 19 females; mean age 35.2 (range 21–59) years) matched for age, gender and race, for a total period of 39 months. All the participants underwent ultrasonographical examination of the gallbladder and common bile duct within the first six months from the injury, in order to investigate the development of biliary sludge and gallstones.
Results The incidence of biliary sludge was significantly higher in patients with SCI compared with the control group. The incidence of biliary sludge and gallstones was also significantly higher in patients with SCI patients in comparison with the healthy subjects. In male SCI patients, the incidence of biliary sludge was significantly increased in comparison with healthy subjects. No significant difference was revealed between the two groups in detection of gallstones.
Conclusion Our study indicates that the detection of gallbladder sludge and gallstones are significantly higher in Greek patients with complete high SCI above the T7 segment, as compared with healthy control subjects within the first six months of the injury onset. The complete disruption of the SNS and the neurological instability in the early post-SCI phase is probably responsible for the biliary sludge and gallstone formation. Our results suggest that ultrasonography should be performed in these patients at the first 3–6 months from the injury for the early diagnosis of the lithogenic bile.

Keywords: biliary sludge, gallstones, spinal cord injury, ultrasonography
Singapore Med J 2009; 50(9): 889-893

Lim BL, Lim GH, Heng WJ, Seow E
Correspondence: Dr Lim Beng Leong, beng_leong_lim@ttsh.com.sg

ABSTRACT
Introduction While non-contrast computed tomography (CT) of the brain can be used to rapidly identify patients with altered mental status (AMS) in the emergency department (ED), with an acute intracranial bleed or infarct, a wide variation in its use exists. The aim of this pilot study was to identify the clinical predictors of an abnormal CT result in ED patients with AMS.
Methods We conducted a retrospective study of patients aged 15 years and older presenting with undifferentiated AMS in a busy urban ED over one year. Data collected included demographical, clinical, laboratory and radiological features. The primary outcome of interest was the presence of an abnormal CT result defined as an acute infarct or intracranial bleed. Secondary outcomes were clinical predictors of an abnormal CT result. The data was analysed using descriptive statistics. Logistic regression was used to identify clinical predictors of an abnormal CT result. Odds ratios (ORs) were reported with 95 percent confidence intervals (CIs).
Results 578 patients were recruited, of which 284 (49.1 percent) were males. 327 (56.6 percent) patients underwent CT of the brain. 128 scans (39.1 percent) were abnormal. Logistic regression revealed seven clinical features that were associated with an abnormal CT result. They were mean age greater than or equal to 73 years (OR 1.03; 95 percent CI 1.015–1.045), drowsiness or unresponsiveness (OR 1.73; 95 percent CI 0.17–17.72), previous cerebrovascular accident (OR 2.03; 95 percent CI 0.82–5.02), previous epilepsy (OR 1.63; 95 percent CI 0.63–4.19), tachycardia [greater than 120/min] (OR 1.16; 95 percent CI 0.38–3.54), bradycardia [less than 60/min] (OR 1.35; 95 percent CI 0.19–9.59) and exposure to drugs (OR 1.90; 95 percent CI 0.58–6.26).
Conclusion We identified seven clinical predictors of an abnormal CT result in AMS patients. Future research in prospective studies is needed to validate these findings.

Keywords: altered mental status, brain infarction, cerebral computed tomography, intracranial haemorrhage
Singapore Med J 2009; 50(9): 885-888