2009

Geeta A, Jamaiyah H, Safiza MN, Khor GL, Kee CC, Ahmad AZ, Suzana S, Rahmah R, Faudzi A
Correspondence: Ms Geeta Appannah, geeta@crc.gov.my

ABSTRACT
Introduction The Third National Health and Morbidity Survey Malaysia 2006 includes a nutritional status assessment of children. This study aimed to assess the inter- and intra- examiner reliability, the technical error of measurement and the validity of instruments for measuring weight, height and waist circumference.
Methods A convenience sample of 130 adults working in a selected office setting was chosen to participate in the study, subject to the inclusion and exclusion study criteria. Two public health nurses, trained to follow a standard protocol, obtained the weight, height and waist circumference measurements. The weight was measured using the Tanita HD-318 digital weighing scale to the nearest 0.1 kg, and Seca Beam Scale to the nearest 0.01 kg. The height was measured using the Seca Bodymeter 206 and Stadiometer, both to the nearest 0.1 cm. The waist circumference was measured using the Seca circumference measuring tape S 201, to the nearest 0.1 cm.
Results The intra-examiner reliability in descending order was weight and height followed by waist circumference. The height measurement, on average, using the test instrument, reported a recording of 0.4 cm higher than the reference instrument, with the upper and lower limits at 2.5 cm and 1.6 cm, respectively. The technical error of measurement and coefficient of variation of weight and height for both inter-examiner and intra-examiner measurements were all within acceptable limits (below five percent).
Conclusion The findings of this study suggest that weight, height and waist circumference measured in adults aged 18 years and above, using the respective abovementioned instruments, are reliable and valid for use in a community survey. Limiting the number of examiners, especially for waist circumference measurements, would yield a higher degree of reliability and validity.

Keywords: anthropometry, height measurement, nutritional status assessment, waist circumference measurement, weight measurement
Singapore Med J 2009; 50(10): 1013-1018

Pal S, Ma SO, Norhasimah M, Suhaida MA, Siti Mariam I, Ankathil R, Zilfalil BA
Correspondence: Dr Zilfalil Bin Alwi, zilfalil@kb.usm.my

ABSTRACT
Introduction This study was done to determine the prevalence of chromosomal abnormalities and the subsequent reproductive outcome in couples who had two or more miscarriages.
Methods 56 couples with a history of at least two previous miscarriages were evaluated for prevalence and types of chromosomal abnormalities from their karyotype records. The study was a retrospective one, and subsequent reproductive outcome after a period of 12-24 months from the time of karyotyping was obtained by telephone interviews and scrutiny of the case records. The comparison of reproductive outcome was done by chi-square statistics.
Results Five couples (8.9 percent) had a chromosomal abnormality in one partner. Three cases of reciprocal translocations t(5;11), t(9;14), dup(9q); one Robertsonian D/D translocation 13/14; and one mosaic Down syndrome male karyotype were found. Among the 32 couples available for follow-up, there was a lower incidence of subsequent live healthy births among chromosomally-normal couples (35.7 percent) compared to chromosomally-abnormal ones (25 percent). However, the difference was not statistically significant (p-value is 1.0). There was a lower incidence of subsequent abortions in chromosomally-normal couples (42.8 percent) compared to chromosomally-abnormal ones (50 percent), but the difference was also not statistically significant (p-value is 1.0).
Conclusion Chromosomal abnormalities were seen in 8.9 percent of the couples, and translocations were the commonest abnormality found. The frequencies of subsequent live healthy births and subsequent abortions showed no significant difference between couples having normal karyotypes and those having chromosomal abnormality in one partner.

Keywords: chromosomal abnormalities, karyotype, miscarriages, reproductive outcome, translocations
Singapore Med J 2009; 50(10): 1008-1012

Saththasivam P, Umadevan D, Ramli N, Voralu K, Naing NN, Ilias MI, Shuib N, Tan BG, van Rostenberghe H
Correspondence: Dr Hans van Rostenberghe, hansvr@kb.usm.my

ABSTRACT
Introduction The aim of this study was to determine whether there was a difference in the pain indicators and effectiveness between venipuncture (VP) and heel prick (HP) for blood glucose monitoring in term neonates (recently, venipuncture was shown superior for the Guthrie test).
Methods 66 term neonates undergoing blood glucose monitoring underwent VP or HP. Primary outcome measures included the Neonatal Facial Scoring System (NFCS) score, duration of the first cry, total duration of cry and duration of procedure. Secondary outcome measured was the number of skin punctures needed to obtain blood.
Results The NFCS score was not significantly different between the two groups and the duration of the procedure was significantly longer for the VP than the HP group (median 27 s vs. 7 s; p-value is less than 0.001). The differences between the two groups in the duration of the first cry, total duration of cry and number of skin punctures needed to obtain blood were not statistically significant, but these parameters displayed a trend, favouring the HP.
Conclusion The HP is still the preferred method of drawing blood in neonates for blood glucose monitoring, as only one drop of blood is required.

Keywords: blood glucose monitoring, heel prick, Neonatal Facial Scoring System score, venipuncture
Singapore Med J 2009; 50(10): 1004-1007

Goh KP, Chew K, Koh A, Guan M, Wong YS, Sum CF
Correspondence: Dr Goh Kian Peng, kian_peng_goh@alexhosp.com.sg

ABSTRACT
Introduction The aim of this study was to analyse the association between the ACE ID polymorphism and aerobic capacity in a homogeneous cohort of national Asian rugby players.
Methods 17 subjects recruited during active training had their maximal oxygen uptake (V0_2max) and ventilatory threshold (VT) measured during maximal exercise testing. ACE genotyping was performed for all players.
Results The likelihood of having a V0_2max above the 80th percentile of a gender-specific reference range for a normal population was 14.3-fold greater among subjects with the II genotype as compared to the ID genotype (p-value is 0.030). Similarly, subjects with the II genotype were 29.4 times more likely to have a VT above the gender-specific median value compared to the ID genotype (p-value is 0.019). The results suggest that the I allele confers an advantage in aerobic capacity as measured by the V0_2max and VT.
Conclusion It is likely that the same physiological mechanisms mediated by the ACE gene are responsible for aerobic capacity in both Asians and Caucasians.

Keywords: aerobic capacity, angiotensin converting enzyme, exercise physiology, gene polymorphism
Singapore Med J 2009; 50(10): 997-1003

Panesar NS, Goggins W
Correspondence: Dr Nirmal Singh Panesar, nspanesar@cuhk.edu.hk

ABSTRACT
Introduction Historical anecdotes suggest human beings can postpone death around important occasions. Some formal studies have claimed that elderly Jewish men and Chinese women in America postponed death around the Passover and Harvest Moon (or Mid-Autumn) Festival (HMF), respectively.
Methods We examined deaths from cancer, cerebrovascular and heart diseases in the Chinese around four important holidays celebrated in Hong Kong. From computerised data in 1995–2000, the expected weekly deaths for 12 weeks before and after Lunar New Year, Ching Ming, HMF and Chung Yeung holidays were calculated using a polynomial regression model for the three diseases in men and women, under and over the age of 75 years. The differences in the observed deaths one week before and one week after the four holidays were tested by the binomial test.
Results There were significantly fewer deaths overall in men before the holidays than after (p-value equals 0.0081), with most of the difference being due to cancer deaths, particularly among men over 75 years of age. For women, there were actually more deaths before the holidays than after. The data, stratified according to age, gender, disease and holiday, yielded only five out of 48 variables with a p-value of less than 0.05, which was slightly above chance, considering the large number of comparisons made. In four of the five situations, there were significantly fewer deaths before than after the holidays; but after Bonferroni correction, only the finding of fewer cancer deaths for men aged over 75 years before HMF was significant.
Conclusion Other than cancer deaths in males, we found little evidence in this dataset of death postponement until after important holidays in the Hong Kong Chinese population.

Keywords: deaths, holidays, postponement, psychological stress
Singapore Med J 2009; 50(10): 990-996

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