Serum lipoprotein(A) profiles in a Singaporean population.

Lipoprotein(a) [Lp(a)] is formed when apolipoprotein(a) is linked to low density lipoprotein (LDL)-cholesterol via a single disulfide bond. It is an independent risk factor for myocardial infarction and raised concentrations are associated with an increased risk of developing coronary artery disease. Singapore has a multi-racial population of 77% Chinese, 14% Malays and 7% Indians. Studies have shown that the Indians have significantly higher standardised mortality ratios (SMR) compared to the Chinese and the Malays. We measured serum Lp(a) concentrations in 803 healthy individuals recruited from the Multiphasic Health Screening Programme, using the Macra Lp(a) sandwich enzyme immunoassay kit (Strategics Diagnostics, Delaware, USA). Lp(a) concentrations were skewed in all three groups. Our population mean was 9.0 mg/dl, with 50th, 75th and 95th percentile values of 10.2, 19.8 and 43.1 mg/dl, respectively, which are lower than values reported from Caucasian populations (15.0, 29.0 and 60.0 mg/dl, respectively). Males had lower Lp(a) concentrations than females (P < 0.05). The Indian group had significantly higher concentrations (median 12.3 mg/dl) compared to their Chinese (median 9.6 mg/dl) and Malay (median 8.4 mg/dl) counterparts (P < 0.05). This could partly account for the higher SMR seen in the Indian population in Singapore. As serum Lp(a) concentrations are method- and population-dependent, we recommend that laboratories determine their own reference ranges by their method to avoid misclassification of the coronary heart disease (CHD) risk of patients.

A fulminant case of neuroleptic malignant syndrome.

We report a fulminant case of Neuroleptic Malignant Syndrome in a 31-year-old male schizophrenic on haloperidol, thioridazine, benzhexol and flurazepam who presented with rigidity, fever, stupor and autonomic instability. He succumbed rapidly over 6 days to rhabdomyolysis, acute renal failure, status epilepticus and disseminated intravascular coagulopathy despite treatment with dantrolene and bromocriptine at the outset.

A window on the current status of diabetes mellitus in Singapore--the Diabcare-Singapore 1998 study.

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.

The status of diabetes mellitus in primary care institution and restructured hospitals in Singapore.

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.

Treatment of spontaneous uncomplicated pneumothorax with aspiration.

Between December 1989 and December 1990, nine patients with significant, uncomplicated, spontaneous pneumothoraces were treated by simple aspiration in the Medical Department, Alexandra Hospital. Only one had a residual 30% pneumothorax that required further aspiration with good results. The majority of the patients stayed three days in hospital. These nine patients were reviewed at various periods between four weeks to twelve months with no recurrence of pneumothoraces. The discomfort and inconvenience of an intercostal tube insertion was avoided. Risk of damage to the lung was minimal. No scar was left behind. Total cost of the procedure and hospitalisation was much less compared with intercostal intubation.

Infective endocarditis in Singapore: a six year survey.

Much has been written about the changing clinical spectrum of infective endocarditis. However our survey shows that the classical text book descriptions still hold good. The majority of our patients were young with 79% either 30 years or below. Fever was present in 93%, splenomegaly in 50% and cerebral embolism in 43% of our patients. Twelve patients had valvular heart disease and 2 patients had a ventricular septal defect. Eleven out of 14 patients had a positive blood culture. Echocardiography detected definite or probable vegetations in 66% of the examinations. Five patients responded satisfactorily to antibiotic therapy, 2 patients discharged themselves from hospital against medical advice, and 4 patients underwent successful cardiac surgery. Three patients died during medical therapy.

Fast fraction haemoglobin (HbA1) in the assessment of diabetes control.

The degree of control of 132 diabetic patients was assessed using historical data, urine glucose and blood glucose measurements. These were then related to HbA1, taken as the final arbiter of glycaemic control. Symptoms of hyperglycaemia and glycosuria were found to be not sensitive or specific indices of control, though symptomatic glycosuric patients tended to have higher HbA1. Fasting blood glucose correlated modestly with HbA1 (r = 0.60, p less than 0.001) but if used alone to determine degree of control, 21% and 9% of patients could be expected to be over or under assessed respectively. The assessment value of timed post-breakfast blood glucose applied only to 120 and 150 minutes post-breakfast blood glucose as they correlated well with HbA1 (r = 0.73, p less than 0.001 and r = 0.96, p less than 0.001 respectively). Clinically impression of degree of control based on a combination of historical data, urine glucose and blood glucose led to "undertreatment" in 41% and "overtreatment" in 27% of patients. The complementary value of a knowledge of HbA1 was thus highlighted.