Ethnic differences among Chinese, Malay and Indian patients with type 2 diabetes mellitus in Singapore.

INTRODUCTION: Ethnic differences exist in patients with diabetes mellitus. Not much is known about such differences in Asian populations. The aim of the study was to determine ethnic differences among Chinese, Malay and Indian patients with type 2 diabetes mellitus in Singapore. METHODS: The study design was cross-sectional, involving 967 patients who were attending follow-up care for type 2 diabetes mellitus at a primary care clinic. Data collection was by patient interview, examination, and from case records. Blood and urine samples were collected for analysis of indicators of diabetic control and albuminuria. RESULTS: Malays had the highest mean body mass index (BMI) after controlling for age, gender, duration of diabetes and exercise status. Adjusted mean BMI for Malays was 27.4kg per square metres, Indians 25.7kg per square metres, Chinese 24.9kg per square metres, with the p value being less than 0.01. HbA1c levels were highest among Indians after controlling for age, duration of diabetes, body mass index and treatment. Adjusted mean HbA1c for Indians was 8.3 percent, Malays 8.0 percent, and Chinese 7.7 percent, with the p value being less than 0.01. Compared with Chinese, Indians were more likely to have a positive family history of diabetes (prevalence rate ratio (PRR) of 1.3, 95 percent confidence interval (CI) of 1.0 to 1.7), but were less likely to have associated hypertension (PRR of 0.7, 95 percent CI of 0.5 to 1.0) and microalbuminuria and macroalbuminuria (PRR of 0.6, 95 percent CI of 0.4 to 1.0). CONCLUSION: Ethnic differences exist with regard to BMI, diabetic control as reflected by HbA1c levels, family history of diabetes, presence of associated hypertension, and severity of albuminuria. Indians, while having poorer control of diabetes, are less prone to hypertension and renal complications than Chinese.

Urinary protein excretion in Type 2 diabetes with complications.

This study examined the association between urinary markers of early diabetic nephropathy and non-renal diabetic complications in 946 patients with type 2 diabetes mellitus. The association with hypertension was also studied. Data on macrovascular complications (ischaemic heart disease, stroke, peripheral vascular disease) and microvascular complications (retinopathy, peripheral neuropathy) were obtained from case records and clinical examination. Urine samples collected were analysed for albumin, beta(2)-microglobulin, retinol-binding protein (RBP), and N-acetyl-beta-D-glucosaminidase (NAG). Results showed that urinary albumin, RBP and beta(2)-microglobulin levels were higher in patients with macro- and/or microvascular complications, compared to those without. NAG levels were higher only in patients with both types of complications. A higher proportion of patients with complications had abnormally raised urinary protein and enzyme levels, compared to those without. Patients with associated hypertension had higher urinary levels of albumin and beta(2)-microglobulin, regardless of whether complications were present or not. RBP excretion was, however, markedly higher only in patients with microvascular complications, whereas hypertension did not influence NAG excretion. Urine albumin and RBP excretion were predictive of microvascular, as well as both macrovascular and microvascular complications, whereas NAG excretion was predictive of macro- and microvascular complications. These findings could mean that increased urinary protein and enzyme excretion were associated with more severe disease in these patients.

Urine protein excretion among Chinese patients with type 2 diabetes mellitus.

BACKGROUND: Urinary excreton of low molecular weight proteins such as beta2-microglobulin and retinol binding protein (RBP), and enzymes such as N-acetyl-beta-D-glucosaminidase (NAG), may be useful as indicators of renal tubular dysfunction in diabetes mellitus. OBJECTIVE: To describe the profile of urinary protein and enzyme excretion in 240 Chinese patients with type 2 diabetes mellitus in Singapore. MATERIALS AND METHODOLOGY: Cross-sectional study of consecutive patients presenting for follow-up at a Government primary care clinic. Information was obtained from interview, physical examination and laboratory analysis. Data analysis included descriptive statistics on urinary protein and enzyme excretion, comparison of unadjusted and adjusted means of these among patient subgroups, as well as correlation with control of diabetes and other clinical parameters. RESULTS: Albuminuria correlated with urine beta2-microglobulin (r=0.34, p<0.01) and RBP (r=0.46, p<0.01). Hypertensive patients had significantly higher mean urine albumin (geometric mean 15.13 mg/gCr) and beta2-microglobulin (363.18 microg/gCr) levels compared to patients without hypertension (7.07 mg/gCr; 219.20 microg/gCr; p<0.05). Patients with complications of diabetes also had higher albumin (15.55 vs 6.20 mg/gCr), beta2-microglobulin (344.47 vs 288.83 microg/gCr) and RBP excretion (152.02 vs 94.54 mg/gCr). Two-hour postprandial sugar correlated with beta2-microglobulin (r=0.33, p<0.01), RBP (r=0.35, p<0.01) and NAG (r=0.28, p<0.01). Urinary protein excretion did not correlate with HbA1c, fasting blood sugar, age of patient or duration since diagnosis. CONCLUSION: These results among 240 Chinese patients in Singapore were consistent with reports from other study populations.

Why do patients complain? A primary health care study.

BACKGROUND/AIM OF STUDY: Patient complaints are indications of their dissatisfaction with the service received. With increasing patient expectations, we need to address this issue for a more satisfying relationship between healthcare provider and user. The objective of this study was to analyse the basis of patients' complaints and to make recommendations to reduce its incidence. METHOD: This is a retrospective descriptive study of all complaints to the Family Health Service between January 1994 and December 1995. All complaints, investigations and replies to complainants were examined and analysed by the authors to determine the reasons for complaints and their justification. RESULTS: There were 226 complaint cases out of 5,620,834 attendances in two years, giving the complaints rate of 4 per 100,000 attendances per year. The complaint rate was highest for the 20-59-year age group and lowest in the 10-19-year age group (3.7 and 2.0 per 100,000 attendances respectively). Sixty-four percent of complaints were verbal and the rest were written. Forty-seven percent of the complaints were made by relatives and 46% were self-complaints. The main reasons for complaints were related to attitude/conduct (28.8%), professional skills (17.8%), patient expectations (16.2%), waiting time (10.0%) and communication (7.8%). Forty-three percent of complaints were evaluated as justifiable, 38% not justifiable and 19% inconclusive. There were no particular sex or ethnic group differences. CONCLUSION: The rate of complaints in Family Health Service was low. Healthcare personnel need to pay attention to areas related to attitude/conduct, professional skills, patient expectations, waiting time and communication.

Infant walker use, injuries, and motor development.

OBJECTIVES: To study the impact of infant walker use on motor development and injuries. POPULATION: One hundred and eighty five parents or primary care givers who attended a Singapore government polyclinic from September 1993 to February 1994, with their infants between 7 to 10 months, for a developmental assessment session. SETTING: A government polyclinic in Singapore. METHODS: The parent or primary care giver answered questions pertaining to infant walker use and injuries attributed to its use. Each infant was then given the Singapore modified version of the Denver Developmental Screening Test (DDST-S), along with a full clinical examination; both testers were blinded to walker use. RESULTS: One hundred and sixty seven (90%) of 185 infants used walkers regularly, and 21 (12.5%) of the users had one or more injuries. Most injuries were minor, such as bruises and swellings on the head, forehead, face, and cheeks. None of the children who did not use walkers showed any abnormal DDST-S results whereas 18 (10.8%) of the 167 walker users had either abnormal or questionable DDST-S results. CONCLUSIONS: 12.5% of walker users had one or more injuries and walker use may also delay the child's motor development. These findings will help the physician or nurse in primary care settings to advise parents about the potential hazards of walker use.

Postural stability in non-insulin dependent diabetics.

Postural stability in 55 non-insulin dependent diabetics was compared with 53 non-diabetic controls matched for age and gender. The study was conducted in a primary care clinic, using a computerised postural sway system. Changes in the centre of pressure while the subjects stood on a force platform were recorded, and sway parameters computed using customised software. Clinical data were obtained by interview, physical examination, and from case records. Results of the study showed that non-insulin dependent diabetics were more unstable than the non-diabetic controls for four out of the six parameters studied (namely L, length of sway path; Vel, average speed of centre of pressure along its path; Ao, area included within the path of the centre of pressure; and Ae, 95% confidence elliptical area), after adjusting for height, weight, adequate sleep and alcohol intake the night before, and history of bone or thyroid disorders. Amongst diabetic subjects, significant factors associated with postural stability were age, weight, presence of peripheral neuropathy or cataract, metformin, use, and HbAlc levels > 9%. Further studies are indicated to look into factors affecting postural stability (other than diabetic neuropathy) in greater depth.

Gestational diabetes in Singaporean women: use of the glucose challenge test as a screening test and identification of high risk factors.

In this study, 1141 antenatal women attending 9 Government polyclinics were screened between 24 and 28 weeks of gestation for gestational diabetes mellitus (GDM) using the glucose challenge test (GCT). An attempt was made to determine whether 7.2 mmol/l or 7.8 mmol/l was an effective cut-off point as an indicator for GDM. The women with GCT levels of > or = 7.2 mmol/l had an oral glucose tolerance test (OGTT) for confirmation of GDM. The results showed that 420 (36.8%) had GCT levels > or = 7.2 mmol/l, including 299 (26.2%) with GCT levels of > or = 7.8 mmol/l. Of the 190 OGTT carried out, 8 (4.2%) were confirmed to have GDM, all of whom had GCT levels of > or = 7.8 mmol/l, indicating that a GCT level of 7.8 mmol/l was the effective cut-off point. Univariate analysis showed that epidemiological features associated with a raised GCT > or = 7.8 mmol/l were, older age that is 30 years and above, Chinese ethnic group, maternal obesity (body mass index > or = 25) and history of > or = 4 pregnancies. Multivariate analysis using stepwise logistic regression, showed that factors significantly and independently associated with raised GCT levels were older age, Chinese ethnic group and maternal obesity. All antenatal women should be screened for GDM using the GCT, and those with levels of > or = 7.8 mmol/l should be subjected to the OGTT for confirmation.

The field testing of Denver Developmental Screening Test Singapore: a Singapore version of Denver II Developmental Screening Test.

The Denver Developmental Screening Test, Singapore (DDST, Singapore), a Singapore version of the Denver II Developmental Screening Test, was field-tested, using trained staff nurses as testers, on 2459 children (known cases excluded), in 5 key ages of 3 months, 9 months, 17 months, 37 months and 60 months. Only 2.6% (65) of the parents suspected developmental problems in their children before screening. Taking children with "questionable" (7.2%), "abnormal" (3.7%) and "untestable" (1.7%) scores as the screened-out cases, the DDST, Singapore had a screened-out rate of 12.6%. A total of 171 screened-out cases and 168 "normal" children were also evaluated by the Development Assessment Clinic (DAC) of the Singapore General Hospital and the results were compared in these 2 groups of children. Among the screened-out cases, 16.6% were confirmed or suspected to have neuro-developmental disorders (NDDs) by the DAC. The computed NDD rate in the study sample was 5.3%. Based on a single DDST, Singapore test result, there was a high false positive rate of 83.5% and lower false negative rate of 3.7% compared to the DAC assessment. However, the high false positive rate would be significantly reduced by doing a repeat screening test on the "questionable" cases and having the screened-out cases assessed by trained primary health care doctors. In conclusion, no major revision is needed in the scoring criteria suggested in the current version of DDST, Singapore. It is a useful tool in identifying children who will otherwise be missed without formal screening.

Mass screening for diabetic retinopathy--a report on diabetic retinal screening in primary care clinics in Singapore.

INTRODUCTION: Mass screening for diabetic retinopathy is expensive and inaccessible if done by institutional ophthalmalogists. Most diabetics are seen in primary care. Hence it is logical to provide mass screening in primary care clinics. In Singapore, government polyclinics are ideal centres of screening as they are well organised and accessible to the community. SCREENING METHOD: An effective mass screening strategy must provide wide coverage, be low cost and have the ability to assess diabetic eyes accurately and quickly. Non-mydriatic fundal photography was used as the screening method. Mass coverage was achieved by rotating two cameras around six government polyclinics. Cost was reduced by training existing staff and organising the programme to provide a high turnover of screenees. The photographs were read by ophthalmologists in a government-owned hospital. Patients that required referral were referred to specialist eye clinics. RESULTS: A total of 13,296 patients were screened or rescreened during a period of 2 years (25 months). 2,911 patients or 21.8% of the total screened were found to have diabetic retinopathy. About half of these (10.8%) had sight threatening retinopathy. The most common sight threatening retinopathy was maculopathy (8.0%). Twenty-two percent of cases screened were referred. These include referral for other ocular conditions detected during the screening. CONCLUSION: Non-mydriatic fundal photography has proven to be both accessible and effective in screening diabetic eyes in urban Singapore and can be recommended for mass screening of diabetic eyes in the community.

Understanding asthma: patient survey.

Eight hundred and two adult patients attending five randomly selected polyclinics in Singapore were interviewed to assess their understanding of asthma. Knowledge of asthma mechanism and its medications was poor with a mean score of 1.4 (median: 1) out of a total score of 6. About a third knew that asthma is due to narrowing of airways and a quarter knew the action of bronchodilators. Only 4.4% (27) knew that steroids decrease airway swelling or inflammation. The best knowledge score was associated with subjects who had the highest education, who had a family history and who had been exposed to pamphlets and books. Incorrect use of prophylaxis was also evident with only one-third (37%) using steroid inhalers regularly as prescribed. Only half (54.5%) of those with no schooling used the correct inhaler technique. Doctors were a source of information for only 49.9% (400) of the patients and it was those with the highest education who were most likely to get information from the doctors. Pamphlets were a source of information for less than one-fifth (16.2%) of the subjects. Greater emphasis should be given to patient education by doctors to help patients understand asthma and its treatment. Important target groups are the older, lesser educated and the moderate or severe patients on steroid inhalers.

Lifestyle and behavioural risk factors associated with asthma morbidity in adults.

We studied the association between morbidity and personal lifestyle/behavioural factors that predispose to exposure to known environmental precipitants of asthma, in a group of asthmatics (n = 787) in primary-care clinics. Clinical severity of asthma was determined by questions regarding the frequency of daytime or nocturnal attacks, the number of visits to primary care or hospital emergency departments for treatment of acute attacks, and the number of hospitalizations, as well as the amount of sick leave in the past year. Questions concerning risk factors included ethnicity, clinical atopic status (current rhinitis/eczema), smoking, occupation, keeping of pets, rugs and carpets, use of brooms, burning of mosquito coils or incense, and outdoor air pollution, as well as the patient's knowledge of asthma care. The most significant independent predictors of asthma morbidity, identified from multivariate logistic regression analyses, were current keeping of either pets or rugs/carpets (OR 1.49; 95% CI 1.12-1.99), and current high-risk occupations (OR 0.59, 95% CI 0.40-0.89). A multiplicity of interacting factors and behavioural responses appear to influence the effects of allergens and other environmental precipitants on asthma morbidity in patients.

Risks of asthma associated with occupations in a community-based case-control study.

The aim of this study was to identify occupational risk groups which might usefully be targeted for occupational asthma surveillance and control, using a community-based case-control approach. Data on previous and current occupations held by subjects were analyzed for 787 adult patients with bronchial asthma and 1591 nonasthmatic patient controls, aged 20-54 years, belonging to the three major races (Chinese, Malays, and Indians) in five outpatient primary care polyclinics. Odds ratios (OR) and 95% confidence intervals (95% CI) of association were adjusted for sex, age, race, smoking, and clinical atopy. No associated risks of asthma were found for clerical or sales workers in general. Significantly reduced risks of association with asthma were found for professional, technical, administrative, and managerial occupations (OR, 0.62; 95% CI, 0.47-0.82). The associated risks of asthma were generally elevated for service workers (OR, 1.35; 95% CI, 1.04-1.74) and manufacturing production and related workers (OR, 1.49; 95% CI, 1.23-1.81). Among them, increased risks were observed for cleaners, particularly municipal cleaners and sweepers (OR, 1.91; 95% CI, 1.22-2.99), textile workers (OR, 5.83; 95% CI, 1.93-17.57), garment markers (OR, 1.61; 95% CI, 1.01-2.58), electrical and electronic production workers (OR, 1.36; 95% CI, 1.06-1.75), printers (OR, 2.24; 95% CI, 1.17-4.31), and construction/renovation workers (OR, 2.24; 95% CI, 1.30-3.85). The odds ratio of association of asthma with exposures in service and production-related occupations overall, relative to the "nonexposed" reference group of nonmanual professional/technical, administrative/managerial, clerical, and sales occupations, was estimated to be 1.72 (95% CI, 1.36-2.19); the estimated population attributable risk was 0.33 (95% CI, 0.22-0.44).

Obesity in preschool children: an intervention programme in primary health care in Singapore.

The Programme on Prevention and Management of Obesity in Preschool Children, aged three to six years, was implemented in 17 Primary Health Clinics in November 1991. The study sample comprised 1128 preschool children who qualified to enter the obesity register, using the defined criteria for obesity of 2 standard deviations above the normal weight for height and age. This group was divided into three categories, namely, mildly overweight (120% to below 140%), moderately overweight (140% to below 160%), and severely overweight (above 160%). The severely overweight category was referred to dietitians for follow-up management, while the other two categories were managed by the clinic staff through pre-planned nurse-conducted counselling sessions. In this paper, we analysed the first 1128 preschool children aged three to six years on the Programme with respect to their demographic characteristics; medical conditions; family history of obesity, diabetes, hypertension and ischaemic heart disease; number of siblings and parents' educational and occupational status. The Malay children showed significantly more severe grades of obesity compared to the Chinese and Indian children. A family history of obesity and hypertension among the three groups were significant (P < 0.001). After one year of follow-up with the intervention programme, the following were found: 40.4% (456) of the children improved in their obesity status and 20.2% (228) reached normal status. The severe, moderate and mild categories reduced from 6.3% to 5.9%, 29.3% to 23.2% and 64.4% to 50.7% respectively and was found to be statistically significant (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Outpatient adult bronchial asthma in Singapore.

OBJECTIVES: To describe the clinical pattern and drug use in adult bronchial asthma seen in Government polyclinics (primary health care centres). DESIGN: A cross-sectional study using a structured questionnaire. SETTING: The five largest Government polyclinics in Singapore. SUBJECTS: Eight hundred and two subjects aged between 21-58 years drawn from the register of outpatient attendances. The response rate was 63%. RESULTS: The mean age of the study subjects was 37.4 years and the mean age of onset was 19.2 years. Thirty-three percent had onset of asthma under 10 years old. The most commonly reported trigger factors were cold drinks (67%), a change of temperature or humidity (65%), influenza or colds (65%), house dust (58%) and cigarette smoke (37%). In 27%, the work environment was a provoking factor. One-fifth had attacks every night or every day. About half of the patients had FEV1 under 80% of predicted. In the past year, 10% had 4 or more acute attacks requiring emergency attendance, 18% had one or more hospital admissions and 21% had sickness absence from asthma for one week or more. Of the 186 subjects who needed bronchodilators/inhalers 3 times or more a day, only 19.3% were on inhaled steroids. CONCLUSIONS: Considerable morbidity existed amongst outpatient asthmatics. Inhaled steroids appeared to be under-used.

Legalized abortion: the Singapore experience.

Abortion has been legal since 1970 in Singapore. This report traces the events leading to the liberalization of abortion laws and examines women's changing attitudes toward abortion, in Singapore. The method of abortion practiced by obstetricians, postabortal sterilization, and the effect of legalized abortion on the incidence of illegal abortion in the country are also examined.

PIP: The Abortion Act of 1969 was instituted to protect women against the dangers of illegal abortions. With this act came a liberalization of attitudes toward abortion. The researchers have done an epidemiological study of legalized abortion in Singapore from 1970 to 1983. They note an annual increase in the number of abortions for this period, with the rate finally plateauing at about 28/1,000 women of reproductive age. An increasing % of these women are unmarried and childless and 3/4 of the abortion seekers are over 20 years of age. The teenage abortion rate has remained stable at 8 to 9% of all abortions. The most common reasons given for desiring abortion were completion of desired family size and inability to finance an additional child. Interestingly, those citing single status as their reason for abortion increased from 4 to 27% by 1983.

Computer calculation of activation energies of irreversible electrode processes at a dropping mercury electrode.

A computer program has been written for calculation of the activation energies of irreversible electrode processes at a dropping mercury electrode, based on the variation of current and half-wave potential with temperature. The program calculates the half-wave potential, the transfer coefficient, and the activation energies of the diffusion process and the irreversible electrode process. It has been written in both ALGOL and FORTRAN.