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Introduction: Microalbuminuria is a marker of increased cardiovascular morbidity and mortality. It represents the earliest clinical evidence of diabetic nephropathy. Its early detection allows for implementation of individually-tailored cardiovascular risk reduction management programmes. Despite this, information on the prevalence of microalbuminuria in hypertensive patients with type 2 diabetes mellitus in Singapore is limited., Methods: The Microalbuminuria Prevalence Study (MAPS) assessed the prevalence of macroalbuminuria and microalbuminuria in consecutively-screened hypertensive adult patients with type 2 diabetes mellitus in ten Asian countries. This paper presents the results of a sub-analysis of data from patients in Singapore., Results: Singapore contributed seven percent of the overall enrolment into MAPS; a total of 499 patients were enrolled and 388 constituted the per-protocol population (patients with bacteriuria and haematuria were excluded). Overall, the prevalence of diabetic kidney disease was high. In our study population, 23.5 percent of patients had macroalbuminuria (95 percent confidence interval [CI] 21.3-25.6), and 48.5 percent of patients had microalbuminuria (95 percent CI 45.9-51.0). Only 28.1 percent (95 percent CI 25.8-30.4) of patients were normoalbuminuric. Associated factors were poor glycaemic control and poor blood pressure control., Conclusion: The high prevalence (72 percent) of microalbuminuria and macroalbuminuria found in hypertensive patients with type 2 diabetes mellitus in Singapore is a cause for concern. These findings highlight the need to screen for microalbuminuria and better manage hypertensive patients with type 2 diabetes mellitus, if we are to avoid a major increase in end-stage renal disease.

We describe three patients with aberrant regeneration of the third nerve secondary to traumatic brain injury. The full blown features of the syndrome include horizontal gaze-eyelid synkinesis, pseudo-Graefe sign, limitation of elevation and depression of the eye with retraction of the globe on attempted vertical movements, adduction of the involved eye on attempted elevation or depression, pseudo-Argyll Robertson pupil and absent vertical optokinetic response. The 'misdirection' incidence in our study is 15%.

A 38-year-old man presented with progressive worsening of choreiform movements. Serum biochemistry analysis did not reveal any abnormality. Magnetic resonance imaging demonstrated symmetrical caudate nucleus atrophy and generalised cerebral strophy. Huntington's disease was diagnosed in view of the clinical presentation and the characteristic imaging findings. The clinical, pathological and imaging features of this disease process are discussed.

Phenytoin toxicity is an uncommon problem seen in clinical practice. The predisposing factors for toxicity are hypoalbuminemia, chronic renal failure, hepatic dysfunction and drugs which interfere with phenytoin metabolism. Common manifestations of toxicity, like confusion and ataxia, are well known. A less well known phenomenon is paradoxical seizures. In this condition, seizures develop as the serum phenytoin level rises and decrease in frequency as levels drop. It may or may not be accompanied by other features of toxicity. We present three patients with paradoxical seizures; their serum phenytoin levels were 43.5 mcg/mL, 46.5 mcg/mL and 38.3 mcg/mL. In all cases, seizures were controlled by withdrawal of phenytoin and reduction of drug levels.

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.

Heterotopic ossification after head injury may occur in the elbow joint. Rarely does this lead to entrapment of the ulnar nerve. We describe the case of a 20-year-old patient who developed heterotopic ossification 6 weeks after a traumatic brain injury. She subsequently developed bilateral ulnar nerve palsy which was confirmed by electrodiagnostic studies and treated by transposition of the ulnar nerve.

The syndrome of painful legs and moving toes is an uncommon and distressing condition with pain in the feet or legs and involuntary movements of the toes. It can follow spinal cord or cauda equina trauma, lumbar radiculopathy, injury to the feet, peripheral neuropathy or without any preceding causes. Ephaptic transmission in damaged nerve roots or peripheral nerves with central reorganisation may be the underlying mechanism of the syndrome. Treatment is difficult. We report a case of this syndrome following peripheral neuropathy, with a good early response to the GABA agonists baclofen and clonazepam. The role of different GABA agonists in the treatment of this condition needs to be better defined.

Aim: DNA amplification by the polymerase chain reaction (PCR) was evaluated as a means for rapid diagnosis of tuberculous meningitis (TBM)., Methods: A 240 bp region (nts 460-700) from the MPB 64 protein coding gene specific for Mycobacterium tuberculosis (TB) was selected for amplification. Nineteen clinical samples were studied. Six were obtained from patients with TBM diagnosed by culture (4/6) or by response to therapy (2/6). The remaining 13 samples were obtained from patients with febrile seizu es (8/13), aseptic meningitis (3/13) and septic meningitis (2/13), and these served as negative controls., Results: We detected TB DNA in all the 6 CSF specimens obtained from patients with TBM. PCR alone was sufficient to detect TB DNA in 5 of these 6 samples. However, one sample was positive only when PCR was followed by oligonucleotide hybridisation. In the 2 patients whose CSF were obtained only after commencement of TB therapy, TB cultures were negative but positive on PCR nd oligoprobe labelling. The diagnosis of TBM was confirmed based on their remarkable response to therapy. Twelve of the thirteen negative controls were TB DNA negative. There was one false positive sample, which was thought to be due to TB DNA contamination., Conclusion: Taken together, our results indicate that DNA amplification using PCR, followed by oligonucleotide hybridisation offers a rapid (5 working days) means of diagnosis of TBM, provided care is taken to ensure that cross contamination of DNA samples is avoided.

The axillary artery was studied by dissection of 50 human cadavers over a two-year period. Except in one instance, the course and relations of the axillary artery of all the other cadavers conformed to the normal description found in standard textbooks of Anatomy. In the exceptional cadaver, the axillary artery of the right side showed two unique features: (1) it pursued a tortuous course and made two sharp bends, and (2) it was situated superficial, rather than deep to, the pectoralis minor muscle. Its branches and relationship to the brachial plexus were also altered. On the left side, the artery was not tortuous but was also situated in front of the pectoralis minor. The present observation has several implications: (1) such a configuration of the artery would render it more prone to kinking and hence compression; (2) surgically, it might make axillary block of the brachial plexus and block dissection of the axillary lymph nodes during radical mastectomy more difficult; (3) it is at risk during infraclavicular percutaneous cannulation of the subclavian vein for a central line insertion or for insertion of a subclavian cannula for haemodialysis.

A 52-year-old Chinese female with recurrent cerebral thrombosis associated with hereditary protein S deficiency is described. The need to consider clotting disorders in young patients with no known risk factors for stroke is emphasized.