Original Article

Saleem MM
Correspondence: Dr Mohammad M Saleem, mohomari@hotmail.com

ABSTRACT
Introduction Acquired oesophageal strictures are common in children. Treatment is either surgical or conservative by dilatations. String-guided dilators (SGD) are not well popularised. This is a report of the paediatric surgery experience at Jordan University Hospital on a group of 38 children, with emphasis on the use of SGD.
Methods Between January 1998 and January 2006, a total of 38 children (median age 3.2 years; range one month to ten years) with acquired oesophageal strictures were managed in the paediatric surgery unit. Main causes of strictures were corrosive strictures (18, 47.3 percent), post-oesophageal atresia repair (9, 23.6 percent) and post-hiatus hernia repair (4, 10.5 percent). SGD was used in 18 children, six following perforation and 12 classified as severe according to the established criteria. 14 were secondary to corrosive strictures.
Results There were 801 dilatation sessions with an average of 20.1 +/- 17.3 dilatation sessions per patient. Corrosive strictures were more severe, and required more dilatations per patient. The mean dilatation was 34.2 +/- 16.6 for corrosive strictures vs. 10.4 +/- 8.2 for non-corrosive strictures (p-value is less than 0.0001). 32 (84.2 percent) were successfully dilatated. Two are currently still under treatment and four failed conservative treatment after dilatation for one year. Two underwent oesophageal replacement and two refused surgery but continued to receive dilatation at 4–6 week intervals. SGD was used on 18 patients, six following perforation episodes. Two (5.3 percent) complications resulted in oesophageal perforations.
Conclusion Tucker’s dilators, with or without string, are safe, cost-effective and the use of string is a safeguard against perforations.

Keywords: acquired stricture, corrosive stricture, oesophageal stricture, string-guided dilator
Singapore Med J 2009; 50(1): 82-86

Evagelidis P, Paraskeva A, Petropoulos G, Staikou C, Fassoulaki A
Correspondence: Prof Argyro Fassoulaki, fassoula@aretaieio.uoa.gr

ABSTRACT
Introduction Exogenous melatonin has sedating and hypnotic actions. The present prospective double-blind randomised study investigated the effect of melatonin premedication on the induction of anaesthesia with sevoflurane.
Methods 71 women of reproductive age, scheduled for a hysteroscopy, were randomised into the melatonin or the control group. 30 minutes before the induction of anaesthesia, patients in the melatonin and control groups sublingually received 9 mg of melatonin or placebo, respectively. In the operating room, patients were attached to a standard monitor and bispectral index (BIS) monitor. Anaesthesia was induced with 8 percent sevoflurane in oxygen via an anaesthetic system primed with 8 percent sevoflurane. BIS values were recorded every 30 seconds,during the first 300 seconds of sevoflurane administration. Inspired and expired sevoflurane concentrations, heart rate and oxygen saturation were also recorded at the same time intervals. Noninvasive blood pressure was recorded before and after the completion of measurements.
Results BIS values (p-value is 0.725, F is 0.125, degrees of freedom [df] 1), inspired (p-value is 0.468, F is 0.535, df 1) and expired (p-value is 0.388, F is 0.756, df 1) sevoflurane concentrations, heart rate (p-values is 0.516, F is 0.427, df 1) and oxygen saturation (p-value is 0.401, F is 0.717, df 1), did not differ between the two groups, at any time point of measurement. Systolic blood pressure before (p-value is 0.131, t 1.530, df 67) and after measurement (p-value is 0.8288, t 0.218, df 54) as well as diastolic blood pressure before (p-value is 0.370, t 0.902, df 67) and after measurement (p-value is 0.764, t 0.302, df 54) did not differ between the two groups.
Conclusion Melatonin premedication under the present study design failed to enhance the induction of anaesthesia with sevoflurane.

Keywords: anaesthesia induction, bispectral index monitoring, central nervous system monitoring, exogenous melatonin, melatonin, sevoflurane
Singapore Med J 2009; 50(1): 78-81

Arslan M, Kurtipek O, Dogan AT, Ünal Y, Kizil Y, Nurlu N, Kamaci S, Kavutcu M
Correspondence: Dr Mustafa Arslan, marslan36@yahoo.com

ABSTRACT
Introduction Although most general anaesthesia procedures are performed without any complications, volatile agents may have adverse effects on various living systems. This study aimed to compare the effects of desflurane and enflurane on liver function.
Methods 40 patients, who were in the ASA I-III risk groups and were planned to undergo head and neck surgery of at least three hours’ duration, were randomly divided into two groups: the desflurane (Group D) and enflurane groups (Group E). Venous blood samples (5 ml) of the patients were obtained before anaesthesia induction, in the postoperative first hour and on the first and seventh days. The samples were centrifuged and then stored at -80°C until the determination of glutathione S-transferase (GST) levels. For maintenance of anaesthesia in Group D, desflurane (6 percent) was used, while in Group E, enflurane (1.2 percent) was used.
Results GST levels were significantly higher in Group E in the postoperative first hour (p-value is 0.002), and on the first day (p-value is 0.025) and seventh day (p-value is 0.035), although there were no differences preoperatively (p-value is more than 0.05). When postoperative levels were compared with preoperative levels, the postoperative GST levels of Group E were significantly higher (first hour [p-value is 0.008], first day [p-value is 0.010], seventh day [p-value is 0.038]).
Conclusion Subclinical hepatic injury after anaesthesia continues to be an issue of interest, particularly with the development of new, more sensitive methods of measuring GST levels. The increase in GST concentration after anaesthesia is thought to be a result of reduced hepatic blood flow. This study has shown that desflurane has fewer effects than enflurane on liver function tests in lengthy operations of up to 330 minutes.

Keywords: alanine aminotransferase, aspartate aminotransferase, desflurane, enflurane, glutathione S-transferase
Singapore Med J 2009; 50(1): 73-77

Raja Lope RJ, Boo NY, Rohana J, Cheah FC
Correspondence: Dr Raja Juanita Raja Lope, juanita@mail.hukm.ukm.my

ABSTRACT
Introduction This study aimed to determine the rates of non-adherence to standard steps of medication administration and medication administration errors committed by registered nurses in a neonatal intensive care unit before and after intervention.
Methods A baseline assessment of compliance with ten standard medication administration steps by neonatal intensive care unit nurses was carried out over a two-week period. Following this, a re-education programme was launched. Three months later, they were re-assessed similarly.
Results The baseline assessment showed that the nurses did not carry out at least one of the ten standard administrative steps during the administration of 188 medication doses. The most common steps omitted were having another nurse to witness drug administration (95 percent); labelling of individual medication prepared prior to administration (88 percent), checking prescription charts against patients’ identification prior to administration (85 percent) and visually inspecting a patient’s identification tag (71 percent). Medication administration errors occurred in 31 percent (59/188) of doses administered, all due to imprecise timing of medication administration. There were no resultant adverse outcomes. Following implementation of remedial measures, there was a significant reduction in non-adherence of seven of the ten medication administration steps and the rate of medication administration errors (p-value is less than 0.001). However, in 94 percent of doses administered, the nurses still did not get a witness to countercheck calculations of drug dosages before administration.
Conclusion Non-compliance with the standard practice of medication administration by nurses is common but can be improved by continuing re-education and monitoring, plus the implementation of a standard operating procedure.

Keywords: medication administration errors, medication errors, neonatal intensive care unit, quality assurance, standard operating procedure
Singapore Med J 2009; 50(1): 68-72

Wong FL, Boo NY, Ainoon O, Wang MK
Correspondence: Prof Nem-Yun Boo, nemyun_boo@imu.edu.my

ABSTRACT
Introduction This study aimed to compare the detection rates of glucose-6-phosphate dehydrogenase (G6PD) deficiency in neonates by fluorescent spot test (FST), enzyme assay and molecular methods, and to identify which method was a significant predictor of severe hyperbilirubinaemia.
Methods 74 term infants of Chinese descent admitted with severe hyperbilirubinaemia (total serum bilirubin equal or greater than 300 micromol/L) and 125 healthy term infants born in the hospital without severe hyperbilirubinaemia were recruited into the study. Specimens of blood were collected from each infant for FST, G6PD enzyme assay and TaqMan^® minor groove binder single nucleotide polymorphism genotyping assay.
Results 26 (13.1 percent) infants were diagnosed to have G6PD deficiency by FST. They had significantly lower median enzyme levels (0.8 IU/g Hb, interquartile range [IQR] 0.4–4.3) than those diagnosed to be normal (12.0 IU/g Hb, IQR 10.3–15.8) (p-value is less than 0.0001). Based on the enzyme assay, 39 (19.6 percent) infants had G6PD deficiency at an enzyme cut-off level of less than 8.5 IU/g Hb. G6PD mutation was detected in 27 (13.6 percent) infants. Logistic regression analysis showed that the only significant predictors of severe hyperbilirubinaemia were G6PD deficiency based on a cut-off level of less than 8.5 IU/g Hb (adjusted odds ratio [OR] 5.3, 95 percent confidence interval [CI] 2.4–11.4; p-value is less than 0.0001) and exclusive breast-feeding (adjusted OR 11.4, 95 percent CI 3.1–42.4; p-value is less than 0.0001). The gender and birth weight of infants, FST results, G6PD mutation and the actual G6PD enzyme levels were not significant predictors.
Conclusion A G6PD enzyme level of less than 8.5 IU/g Hb is a significant predictor of severe hyperbilirubinaemia.

Keywords: glucose-6-phosphate dehydrogenase, fluorescent spot test, enzyme level, hyperbilirubinaemia, neonatal jaundice
Singapore Med J 2009; 50(1): 62-67

Tan C, Wong B, Goh DY, Van Bever HP
Correspondence: Prof HugoVan Bever, paevbhps@nus.edu.sg

ABSTRACT
Introduction Asthma is the most common chronic disease in children in Singapore. More than 20 percent of children will have been diagnosed with asthma by the age of 15 years. Most children are seen in the primary care setting, thus it is of value to study the management practices, especially of general practitioners, with comparison to gold standards. The aims of the study were to investigate: (a) Methods of monitoring asthma control; (b) Practices in managing acute exacerbations; and (c) Choice of therapy in maintenance treatment.
Methods 2,100 questionnaires consisting of 35 questions were sent by post to general practitioners and various paediatric doctors throughout Singapore. 173 valid responses were received and results were compared to the 2006 Global Initiative for Asthma guidelines.
Results 76.3 percent of respondents were general practitioners. 89.1 percent did not use symptom score cards/diaries. 37.6 percent did not use peak-flow meters/spirometers. 83.8 percent used a short-acting beta-agonist in acute exacerbations, but only 41.0 percent used oral corticosteroids in outpatients. A significant number used long-acting beta-agonists (LABA) in combination with inhaled steroids (29.5–41.6 percent) or as monotherapy (5.8–8.7 percent) for maintenance treatment. 91.3 percent never used immunotherapy in practice.
Conclusion Greater usage of diaries/score cards can be encouraged along with objective peak flow/spirometry measurements. Management of acute exacerbations is appropriate but corticosteroids are under-prescribed by most doctors. LABA continues to be prescribed for maintenance despite a lack of established safety profile for infants, along with recommendations that they only be used selectively in patients poorly-controlled by medium-dosage inhaled corticosteroids.

Keywords: asthma, childhood asthma, corticosteroids, inhaled corticosteroids, long-acting beta-agonists
Singapore Med J 2009; 50(1): 54-61

Wong LP, Wong YL, Low WY, Khoo EM, Shuib R
Correspondence: Dr Wong Li Ping, wonglp@ummc.edu.my

ABSTRACT
Introduction Cervical cancer is one of the commonest cancers in women worldwide. Despite the existence of effective screening using Pap smear, the uptake of screening is poor. A qualitative study was undertaken using face-to-face in-depth interviews to investigate knowledge, attitudes and beliefs on cervical cancer screening of Malaysian women.
Methods In-depth interviews were conducted with 20 Malaysian women aged 21–56 years and who have never had a Pap smear test, with the aim to explore their knowledge and awareness of cervical cancer and its screening.
Results A lack of knowledge on cervical cancer and the Pap smear test was found among the respondents. Many women did not have a clear understanding of the meaning of an abnormal cervical smear and the need for the early detection of cervical cancer. Many believe the purpose of the Pap smear test is to detect existing cervical cancer, leading to the belief that Pap smear screening is not required because the respondents had no symptoms. Despite considerable awareness of a link between cervical cancer and sexual activity, as well as the role of a sexually-transmitted infection, none of the respondents had heard of the human papillomavirus.
Conclusion The findings highlight the importance of emphasising accurate information about cervical cancer and the purpose of Pap smear screening when designing interventions aimed at improving cervical cancer screening for Malaysian women.

Keywords: cervical cancer screening, health screening, Pap smear, qualitative study
Singapore Med J 2009; 50(1): 49-53

Wang MLC, Foo KF
Correspondence: Dr Michael Lian Chek Wang, ntrwlc@nccs.com.sg

ABSTRACT
Introduction The role of adjuvant chemoradiotherapy for resected pancreatic cancer remains controversial. Several trials have failed to draw firm conclusions. The risk of local and metastatic relapse remains high after radical surgery. This is a single institutional review, evaluating the outcomes of patients with high-risk resected pancreatic cancer and treated with adjuvant chemoradiotherapy.
Methods A retrospective review was conducted on 18 consecutive patients with pancreatic cancer and treated with adjuvant chemoradiotherapy at the Department of Radiation Oncology, National Cancer Centre, Singapore, between January 2000 and December 2004. 56 percent were women. The mean age was 61.5 (range 50–73) years. Patients had either AJCC 2002 Stage I (17 percent), Stage II (11 percent), Stage III (22 percent) or Stage IVA (50 percent). The median radiation dose delivered was 5,400 (range 4,140–5,500) cGy using 180 cGy fractions. Concurrent chemotherapy was administered with 5-fluorouracil (56 percent), gemcitabine (28 percent) or capacetabine (17 percent).
Results The median follow-up of patients still alive at the time of analysis was 48 months. Metastatic disease had developed in 13 patients. Two patients had local recurrence within the radiation field. The median survival of the cohort is 21.6 (range 8.5–62.7) months. One-year survival is 89 percent, 2-year survival 39 percent and 3-year survival 28 percent.
Conclusion The data supports the use of adjuvant chemoradiotherapy for high-risk pancreatic cancer. Our results are comparable to published data from similar studies. Although radiotherapy is effective in reducing local failure, effective systemic treatment is also essential.

Keywords: adjuvant chemoradiotherapy, chemoradiotherapy, pancreatic cancer, resected pancreatic cancer
Singapore Med J 2009; 50(1): 43-48

Chong E, Poh KK, Shen L, Yeh IB, Chai P
Correspondence: Dr Eric Chong, ericchong80@hotmail.com

ABSTRACT
Introduction Subutex (buprenophine) was approved by the Health Science Authority of Singapore for heroin detoxification in 2002. The number of heroin addicts has decreased in Singapore since the introduction of Subutex. However, Subutex abuse and its associated complications became arising medical problems. We report the management of a series of infective endocarditis cases secondary to Subutex abuse.
Methods We identified 12 cases of infective endocarditis in former heroin addicts treated with Subutex from August 2005 to April 2006. All patients were interviewed by the research coordinator and prospectively followed-up for two years.
Results The treatment period of Subutex endocarditis was often prolonged with a mean hospitalisation stay of 48 days, with 3.8 days in the intensive care unit. Multiple medical complications were noted. Staphylococcus aureus septicaemia accounted for 92 percent of cases. Mortality rate was 42 percent. Failure rate of medical therapy alone was common. 25 percent underwent open heart valve surgery. All patients were subsidised. Mean hospitalisation expenses was S$31,218.
Conclusion Subutex endocarditis causes significant morbidity and mortality. It imposes a heavy medical and financial burden to the patient and society. Multidisciplinary treatment involving cardiologists, infectious disease physicians, psychiatrists, surgeons, medical counsellors and social workers is required to manage these patients.

Keywords: buprenorphine, drug abuse complication, endocarditis, heart infection, infective endocarditis, Subutex
Singapore Med J 2009; 50(1): 34-42

Teo L, Tay YK, Liu TT, Kwok C
Correspondence: Dr Lynn Teo, lynnteohweeying@hotmail.com

ABSTRACT
Toxic epidermal necrolysis (TEN) is a rare, severe adverse drug reaction. Steven-Johnson syndrome (SJS) represents the milder end of the spectrum. The exact pathogenesis of TEN and SJS is still unknown and many drugs, including prednisolone, cyclosporin and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of IVIG in particular is controversial. We share our experience with the use of IVIG in six patients with TEN. We will also review the various proposed mechanisms underlying TEN, the mechanism of action of IVIG in TEN and summarise useful treatment options.

Keywords: adverse drug reaction, corticosteroids, intravenous immunoglobulin, Stevens-Johnson syndrome, toxic epidermal necrolysis
Singapore Med J 2009; 50(1): 29-33