Original Article

Fatima M, Nawaz H, Kassi M, Rehman R, Kasi PM, Kassi M, Afghan AK, Baloch SN
Correspondence: Mr Pashtoon Murtaza Kasi, pashtoon.kasi@gmail.com

ABSTRACT
Introduction Osteoporosis-related bone fractures are a significant public health problem. The aim of this study was to determine the prevalence of osteoporosis among Pakistani women and identify modifiable risk factors.
Methods A cross-sectional study was conducted in an obstetrics/gynaecology setting during March–April 2007 in Quetta, Pakistan. A total of 334 women older than 20 years of age underwent quantitative ultrasonography and were interviewed to find out the risk factors for osteoporosis. Bone mineral density was assessed by the speed of sound using a quantitative ultrasound device. The sociodemographic characteristics of normal, osteopenic and osteoporotic women were compared using the chi-square test for categorical variables and ANOVA for continuous variables. Binary logistic regression was used to determine the independent predictors of being osteopenic or osteoporotic.
Results 146 (43.7 percent) women were reported to be normal, 145 (43.4 percent) were osteopenic and 43 (12.9 percent) were osteoporotic. The mean age and standard deviation of the participants were 36.7 years +/-13.0 years, with a body mass index (BMI) of 25.81 (standard deviation 5.10) kg per square metre. In the univariate analysis, factors that were associated with osteoporosis/osteopenia included age, parity, BMI, smoking (pack years), consumption of calcium-rich food/week, personal and family history of osteoporosis, education and socioeconomic status (p-value is less than 0.05). Using binary logistic regression with osteoporosis/osteopenia as an outcome compared to normal individuals, BMI, smoking pack years, a family history of osteoporosis/fracture and house ownership were found to be independent predictors of the outcome.
Conclusion The prevalence of osteoporosis and osteopenia is high, especially among young Pakistani women, and is associated with modifiable risk factors.

Keywords: osteoporosis prevalence, osteoporosis risk factors, quantitative ultrasonography, women’s health
Singapore Med J 2009; 50(1): 20-28

Liu YEB, Hu S, Chan SP, Sathappan SS
Correspondence: Dr Sathappan S Sathappan, sathappan@ttsh.com.sg

ABSTRACT
Introduction The number of total knee replacements far exceeds the number of primary total hip replacements (THR) in Singapore. There is a paucity of data regarding patients who undergo THR in Singapore. This paper aimed to study the epidemiology and early postoperative outcomes of patients receiving primary THR in a single tertiary institution.
Methods This is a retrospective study of all patients undergoing primary THR between January 2003 and December 2005. The following variables were analysed: patient demographics, surgical approach, mode of implant fixation, postoperative complications and functional outcomes using D’Aubigne and Postel scoring.
Results There were a total of 115 patients who underwent primary THR over a 36-month period. The mean age of patients was 55 (range 23–80) years. The male-to-female ratio was 1:2. The most common diagnoses in descending order were as follows: inflammatory arthritis, osteoarthritis, avascular necrosis, hip dysplasia and post-traumatic osteoarthritis. Patients were evaluated at a mean follow-up of 41 months, with 90.8 percent having excellent and good outcomes. There were no statistical differences between the surgical approach and implant fixation with regard to postoperative outcome.
Conclusion In Asian patients, the three commonest aetiologies for degenerative hip arthritis were inflammatory arthropathies, primary osteoarthritis and avascular necrosis. Regardless of diagnosis, the patient groups had comparable functional outcomes following THR.

Keywords: arthropathy, degenerative hip arthritis, hip replacement, primary total hip replacement, total hip replacement
Singapore Med J 2009; 50(1): 15-19

Jahnavi G, Sudha CH
Correspondence: Dr G Jahnavi, jahnavi_doc@yahoo.com

ABSTRACT
Introduction Wasting is the cardinal feature of tuberculosis, but not much documentary evidence supporting food supplements exists. This study was done to assess the effects of food supplements on body weight, physical function, quality of life and treatment outcomes in patients with tuberculosis and wasting.
Methods The study was conducted in 30 Anganwadi centres of 16 villages in the catchment area of Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation and the Gannavaram Directly Observed Treatment Short Course chemotherapy centre from August 2005 to December 2005. A total of 100 patients participated in the study. Patients who were started on anti-tubercular therapy within the previous two weeks were randomly assigned to either the control or the food supplement group. At the end of three months, their body weight was measured and physical function and quality of life were assessed. Treatment outcomes were assessed at the one-year follow-up for both groups.
Results Patients who received supplements had a significant increase in body weight (8.6 percent versus 2.6 percent, p-value less than 0.001) and maximum grip strength (p-value less than 0.001), a higher sputum conversion rate (p-value is 0.039), a higher treatment completion rate (p-value is 0.031) and improvements in the quality of life scores.
Conclusion Intake of food supplements resulted in a definitive increase in body weight and physical function in our study sample. Improvements can be observed in all areas, including psychologically, physiologically, socially and in the treatment outcomes.

Keywords: body weight, food supplements, tuberculosis, wasting disease
Singapore Med J 2010; 51(12): 957-962

Mohammadizadeh M, Ghazinour M, Iranpour R
Correspondence: Dr Majid Mohammadizadeh, m_mohammadizadeh@med.mui.ac.ir

ABSTRACT
Introduction Enteral feeding intolerance is a major problem in preterm infants. This study evaluated the safety and efficacy of prophylactic low-dose oral erythromycin, a motilin agonist, as a prokinetic agent in reducing the incidence of this problem.
Methods From February to May 2008, a prospective randomised controlled trial was conducted at the Isfahan University of Medical Sciences, Isfahan, Iran. 70 uncomplicated preterm infants (28–34 weeks’ gestation) weighing 1,000–1,500 g were randomly assigned to either a case group receiving low-dose oral erythromycin (6 mg/kg/day, in four doses over ten days) or a control group (n is 35 in each group) until they were fully fed enterally (150 ml/kg/day). Gavage feeding of the mother’s milk was started within the first three days of life, and erythromycin was given simultaneously. The time taken to reach full enteral feeding and the total duration of feeding interruption due to intolerance were compared.
Results The time taken to reach full enteral feeding was significantly shorter in the erythromycin group than the control group (10.11 +/- 2.51 versus 12.71 +/- 5.76 days, p is 0.01). In the control group, the mean duration of feeding interruption was significantly longer (84.00 +/- 62.58 versus 32.57 +/- 11.93 hours, p is 0.005) and more episodes of abdominal distention and significant gastric residue were also noted (p less than 0.05). No infant in the erythromycin group developed cardiac arrhythmias or pyloric stenosis.
Conclusion The prophylactic use of erythromycin may be warranted in very low birth weight infants, provided the efficacy and safety of the drug can be confirmed in further studies.

Keywords: erythromycin, feeding intolerance, preterm infant
Singapore Med J 2010; 51(12): 952-956

Al-Osail AM, Sadat-Ali M, Al-Elq AH, Al-Omran AS, Azzam Q
Correspondence: Prof Mir Sadat-Ali, drsadat@hotmail.com

ABSTRACT
Introduction This study was conducted to evaluate the prevalence of fractures secondary to steroid use.
Methods A total of 165 patients (100 male and 65 female) who received glucocorticoid therapy at a dose of 7.5 mg or more, or its equivalent, for more than six months were identified from July 1, 2007 to December 30, 2007. Data extracted included age, gender, dose of glucocorticoid, concomitant diseases, the use of anti-resorptive therapy, calcium and vitamin D supplementation, and the results of bone mineral density (BMD) tests, if performed. Any fragility fractures, the site involved and the treatment administered were also recorded. The data was entered and analysed using the Statistical Package for the Social Sciences.
Results 140 patients had no fractures while 25 (15.2 percent) sustained an osteoporotic fracture. The age (p-value less than 0.5), dose of steroids (p-value less than 0.001) and duration of glucocorticoid therapy (p-value less than 0.001) were significantly higher among patients who sustained fractures. Of these, 12 were male and 13 were female. None of the patients in both groups was started on antiresorptive therapy. The dosage of glucocorticoids was higher among women than men (11.5 versus 24.5 mg/day, p-value is 0.05). The commonest sites of osteoporotic fracture were the spine (44 percent) and proximal femur (24 percent). Eight out of 11 patients had more than one vertebra involved.
Conclusion Fractures due to steroid-induced osteoporosis could have been prevented if appropriate measures were taken.

Keywords: glucocorticoids, osteoporosis-related fractures, secondary osteoporosis
Singapore Med J 2010; 51(12): 948-951

Adekanle O, Ndububa DA, Ayodeji OO, Paul-Odo B, Folorunso TA
Correspondence: Dr Olusegun Adekanle, olusegunadekanle@yahoo.co.uk

ABSTRACT
Introduction Hepatitis B can be spread by several routes, including sexually. This study aimed to determine the prevalence of sexual transmission of the virus among the Nigerian population.
Methods This was a prospective cross-sectional study involving 234 blood donors in a Nigerian tertiary hospital. Each prospective donor was screened for hepatitis B surface antigen using an enzyme-linked immunosorbent assay test. A structured questionnaire was used to obtain information regarding the possible routes of hepatitis B acquisition and the number of lifetime heterosexual partners. Respondents were divided into three risk groups. The data obtained was analysed, and the frequencies, percentages, means and standard deviations were obtained. The chi-square test was used to compare categorical variables, and a p-value equal or less than 0.05 was considered statistically significant.
Results A total of 234 respondents aged 18 to 56 years (mean 27.3 years) participated in the study. 223 were male and 11 were female. The overall seroprevalence of hepatitis B was 17.1 percent. The seroprevalence was higher among participants without sexual partners (20.6 percent) and those with multiple sexual partners (20.0 percent), but lower among those with single sexual partners (15.0 percent). A history of needle injuries, jaundice and injections from quacks were statistically significant when these risks were combined with a sexual risk for hepatitis B virus infection (p-value is less than 0.05).
Conclusion Sexual transmission of hepatitis B was not found to be an important factor. Preventive strategies should include universal hepatitis B vaccination and discouraging the indiscriminate use of sharp objects and unauthorised medical practices.

Keywords: blood, hospital, institution, transmission, virus
Singapore Med J 2010; 51(12): 944-947

Kiong KL, Ganesh R, Cheng AKS, Lekshiminarayanan R, Lim SC
Correspondence: Dr Ganesh Ramalingam, rganesh16@hotmail.com

ABSTRACT
Introduction Obesity is a growing problem worldwide that is closely related to type 2 diabetes mellitus (T2DM). The Roux-en-Y gastric bypass (RYGBP), a restrictive and malabsorptive bariatric procedure, shows mounting evidence of inducing improvement of T2DM. Few studies, especially those examining the early changes in diabetic parameters, have been done in the Asian population.
Methods All morbidly obese patients with T2DM undergoing RYGBP at our institution from August 2008 to January 2010 were prospectively studied. Six patients had RYGBP, and one had a laparoscopic sleeve gastrectomy with a duodeno-jejunal bypass. Data collected included pre- and postoperative 75 g oral glucose tolerance test, daily postoperative fasting plasma glucose, and haemoglobin A1c (HbA1c) pre-operation and at two, four and 12 weeks post operation.
Results After 12 weeks, the mean drop in HbA1c was 2.29 +/- 1.39 percent. The change in HbA1c at four (p is 0.039) and 12 (p is 0.005) weeks showed significant improvements. A significant decrease in diabetic medication usage was observed, with four (57 percent) patients not requiring medications within four weeks. Remission of DM was achieved in two (28.6 percent) patients within 12 weeks. Weight loss by various parameters was significant from two weeks onwards.
Conclusion The cure rate of 28.6 percent and an improvement rate of 100 percent of T2DM in morbidly obese Asian patients within 12 weeks post operation are promising. Many patients discontinued their diabetic medications in the immediate postoperative period, even before significant weight loss had occurred, indicating that RYGBP has an effect on hormonal mechanisms that influence glucose homeostasis in the body.

Keywords: Asian, haemoglobin A1c, morbid obesity, Roux-en-Y gastric bypass, type 2 diabetes mellitus
Singapore Med J 2010; 51(12): 937-943

Acibucu F, Kayatas M, Candan F
Correspondence: Dr Fettah Acibucu, dr.feto@hotmail.com

ABSTRACT
Introduction Insulin resistance (IR), hyperinsulinaemia and concomitant metabolic syndrome (MS) are known to be independent risk factors for coronary arterial disease (CAD). The aim of this study was to examine the frequency of IR, hyperinsulinaemia and MS in individuals with early androgenetic alopecia (AGA).
Methods The Hamilton-Norwood scale was used to grade AGA. The homeostasis model assessment of insulin resistance formula was used to detect IR, and a value above 2.7 was considered to show IR. According to the National Cholesterol Education Programme Adult Treatment Panel III-2001 diagnosis criteria, patients with three or more positive criteria were considered to have MS.
Results In this study, we evaluated 80 patients with early AGA and 48 healthy participants. The serum level of insulin was higher in patients with early AGA compared to the healthy participants, although not significantly. IR was detected in 25 patients with early AGA and in six healthy participants. The difference between the groups was statistically significant. Although 20 patients with AGA were diagnosed with MS, it was only diagnosed in five healthy participants. The occurrence of MS was significantly higher in the AGA group than in the control group.
Conclusion The prevalence of IR and MS was observed to have increased in early AGA patients. Hence, patients with early AGA should be followed up for CAD in the long term. Our results should be confirmed with prospective studies.

Keywords: androgenetic alopecia, insulin resistance, metabolic syndrome
Singapore Med J 2010; 51(12): 931-936

Al-Baghli NA, Al-Ghamdi AJ, Al-Turki KA, Al Elq AH, El-Zubaier AG, Bahnassy A
Correspondence: Dr Nadira A Al-Baghli, nadiraa@windowslive.com

ABSTRACT
Introduction This study aimed to estimate the prevalence of diagnosed and undiagnosed diabetes mellitus (DM) in the Eastern Province of Saudi Arabia, and to study its relationship with socioeconomic factors.
Methods The study targeted all Saudi subjects aged 30 years and above who resided in the Eastern Province in 2004. DM screening was conducted by taking the capillary fasting blood glucose (CFBG) after eight hours or more of fasting, or the casual capillary blood glucose (CCBG). A positive screening test for hyperglycaemia was defined as CFBG more than or equal to 100 mg/dl (5.6 mmol/l), or CCBG more than or equal to 140 mg/dl (7.8 mmol/l). A positive result was confirmed on another day through the measurement of fasting plasma glucose (FPG) levels from a venous sample. A diagnosis of DM was considered if FPG was more than or equal to 126 mg/dl (7.0 mmol/l), or when there was a history of a previous diagnosis.
Results Out of 197,681 participants, 35,929 (18.2 percent) had a positive history of DM or a positive screening test for hyperglycaemia. After confirmation by venous blood testing, the prevalence of DM dropped to 17.2 percent while the prevalence of newly diagnosed DM was 1.8 percent. The prevalence increased with age and was higher in women, widows, divorcees, those who had a low education level and the unemployed.
Conclusion The prevalence of DM in Saudi Arabia is one of the highest reported in the world, and its yield of screening is high.

Keywords: diabetes mellitus, prevalence, Saudi Arabia, screening
Singapore Med J 2010; 51(12): 923-930

Chan ML, Gustafsson L, Liddle J
Correspondence: Ms Chan Mei Leng, meileng.chan@uq.edu.au

ABSTRACT
Introduction With an ageing population, policy makers need to balance active ageing needs with older driver safety. In 2009, a survey of licensing policies for taxi drivers in Singapore, Hong Kong and Australia was undertaken for an evidence-based review of policies.
Methods Licensing requirements collected using semi-structured questionnaires were compared descriptively and with evidence from licensing policies on older drivers.
Results All the regions used medical certifications with vision screening. The frequency of medical certification varied according to the renewal cycle and age. Medical guidelines on fitness to drive were available in Australia and Singapore. Legislation for self-reporting of medical conditions by drivers existed in Australia and Hong Kong. Legislation for reporting at-risk drivers by doctors was limited to two Australian states. There were differences in the minimum age and driving experience criteria, the use of practical training, written and English tests, age-based screening, mandatory retirement age, refresher courses, off- and on-road tests.
Conclusion Medical screening for at-risk drivers remains crucial. Age-based mandatory retirement policy at 73 years in Singapore is contrary to evidence-based practice. The lack of legislation for self-reporting of illness by drivers, the high minimum age criteria and therapy driving assessments for healthy taxi drivers are also unique to Singapore. There was stricter age-based relicensing from the age of 65 years in some Australian states and in Singapore. Continuing education for doctors, multi-tier screening for at-risk drivers and licensing policy changes are indicated.

Keywords: driver, evidence, health policy, licensing, medical guidelines
Singapore Med J 2010; 51(12): 913-922